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.

HOLLY HILL MENTAL HEALTH SERVICES 3019 FALSTAFF RD RALEIGH, NC 27610 June 12, 2020
VIOLATION: NURSING SERVICES Tag No: A0385
Based on policy review, medical record review, and staff and physician interviews, the hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations by failing to ensure systems were in place to supervise and provide safe delivery of care to behavioral health patients.
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The findings include:

1. Nursing staff failed to supervise handoff of a vulnerable, incompetent adult patient during departure from the facility for 1 of 10 sampled discharged patients (Patient #5).

~cross refer to 482.23 (b)(3) Nursing Services Standard: RN Supervision, Tag A0395

2. Nursing staff failed to monitor and supervise an adolescent behavioral health patient search to prevent contraband items from being available and used to perform self-harm in 3 of 8 sampled adolescent patients (#1, #8 and #18).

~cross refer to 482.23 (b)(3) Nursing Services Standard: RN Supervision, Tag A0395

3. Nursing staff failed to investigate reported patient to patient sexual abuse for 1 of 2 sampled allegations of abuse (#2 and #15).

~cross refer to 482.23 (b)(3) Nursing Services Standard: RN Supervision, Tag A0395
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policy, medical record review, staff and physician interviews, nursing staff failed to supervise the handoff of a vulnerable, incompetent adult patient during departure from the facility in 1 of 10 sampled discharged patients (Patient #5); nursing staff failed to monitor and supervise an adolescent behavioral health patient search to prevent contraband items from being available and used to perform self-harm in 3 of 8 sampled adolescent patients (#1, #8 and #18); and nursing staff failed to investigate reported patient to patient sexual abuse for 1 of 2 sampled allegations of abuse (#2 and #15).

The findings include:

A. Review of the facility policy titled "DISCHARGE PLANNING/PROCEDURES" last reviewed March 2019 revealed "...PROCEDURE Responsible Party: Registered Nurse or designee...7. Upon discharge, a Discharge Note will be entered in the Progress Notes, which includes behavioral expressions, date/time of discharge, where the patient is going and who is accompanying the patient...9. The patient will be escorted to the front door of the hospital by staff..."

Medical record review on 06/09/2020 revealed Patient (Pt) #5 was a [AGE] year-old female voluntarily admitted to Hospital A on 10/18/2019 at 1714 with suicide ideation (thoughts of killing self) and homicidal ideation (thoughts of killing others). Medical record review revealed Pt #5 had a history of Major depressive disorder with psychotic features and IDD (Intellectual developmental disability or below average intelligence and life skills). Medical record review revealed documentation that Pt #5 was an adult with a legal guardian. Review of the "Social Services Progress Note" dated 10/30/2019 (no time recorded) revealed "...Group home reported that they will pick patient up upon discharge..." Review of the "Discharge Log" revealed Pt #5 was discharged from Hospital A on 11/5/2019 at 1357.

Review of a "Progress Note" signed by the Chief Clinical Officer (CCO) on 11/12/2019 at 1005 revealed "...On 11/6 Chief Clinical Officer was informed of an incident that occurred on 11/5 by the two therapist that had worked with this patient. (Patient #5), an adult patient with a legal guardian, was scheduled to be discharged on ,d+[DATE] to return to her previous group home. On the day of discharge, the patient was brought to the lobby of the hospital where (Patient #5) was waiting for her ride back to her group home. During this time, (Patient #5) walked over to the front door and exited it without incident. The group home called to say their transportation broke-down and that they were not able to pick the patient up as planned. The group home called the therapists the next day to let them know they never picked up the patient and that they did not know her whereabouts..."

Review of the "ED Provider Note" dated 11/6/2019 at 2139 revealed Patient #5 presented to Hospital B on 11/06/2019 at 1842 via car and group home staff with a chief complaint of suicidal thoughts. Review of the "Behavioral Health and Substance Use Services Initial Assessment" signed on 11/06/2019 at 2227 revealed "...History of Present Illness...Patient was admitted on [DATE] for evaluation into concerns of reported suicidal ideation and psychosis...Group home staff reports that...she was discharged from (Hospital A) yesterday and sent back to the group home on a bus. Pt was then missing for about 24 hours before Raleigh Police Department found pt. Pt told Raleigh Police Department that she had suicidal thoughts..." Medical record review revealed Pt #5 was involuntarily committed to Hospital B on 11/7/2019 at 0738 pending behavioral health placement due to concerns about possibility of suicidal actions. Review of an "Inpatient Psychiatric Progress Note" dated 11/11/2019 at 1330 revealed "...On exam patient is more alert and interactive...She discussed events that occurred before she came to (Hospital B) and states she got tired of waiting at (Hospital A) on 11/5 for group home to pick her up and 'men picked her up. They were nice to help me but they were bad people. They smoked and gave me some.' She states they did not assault her because she slept on the bus. However later she said they tried to assault her but she didn't let them..." Review of the "Urine Drug Screen" on 11/06/2019 revealed "Cocaine, Urine Screen POSITIVE..." Medical record review revealed on 11/13/2019 at 1150 Patient #5 was discharged from Hospital B back to the group home.

Interview on 06/10/2020 at 1635 with Registered Nurse (RN) #18 revealed on 11/05/2019 she was notified by Therapist #20 that the group home staff would arrive at 1330 to pick up Patient #5 for transport back to the group home. Interview revealed that at approximately 1330 she answered an inbound telephone call at the nurses' station from an individual that stated they were "coming for (Patient #5)." Interview revealed RN #18 notified Mental Health Technician #19 to retrieve Patient #5's belongings and to escort her to the lobby for discharge.

An interview was requested with Mental Health Technician #19 who was not available for interview.

Interview on 06/11/2020 at 0955 with the Receptionist revealed at the time a patient is escorted to the lobby, the patient is "technically considered discharged " and they are able to wait for their transportation either inside the lobby or outside of the hospital. Interview revealed the Receptionist was not required to obtain names, signatures or other details of the person that transports the patient after discharge. Interview revealed on 11/05/2019, Patient #5 was in the lobby with her belongings waiting for transportation after being discharged from the hospital. Interview revealed Patient #5 collected her belongings and requested to go outside of the hospital's lobby. Interview revealed the Receptionist released the remote door lock (stationed at the front desk), and Patient #5 exited the lobby. Interview revealed the Receptionist was unaware of a hospital policy or protocol that a staff member must stay in the lobby with patient's that have a legal guardian.

Interview on 06/10/2020 at 1100 with the attending Psychiatrist (Medical Doctor #17) revealed it was the hospital's standard of practice for the Therapist or Mental Health Technician to escort the patient to the lobby to wait for their transportation. Interview revealed MD #17 was unaware that Patient #5 left the facility alone. Interview revealed "next time patients with Intellectual developmental disability or a guardian should not be left without a staff member in the lobby." Interview revealed "...perhaps the patient should wait on the unit for safety because one person working at the desk may not be able to monitor appropriately and a patient with IDD may need to be watched closely."

Interview on 06/11/2020 at 1010 with the Chief Nursing Officer revealed that once a patient is discharged from the unit, the patient is allowed to wait for their transportation in the lobby. Interview revealed there was no policy that stated the staff must stay in the lobby with a patient while awaiting transport. Interview revealed the RN should ultimately be responsible for making sure the patient is safe until they leave the hospital.





B. Review on 06/10/2020 of the policy and procedure titled "Contraband Search Guidelines" last reviewed 01/20 revealed "...II. Patient Search: All inpatients have a routine, non-invasive search and skin assessment conducted by RN (Registered Nurse) and staff upon admission to the inpatient unit...Under the supervision of the RN in attendance the patient is instructed to put on a hospital gown, removing all clothing with the exception of underwear. After the patient gown is on, the patient should be requested to remove any underwear. vi. After all clothing is removed carefully search the patient's personal clothing. This includes pockets, hems, inside shoes and socks and other places where items may be hidden..."

1. Review on 06/09/2020 of the closed medical record for the Patient #1 revealed a [AGE]-year-old female was admitted on [DATE] voluntarily for suicidal ideation with a plan to "jump from a window." Review of the "Nursing Progress Note" (RN #10) dated 05/21/2020 at 0900 revealed "Per (Named) MD #9 (medical doctor) pt was allowed to make a phone call to mom because she had opened up (with symbol) mom, told her that a peer (Patient #8) had given her a razor blade and that both patients had used it to cut self... Pt noted (with symbol) a superficial laceration to her thigh. No treatment needed. Contraband was found in the dayroom in the fold of a chair. Contraband removed. Will monitor closely." Review of MD #9 Discharge Summary dated 05/21/2020 at 1446 revealed " ...She and her roommate collaborated on scratching with a piece of metal that they had obtained from another patient and this was found in the morning... I had talk to her mom and she told her mom her roommate gave her the piece of metal and this was investigated and it turned out to be true..." Patient #1 was discharged on [DATE].

2. Review of the medical record for the peer who had the contraband, Patient #8, revealed a [AGE]-year-old female admitted on [DATE] voluntarily for suicidal ideation with a plan to "cut her wrist." Review revealed Patient #8 was discharged from same hospital earlier in the day on 05/19/2020. Review of the "Comprehensive Nursing Assessment" (RN #15) dated 05/20/2020 at 0115 revealed a skin assessment and contraband search was completed, no contraband was discovered. Review of the "Patient Contraband Search" dated 05/20/2020 (no time) revealed a non-invasive body search was completed by RN #15, Patient #8 was wanded with a metal detector and her clothes and luggage bag were searched. Review of the "Nursing Progress Note" (RN #15) dated 05/20/2020 at 0120 revealed "This 12yo (year old) white female admitted to (named unit) @ 0045 ...Had superficially cut right arm (with symbol) razor ...Was searched and no contraband found on her..." Review of the "Nursing Progress Note" (RN #10) dated 05/21/2020 at 1656 revealed "This morning, a peer reported that this patient gave her a 'razor blade.' Peer reported that both patients had used the razor to cut selves...When found, it was a small thin piece of sharp metal that isn't a traditional razor blade, but maybe a piece of a razor blade...Mom reported that pt had torn up a razor at home to harm self. Peer initially reported that pt had been hiding the piece of razor in her pocket, then when searched, moved it to her mouth, hidden by her braces..." Review revealed Patient #8 had two superficial cuts to her left arm as a result of the incident. Patient #8 was discharged on [DATE].

3. Review of the third patient (Patient #18-open record) involved in cutting herself with the razor from Patient #8 revealed she was a [AGE]-year-old female admitted on [DATE] for homicidal behaviors toward her family. Review of the "Nursing Progress Note" dated 05/20/2020 at 0900 revealed "Late entry:...she had scratched herself yesterday with a piece of a fork. Asked pt if she had actually cut herself with a razor from another pt...Pt then admitted to using the razor..."

Interview on 06/10/2020 at 1017 with RN #10 revealed she was the nurse on duty on 05/21/2020 when Patient #1 told the RN she had used a razor to cut herself. RN #10 stated the razor was approximately 1.5-2 inches in length and little wider than a paper clip. Interview revealed when RN #10 spoke with Patient #8's mother, the mother informed her after Patient #8 was discharged earlier in the day from the hospital and returned home, Patient #8 "tore up" a disposable razor and used it to cut herself. RN #10 stated Patient #8 told her she had the razor in her pocket until the time to be searched, then she put it in her mouth.

Interview on 06/10/2020 at 1407 with MHT #12 revealed she was the second staff member that completed Patient #8's contraband search on 05/20/2020 during admission. Interview revealed MHT #12 could not recall specifically assisting with Patient #8's contraband search, however she did recall recently conducting a search and the nurse gave the patient a gown, the patient stepped behind the curtain in the exam room and changed into the gown. MHT #12 stated the patient then stepped back in front of the curtain and her clothes and body were searched for contraband. Interview revealed MHT #12 did not recall an oral exam being conducted during that search.

In summary, findings revealed nursing staff failed to supervise and monitor contraband searches to prevent prohibited items from being available and used for self harm. Findings revealed no internal investigation had been conducted related to this incident.





C. Review of policy titled "Patient Sexual Familiarity Prevention" with reviewed date of 01/18, revealed "Patients receiving behavioral healthcare services, particularly minors, can be vulnerable and often times unable to make health decisions about intimate relationships. It is the policy of (named hospital) to provide a safe and secure environment that discourages the development of intimate relationships with fell ow patients during or after hospitalization ...Response to Alleged Sexual Familiarity Occurrences: Facility staff and physicians take all reports of sexual familiarity between patients seriously and respond accordingly. Staff duties in the event of sexual acting out between patients include the following: 1. Staff will take immediate action to ensure the safety of involved parties. 2. Separate the parties involved and maintain separation until directed otherwise by hospital authorities. 3. Notify the House Supervisor/Risk Manager/CNO (Chief Nursing Officer) immediately. 4. Notify each patient's attending physician immediately. 5. In the case of a minor or patient declared legally incompetent, the patient's parent or legal guardian should be notified of the incident by the appropriate personnel. 6. Staff interview involved parties separately to determine exact nature of the alleged occurrence. 7. Patient/Guardians are notified regarding their rights to report any sexual, verbal/physical abuse, threats of sexual abuse, perceived or real allegations from patients or staff to law enforcement agencies. 8. Any allegation of sexual assault or non-consensual sex will be reported to local law enforcement by hospital administration. The Risk Manager and/or CNO will consult with the CEO (Chief Executive Officer) regarding the need to report to law enforcement ..."

Review of a closed medical record revealed Patient #2 was a [AGE]-year-old female admitted on [DATE] with mood disorder and a history of trauma. Review of a closed medical record revealed Patient #15 was a [AGE]-year-old female admitted on [DATE] with mood disorder and suicide ideations. Review of a nurses note dated 01/16/2020 at 2330 written by RN #1 (Registered Nurse #1) revealed Patient #2 reported to a staff nurse on 01/16/2020 that Patient #15 had touched her "sensitive areas" while Patient #2 was in the shower and wouldn't stop touching her when asked. Patient #2 reported this had occurred sometime during the prior week. Findings revealed the allegation was reported to the nursing house supervisor. Findings revealed no incident report or investigation was conducted and no action taken to prevent reoccurrence.

Interview on 06/09/2020 at 1615 with RN #1 revealed no incident report was written after Patient #2 reported the incident. Interview revealed "would have handled this incident differently if the patient had reported it on time." Interview revealed if the incident "had happened between male and female, I would have made an incident report."

Interview on 06/10/2020 at 1640 with RN #2 (second shift house supervisor) revealed remembering completing the shift summary. Interview revealed the assigned nurse (RN #1) was told to complete an incident report. Interview revealed RN #2 did not verify that an incident report was completed.

Interview on 06/10/2020 at 0900 with the hospital's Risk Manager revealed an incident report could not be found regarding the allegation from Patient #2. Interview revealed no internal investigation was conducted regarding the report of sexual abuse between adolescent patients. Interview revealed the hospital policy was not followed.

In summary, findings revealed facility staff failed to ensure a safe environment for adolescent patients by failing to supervise and monitor hygiene time to prevent abuse. Findings revealed no internal investigation had been conducted related to this incident.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on policy and procedure review, medical record review, internal documents review, staff and physician interview, the hospital's governing body failed to provide oversight and have systems in place to ensure the protection and promotion of patient's rights to ensure a safe environment for behavioral health patients; failed to maintain an organized and effective quality assessment and improvement program; and failed to have an organized Nursing Service to meet patient care and safety needs.

The findings included:

1. The hospital's staff failed to promote and protect patients' rights by failing to maintain a safe environment for behavioral health patients that was free of items that were available and used for self-harm; failing to supervise the handoff of a vulnerable, incompetent adult patient during departure from the facility; and assure staff immediately reported and investigated abuse.

~cross refer to 482.13 Patient Rights' Condition: Tag 0115

2. The facility's leadership staff failed to implement and maintain an effective quality assessment and performance improvement program to ensure the safety of patients by failing to have systems in place to ensure adverse events were evaluated and services were performed in a safe manner.

~cross refer to 482.21 QAPI Condition: Tag A0263

3. The hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations by failing to ensure systems were in place to supervise and provide safe care delivery of care to behavioral health patients.

~cross refer to 482.23 Nursing Services Condition: Tag 0385.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on policy and procedure review, medical record review, staff and physician interview, the hospital's staff failed to promote and protect patients' rights by failing to maintain a safe environment for behavioral health patients that was free of items that were available and used for self-harm; failing to supervise the handoff of a vulnerable, incompetent adult patient during departure from the facility; and assure staff immediately reported and investigated abuse.

The findings include:

1. The facility staff failed to monitor and supervise an adolescent behavioral health patient search to prevent contraband items from being available and used to perform self-harm in 3 of 8 sampled adolescent patients (#1, #8 and #18).

~cross refer to 482.13(c)(2) Patients' Rights: Care in Safe Setting Tag A0144

2. The facility staff failed to supervise the handoff of a vulnerable, incompetent adult patient during departure from the facility in 1 of 10 discharged patients (Patient #5).

~cross refer to 482.13(c)(2) Patients' Rights: Care in Safe Setting Tag A0144

3. The facility failed to investigate reported patient to patient sexual abuse for 1 of 2 sampled allegations of abuse (#2 and #15).

~cross refer to 482.13(c)(3) Patients' Rights: Free From Abuse/Harassment Tag A0145
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, medical record review, staff and physician interview the hospital staff failed to monitor and supervise an adolescent behavioral health patient search to prevent contraband items from being available and used to perform self-harm in 3 of 8 sampled adolescent patients (#1, #8 and #18); and hospital staff failed to supervise the handoff of a vulnerable, incompetent adult patient during departure from the facility in 1 of 10 discharged patients (Patient #5).

The findings include:

A. Review on 06/10/2020 of the policy and procedure titled "Contraband Search Guidelines" last reviewed 01/20 revealed "...II. Patient Search: All inpatients have a routine, non-invasive search and skin assessment conducted by RN (Registered Nurse) and staff upon admission to the inpatient unit...d. All new admissions will remain within eyesight of unit staff until the completion of a patient search. e. A non-evasive body search and skin assessment will be conducted in the following manner:...ii....a screen or bathroom stall may be used to carry out this process, with the staff member checking the area while the patient is gowned to assure that nothing has been hidden during the disrobing process...v. Under the supervision of the RN in attendance the patient is instructed to put on a hospital gown, removing all clothing with the exception of underwear. After the patient gown is on, the patient should be requested to remove any underwear. vi. After all clothing is removed carefully search the patient's personal clothing. This includes pockets, hems, inside shoes and socks and other places where items may be hidden ...VI...c. Weapons -Dangerous items used as weapons, such as firearms and knives, will be tagged with the patient's name and locked in an office or safe away from the patient care area. The Director of Clinical Services, Safety Officer, Risk Manager and Medical Director will be notified when dangerous contraband is found ...d. The discovery of contraband will be documented in the Healthcare Peer Review- Report and forwarded to the House Supervisor and the Risk Manager for review and appropriate action, as necessary ..."

1. Review on 06/09/2020 of the closed medical record for the Patient #1 revealed a [AGE]-year-old female was admitted on [DATE] voluntarily for suicidal ideation with a plan to "jump from a window." Review of the "Nursing Progress Note" (RN #10) dated 05/21/2020 at 0900 revealed "Per (Named) MD #9 (medical doctor) pt was allowed to make a phone call to mom because she had opened up (with symbol) mom, told her that a peer (Patient #8) had given her a razor blade and that both patients had used it to cut self. (Named) MD #9 Was notified and ordered a search of the patient and her room, unit restriction, and blocked room. Pt (patient) was searched. No contraband found. Pt noted (with symbol) a superficial laceration to her thigh. No treatment needed. Contraband was found in the dayroom in the fold of a chair. Contraband removed. Will monitor closely." Review of the "Nursing Progress Note" (RN #8) dated 05/21/2020 at 1230 revealed "Spoke with patient's mom regarding daughter self harming herself last night 5/20/2020 at approximately 2000 hrs (hours) ..." Review of MD #9 Discharge Summary dated 05/21/2020 at 1446 revealed " ...She and her roommate collaborated on scratching with a piece of metal that they had obtained from another patient and this was found in the morning when I did my exam on the second day she was there, she told me she had done it herself and was very upset. I had talk to her mom and she told her mom her roommate gave her the piece of metal and this was investigated and it turned out to be true and mom felt that she was not kept safe here enough for mom to trust her to stay here and so mom requested discharge, so she could try to admit her to (Named) Psychiatry Hospital Program. Second opinion was done, which agreed with discharge and she was discharged to mom's care at mom's request ..." Patient #1 was discharged on [DATE].

2. Review of the medical record for the peer who had the contraband, Patient #8, revealed a [AGE]-year-old female admitted on [DATE] voluntarily for suicidal ideation with a plan to "cut her wrist." Review revealed Patient #8 was discharged from same hospital earlier in the day on 05/19/2020. Review of the "Comprehensive Nursing Assessment" (RN #15) dated 05/20/2020 at 0115 revealed a skin assessment and contraband search was completed, no contraband was discovered. Review of the "Patient Contraband Search" dated 05/20/2020 (no time) revealed a non-invasive body search was completed by RN #15, Patient #8 was wanded with a metal detector and her clothes and luggage bag were searched. Review of the "Nursing Progress Note" (RN #15) dated 05/20/2020 at 0120 revealed "This 12yo (year old) white female admitted to (named unit) @ 0045 ...Had superficially cut right arm (with symbol) razor ...Was searched and no contraband found on her..." Review of the "Nursing Progress Note" (RN #10) dated 05/21/2020 at 1656 revealed "This morning, a peer reported that this patient gave her a 'razor blade.' Peer reported that both patients had used the razor to cut selves. (Named) MD #9 was notified and ordered unit restrictions, blocked room and to search the patient and her room for contraband. Pt was searched. No contraband found on person. No contraband found in room. Pt finally opened up to this nurse and showed RN where the contraband was hidden-in a fold in a chair in the main dayroom. All chairs in dayroom were searched ...When found, it was a small thin piece of sharp metal that isn't a traditional razor blade, but maybe a piece of a razor blade. Called and spoke to pt's mother to notify. Mom reported that pt had torn up a razor at home to harm self. Peer initially reported that pt had been hiding the piece of razor in her pocket, then when searched, moved it to her mouth, hidden by her braces. Mother was understanding. Requested blood testing given both girls used the same metal to cut with...Pt is now in a room closer to the nurse's station." Review revealed Patient #8 had two superficial cuts to her left arm as a result of the incident. Patient #8 was discharged on [DATE].

3. Review of the third patient (Patient #18-open record) involved in cutting herself with the razor from Patient #8 revealed she was a [AGE]-year-old female admitted on [DATE] for homicidal behaviors toward her family. Review of the "Nursing Progress Note" dated 05/21/2020 at 0845 revealed "Pt noted with 2 superficial scratches on her left arm. Cleaned area and applied bandages. Pt reported that the paper towel holder in the common bathroom scratched her arm when she reached for a paper towel. This RN looked at paper towel holder and did not see any sharp areas..." Review of the "Nursing Progress Note" dated 05/20/2020 at 0900 revealed "Late entry:...she had scratched herself yesterday with a piece of a fork. Asked pt if she had actually cut herself with a razor from another pt...Pt then admitted to using the razor..."

Interview on 06/09/2020 at 1119 with Nursing Supervisor of the children's unit (RN #8) revealed she was aware of the razor incident. Interview revealed Patient #1 reported to her mother that Patient #8 had brought the razor into the hospital and shared it with her (Patient #1). Interview revealed it was suspected Patient #8 hid the razor in her braces.

Interview on 06/09/2020 at 1243 with the Director of Nursing (DON) revealed she was unaware of the razor incident.

Interview on 06/10/2020 at 0909 with MD #9 revealed he was the provider for Patient #1, Patient #8 and Patient #18. Interview revealed he was notified about the razor following the discovery of the incident. MD #9 stated he did not see the razor. Interview revealed following the incident, he placed orders for the patients to be on unit restrictions, blocked their rooms and blood work ordered to rule out infectious diseases. MD #9 stated he spoke with Patient #1's mother and she requested to discharge Patient #1 so she could get her admitted to another hospital.

Interview on 06/10/2020 at 1017 with RN #10 revealed she was the nurse on duty on 05/21/2020 when Patient #1 told the RN she had used a razor to cut herself. RN #10 stated she interviewed the patients immediately, notified the charge nurse (RN #8) and notified MD #9. RN stated she received orders from MD #9 to perform a contraband search. RN #10 stated staff were able to remove the other patients from the unit while the search was being conducted. RN #10 stated Patient #8 finally told RN #10 where the contraband was hidden. RN #10 stated the contraband was hidden in a "crack" of a chair in the activity room. RN #10 stated the razor was approximately 1.5-2 inches in length and little wider than a paper clip. Interview revealed when RN #10 spoke with Patient #8's mother, the mother informed her after Patient #8 was discharged earlier in the day from the hospital and returned home, Patient #8 "tore up" a disposable razor and used it to cut herself. RN #10 stated that was why Patient #8's mother brought her back to the hospital. Interview revealed Patient #8's braces and razor were very similar in color. Interview revealed RN #10 confiscated the razor after discovery and placed it in a bag, on top of a cabinet in the locked nurse's station. RN #10 stated Patient #8 told her she had the razor in her pocket until the time to be searched, then she put it in her mouth.

Interview on 06/10/2020 at 1157 with RN #8 revealed she was unaware of a third patient (Patient #18) using the razor to cut herself. Interview revealed she was notified of the razor incident by RN #10 on the morning of 05/21/2020. Interview revealed RN #8 disposed of the razor in the sharp's container in the medication room on the unit. RN #8 stated the razor was approximately 1-1.5 inches in length and very thin. RN #8 stated the razor was the same color as Patient #8's braces.

Interview on 06/10/2020 at 1332 with MHT #11 (Mental Health Technician) revealed he worked on the children's unit. Interview revealed following the razor incident, there was some discussion about the incident. Interview revealed he "signed a paper" stating staff would conduct oral cavity checks when performing a contraband search. Interview revealed it was not MHT #11's process to do a visual inspection of a patients mouth prior to the incident. Interview revealed MHT #11's practice was to wand a patient, but wanding a patient with braces was "tricky."

Interview on 06/10/2020 at 1407 with MHT #12 revealed she was the second staff member that completed Patient #8's contraband search on 05/20/2020 during admission. Interview revealed MHT #12 could not recall specifically assisting with Patient #8's contraband search, however she did recall recently conducting a search and the nurse gave the patient a gown, the patient stepped behind the curtain in the exam room and changed into the gown. MHT #12 stated the patient then stepped back in front of the curtain and her clothes and body were searched for contraband. Interview revealed MHT #12 did not recall an oral exam being conducted during that search.

Interview on 06/10/2020 at 1634 with MHT #14 revealed he performed Patient #8's initial contraband screening upon admission into the hospital, no contraband was found at that time. Interview revealed a same sex staff member assisted in the body/skin assessment for Patient #8. Interview revealed MHT #14's practice when assisting in a body/skin assessment of the same sex, was to allow the patient to change into a gown behind the curtain in the exam room then the search would be conducted. MHT #14 stated the patients were wanded and a body scan was performed.

Interview on 06/10/2020 at 1742 with MHT #16 revealed the contraband search process "changed a little depending on the nurse." Interview revealed MHT #16 had participated in searches where the nurse allowed the patient go change clothes behind the curtain. MHT #16 was unsure if the nurse maintained eye contact of the patient, however she stated it was a "pretty quick" process when the patient was allowed behind the curtain. Interview revealed MHT #16 did not recall the nurses checking the patients mouth during the contraband search.

Interview on 06/11/2020 at 0952 with RN #15 revealed she was the nurse that conducted Patient #8's contraband search. Interview revealed RN #15's process for contraband searches was to hold the gown up in front of the patient and have them to remove upper garments then exam the front and back side of the chest, place gown on, remove under garments and exam. RN #15 instructs the patients to remove their socks and exams the bottoms of their feet, have them to "shake" their hair, exam behind the ears, open their mouth, lift their tongue, open their cheeks, wand the patient while the MHT checked their clothes for contraband. Interview revealed RN #15 recalled examining Patient #8's oral cavity and did not notice any contraband. RN #15 stated she did not allow Patient #8 to change clothes behind the curtain. RN #15 stated she kept Patient #8 in her eyesight during the screening process.





B. Review of the facility policy titled "DISCHARGE PLANNING/PROCEDURES" last reviewed March 2019 revealed "...PROCEDURE Responsible Party: Registered Nurse or designee...7. Upon discharge, a Discharge Note will be entered in the Progress Notes, which includes behavioral expressions, date/time of discharge, where the patient is going and who is accompanying the patient...9. The patient will be escorted to the front door of the hospital by staff..."

1. Review of a closed medical record revealed Patient #5 was a [AGE] year-old female admitted on [DATE] with suicidal and homicidal ideations. Record review revealed the patient had a history of Intellectual development disability (IDD) and was an adult with an assigned legal guardian. Review revealed the patient resided at a group home prior to admission. Review of the medical record revealed the patient was discharged to return to the group home on 11/05/2019 and arrangements were made for the group home staff to pick up the patient upon discharge. The latest time the patient was documented as located on the unit was at 1345. Findings revealed the patient was escorted to the hospital's lobby to wait on her ride to pick her up. The patient was left in the lobby with a receptionist. Findings revealed the patient departed the hospital on [DATE] at 1357 when the receptionist released the door at the patient's request. The group home called the therapists the next day (11/06/2019) to let them know they never picked up the patient and that they did not know her whereabouts. Findings revealed Patient #5 had presented to an acute hospital emergency department on 11/06/2019 at 1842 (28 hours and 45 minutes after departing the behavioral health hospital) with a chief complaint of suicidal thoughts. Review revealed the patient tested positive for cocaine and reported she got tired of waiting on 11/05/2019 for the group home to pick her up and she left the behavioral health hospital. The patient reported that some "men picked her up." Review revealed the patient was admitted under petition for involuntary commitment and discharged back to the group home on 11/13/2019.

Findings revealed the group home staff had notified a registered nurse on 11/05/2019 that their transportation had broken down and they would not be able to pick up the patient as planned. Staff interview revealed the patient was escorted to the lobby for discharge and was left with a receptionist to wait in the lobby. Review of the "Discharge Log" revealed Pt #5 was discharged from Hospital A on 11/5/2019 at 1357. Review of a "Progress Note" signed by the Chief Clinical Officer (CCO) on 11/12/2019 at 1005 revealed "...On 11/6 Chief Clinical Officer was informed of an incident that occurred on 11/5 by the two therapist that had worked with this patient. (Patient #5), an adult patient with a legal guardian, was scheduled to be discharged on ,d+[DATE] to return to her previous group home. On the day of discharge, the patient was brought to the lobby of the hospital where (Patient #5) was waiting for her ride back to her group home. During this time, (Patient #5) walked over to the front door and exited it without incident. The group home called to say their transportation broke-down and that they were not able to pick the patient up as planned. The group home called the therapists the next day to let them know they never picked up the patient and that they did not know her whereabouts..."

Review of the "ED Provider Note" dated 11/6/2019 at 2139 revealed Patient #5 presented to Hospital B on 11/06/2019 at 1842 via car with a chief complaint of suicidal thoughts. Patient #5 was admitted on [DATE] for evaluation into concerns of suicidal ideation and psychosis. Medical record review revealed "...Group home staff reports that...she was discharged from (Hospital A) yesterday and sent back to the group home on a bus. Pt was then missing for about 24 hours before Raleigh Police Department found pt. Pt told Raleigh Police Department that she had suicidal thoughts..." Medical record review revealed Pt #5 was involuntarily committed to Hospital B on 11/7/2019 at 0738 pending behavioral health placement due to concerns about possibility of suicidal actions. Review of an "Inpatient Psychiatric Progress Note" dated 11/11/2019 at 1330 revealed "...On exam patient is more alert and interactive...She discussed events that occurred before she came to (Hospital B) and states she got tired of waiting at (Hospital A) on 11/5 for group home to pick her up and 'men picked her up. They were nice to help me but they were bad people. They smoked and gave me some.' She states they did not assault her because she slept on the bus. However later she said they tried to assault her but she didn't let them..." Review of the "Urine Drug Screen" on 11/06/2019 revealed "Cocaine, Urine Screen POSITIVE..." Medical record review revealed on 11/13/2019 at 1150 Patient #5 was discharged from Hospital B back to the group home.

Interview on 06/10/2020 at 1635 with Registered Nurse (RN) #18 revealed on 11/05/2019 at approximately 1330 she answered an inbound telephone call at the nurses' station from an individual that stated they were "coming for (Patient #5)." Interview revealed RN #18 notified Mental Health Technician #19 to escort Patient #5 to the lobby for discharge.

An interview was requested with Mental Health Technician #19 who was not available for interview.

Interview on 06/11/2020 at 0955 with the Receptionist revealed at the time a patient is escorted to the lobby, the patient is "technically considered discharged ." Interview revealed the transporter was not required to enter the hospital's lobby for handoff of the patient. Interview revealed the Receptionist was not required to obtain names, signatures or other details of the person that transports the patient after discharge. Interview revealed on 11/05/2019, Patient #5 was in the lobby with her belongings waiting for transportation after being discharged from the hospital. Interview revealed Patient #5 requested to go outside of the hospital's lobby. Interview revealed the Receptionist released the remote door lock (stationed at the front desk), and Patient #5 exited the lobby.

Interview on 06/10/2020 at 1100 with the attending Psychiatrist (Medical Doctor #17) revealed it was the hospital's standard of practice for the Therapist or Mental Health Technician to escort the patient to the lobby to wait for their transportation. Interview revealed "the next time patients with Intellectual developmental disability or a guardian should not be left without a staff member in the lobby." Interview revealed "...perhaps the patient should wait on the unit for safety because one person working at the desk may not be able to monitor appropriately and a patient with IDD may need to be watched closely."

Interview on 06/11/2020 at 1010 with the Chief Nursing Officer revealed that once a patient is discharged from the unit, the patient is allowed to wait for their transportation in the lobby. Interview revealed there was no policy that stated the staff must stay in the lobby with a patient while awaiting transport. Interview revealed the RN should ultimately be responsible for making sure the patient is safe until they leave the hospital.

In summary, findings revealed facility staff failed to supervise the handoff of a vulnerable, incompetent patient during departure from the facility.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, medical record review, staff and physician interviews, the hospital staff failed to investigate reported patient to patient sexual abuse for 1 of 2 sampled allegations of abuse (#2 and #15).

The finding include:

Review of policy titled "Reporting and Investigating Patient Neglect, Abuse and Exploitation" with revision date of 01/19, revealed "Patients are treated with dignity and respect, and have a right to be free from abuse, neglect or exploitation in any manner. If any abuse is suspected, alleged or observed, it reported in accordance with this policy... POLICY: It is the policy of (named facility) to prohibit the abuse, neglect or exploitation of patients in any manner from staff, patients or visitors...."

Review of policy titled "Patient Sexual Familiarity Prevention" with reviewed date of 01/18, revealed "Patients receiving behavioral healthcare services, particularly minors, can be vulnerable and often times unable to make health decisions about intimate relationships. It is the policy of (named hospital) to provide a safe and secure environment that discourages the development of intimate relationships with fell ow patients during or after hospitalization ...Response to Alleged Sexual Familiarity Occurrences: Facility staff and physicians take all reports of sexual familiarity between patients seriously and respond accordingly. Staff duties in the event of sexual acting out between patients include the following: 1. Staff will take immediate action to ensure the safety of involved parties. 2. Separate the parties involved and maintain separation until directed otherwise by hospital authorities. 3. Notify the House Supervisor/Risk Manager/CNO (Chief Nursing Officer) immediately. 4. Notify each patient's attending physician immediately. 5. In the case of a minor or patient declared legally incompetent, the patient's parent or legal guardian should be notified of the incident by the appropriate personnel. 6. Staff interview involved parties separately to determine exact nature of the alleged occurrence. 7. Patient/Guardians are notified regarding their rights to report any sexual, verbal/physical abuse, threats of sexual abuse, perceived or real allegations from patients or staff to law enforcement agencies. 8. Any allegation of sexual assault or non-consensual sex will be reported to local law enforcement by hospital administration. The Risk Manager and/or CNO will consult with the CEO (Chief Executive Officer) regarding the need to report to law enforcement ..."

1. Review of a closed medical record for Patient #2 revealed a [AGE]-year-old female, admitted on [DATE] with significant mood symptoms, who was known to the facility staff from a previous admission after cutting herself. Patient #2 was admitted on involuntary commitment with a history of trauma. Review of observation sheets revealed Patient #2 was visually observed every 15 minutes as ordered by the physician. Review of a nurses note dated 01/16/2020 at 2330 written by RN #1 (Registered Nurse #1) revealed "(Patient #2) did report to staff today that she was a victim of a sexual aggression from another female pt (patient). The aggressor went to her room during shower time and touched her sensitive areas. (Patient #2) stated, when she was asked why she did not ask her to stop, she said that she did asked (sic) to stop but she wouldn't, the pt denied reporting the incident that happened some time (sic) last week, according to (Patient #2). The pt's mom was informed today around 1030 pm." Review revealed Patient #2 was discharged on [DATE] to home with family.

2. Review of a closed medical record for Patient #15 revealed a [AGE]-year-old female, admitted on [DATE] with "significant mood symptoms and stated she was getting upset in the family unit." The patient was admitted due to suicidal ideation and thoughts of hanging herself. Review of nurses note dated 01/16/2020 at 2335 written by RN #1 revealed "A female pt reported that (Patient #15) went to her room sometime last week during shower time and touched her innappropriately (sic). The pt (Patient #2) reported she asked her stop (sic) but she didn't. The victim's guardian was informed trought (sic) the phone about the incident but (Patient #15) guardian was unreachable." Review revealed Patient #15 was discharged on [DATE] to the guardian's home.

Review of "Shift Report Sheet" dated 01/16/2020 (no time) revealed "(Patient #2) said (Patient #15) went (sic) her room early this morning during hygine (sic) and one other time a few days ago and touched her inappropriately, (Patient #15) stated she just went to her room once and tickled (Patient #2)."

Review of Incident Report log dated January 2020 revealed no incident report of the alleged abuse reported by Patient #2.

Interview on 06/09/2020 at 1615 with RN #1 revealed no incident report was written after Patient #2 reported the incident. Interview revealed "would have handled this incident differently if the patient had reported it on time." Interview revealed if the incident "had happened between male and female, I would have made an incident report."

Interview on 06/10/2020 at 1640 with RN #2 (second shift house supervisor) revealed remembering completing the shift summary. Interview revealed a shift summary is a written report of events that occurred during the shift. Interview revealed the assigned nurse (RN #1) was told to complete an incident report. Interview revealed RN #2 did not verify that an incident report was completed by RN #1.

Interview on 06/10/2020 at 1239 with MD #1 (Medical Doctor) revealed no recollection of call regarding issues with inappropriate touching. Interview revealed no physician documentation of inappropriate touching or incident in Patient #2 or Patient #15's charts.

Interview on 06/09/2020 at 1435 with the Assistant Director of Nursing (ADON) revealed safety of our patients is our primary concern.

Interview on 06/10/2020 at 0900 with the hospital's Risk Manager revealed an incident report could not be found. Interview revealed "we don't know how it (the incident) happened." Interview revealed no internal investigation was conducted regarding the report of sexual abuse between adolescent patients. Interview revealed no documentation of the physician being notified with details of the incident. Interview revealed the hospital policy was not followed.
VIOLATION: QAPI Tag No: A0263
Based on policy and procedure review, medical record review, internal documents review, staff and physician interview, the facility's leadership staff failed to implement and maintain an effective quality assessment and performance improvement program to ensure the safety of patients by failing to have systems in place to ensure adverse events were evaluated and services were performed in a safe manner.

The findings include:

1. The hospital staff failed to conduct an internal investigation and implement corrective actions for a adverse event that resulted in patient self-harm for 3 of 8 sampled adolescent patients (#1, #8 and #18).

~cross refer to 482.21(a), (c)(2), (e)(3) QAPI Standard: Patient Safety, Tag A0286

2. The hospital staff failed to evaluate and investigate a reported patient to patient sexual abuse incident for 1 of 2 sampled abuse allegations (#2 and #15).

~cross refer to 482.21(a), (c)(2), (e)(3) QAPI Standard: Patient Safety, Tag A0286

3. The hospital staff failed to document and investigate a medication error for 1 of 1 medication errors reviewed (Patient #3).

~cross refer to 482.21(a), (c)(2), (e)(3) QAPI Standard: Patient Safety, Tag A0286
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, medical record review, internal documents review, staff and physician interview, the hospital staff failed to conduct an internal investigation and implement corrective actions for an adverse event that resulted in patient self harm for 3 of 8 sampled adolescent patients (#1, #8 and #18); the hospital staff failed to evaluate and investigate a reported patient to patient sexual abuse incident for 1 of 2 sampled abuse allegations (#2 and #15); and failed to document and investigate a medication error for 1 of 1 medication errors reviewed (Patient #3).

The findings include:

A. Review on 06/10/2020 of the policy and procedure titled "Occurrence Reporting" last reviewed 01/2020 revealed "POLICY -The responsibility for completing a Healthcare Peer Review (HPR) report rests with any hospital staff member who witnesses, discovers or has direct knowledge of an occurrence...PURPOSE -The Healthcare Peer Review Report is a risk management tool that notifies the hospital of potential areas of loss. It enables the hospital to take corrective action, reducing the losses and improving the quality of healthcare provided in the hospital. The HPR Report is also a reporting vehicle by which to notify Risk Management of potential liability claims. The HPR Report can help the various hospital committees and administration in identifying potential areas of risk and implementing measures to reduce and prevent future claims. The overall effect is an increase in the quality of patient care provided by the hospital ...Classifying Severity -1. All HPR Reports received by the Risk Manager will be assigned a severity classification level in accordance with established criteria approved by MEC/Board (Medical Executive Committee). 2. The severity classification system will be utilized to identify significant incidents in an effort to facilitate referral of issues needing further evaluation and/or action. 3. The following severity classifications shall be used: ...b. Level II-Non-Serious: incidents where the potential for litigation is thought to be minimal. Minor injury or impairment in which a patient or visitor's function may be altered temporarily...4. The Risk Manager or Risk Analyst shall review each HPR that is submitted and assign a severity level. a. It is the responsibility of the Risk Manager and Risk Analyst to weigh all relevant facts when classifying incidents ...6. All Level III and IV incidents require an AER (Adverse Event Report) to be completed and a case file established by the Risk Manager..."

Review on 06/10/2020 of the policy and procedure titled "Performance Improvement Plan" last revised 01/19 revealed "I. PURPOSE ...The purpose of the Performance Improvement Plan is to provide an ongoing process by which (Named) Hospital objectively and systemically monitors and evaluates the quality and appropriateness of patient care, identifies acceptable levels of care, finds and implements opportunities to improve care, and resolves problems and/or submits proposals for the resolution of problems to the Medical Staff Committee, Quality Council and/or the Board of Governors for approval..."

1. Review on 06/09/2020 of the closed medical record for the Patient #1 revealed a [AGE]-year-old female was admitted on [DATE] voluntarily for suicidal ideation with a plan to "jump from a window." Review of the "Nursing Progress Note" (RN #10) dated 05/21/2020 at 0900 revealed "Per (Named) MD #9 (medical doctor) pt was allowed to make a phone call to mom because she had opened up (with symbol) mom, told her that a peer (Patient #8) had given her a razor blade and that both patients had used it to cut self... Pt noted (with symbol) a superficial laceration to her thigh. No treatment needed. Contraband was found in the dayroom in the fold of a chair. Contraband removed. Will monitor closely." Patient #1 was discharged on [DATE].

2. Review of the medical record for the peer who had the contraband, Patient #8, revealed a [AGE]-year-old female admitted on [DATE] voluntarily for suicidal ideation with a plan to "cut her wrist." Review revealed Patient #8 was discharged from same hospital earlier in the day on 05/19/2020. Review of the "Comprehensive Nursing Assessment" (RN #15) dated 05/20/2020 at 0115 revealed a skin assessment and contraband search was completed, no contraband was discovered. Review of the "Patient Contraband Search" dated 05/20/2020 (no time) revealed a non-invasive body search was completed by RN #15, Patient #8 was wanded with a metal detector and her clothes and luggage bag were searched. Review of the "Nursing Progress Note" (RN #10) dated 05/21/2020 at 1656 revealed "This morning, a peer reported that this patient gave her a 'razor blade.' Peer reported that both patients had used the razor to cut selves...When found, it was a small thin piece of sharp metal that isn't a traditional razor blade, but maybe a piece of a razor blade...Mom reported that pt had torn up a razor at home to harm self. Peer initially reported that pt had been hiding the piece of razor in her pocket, then when searched, moved it to her mouth, hidden by her braces..." Review revealed Patient #8 had two superficial cuts to her left arm as a result of the incident. Patient #8 was discharged on [DATE].

3. Review of the third patient (Patient #18-open record) involved in cutting herself with the razor from Patient #8 revealed she was a [AGE]-year-old female admitted on [DATE] for homicidal behaviors toward her family. Review of the "Nursing Progress Note" dated 05/20/2020 at 0900 revealed "Late entry:...she had scratched herself yesterday with a piece of a fork. Asked pt if she had actually cut herself with a razor from another pt...Pt then admitted to using the razor..."

Review of internal documents revealed an incident report was completed for Patient #1, #8 and #18 following the discovery of contraband that was used to perform self-harm. Review revealed each incident was triaged as a "Level 2." Review failed to reveal any internal investigation being conducted.

Interview on 06/09/2020 at 1119 with Nursing Supervisor of the children's unit (RN #8) revealed she was aware of the razor incident. Interview revealed it was suspected Patient #8 hid the razor in her braces. Interview revealed RN #8 had "verbal" conversations with the lead MHTs on the unit and discussed that staff needed to pay close attention, especially patients with braces, during the contraband search.

Interview on 06/09/2020 at 1243 with the Director of Nursing (DON) revealed she was unaware of the razor incident.

Interview on 06/10/2020 at 0909 with MD #9 revealed he was the provider for Patient #1, Patient #8 and Patient #18. Interview revealed he was notified about the razor following the discovery of the incident. Interview revealed MD #9 was not involved in an internal investigation following the incident, that was "normally patient safety and nursing" that completed an investigation.

Interview on 06/10/2020 at 1017 with RN #10 revealed she was the nurse on duty on 05/21/2020 when Patient #1 told the RN she had used a razor to cut herself. RN #10 stated Patient #8 told her she had the razor in her pocket until the time to be searched, then she put it in her mouth. Interview revealed there had been some verbal conversations with some staff about "making sure they're super safe doing searches moving forward." RN #10 stated there had been no formal education released following the incident.

Interview on 06/10/2020 at 1157 with RN #8 revealed she was unaware of a third patient (Patient #18) using the razor to cut herself. Interview revealed RN #8 spoke with the day shift staff members and brought awareness and understanding about the situation. Interview revealed RN #8 reported the incident to the second shift supervisor at shift change. Interview revealed RN #8 did not conduct an internal investigation following the incident, "risk management was responsible for follow-up."

Interview on 06/10/2020 at 1219 with the Assistant Director of Nursing (ADON) of the Children's unit revealed she did not conduct an internal investigation following the incident. Interview revealed it was the responsibility of Risk Management to follow-up on incident reports. Interview revealed there had been 8 staff members to "sign an attestation" regarding the contraband search process and updates. Interview revealed the ADON had not conducted an internal investigation.

Interview on 06/10/2020 at 1318 with the Risk Manager revealed he was on medical leave from 05/11/2020-06/03/2020. Interview revealed the incident reports for the razor incident were classified as a level two and level twos did not require follow-up, "but could" follow-up. Interview revealed the razor incident had been a "good lesson learned, but the hospital was not done making changes to policies and education." Interview revealed the contraband search policy was currently being updated to reflect changes in the process for patients with braces. Interview revealed there was a draft policy currently being conducted. Interview revealed there would be monitoring related to contraband searches forthcoming.

Interview on 06/10/2020 at 1407 with MHT #12 (Mental Health Technician) revealed she was the second staff member that completed Patient #8's contraband search on 05/20/2020 during admission. MHT #12 stated following the razor incident she was made "aware to be thorough especially with braces." Interview revealed MHT #12 was unsure if any process changes had been made since the razor incident.

Interview on 06/10/2020 at 1634 with MHT #14 revealed he performed Patient #8's initial contraband screening upon admission into the hospital, no contraband was found at that time. Interview revealed MHT #14 had not received any re-education on contraband searches.

Interview on 06/11/2020 at 0952 with RN #15 revealed she was the nurse that conducted Patient #8's contraband search. Interview revealed she had not received any re-education on contraband searches.

Follow-up interview with the Risk Manager on 06/11/2020 at 1724 revealed if an incident report was categorized at a level 1 or 2, the nursing supervisor and/or ADON could do their own investigation into the incident and collaborate with the Risk Manager. Interview revealed incidents categorized at a 1 or 2 could be escalated up the administrative ranks if there were a concern about the incident.

In summary, facility staff failed to conduct an internal investigation and implement corrective actions after it was discovered that three patients had cut themselves with a razor blade that had not been found or confiscated during a patient search.





B. Review of policy titled "Patient Sexual Familiarity Prevention" with reviewed date of 01/18, revealed "Patients receiving behavioral healthcare services, particularly minors, can be vulnerable and often times unable to make health decisions about intimate relationships. It is the policy of (named hospital) to provide a safe and secure environment that discourages the development of intimate relationships with fell ow patients during or after hospitalization ...Response to Alleged Sexual Familiarity Occurrences: Facility staff and physicians take all reports of sexual familiarity between patients seriously and respond accordingly. Staff duties in the event of sexual acting out between patients include the following: 1. Staff will take immediate action to ensure the safety of involved parties. 2. Separate the parties involved and maintain separation until directed otherwise by hospital authorities. 3. Notify the House Supervisor/Risk Manager/CNO (Chief Nursing Officer) immediately. 4. Notify each patient's attending physician immediately. 5. In the case of a minor or patient declared legally incompetent, the patient's parent or legal guardian should be notified of the incident by the appropriate personnel. 6. Staff interview involved parties separately to determine exact nature of the alleged occurrence. 7. Patient/Guardians are notified regarding their rights to report any sexual, verbal/physical abuse, threats of sexual abuse, perceived or real allegations from patients or staff to law enforcement agencies. 8. Any allegation of sexual assault or non-consensual sex will be reported to local law enforcement by hospital administration. The Risk Manager and/or CNO will consult with the CEO (Chief Executive Officer) regarding the need to report to law enforcement ..."

Review of a closed medical record revealed Patient #2 was a [AGE]-year-old female admitted on [DATE] with mood disorder and a history of trauma. Review of a closed medical record revealed Patient #15 was a [AGE]-year-old female admitted on [DATE] with mood disorder and suicide ideations. Review of a nurses note dated 01/16/2020 at 2330 written by RN #1 (Registered Nurse #1) revealed Patient #2 reported to a staff nurse on 01/16/2020 that Patient #15 had touched her "sensitive areas" while Patient #2 was in the shower and wouldn't stop touching her when asked. Patient #2 reported this had occurred sometime during the prior week. Findings revealed the allegation was reported to the nursing house supervisor. Findings revealed no incident report or investigation was conducted and no action taken to prevent reoccurrence.

Interview on 06/09/2020 at 1615 with RN #1 revealed no incident report was written after Patient #2 reported the incident. Interview revealed "would have handled this incident differently if the patient had reported it on time." Interview revealed if the incident "had happened between male and female, I would have made an incident report."

Interview on 06/10/2020 at 1640 with RN #2 (second shift house supervisor) revealed remembering completing the shift summary. Interview revealed the assigned nurse (RN #1) was told to complete an incident report. Interview revealed RN #2 did not verify that an incident report was completed.

Interview on 06/10/2020 at 0900 with the hospital's Risk Manager revealed an incident report could not be found regarding the allegation from Patient #2. Interview revealed no internal investigation was conducted regarding the report of sexual abuse between adolescent patients. Interview revealed the hospital policy was not followed.

In summary, findings revealed facility staff failed to protect adolescent patients from abuse by failing to investigate a reported patient to patient abuse.

C. Review of policy titled "The Role of Nursing in Medication Administration" with revision date of 01/2020, revealed "...4.7 Missed or late doses: When a medication is not administered at the schedule time, the nurse will properly document the reason(s) on the MAR or patient record. The nurse will need to communicate the reason to the physician or covering physician for further instructions. ...4.8 If the scheduled medication is available and the patient can receive it during the time the nurse is on duty, but the medication is missed.... then a hospital incident report will be completed and directed to the designated department."

Review of a closed medical record for Patient #3 revealed a [AGE]-year-old female admitted on [DATE] as a voluntary admission for suicidal thoughts. Review of MD #9's note dated 02/04/2020 at 0750 revealed "We missed her medication last evening due to a nursing error, so I let parents know and the nursing supervisor ..." Review of the record revealed Patient #3 was discharged on [DATE].

Review of an incident report log for February 2020 revealed no documentation of medication error for Patient #3.

Interview on 06/11/2020 at 0950 with MD #9 revealed Patient #3 did not receive her antipsychotic medications on 02/03/2020 due to a nursing error. Interview revealed a verbal order was given to the nurse, but the order was not written. Interview revealed medications were started on 02/04/2020 after discussion with Patient #3's parents.

Interview on 06/10/2020 at 1421 with RN #22, who worked with Patient #3 on 02/03/2020 revealed no recollection of receiving a verbal order from the physician for antipsychotic medications for Patient #3.

Interview on 06/12/2020 at 1205 with the Chief Nursing Officer revealed no recollection of discussion with MD #9 regarding a medication error. Interview revealed no incident report or investigation was found for Patient #3 regarding this medication error. Interview revealed an incident report should have been documented and an investigation conducted for the medication error. Interview revealed the hospital's policy was not followed.
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on review of the job description, review of the personnel file and staff interview, the facility failed to appoint a qualified Infection Control professional to be responsible for the hospital's infection control program.

The findings include:

Review on 06/12/2020 of the Infection Control Coordinator's "JOB DESCRIPTION AND PERFORMANCE EVALUATION FORM" signed by the Infection Control Coordinator and the Director of Nursing on 08/01/2019 revealed " ...QUALIFICATIONS: Education/Training: 1- Registered Nurse with a Bachelor's Degree preferred 2-Training in healthcare infection control programs, monitoring, and compliance preferred. Experience ...2-Experience as Infection Control Nurse/Preventionist or equivalent experience. Licensure/Certification ...4-APIC (Association for Professionals in Infection Control) Certification in infection control preferred ..."

Review of the Infection Control Coordinator's personnel file revealed a hire date of 08/01/2019 as the Infection Control Coordinator. Review revealed evidence of an Associates of Science degree in Nursing awarded 05/08/2015. Review of the personnel file failed to reveal evidence the Infection Control Coordinator had training in healthcare infection control programs, monitoring and compliance. Review of the personnel file failed to reveal evidence the Infection Control Coordinator had prior experience as an Infection Control Nurse/Preventionist. Review of the personnel file failed to reveal evidence the Infection Control Coordinator held a certification in infection control.

Interview on 06/12/2020 at 1250 with the Infection Control Coordinator revealed she had not received training in infection control. Interview revealed she did not have certification in Infection Control. Interview revealed she planned to complete training courses in infection control in order to obtain certification.
VIOLATION: IC PROFESSIONAL RESPONSIBILITIES POLICIES Tag No: A0772
Based on review of policy and procedures, internal documents, observations, and staff interviews, the facility staff failed to ensure face masks were worn properly for five staff members observed in the facility.

The findings include:

Review on 06/11/2020 of the facility policy titled, "Isolation and Precautions," date reviewed, 01/20 revealed, " ...Masks 1. Adjust mask snugly over nose and mouth ..."

Review on 06/11/2020 of the facility procedure titled, "[Named Facility] Employee Mask Distribution," hand delivered to employees starting on 04/28/2020 revealed, " ...Masks should be worn correctly over the nose and mouth until removed."

Review on 06/12/2020 of the facility Inservice titled, "Hand hygiene, Precautions, and PPE [Personal Protective Equipment] Usage," with employee completion dated 04/02/2020 through 06/02/2020 revealed, " ...PPE must be worn properly to be effective ..."

Review on 06/11/2020 of the Coronavirus Management Task Team Meeting minutes revealed, on 04/27/2020, " ...All hospital employees to begin wearing masks unless alone in an office ..."

1. Observation on 06/09/2020 at 1125, revealed dietary staff #1 was not wearing face mask while preparing pudding for patient trays.

2. Observation on 06/09/2020 at 1125, revealed dietary staff #2 was was not wearing a face mask while stirring spaghetti sauce on the stove in the kitchen.

3. Observation on 06/10/2020 from 1255 through 1305, revealed LPN #21 (Licensed Practical Nurse) was in the patient care area on unit 2East approximately 4 feet from a patient with a facemask not covering her nose, while administering medication to the patient.

4. Observation on 06/10/2020 from 1305 through 1320, in the dietary kitchen revealed at 1312 dietary staff #3 `s face mask was not covering the nose while placing food in trays.

5. Observation on 06/11/2020 at 1115 through 1118, on the main first floor, in a recreational art therapy room, revealed five patients and 1 staff member were seated at two small tables. Observation revealed Therapist #23`s face mask was not covering her nose.

Interview with dietary staff #1 on 06/09/2020 at 1127, revealed masks should be worn while preparing food in kitchen.

Interview with dietary staff #2 on 06/09/2020 at 1128, revealed masks should be worn while preparing food in the kitchen.

Interview with Director of Food Services on 06/09/2020 at 1130, revealed masks should be worn during meal preparation. Interview revealed facility policy was not followed.

Interview with LPN #21 on 06/10/2020 at 1305, revealed, Masks should be worn "at all times," and "over the nose."

Interview with the Assistant Director of Nursing #4 on 06/10/2020 at 1230 revealed, it was the expectation that the "nasal area" be covered and face masks were "worn properly."

Interview with the Chief Nursing officer on 06/09/2020 at 1350, revealed personal protective equipment usage training, to include face masks to be worn over the mouth and the nose area, was reviewed with all staff at initial orientation, annually, and multiple times since April 2020.


NC 880; NC 720; NC 271; NC 862; NC 640; NC 557