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Based on policy and procedure review, medical records review, and staff and physician interviews, facility staff failed to ensure a legal guardian was notified of a patient injury for 1 of 10 adolescent patient records (#4) reviewed and failed to document AMA discharges of adolescent patients for 3 of 10 adolescent patient records reviewed (#3, #4, #6)

Findings are as follows:

Review of the policy "Occurrence Reporting" effective date 09/18/2018 revealed, "PURPOSE: A. To improve patient care, ensure safe healthcare facility practices through identification of serious injuries, conducting timely peer review, evaluation of patient care and intervention to reduce occurrences ...POLICY: DEFINITIONS: A. Occurrence (Incident Type): which is not consistent with the routine care of a patient and/or the desired operations of the facility ...B. Serious Injuries/Events ...Injury/Physical harm to Patients ...PROCEDURE: A. Any facility employee or staff member who discovers, is directly involved in ...is to complete an Occurrence/Incident report form ...D. Completing the Report: ...e. The event is documented in the medical record ...and includes ...Names, times of notification of physician, supervisory personnel, family members ..."

Review of the policy "Aftercare/Discharge Plan" revised date 06/01/2016 revealed, "It is the policy of (Named) Behavioral Health all patients/caregivers receive communication regarding their discharge continuing care plan ...The facility ensures each patient/caregiver ...understands their discharge plan and discharge instructions ...Procedure ...5.0 Program staff reviews the plan upon discharge with the patient and/or family and obtains their signatures. 6.0 The therapist/case manager ensures the patient/caregiver ...understands the plan ..."

Review of the policy "AMA Discharge" revised 06/01/2016 revealed, POLICY Against Medical Advice (AMA) is a discharge of a patient (with the legal guardian's consent) who insists on leaving the facility against the advice of the attending physician. Procedure ...1. The Nurse will notify the physician of the patient's/legal guardian's decision to leave AMA, an AMA order may be given ...5. Standard discharge procedure should be followed in addition to AMA discharge protocol ...6. The AMA procedure will be explained to the patient/legal guardian by the Nurse and will include the releasing of the facility and its employees of any obligation or responsibility for any ill effects that might result from the patient's premature discharge ...9. Nursing documentation for patients leaving AMA shall include the following: ...b. notification and response of the physician ...c. Signing and witnessing the AMA Release form ..."

1A. Review of a closed medical record on 09/16/2021 revealed Patient #4 was a thirteen-year-old male admitted to the facility on 08/29/2021 at 1136 under involuntary commitment (IVC) orders per request of his mother because of unsafe and suicidal behaviors at home as well as disruptive behaviors in the community. Review of the medical record revealed Patient #4's diagnoses included DMDD (disruptive mood dysregulation disorder), Autism spectrum and impulsive and dangerous behaviors. Review of the medical record revealed Patient #4 was placed on "Line of Sight" observation with fifteen-minute documentation at admission and was noted to require frequent "redirection" for inappropriate behavior during peer interactions on 09/01/2021 through 09/04/2021, and on 09/06/2021 and 09/08/2021. Review of Patient Observation Rounds records revealed Patient #4 was hit in the face during an altercation on 09/08/2021. Review of Nursing Notes revealed no evidence of an altercation on 09/04/2021. Review of Psychiatric Progress Notes revealed no documentation related to physical altercations with peers during the admission. Review revealed Patient #4 was discharged home against medical advice (AMA) on 09/09/2021 at 1523.

Review of a facility Incident Report on 09/17/2021 revealed Patient #4 had reported a fall in his room on 09/05/2021 and sustained a scrape injury to his right shin which was cleaned and bandaged. No additional incident reports were noted for Patient #4.

Telephone interview with a registered nurse, RN #5, on 09/16/2020 at 1010 revealed she had been Patient #4's unit nurse on 09/04/2021 and as the group was returning to the unit from the courtyard for water Patient #4 was behind a larger peer who turned and "slapped" Patient #4 hard on the left side of his face. Interview revealed RN #5 sent the peer to his room and tended to Patient #4. Interview revealed RN #5 was later told by the peer that Patient #4 had pushed him while standing in the water line and had been "picking at him" while they were outside. RN #5 stated that she told Patient #4 he needed to respect other people's boundaries but had not informed the physician, or parent and had not completed an incident report. RN #5 stated the unit had been "very busy" at the time and she had forgotten to file an incident report. Interview revealed RN #5 had worked with Patient #4 on 09/08/2021, and 09/09/2021, and discharged him from the facility on 09/09/2021. RN #5 stated that Patient #4 had "mild discoloration" on the right side of his face at the time but RN #5 did not know why Patient #4's face was discolored.

Interview with RN #6 on 09/16/2020 at 1615 revealed she had been Patient #4's unit nurse on 09/05/2021 and had notified the guardian about a shin injury which occurred on 09/05/2021 and spoke with the guardian again on the evening of 09/08/2021. RN #6 stated that during the 09/08/2021 conversation, the guardian stated that it was "strange" that staff notified her of a shin scrape, but not about a fight with a peer. RN #6 stated she had no knowledge of a fight between Patient #4 and a peer and had not responded to the guardian's comment. RN #6 stated that staff were expected to notify the physicians, the guardian, and enter an incident report when there was a fight between peers.

Telephone interview with a mental health technician, MHT #15, on 09/21/2020 at 1100 revealed he was working on the Unit on 09/08/2021 when Patient #4 was hit in the right side of the face by a peer. Interview revealed the peers were separated, and ice was applied to Patient #4's injury. MHT #15 stated that the peers had been "annoying" each other that day and he had been "redirecting" and trying to calm them throughout the day before the time of the altercation. MHT #15 stated that he believed an incident report had been filed by the RN and the RN had notified the physician and the family, but he was not certain.

Interview with an attending psychiatrist, MD #1, on 09/17/2021 at 1150 revealed he was aware Patient #4 had been in altercations with his peers although no injuries were visible during tele-visit sessions and MD #1 "didn't see anything significant" about the events. Interview revealed MD #1 did not recall the dates of the altercations and neither he nor Patient #4 had mentioned injuries during their discussions.

2A. Reviewed by Teammate

1B. Review of a closed medical record on 09/16/2021 revealed Patient #4 was a thirteen-year-old male admitted to the facility on 08/29/2021 at 1136 under involuntary commitment (IVC) orders per request of his mother because of unsafe and suicidal behaviors at home as well as disruptive behaviors in the community. Review of the medical record revealed Patient #4's diagnoses included DMDD (disruptive mood dysregulation disorder), Autism spectrum and impulsive and dangerous behaviors by wrapping a blanket around his neck and trying to choke himself. Review of the medical record revealed Patient #4 was placed on "Line of Sight" observation at admission. Review of the daily Psychiatric Progress Notes revealed there were no notes for September 4, 2021, September 8, 2021, and September 9, 2021 (three days of the eleven-day hospitalization). Review revealed Patient #4 was discharged from the facility on 09/09/2021 at 1523. Medical record review failed to reveal evidence of a physician's order to discharge Patient #4 or evidence of an AMA Release form. Review of Patient #4's demographic sheet revealed the letters "A.M.A" handwritten in a non-defined area on the top left of the sheet.

Requests for interview with Patient #6's Therapist on the day of discharge was unsuccessful. No documentation was evident in the medical record and the names of responsible staff were not provided by the interim Director of Therapy, T #4 or the Chief Nursing Officer.

Interview on 09/17/2021 at 1150 with the attending psychiatrist, MD #1 revealed he had done telepsychiatry at the time of Patient #4's admission and the facility had also changed from paper to an electronic medical record system and he had "missed the boat for a while" on documentation until he "was able to get up to speed."

Interview on 09/17/2021 at 1537 with the chief medical officer, MD #2, revealed there was a week in early September after T #3 resigned that he received calls and complaints from families about the therapy schedule and discharge arrangements. Interview revealed he had discussed it with the chief executive officer, CEO, and had been instructed to forward the calls to her office.

Telephone interview on 09/21/2021 at 1400 with a registered nurse, RN #5, revealed she was Patient #4's discharging RN on 09/09/2021. Interview revealed she reviewed medications with the family but a Therapist was expected to review the remainder of the discharge instructions. Interview revealed she did not recall who Patient #4's Therapist was that day and had called MD #1 for a discharge order. Interview revealed RN #5 would typically place an order into the electronic record for the physician to cosign, but "I do not remember doing that" because it was a busy day and his family had been in the lobby waiting to sign him out.

Interview on 09/21/2021 at 1440 with the interim Director of Therapy, T #4, revealed, except for the Recreation Therapist's documentation, she had been unable to find Therapist documentation of therapy and discharge planning in the medical record for Patient #4. Interview revealed Patient #4 had discharged from the facility AMA on 09/09/2021, but she saw no record of it in Patient #4's record and it was expected to be in the medical record.

Interview on 09/21/2021 at 1455 with the Chief Nursing Officer, CNO, confirmed Patient #4 had discharged AMA and the electronic medical record AMA form had not been found. The CNO stated that the electronic form in the new electronic medical record was "a learning curve" but a paper form was available. The CNO also stated she had instructed nursing staff to use the facility's paper form if staff had difficulty completing the electronic form.

2B. Review of a closed medical record on 09/16/2021 revealed Patient #6 was a fifteen-year-old male admitted to the facility on 09/02/2021 at 1702 from an unaffiliated emergency department (ED) under involuntary commitment (IVC) orders "after making suicidal comments to his school therapist." Review of the Initial Psychiatric Evaluation dated 09/03/2021 at 0347 revealed his history included major depressive disorder (MDD) and a suicide attempt at age 13. Review of the medical record revealed Patient #4 was placed on "Line of Sight" observation at admission. Review of the daily Psychiatric Progress Note revealed there were no provider notes for September 4, 2021, September 8, 2021, and September 9, 2021 (three days during the seven-day hospitalization). Review revealed Patient #6 was discharged from the facility on 09/09/2021 at 1818. Medical record review failed to reveal evidence of a physician's order to discharge Patient #6 or evidence of an AMA Release form.

Requests for interview with Patient #6's therapist on the day of discharge was unsuccessful. No documentation was evident in the medical record and the names of responsible staff were not provided by the interim Director of Therapy, T #4, or the CNO.

Interview on 09/17/2021 at 1150 with the attending psychiatrist, MD #1 revealed he had done telepsychiatry at the time of Patient #6's admission and the facility had also changed from paper to an electronic medical record system. MD #1 stated that he had "missed the boat for a while" on documentation until he "was able to get up to speed." MD #1 stated he performed daily tele-visits, wrote notes for the sessions and was currently completing over one hundred and fifty tele-visit notes for the sessions before his in-person return to the facility on 09/10/2021.

Interview on 09/17/2021 at 1537 with the chief medical officer, MD #2, revealed there was a week in early September after a therapist resigned that he received calls and complaints from families about the therapy schedule and discharge arrangements. Interview revealed he had discussed it with the chief executive officer and had been instructed to forward the calls to her office.

Telephone interview on 09/21/2021 at 1400 with a registered nurse, RN #5, revealed she was Patient #6's discharging RN on 09/09/2021. Interview revealed she had reviewed medications with a family member and a Therapist was expected to review the remainder of the discharge instructions. Interview revealed she did not recall who Patient #6's Therapist was that day and had called MD #1 for a discharge order. Interview revealed RN #5 would typically place an order into the electronic record for the physician to cosign, but "I do not remember doing that," and his mother was waiting in the lobby to take him home.

Interview on 09/21/2021 at 1440 with the interim Director of Therapy, T #4, revealed she had been unable to find therapist documentation on therapy and discharge planning for Patient #6 in the new electronic medical record. Interview revealed Patient #6 had discharged from the facility AMA on 09/09/2021 but saw no evidence of it in the patient's record.

Interview on 09/21/2021 at 1455 with the Chief Nursing Officer, CNO, confirmed Patient #6 had discharged AMA and the electronic medical record AMA form had not been found. The CNO stated that the electronic form was "a learning curve" but a paper form was available. The CNO also stated she had instructed nursing staff to use the facility's paper form if staff had difficulty completing the electronic form.


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3. Review of a closed medical record on 09/14/2021 revealed Patient #3 was a 16-year-old male involuntarily committed to the facility on 09/02/2021 with suicide ideation (thoughts of killing self). Medical record review revealed Patient #3 had a history of Attention deficit hyperactivity disorder, Autism spectrum disorder, Asperger's syndrome and Major depressive disorder (persistent depression). Review of a "Psychiatric Progress Note" signed by the attending Psychiatrist (MD #1) on 09/06/2021 at 1600 revealed "...Talked to grandmother...She wanted to take (named Patient) home. We agreed that it could be done as AMA discharge..." Review of a "Nursing Progress Note" signed by Registered Nurse (RN) #7 on 09/06/2021 at 1719 revealed Patient #3 "...was discharged today...accompanied by his grandmother..." Medical record review failed to reveal evidence of an AMA Release form signed by Patient #3's guardian. Medical record review failed to reveal documentation that Patient #3's guardian refused to sign an AMA Release form.

Interview on 09/16/2021 at 1430 with Registered Nurse #7 revealed she was unable to locate an AMA Release form in Patient #3's medical record. Interview revealed she could not recall if Patient #3's guardian signed an AMA Release form at discharge.

Interview on 09/16/2021 at 1145 with MD #1 revealed after speaking with Patient #3's guardian, he agreed to discharge the patient against medical advice. Interview revealed the nursing staff were responsible for obtaining the guardian's signature on the AMA Release form.

Interview on 09/20/2021 at 1130 with the Chief Nursing Officer revealed the expectation was the nurse was to request the patient's guardian to sign the AMA Release form per facility policy. Interview revealed the nurse would be expected to document if the guardian refused to sign the AMA Release form.

Based on review of the facility's Quality Improvement Plan, treatment plan data collection, quality indicator data and staff interviews, the hospital staff failed to accurately measure, analyze and track quality indicators related to treatment plans and failed to show measurable improvement associated with treatment plans.

The findings include:

Review on 09/16/2021 of the "Quality/Performance Improvement Plan" revealed the purpose was to "...provide a consistent, systematic evaluation of performance/processes across departments/services. The goal of the Performance Improvement Program...is to improve safety and quality of care, treatment, and services at Hospital by monitoring, aggregating, analyzing, and comparing data and using the data to make improvements, as appropriate...The overall objectives of the Performance Improvement Program are as follows...To define the expectations and roles of leadership within the organization for their participation in patient safety and performance improvement; To provide a consistent structure for monitoring and improving the organizational systems and processes to achieve patient care delivery that is appropriate, timely, effective, continuous...To ensure that departments/services...are properly monitoring the stability of existing processes, identifying opportunities for improvement, identifying, and making changes that will lead to improvement and sustaining improvement...The roles and responsibilities of each of these leaders in quality/performance improvement is Summarized as follows...Department Directors. Directors...are responsible for participation in the identification and prioritization of quality/performance improvement activities, the direct implementation of actions to improve findings, the monitoring for improvement, and follow-up actions, as required to sustain improvements...Supervisors and Charge personnel are responsible for collecting data, ensuring that systems to improve care are upheld and for reporting opportunities for improvement..."

Review of the "Interim Director of Clinical Services Position Summary" (job description) revealed "...ESSENTIAL JOB FUNCTION AND RESPONSIBILITIES...Safety & Quality Management ...2. Supports a facility-wide quality/performance improvement plan. Opportunities for improvement are identified, initiatives are implemented as indicated and monitored to desired outcomes..." Review revealed the document was signed by the Chief Executive Officer (CEO) and the Interim Director of Clinical Services and dated 07/05/2021.

Review on 09/16/2021 of the 2021 Quality Assurance and Performance Improvement (QAPI) data for the indicator "Completion of All Elements of the Treatment Plan" revealed the target was 95% and the threshold for action was 90%. Review revealed the hospital's monthly score for Treatment Plans was: January 2021 54%; February 2021 58.42%; March 2021 70.77%; April 2021 74.57%; May 2021 78.96%. Review failed to reveal evidence of treatment plan data for June 2021, July 2021 or August 2021.

Interview on 09/16/2021 at 1050 with the Interim Director of Clinical Services revealed she had accepted the position at the end of June 2021. Interview revealed she had not completed monthly chart audits nor submitted quality data to the hospital's Director of Quality and Risk Management. Interview revealed the Therapists were instructed to complete self audits utilizing a discharge planning checklist and submit the audits to her for review. Interview revealed that due to managing a full case load as well as training and supervising clinical staff, she had not had the opportunity to complete audits for the therapy services department. Interview revealed she was not made aware of any other action items for therapy services department. Interviewed revealed she had not been trained on how to complete the quality audits for the clinical services department.

Interview on 09/17/2021 at 1115 with the Director of Quality and Risk Management revealed quality data from each department was due by the 10th day of the month. Interview revealed the Interim Director of Clinical Services was made aware of the reporting expectations when she assumed the role. Interview revealed the Director of Quality and Risk Management could not determine if therapy services were improving as there was no data available for June 2021, July 2021 or August 2021.

Interview on 09/16/2021 at 1530 with the Chief Executive Officer revealed the Interim Director of Clinical Services was responsible for submitting quality data for therapy services to the Director of Quality and Risk Management per the hospital's Quality and Performance Improvement Plan. Interview revealed the Interim Director of Clinical Services was expected to fulfill the job functions and responsibilities while in that position.

Based on policy and procedure review, medical staff bylaws, medical record reviews, and staff and physician interviews, the facility staff failed to ensure telemedicine physician notes were documented in 3 of 3 patient records (Patient #4, #5, #6).

The findings include:

Review on 09/16/2021 of the policy titled "Telemedicine Procedures" with revision date of 06/12/2020 revealed "POLICY: 'Telemedicine' is the practice of medicine using electronic communication, information technology, or other means between a licensee in one location and a patient in another location with or without an intervening health care provider....Primary health care providers are trained in the use of telemedicine equipment to ensure the high-quality delivery of behavioral health services for patient assessment, consultation, referral, psychiatric evaluation, follow up care, and discharge....E. Clinical Records. 2. The clinical record generated during the telemedicine session is scanned, documented in HCS (electronic medical record), mailed, faxed, or sent Federal Express securely...."

Review on 09/16/2021 of the policy titled "Information Management Plan" with effective date of 07/01/2021 revealed "GOALS: A. To ensure adequate and complete medical records are maintained for every patient..."

Review on 09/16/2021 of the facility's "Medical Staff Rules and Regulations 2021" revealed "...16...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...."

Review on 09/15/2021 of the closed medical record for Patient #5 revealed a 16-year-old male was admitted on 08/13/2021 after an argument with his foster parents and breaking car windows with a baseball bat. Patient #5 was discharged to a PRTF (Psychiatric Residential Treatment Facility) on September 2, 2021, a total stay of 20 days. Review of psychiatric progress notes revealed no progress notes for August 15, 2021, August 18, 2021, August 23, 2021, August 26, 2021, and August 28, 2021 through August 30, 2021 (Missing total of 7 days of notes). Review revealed there were missing four notes from one week.

Interview on 09/17/2021 at 1215 with MD #1 (attending psychiatrist) revealed the Patient #5 was seen by telemedicine by MD #1 during his stay. Interview revealed MD #1 was out of the country during the Patient #5's stay. Interview revealed MD #1 performed the visits and the notes were written.

Interview on 09/17/2021 at 1535 with MD #2 (CMO--Chief Medical Officer) revealed the psychiatric notes should have been written every day that the patient was seen. Interview revealed the psychiatric notes should be in the medical record.

Interview on 09/20/2021 at 1145 with the CNO (Chief Nursing Officer) revealed the missing psychiatric notes had not been located. Interview confirmed the seven psychiatric notes were not available in the medical record.



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2. Review of a closed medical record on 09/16/2021 revealed Patient #4 was a thirteen-year-old male admitted to the facility on 08/29/2021 at 1136 under involuntary commitment (IVC) orders per request of his mother because of unsafe and suicidal behaviors at home as well as disruptive behaviors in the community. Review of the medical record revealed Patient #4's diagnoses included DMDD (disruptive mood dysregulation disorder), Autism spectrum and impulsive and dangerous behaviors by wrapping a blanket around his neck and trying to choke himself. Review of the medical record revealed Patient #4 was placed on "Line of Sight" observation at admission. Review of the daily Psychiatric Progress Notes revealed there were no physician progress notes for September 4, 2021, September 8, 2021, and September 9, 2021 (three days of the eleven-day hospitalization). Review revealed Patient #4 was discharged from the facility against medical advice (AMA) on 09/09/2021 at 1523.

Interview on 09/17/2021 at 1157 with the attending Psychiatrist, MD #1 revealed he saw Patient #4 via telemedicine during the stay. Interview revealed MD #1 was out of the country during Patient #4's stay and MD #1 returned for face to face visits on 09/10/2021. Interview revealed MD #1 stated he performed daily tele-visits, wrote notes for the sessions and was currently completing over one hundred and fifty tele-visit notes for the tele-visit sessions before his in-person return to the facility.

Interview on 09/17/2021 at 1535 with the Chief Medical Officer, MD #2, revealed psychiatric notes were expected to be written in the chart each day that a patient was seen and at least six days of each week.

Interview on 09/20/2021 at 1145 with the Chief Nursing Officer, CNO, revealed all available Daily Psychiatric Notes for Patient #4 had been provided.

3. Review of a closed medical record on 09/16/2021 revealed Patient #6 was a fifteen-year-old male admitted to the facility on 09/02/2021 at 1702 from an unaffiliated emergency department (ED) under involuntary commitment (IVC) orders "after making suicidal comments to his school therapist." Review of the Initial Psychiatric Evaluation dated 09/03/2021 at 0347 revealed his history included major depressive disorder (MDD) and a suicide attempt at age 13. Review of the medical record revealed Patient #6 was placed on "Line of Sight" observation at admission. Review of the daily Psychiatric Progress Note revealed there were no physician progress notes for September 4, 2021, September 8, 2021, and September 9, 2021 (three days of the seven-day hospitalization). Review revealed Patient #6 was discharged against medical advice (AMA) from the facility on 09/09/2021 at 1818.

Interview on 09/17/2021 at 1157 with the attending Psychiatrist, MD #1 revealed he saw Patient #6 via telemedicine during the stay. Interview revealed MD #1 was out of the country during Patient #6's stay and MD #1 returned for face to face visits on 09/10/2021. Interview revealed MD #1 stated he performed daily tele-visits, he wrote notes for the sessions and was currently in process of completing over one hundred and fifty tele-visit notes for the period prior to in-person visits on 09/10/2021.

Interview on 09/17/2021 at 1535 with the Chief Medical Officer, MD #2, revealed psychiatric notes were expected to be written in the chart each day that a patient was seen and at least six days of each week.

Interview on 09/20/2021 at 1145 with the Chief Nursing Officer, CNO, revealed all available Daily Psychiatric Notes for Patient #6 had been provided.

Based on policy and procedure review, medical records review, and staff and physician interviews, facility staff failed to assure active therapeutic efforts were documented for 3 of 10 adolescent patient records (#3, #4, #6) reviewed.

Findings are as follows:

Review on 09/21/2021 of the policy titled "Assessment of a Patient" with revision date of 06/15/2017 revealed, " I. SUMMARY Distinctions have been made to classify therapies into categories, each of which may be applied in a group setting and/or on a one-to-one basis. These therapies will be available to all patients in the program...II. (Named) Psychiatric Program offers a variety of therapeutic services for individuals 12 years and older which (sic) suffer from acute or chronic psychiatric disorders...Under the direction of a Psychiatrist members of the team...assess the patient's needs, develop an individualized treatment plan to address those needs and implement the therapy program..."

Review of the facility policy titled "Clinical Team Responsibilities" effective 05/01/2020 revealed "SUMMARY This policy and procedure is designed to delineate the duties and responsibilities of various members of the Interdisciplinary Treatment Team and their roles in the treatment planning process...PROCEDURE...2. Therapy Services/Clinical Services: b. Provides necessary groups and documents the patient's progress. a. [sic] Provide and document all necessary therapy services with the patient and/or family or guardian, if indicated..."

1. Review of a closed medical record on 09/16/2021 revealed Patient #4 was a thirteen-year-old male admitted to the facility on 08/29/2021 at 1136 under involuntary commitment (IVC) orders per request of his mother because of unsafe and suicidal behaviors at home as well as disruptive behaviors in the community. Review of the medical record revealed Patient #4's diagnoses included DMDD (disruptive mood dysregulation disorder), Autism spectrum and impulsive and dangerous behaviors by wrapping a blanket around his neck and trying to choke himself. Review of the medical record revealed Patient #4 was placed on "Line of Sight" observation at admission. Review of the medical record revealed a Psychosocial Assessment by the unit's primary therapist, T #3, dated 09/01/2021 at 1935 that indicated "...Therapist will facilitate: Process Group, Psychoeducation Group, Individual Therapy, Discharge Planning/Referrals, Family Therapy and Treatment Team..." Review revealed Nursing Group Note(s) dated 08/29/2021 at 1605, 09/05/2021 at 1045, and 09/06/2021 at 1745, one Mental Health Technician (MHT) Group Note dated 09/07/2021 and daily Recreational Therapy Group Note(s) dated 08/29/2021 through 09/09/2021, but except for Patient/Family Daily Education Note on 09/01/2021, no evidence of Therapist documentation of Patient #4's treatment. Review of the Discharge Continuing Care Plan Assessment dated 09/09/2021 at 1344 revealed "Parent to arrange follow up care via therapy and psychiatry." Record review revealed Patient #4 was discharged against medical advice (AMA) from the facility on 09/09/2021 at 1523 after eleven days at the facility.

Requests for interview with the weekend covering unit Therapist, T #8, for the days 09/04-06/2021 was unsuccessful.

Request for interview with Patient #4's covering Therapist(s) after 09/07/2021 and on the day of discharge, 09/09/2021, was unsuccessful. No documentation was evident in the medical record and the names of responsible staff were not provided by the interim Director of Therapy, T #4, or the CNO.

Interview on 09/21/2021 at 1510 with the interim Director of Therapy, T #4 revealed primary therapists, once assigned, followed a patient throughout their stay. T #4 stated that therapists were expected to develop a treatment plan, document, arrange for, and/or secure services needed by patients and caregivers. Interview revealed Patient #4's primary therapist had resigned five days after Patient #4's arrival. Interview revealed T #4 expected that T #3's documentation would have been completed up until her resignation. Interview revealed T #4 had been engaged in ongoing discussions with T #3 about her "role" and facility "expectations" prior to T #3's resignation. T #4 stated that staff who covered T #3's assignments were expected to document their involvement until a new, permanent therapist was hired. T #4 also stated that she had not been able to locate Therapist documentation between 09/04/2021 and 09/09/2021 when Patient #4 discharged AMA from the facility.

Interview on 09/21/2021 at 1137 with the Chief Nursing Officer, CNO, indicated that T #4 had provided her with a timeline for therapy coverage on the male adolescent unit between 09/03/2021 and 09/10/2021 and she was "reviewing it." Interview revealed PRN (as needed) Therapists provided coverage on weekends and holidays and "they might not see patients individually but there should be notes" in patient charts documenting their work. The CNO also stated that each patient was expected to have a treatment plan that was addressed in the therapist notes.

Interview on 09/17/2021 at 1150 with the attending psychiatrist, MD #1 revealed the primary therapist, T #3, for the adolescent male unit had been unable to keep up with her caseload and resigned. MD #1 stated the primary therapist typically made discharge and follow up arrangements for patients as they stabilized but he did not remember who had picked T #3's case load and did not know who Patient #4's primary therapist was later during his admission. Interview revealed MD #1 had not physically been at the facility during Patient #4's admission and had followed each of his patients' progress via a telepsychiatry link. Interview revealed MD #1 expected that patient assignments had been "divided up" after T #3 resigned, and "team meetings" would have continued without his physical presence until MD #1 returned to provide in-person treatment services on 09/10/2021.

2. Review of a closed medical record on 09/16/2021 revealed Patient #6 was a fifteen-year-old male admitted to the facility on 09/02/2021 at 1702 from an unaffiliated emergency department (ED) under involuntary commitment (IVC) orders "after making suicidal comments to his school therapist." Review of the Initial Psychiatric Evaluation dated 09/03/2021 at 0347 revealed his history included major depressive disorder (MDD) and a suicide attempt at age 13. Review of the medical record revealed Patient #6 was placed on "Line of Sight" observation at admission. Medical record review revealed Nursing Group Notes dated 09/05/2021 and 09/06/2021, one MHT (mental health technician) Group Note on 09/07/2021, Recreation Therapy Group Notes on 09/03/2021 through 09/09/2021 and no Therapist Notes documentation for Patient #6 during the admission. Review of the Discharge Continuing Care Plan Assessment dated 09/09/2021 at 1420 revealed "Parent to arrange follow up care...Follow up care with Orthopedic medicine of your choice. Follow up care with Psychiatry of your choice ..." Review revealed Patient #6 was discharged AMA from the facility on 09/09/2021 at 1818.

Requests for interview with the weekend covering unit Therapist, T #8, for the days 09/04-06/2021 was unsuccessful.

Requests for interview with Patient #6's interim Therapist(s) from 09/02/2021 through the day of discharge, 09/09/2021, was unsuccessful. No documentation was evident in the medical record and the names of responsible staff were not provided by the interim Director of Therapy, T #4, or the CNO.

Interview on 09/21/2021 at 1510 with the interim Director of Therapy, T #4 revealed primary therapists, once assigned, followed a patient throughout their stay. T #4 stated that therapists were expected to develop a treatment plan, document, arrange for, and/or secure services needed by patients and caregivers. Interview revealed Patient #6's primary therapist had resigned the day after Patient #6's arrival. Interview revealed T #4 expected that T #3's documentation would have been completed up until her resignation. Interview revealed T #4 had engaged in ongoing discussions with T #3 about her "role" and facility "expectations" prior to T #3's resignation. T #4 stated that staff who covered T #3's assignments were expected to document their involvement until a new permanent therapist was hired. T #4 also stated that she had not been able to locate therapist documentation between 09/02/2021 and 09/09/2021 when Patient #6 discharged from the facility.

Interview on 09/21/2021 at 1137 with the Chief Nursing Officer, CNO, indicated that T #4 had provided her with a timeline for therapy coverage on the male adolescent unit between 09/03/2021 and 09/10/2021 and she was "reviewing it." Interview revealed PRN (as needed) Therapists provided coverage on weekends and holidays and "they might not see patients individually but there should be notes" in patient charts documenting their work. The CNO also stated that each patient was expected to have a treatment plan that was addressed in the therapist notes.

Interview on 09/17/2021 at 1150 with the attending psychiatrist, MD #1 revealed the primary therapist, T #3, for the adolescent male unit had been unable to keep up with her caseload and resigned. MD #1 stated he did not remember who had picked her case load and did not remember signing a treatment plan for Patient #6. MD #1 stated he did not know who Patient #6's primary Therapist after T #3's resignation was. Interview revealed MD #1 had not physically been at the facility during Patient #6's admission but had followed each of his patients' progress via a telepsychiatry link. Interview revealed MD #1 believed that patient assignments had been "divided up" after T #3 resigned. and "team meetings" would have continued until he returned to provide in person services on 09/10/2021.


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3. Review of the facility policy titled "Clinical Team Responsibilities" effective 05/01/2020 revealed "SUMMARY This policy and procedure is designed to delineate the duties and responsibilities of various members of the Interdisciplinary Treatment Team and their roles in the treatment planning process...PROCEDURE...2. Therapy Services/Clinical Services: b. Provides necessary groups and documents the patient's progress. a. [sic] Provide and document all necessary therapy services with the patient and/or family or guardian, if indicated..."

Review of a closed medical record on 09/14/2021 revealed Patient #3 was a 16-year-old male involuntarily committed to the facility on 09/02/2021 with suicide ideation (thoughts of killing self). Medical record review revealed Patient #3 had a history of Attention deficit hyperactivity disorder, Autism spectrum disorder, Asperger's syndrome and Major depressive disorder. Medical record review failed to reveal documentation Patient #3 received therapy while admitted to the facility. Medical record review revealed Patient #3 discharged home against medical advice on 09/06/2021.

Telephone interview on 09/16/2021 at 1005 with Registered Nurse #5 revealed Patient #3 did not receive therapy on Friday (09/03/2021), Saturday (09/04/2021) or Sunday (09/05/2021). Interview revealed 09/03/2021 was the unit therapist's (T #3) last day of employment and she did not facilitate group or individual therapy sessions that day. Interview revealed the weekend therapist (T #9) worked until noon on 09/04/2021 and spent the shift "putting out fires" and did not hold therapy sessions. Interview revealed Registered Nurse #5 did not recall seeing a Therapist on the unit on 09/05/2021.

An interview was requested with Therapist #9 who was unavailable for interview.

Interview on 09/20/2021 with the Interim Director of Clinical Services revealed 09/03/2021 was T #3's last day of working and the expectation was that she carried out all of her assigned duties including facilitating group or individual therapy and documentation. Interview revealed the Interim Director of Clinical Services was unaware T #3 did not have group therapy on 09/03/2021. Interview revealed the Interim Director of Clinical Services was unaware T #9 did not have group therapy on 09/04/2021.


NC00181025, NC00180757, NC00180102, NC00181269, NC00181165, NC00181161, NC00181290

Based on policy and procedure review, medical records review, and staff and physician interviews, facility staff failed to ensure individualized treatment plans were documented for 3 of 10 adolescent patient records (#3, #4, #6) reviewed.

Findings are as follows:
Review on 09/21/2021 of the policy titled "Assessment of a Patient" with revision date of 06/15/2017 revealed, "I. SUMMARY Distinctions have been made to classify therapies into categories, each of which may be applied in a group setting and/or on a one-to-one basis. These therapies will be available to all patients in the program...II. (Named) Psychiatric Program offers a variety of therapeutic services for individuals 12 years and older which (sic) suffer from acute or chronic psychiatric disorders...Under the direction of a Psychiatrist members of the team...assess the patient's needs, develop an individualized treatment plan to address those needs and implement the therapy program..."

Review of the facility policy titled "Clinical Team Responsibilities" effective 05/01/2020 revealed "SUMMARY This policy and procedure is designed to delineate the duties and responsibilities of various members of the Interdisciplinary Treatment Team and their roles in the treatment planning process...PROCEDURE...2. Therapy Services/Clinical Services: b. Provides necessary groups and documents the patient's progress. a. [sic] Provide and document all necessary therapy services with the patient and/or family or guardian, if indicated..."

1. Review of a closed medical record on 09/16/2021 revealed Patient #4 was a thirteen-year-old male admitted to the facility on 08/29/2021 at 1136 under involuntary commitment (IVC) orders per request of his mother because of unsafe and suicidal behaviors at home as well as disruptive behaviors in the community. Review of the medical record revealed Patient #4's diagnoses included DMDD (disruptive mood dysregulation disorder), Autism spectrum and impulsive and dangerous behaviors by wrapping a blanket around his neck and trying to choke himself. Review of the medical record revealed Patient #4 was placed on "Line of Sight" observation at admission. Medical record review revealed a Recreation Therapy treatment plan dated 08/30/2021 at 1115. Further review revealed evidence of Treatment Items for Patient #4 by the primary Therapist (T#3) dated 08/31/2021 (no time) but no evidence of an Initial Care Plan or physician and nursing services participation in treatment plan development. Review of a Communication Log dated 09/03/2021 at 1302 by T #3 revealed, "Clinician called the family to advise of change of clinician..." Further review revealed Patient #4 was discharged AMA from the facility on 09/09/2021 at 1523 without further Therapist documentation.

Requests for interview with the weekend covering unit Therapist, T #8, for the days 09/04-06/2021 was unsuccessful.

Requests for interview with Patient #4's Therapist from 09/07/2021 through the day of discharge, 09/09/2021, was unsuccessful. No documentation was evident in the medical record and the names of responsible staff were not provided by the interim Director of Therapy T #4 or the CNO.

Interview on 09/21/2021 at 1440 with the interim Director of Therapy (T #4) revealed Therapists followed a patient throughout their stay. T #4 stated that Therapists were expected to develop a treatment plan, document, arrange for, and/or secure services needed by patients and caregivers. Interview revealed Patient #4's primary Therapist, T #3, had resigned a few days after Patient #4's arrival. Interview revealed T #4 expected that T #3's documentation would have been completed up until her resignation. Interview revealed T #4 had engaged in ongoing discussions with T #3 about her "role" and facility "expectations" prior to T #3's resignation. T #4 stated that staff who covered T #3's assignments were expected to document their involvement until a new therapist was hired. T #4 also stated that she had not been able to locate any Therapist documentation between 09/04/2021 and 09/09/2021 when Patient #4 discharged from the facility.

Interview on 09/21/2021 at 1137 with the Chief Nursing Officer, CNO, indicated that T #4 had provided her with a timeline for therapy coverage on the male adolescent unit between 09/03/2021 and 09/10/2021 and she was "reviewing it." Interview revealed PRN (as needed) Therapists provided coverage on weekends and holidays and "they might not see patients individually but there should be notes" in patient charts documenting their work. The CNO also stated that each patient was expected to have a treatment plan that was addressed in the therapist notes.

Interview on 09/21/2021 at 1137 with the Chief Executive Officer, CEO, revealed she was currently reviewing the therapist staffing on the facility's male adolescent unit for September 2021. Interview revealed, prior to 09/03/2021, T #3 was responsible for guiding therapy on the adolescent males' unit and a weekend therapist, T #8, was responsible for therapy between September 4th and 6th. The CEO stated that the covering weekend therapist was expected to write therapy notes for those days. The CEO stated, "there were three days, the 7th, 8th and 9th when kids would not have known who their personal therapists were..." but the Therapist who had picked up T #3's assignment was expected to write treatment notes.

Interview on 09/17/2021 at 1150 with the attending psychiatrist, MD #1, revealed the primary therapist, T#3, had been unable to keep up with the documentation requirements of her caseload during her time at the facility. Interview revealed MD #1 had not been physically at the facility during Patient #4's admission but had followed his patients' progress via a telepsychiatry link. MD #1 stated that T #3's patient assignment had been "divided up" after she resigned, and "team meetings" had continued. MD #1 also stated that he resumed in person treatment at the facility on 09/10/2021 but did not recall seeing treatment notes in the new electronic medical record.


2. Review of a closed medical record on 09/16/2021 revealed Patient #6 was a fifteen-year-old male admitted to the facility on 09/02/2021 at 1702 from an unaffiliated emergency department (ED) under involuntary commitment (IVC) orders "after making suicidal comments to his school therapist." Review of the Initial Psychiatric Evaluation dated 09/03/2021 at 0347 revealed his history included major depressive disorder (MDD) and a suicide attempt at age 13. Review of the medical record revealed Patient #6 was placed on "Line of Sight" observation at admission. Medical record review revealed no evidence of an Initial Care Plan for Patient #6. Review revealed Patient #6 was discharged against medical advice (AMA) from the facility on 09/09/2021 at 1818.

Requests for interview with the weekend covering unit Therapist, T #8, for the days 09/04-06/2021 was unsuccessful.

Request for interview with Patient #6's Therapist from 09/07/2021 through the day of discharge, 09/09/2021, was unsuccessful. No documentation was evident in the medical record and the names of responsible staff were not provided by the interim Director of Therapy, T #4, or the CNO.

Interview on 09/21/2021 at 1510 with the interim Director of Therapy, T #4 revealed primary Therapists, once assigned, followed a patient throughout their stay. T #4 stated that therapists were expected to develop a treatment plan, document, arrange for, and/or secure services needed by patients and caregivers. Interview revealed Patient #6's primary Therapist had resigned the day after Patient #6's arrival, but a covering Therapist was assigned in the interim. Interview revealed T #4 expected that T #3's documentation would have been completed up until her resignation. Interview revealed T #4 had engaged in ongoing discussions with T #3 about her "role" and facility "expectations" prior to T #3's resignation. T #4 stated that staff who covered T #3's assignments were expected to document their involvement until a new, permanent therapist was hired. T #4 also stated that she had not been able to locate therapist documentation between 09/04/2021 and 09/09/2021 when Patient #6 discharged from the facility.

Interview on 09/21/2021 at 1137 with the Chief Nursing Officer, CNO, indicated that T #4 had provided her with a timeline for therapy coverage on the male adolescent unit between 09/03/2021 and 09/10/2021 and she was "reviewing it." Interview revealed PRN (as needed) therapists provided coverage on weekends and holidays and "they might not see patients individually but there should be notes." The CNO also stated that each patient was expected to have a treatment plan that was addressed in the therapist's notes.

Interview on 09/21/2021 at 1137 with the Chief Executive Officer, CEO, revealed she was currently reviewing Therapist staffing for the facility's male adolescent unit for September 2021. Interview revealed, prior to 09/03/2021, T #3 was responsible for guiding therapy for the adolescent males' unit and a weekend therapist, T #8, was responsible for therapy between September 4th and 6th. The CEO stated that the covering weekend therapist was expected to write therapy notes for those days. The CEO stated, "there were three days, the 7th, 8th and 9th when kids would not have known who their personal therapists were..." but the covering therapist who had picked up T #3's assignment would have been expectd to write treatment notes.

Interview on 09/17/2021 at 1150 with the attending psychiatrist, MD #1, revealed he did not recall signing a treatment plan for Patient #6 and did not know who Patient #6's primary Therapist was during the admission. MD #1 stated he had not been physically at the facility during Patient #6's admission but had followed his patients' progress via a telepsychiatry link. During interview MD #1 stated that T #3's patient assignment had been "divided up" after she resigned, and "team meetings" had continued. MD #1 stated that he resumed in-person treatment at the facility on 09/10/2021 but was unable to locate Therapist and Team Meeting notes in the facility's electronic medical record.



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2. Review on 09/14/2021 of the facility policy titled "Clinical Team Responsibilities" effective 05/01/2020 revealed "SUMMARY This policy and procedure is designed to delineate the duties and responsibilities of various members of the Interdisciplinary Treatment Team and their roles in the treatment planning process...PROCEDURE...Nurses:...e. The RN (registered nurse) participates in the treatment planning process, initiates goals, and individualized interventions and updates target dates and interventions as indicated...Therapy Services/Clinical Services:...d. documents appropriate goals and individualized interventions in the Treatment Plan..."

Review on 09/14/2021 of the facility policy titled "Treatment Plan Acute Inpatient" last reviewed/revised: 12/2016 revealed "...POLICY Each patient admitted to the psychiatric unit shall have an individualized person centered treatment plan which is based on interdisciplinary clinical assessments...PROCEDURE Master Treatment Plan 1. Each clinical team member of the treatment team should review and contribute to the Master Treatment Plan. The Master Treatment Plan should be completed within 72 hours of the patient's admission..."

Review of a closed medical record on 09/14/2021 revealed Patient #3 was a 16-year-old male involuntarily committed to the facility on 09/02/2021 with suicide ideation (thoughts of killing self). Medical record review revealed Patient #3 had a history of Attention deficit hyperactivity disorder, Autism spectrum disorder, Asperger's syndrome and Major depressive disorder. Medical record review failed to reveal evidence of an Initial Care Plan or a Master Treatment Plan for Patient #3. Medical record review revealed Patient #3 discharged from the facility against medical advice on 09/06/2021.

An interview was requested with Registered Nurse #8 who was not available for interview.

An interview was requested with Therapist #4 who was not available for interview.

Interview on 09/20/2021 at 1130 with the Chief Nursing Officer revealed based on review of the medical record, nursing had not created an Initial Treatment Plan for Patient #3. Interview revealed the expectation was the nursing staff would complete the initial treatment plan within 24-hours of the patient's admission.

Interview on 09/20/2021 at 1045 with the Interim Director of Clinical Services revealed based on review of the medical record, there was no Master Treatment Plan for Patient #3. Interview revealed the expectation was the Interdisciplinary Team would develop the patient's Master Treatment Plan within 72 hours of the patient's admission to the facility.