HospitalInspections.org

Based on observation, record review and interview, the hospital failed to ensure each patient's right to receive care in a safe setting. The deficient practice was evidenced by:
1) failure to ensure hypersexual Patient #1 was in a safe setting by failure to ensure Patient #2 was unable enter her room unseen by staff; and
2) failure to maintain a safe outdoor recreation environment as evidenced by a detached picket fence from its stringer with two nails partially removed exposing the sharp ends posing a potential risk of injury.
Findings:

Review of psychiatric hospital's policy# NU 207, titled "Patient and Family Rights", revised on 05/17/2017, revealed in part: Policy, in part: "18. The right to receive care in a safe setting."

1) Failure to ensure hypersexual Patient #1 was in a safe setting by failure to ensure Patient #2 was unable enter her room unseen by staff.

Review of psychiatric policy# NU 432 titled, "Levels of Observation", revised on 11/2024, revealed in part: "66. Q 15 Minute Observations, in part: iii. Remain vigilant for specific risks for patients on Special Precautions." BHA Conducting Observations, in part: Staff completing observations will not be responsible for other duties but may assist with patient needs as long as it doesn't delay observations. Monitoring, in part: 2. Monitoring for compliance with observations will be a continuous, ongoing process. For safety and quality improvement purposes, this will be conducted In-Person and/or via Video Review. It is preferable that Video Review be done at least monthly for ALL shifts.

Review of psychiatric policy# NU 432A titled, "Precautions: Fall, Seizure, Elopement, Suicide, Aggression, Withdrawal, Cheeking, and Sexual", revised on 11/2024, revealed in part: E. Sexually Acting out Precautions (SAO)2. Factors that may indicate a risk of sexually acting out, inpart: Prior sexual acting out. 4. Staff interventions may include, in part: Increase level of observation for severe or repeated behaviors to reduce impulsivity.

Review of Patient #1's medical record revealed and admission date of 01/30/2025, with a history of depression and anxiety. Patient ran away from school and got into trouble for hypersexual behaviors, attempting to give oral sex to multiple peers at school. Has a history of cutting herself around twice a month. Patient #1 with a history of being bullied at school and PTSD due to suffering a gunshot wound less than 30 days ago during a drive by shooting.

Review of document titled "Hospital / Licensed Provider Abuse/Neglect Initial Report" dated
02/11/2025 revealed an incident that occurred on 02/04/2025 at 9:40 PM. S11BHA entered Patient #1's room while performing Q 5 minute rounds. S11BHA's electronic observation tablet detected a signal from 2 beacons coming from the bathroom. S11BHA heard noises in the bathroom. She opened the bathroom door to find Patient #2 (12 y/o) lying on the ground with his pants down and Patient #1 (14 y/o) on top of him with her pants down and her bra open. The two appeared to be attempting to have intercourse. S11BHA immediately separated the patients. Further review revealed Patient #2 had been restless around 9:25 PM after having punched a wall earlier in the night (7:00 PM). Around 9:35 PM, he was allowed to help the technicians clean and reset the day room after bedtime to help him calm down. The report indicated Patient #2 did not have a history of sexually acting out. Patient #1 had a history of sexually acting out prior to admission to the facility, therefore was placed on Sexually Acting Out Precautions and Q5 minute observations upon admission.

Review of nursing note dated 02/05/2025 at 3:46 AM revealed around 9:35 PM Patient #2 was allowed to help the technicians clean and reset the day room after bedtime to help him calm down. According to Patient #2's own statement, he was helping to sweep the floor. He walked across the unit to empty the dustpan. His path took him past Patient #1's room and he entered the room after which Patient #2 asked Patient #1 to go in the bathroom with him.

Review of Patient #1's observation sheets dated 02/04/2025 revealed observation level from 12:00 AM to 10:42 PM was every 5 minutes. Precautions: assault, blocked room, elopement, restrict to unit, sexually acting out and moderate suicide risk/precaution.
Continued review revealed the following:
9:30 PM-S12BHA-documented patient was in her bedroom asleep.
9:34 PM-S11BHA-documented patient was in her bedroom asleep.
9:40 PM-S11BHA-documented patient was in her bedroom asleep.
9:46 PM-S11BHA-documented patient was in her bedroom asleep.
9:50 PM-S11BHA-documented patient was in her bedroom asleep.
9:54 PM-S11BHA-documented patient was in her bedroom asleep.
9:55 PM-S11BHA-documented patient was in her bedroom asleep.
10:00 PM-11:56 PM-S11BHA, S12BHA, and S16BHA.

Review of Patient #2's observation sheets dated 02/04/2025 revealed observation level from 12:00 AM to 11:48 PM was every 15 minutes. Precautions: Suicide Precautions, Suicide Risk-Low.
Continued review revealed the following:
9:21 PM-S12BHA-documented patient was in the dayroom Assaultive / Destructive.
9:31 PM-S12BHA-documented patient was in the dayroom Assaultive / Destructive.
9:46 PM-S11BHA-documented patient was in the dayroom Assaultive / Destructive.
10:00 PM-S11BHA-documented patient was in the dayroom Assaultive / Destructive.
10:13 PM- S11BHA-documented patient was in the dayroom Assaultive / Destructive.
10:25 PM-11:48 PM-S11BHA and S12BHA-documented patient was in his bedroom calm.

Review of psychiatric hospital's document titled "Shift Assignment Sheet" dated 02/04/2025 for Unit a, 7 PM shift, revealed D11BHA, S13BHA, S20BHA, S21BHA and S22BHA. The assignment sheet listed only Patient #R1 who was on 1:1 assigned to S21BHA and S13BHA.

Review of untitled psychiatric document dated 02/04/2025 for Unit a, 7P-7A shift, revealed S10BHA, S11BHA, S12BHA, and S16BHA (orientation). The document listed S10BHA on a 1:1 with Patient #R2 starting at 11:00 PM; D11BHA on a 1:1 with Patient #R2 until 11:00 PM; S16BHA on a 1:1 with Patient #1 at 10:30 PM.

Observation of Unit a on 03/10/2025 at 9:00 AM revealed an open floor plan where all of the patient rooms opened up into the large dayroom from each side. The nurses station was centrally located overlooking the dayroom.

During an interview on 03/12/2024 at 12:34 PM, S1ADM stated there was no policy on separating the boys and girls on the adolescent units.

During an interview on 03/12/2025 at 2:45 PM, S2DOR stated that S12BHA was cleaning up the dayroom after dinner around 9:30 PM and gave Patient #2 a broom and dust pan to help with the cleanup. He did not see Patient #2 put down the broom and go into Patient #1's room.

S2DOR did not know why the nurse did not notice Patient #2 go into Patient #1's room but thought the nurse could not view Patient #1's room from the nursing station.
S2DOR did not know why S11BHA was rounding when, according to the assignment sheet, she was supposed to be on 1:1 with Patient #R2.
S2DOR was unable to say why S11BHA documented Patient #1 was sleeping in her bedroom at the time of the incident when the incident report stated she was in her bathroom with Patient #2. She was unable to say why S12BHA documented Patient #2 was in the dayroom "Assaultive/destructive" and was not being observed when he walked into patient #1's room at around 9:40 PM.

During an interview on 03/12/2025 at 12:34 PM, S1ADM stated the psychiatric hospital began using electronic monitoring system in December 2023. S1ADM verified the hospital did not have policies and procedures regarding the use of electronic monitoring system A and staff expectations for the following:
-hand-offs of tablet/assignments between technicians using electronic monitoring system A.
-when staff are unable to sign-in to the electronic monitoring system A to prevent delay in observations.
- signal loss or beacon loss.
- logging in to the electronic monitoring system using another staff's name.
-"forced" entries and the process to prevent them.
-compliance rate
-proximity of electronic monitoring system A to patient.
-Registered Nurse observation rounds using electronic monitoring system A.
-process for the assignment of patients to staff using the electronic monitoring system A.

During an interview on 03/10/2025 at 12:15 PM, S1ADM confirmed the Shift Assignment Sheets did not list the names of the patients that are on 1:1 observations with an assigned BHA. She indicated the patients on 1:1 should be listed next to the asigned BHA on the assignment sheet. S1ADM verified that none of the patients were listed on the Shift Assignment Sheets because all of the staff monitor all of the patients.

During an interview on 03/12/2025 at 3:07 PM S18RNS indicated the assignment sheets did not agree with the observation sheets. S18RNS confirmed she was unable to determine the staff who were on 1:1 and the staff who were doing rounds.

During an interview on 03/12/2025 at 3:35 PM, S1ADM confirmed there is no video footage available to review because there are no cameras in the hospital except in the seclusion rooms.

2) Failure to maintain a safe outdoor recreation environment as evidenced by a detached picket fence from its stringer with two nails partially removed exposing the sharp ends posing a potential risk of injury.

On 03/12/2025 at 4:39 PM, observations of the outdoor recreation area located near Units a and b revealed a detached picket fence from its stringer with two nails partially removed exposing the sharp ends posing a potential risk of injury.

During an interview on 03/12/2025 at 4:39 PM, S15 confirmed the detached picket fence from its stringer with two nails partially removed exposing the sharp ends posed a potential risk of injury to any patients that were in the recreation area and stated she would take a picture and have it repaired as soon as possible.

48050

Based on record review and interview the hospital failed to protect patients from abuse and neglect. The deficient practice is evidenced by:
1) failure implement disciplinary actions per hospital policy regarding observations;
2) failure of Registered Nurses to make observation rounds per psychiatric hospital policy 5 (#1,#2,#4, #5, and #6) of 6 (#1-#6) patient records reviewed.; and
3) failure of staff to follow physician orders for observation levels in 3 (#2, #4, #5) of 6 (#1-#6) patient observation sheets reviewed.
Findings:

1) Failure implement disciplinary actions per hospital policy regarding observations

Review of hospital policy titled "Progressive Discipline" last reviewed 01/2024 revealed in part: POLICY: It is the expectation that employees conduct themselves in a professional manner at all times adhering to all standards and polices set forth by the company. Employees should act with due regard to the facility, fellow employees, and patients. If the need arises for management to address an employee's performance, conduct, or attendance issues; management may choose a disciplinary action plan. Disciplinary action may include one of more of the following: Counseling, verbal or written warnings, suspension or termination. The course of action taken may depend on the number and frequency of past violations and the seriousness of the offense. COACHING: Supervisors are expected to regularly communicate with their employees regarding work expectations and performance matters. This may include coaching with an employee when a specific performance or conduct issue is identified in order to provide direction for necessary and successful correction. STEP 1: VERBAL COUNSELING: A verbal counseling should be given for minor infractions or to address performance deficiencies when coaching has not resolved the issue. STEP 2: WRITTEN WARNING: Written warnings will be issued for repeated conduct and performance issues that persist after a verbal counseling or if the behavior involves a more serious violation of policy or deficiency in performance.


Review of S11BHA personnel file revealed the following coaching forms: 1) A coaching form dated 11/15/2024 indicated S11BHA didn't start observation rounds on a patient that was admitted on 11/13/2024 at 9:50 PM until 10:48 PM. 2) A coaching form dated 12/10/2024 indicated S11BHA is below expectations on compliance with Q5 minute observations being done to over 7 minute intervals on the ObservSmart report. 3) A coaching form dated 2/13/2025 indicated S11BHA conducted rounds on a patient, but failed to change the behavior and location within ObservSmart system.

On 03/11/2025 at 11:30 AM S19HR verified S11BHA three coaching forms were all related to the same issues and should have been advanced per hospital disciplinary policy.

2) Failure of the registered nurses to make observations rounds per psychiatric hospital policy in 5 (#1,#2, #4, #5, and #6) of 6 (#1-#6) patient records reviewed.

Review of psychiatric policy# NU 432 titled, "Levels of Observation", revised on 11/2024, revealed in part: "Charge RN/RN Designee, in part: The Charge RN/RN Designee should observation at least once per 8-hour shift (twice per 12-hour shift) to assess the general safety of the unit/milieu and to check in with the team member assigned to observations to provide an additional opportunity for the assigned team member to report on safety concerns. Each RN is responsible for general oversight of the safety observations on his/her assigned patients.

Patient #1
Review of medical record revealed admission date of 01/30/2025 and discharge date 02/05/2025.

Review of observation sheets dated 01/31/2025-02/05/2025 revealed a registered nurse made observation rounds on Patient #1 on the following dates and times:
-02/02/2025 at 1:14 PM, 1:15 PM, 1:20 PM, 1:27 PM, 1:32 PM, 1:45 PM, 3:03 PM, 3:17 PM, 3:22 PM, 3:26 PM, 3:35 PM, 3:40 PM and 3:49 PM.
-02/05/2025 at 1:00 PM.

Review of observations sheets dated 01/31/2025-02/05/2025 failed to reveal a registered nurse made observation rounds on Patient #1 on the following dates:
01/31/2025, 02/01/2025, 02/03/2025/ and 02/04/2025.

Patient #2

Review of medical record revealed admission date of 01/29/2025 and discharge date of 02/07/2025.

Review of observation sheets dated 01/29/2025-02/07/2025 revealed a registered nurse made observation rounds on Patient #2 on the following dates and times:
-02/02/2025 at 1:15 PM

Patient #3
Review of medical record revealed admission date of 10/24/2024 and discharge date 11/13/2024.

Review of observation sheets dated 11/05/2024-11/13/2024 revealed a registered nurse made observation rounds on Patient #3 on the following dates and times:
-11/05/2024 at 6:30 PM
-11/06/2024 at 3:00 PM and 4:00 PM.
-11/11/2024 at 7:15 AM

Review of observations sheets dated 11/05/2024-11/13/2024 failed to reveal a registered nurse made observation rounds on Patient #3 on the following dates:
11/07/2024, 11/08/2024, 11/09/2024, 11/10/2024, 11/12/2024 and 11/13/2024.

Patient #4

Review of medical record revealed Patient #4 was admitted on 11/06/2024 and discharged on 11/12/2024.

Review of observation sheets dated 11/06/2024-11/12/2024 revealed a registered nurse made observation rounds on Patient #4 on the following dates and times:
-11/08/2024 at 7:20 PM, 7:45 PM, 8:00 PM, 8:05 PM, 8:30 PM, 8:35, 8:45 PM, 11:10 PM, 11:25 PM, 11:345 PM, and 11:50 PM
-11/09/2024 at 1:10 AM, 1:20 AM, 1:35 AM, 3:10 AM, 3:30 AM, 3:45 AM, 5:00 AM, 5:30 AM, 6:00 AM, 6:15AM, 6:40 AM, 8:10 PM, 8:45 PM, and 9:15 PM
-11/10/2024 at 2:10 AM, 2:25 AM, 2:35 AM, 2:50 AM, and 3:05 AM
-11/11/2024 at 7:25 AM, 7:40 AM, 7:50 AM, 8:15 AM, 8:55 AM, and 9:05 AM

Patient #5
Review of medical record revealed admission date of 10/24/2024 and discharge date 11/15/2025.

Review of observation sheets dated 10/26/2024-11/15/2024 revealed a registered nurse made observation rounds on Patient #5 on the following dates and times:
-10/26/2024 at 8:00 PM
-10/27/2024 at 6:15 PM and 6:30 PM
-10/30/2024 at 10:15 AM and 10:30 AM
-11/01/2024 at 2:45 PM, 4:45 PM, 5:00 PM, and 5:15 PM
-11/10/2024 at 2:30 AM, 2:45 AM, and 3:00 AM
-11/11/2024 at 7:30 AM, 7:45 AM, and 8:15 AM

Review of observations sheets dated 11/05/2024-11/13/2024 failed to reveal a registered nurse made observation rounds on Patient #5 on the following dates:
10/28/2024, 10/29/2024, 10/31/2024, 11/02/2024, 11/03/2024, 11/04/2024, 11/05/2024, 11/06/2024, 11/07/2024, 11/08/2024, 11/09/2024, 11/12/2024, 11/13/2024, 11/14/2024, and 11/15/2024.

Patient #6
Review of medical record revealed admission date of 02/15/2025 and was still admitted as of 03/12/2025.

Review of observation sheets dated 02/15/2025-03/12/2025 revealed a registered nurse made observation rounds on Patient #6 on the following dates and times:
-02/19/2025 at 3:13 PM, 3:14 PM, and 3:19 PM
-02/21/2025 at 1:06 AM
-02/22/2025 at 08:00 AM- 08:10 AM, 9:41 AM, 12:36 PM-1:24 PM
-02/23/2025 at 10:40 PM-10:51 PM
-02/28/2025 at 1:41 PM-2:11 PM
-03/01/2025 at 11:19 PM
-03/02/2025 at 11:38 AM-12:20 PM, 9:13 PM
-03/03/2025 at 12:55 AM-12:59 AM.
-03/04/2025 at 7:19 AM and 5:09 PM-5:18 PM.
-03/05/2025 at 2:03 AM and 3:50 PM
-03/09/2025 at 2:30 PM-2:35 PM
-03/10/2025 at 7:28 AM and 2:01 PM
-03/11/2025 at 10:30 PM
-03/12/2025 at 12:08 AM-12:45 AM, 8:52 AM, 3:17 PM, 3:19 PM, 3:20 PM, 3:43 PM, and 3:49 PM.

Review of observations sheets dated 02/15/2025-03/12/2025 failed to reveal a registered nurse made observation rounds on Patient #6 on the following dates:
02/15/2025, 02/16/2025, 02/17/2025, 02/18/2025, 02/20/2025, 02/24/2025, 02/25/2025, 02/26/2025, 02/27/2025, 03/06/2025, 03/07/2025, and 03/08/2025

During an interview on 03/11/2025 at 4:28 PM., S23DON verified the observation sheets fail to reveal the registered nurses are making observation rounds per hospital policy.

During an interview on 3/12/2025 at 12:24 PM, S1ADM verified the hospital did not have policies and procedures regarding Registered Nurse observation rounds using electronic monitoring system A.

During an interview on 03/12/2025 at 1:25 PM, S2DOR reported S23DON was concerned that the registered nurses were not documenting nursing rounds in the patients' medical records.

3) Failure of staff to follow physician orders for observation levels in 3 (#2, #4, #5) of 6 (#1-#6) patient observation sheets reviewed.

Patient #2
Review of medical record revealed Patient #2 was admtted on 01/29/2025 and discharged on 02/07/2025. Orders entered on 01/29/2025 at 12:50 PM revealed observtions every 15 minutes. Further review of Patient #2's observation sheetsp revealed greater than every 15 minutes rounding on the following dates and times:
-01/31/2025 rounding was done at 5:44 PM then agian at 6:03 PM
-02/02/2025 rounding was done at 5:27 AM then again at 5:43 AM
-02/02/2025 rounding was done at 9:56 AM then again at 10:12 AM
-02/02/2025 rounding was done at 11:52 AM then again at 12:09 PM
-02/02/2025 rounding was done at 1:38 PM then again at 1:55 PM
-02/02/2025 rounding was done at 7:34 PM then again at 8:00 PM
-02/03/2025 rounding was done at 7:18 AM then again at 7:37 AM
-02/04/2025 rounding was done at 3:45 PM then again at 4:03 PM
-02/04/2025 rounding was done at 5:17 PM then again at 5:34 PM

Orders entered on 02/04/2025 at 10:30 PM revealed observations were to be performed every 5 minutes. Further review on Patient #2's observation sheets revealed rounding was done in intervals greater than every 5 minutes on 02/06/2025, with rounding performed at 5:08 PM then again at 7:27 PM

Patient #4
Review of medical record revealed Patient #4 was admitted on 11/06/2024 and discharged on 11/12/2024. Orders entered on 11/06/2024 revealed observations were to be performed every 5 minutes.

Review of observation sheet dated 11/06/2024 failed to reveal observations occured every 5 minutes between 1:30 PM and 10:15 PM as ordered. Further review of the observation sheet dated 11/06/2025 revealed rounding occured every 15 minutes between 1:30 PM and 10:15 PM.

During an interview on 03/12/2024 at 1:45 PM, S17CD confirmed the above findings.

Patient #5
Review of medical record revealed Patient #5 was admitted on 10/24/2024 and discharged 11/15/2024. Orders entered on 10/24/2024 revealed observations were to be performed every 15 minutes.

Review of observation sheet dated 11/03/2025 failed to reveal observations occurred between 5:30 PM and 6:30 PM.

During an interview on 03/12/2025 at 10:35 AM, S2DOR confirmed the above findings.

Based on record review and interview, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by failure to measure, analyze, track and report adverse patient events in 2 (#3 and #4) of 6 (#1-#6) patients involved in patient-to-patient physical and sexual abuse involving adolescents.
Findings:

Review of psychiatric hospital's policy# NU 206, titled "Patient Abuse and/or Neglect", reviewed on 02/2024, revealed in part: "I. A. It is the policy of Covington Behavioral Health, in accordance with state and federal law, that suspected cases of abuse and/or neglect will be reported to the appropriate protective services agency."

Patient #3
Review of medical record revealed Patient #3 was admitted on 11/05/2024 with a long history of anxiety, depression and ADHD and attempted suicide by bashing her head into the wall 10 times in an attempt to kill herself. Patient reported having suicidal thoughts of drowning and cutting herself. Patient struggled with her sexual identity and was bullied in school.

Review of document titled "Incident Report Form", dated 11/11/2024, revealed on 11/11/2024 at 7:50 PM Patient #3 notified the nurses that during rest time she was napping in her room when she felt her roommate, Patient #4, touch her side and then reach for her pelvic area. Patient #3 then fully awakened and sat up, stopping the incident. Patient #3 was moved to another room with a peer she identified as supportive. Patient #4 was placed on 1:1 observation and the provider and parents were notified.

Further review of psychiatric hospital documents failed to reveal the incident was further investigated, analyzed and reported to the appropriate protective services agency.

In an interview on 03/11/2025 at 2:15 PM, S2DOR confirmed the incident had not been investigated or reported as per hospital policy.

Patient #4

Review of Patient #4's medical record revealed Patient #4 was accused of touching another patient inappropriately then a male patient physically assaulted Patient #4 by hitting her in the face.

An interview on 03/12/2025 at 2:15 PM, S17CD confirmed the incident of physical assault had not been investigated or reported as per hospital policy.



48050

48050

Based on record review and interview, the hospital failed to ensure the Registered Nurse supervised and evaluated the care of each patient on an ongoing basis, in accordance with the accepted standards of nursing practice and hospital policy. This deficient practice is evidenced by failure to notify MD and document an assessment following patient-to-patient abuse causing an injury.
Findings:

Review of Patient #4's medical record revealed a nursing note documented on 11/11/2024 at 11:36 PM revealing the following:
7:50 PM- staff notified by the roommate of Patient #4, that while she was taking a nap during shift change, Patient #4 touched her on her side and then "tried to touch me in my pelvic area."
7:55 PM- Patient #4 was asked about the incident and became anxious responded only "it was an accident, it was an accident." Patient #4 didn't clarify further, but remained anxious and agitated- difficult to calm.
8:09 PM- NP notified
8:13 PM- Patient #4 placed on 1:1 precautions
While the RN was obtaining orders and assigning 1:1 the roommate that alleged she was touched by Patient #4 told other patients on the unit about the incident. A male patient became angry and ran into the Patient #4's room hitting Patient #4 in the face before he could be stopped by staff.
Staff separated patients, and a staff member remained 1:1 with Patient #4 at bedside.
The male patient who was the aggressor was placed on assault precautions and received Zyprexa 5mg IM and Benadryl 50mg IM.
10:38 PM- Patient #4's mother notified.

Review of Patient #4's medical record failed to reveal nursing documentation that the provider was notified of assault by another patient which resulted in being hit in the face.

An interview on 03/12/2025 at 2:15 PM, S17CD verified there is no documentation that staff reported the assault agianst Patient #4 by a male patient resulting in Patient #4 being hit in the face. S17CD also verified there was no incident report completed for Patient #4 being hit by male patient.

Based on record review and interview, the psychiatric hospital failed to ensure a registered nurse assigned the nursing care of each patient to other personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available. This deficient practice is evidenced by failure to ensure an Registered Nurse made all patient care assignments.
Findings:

Review of psychiatric hospital policy# NU 432 titled, "Levels of Observation", revised on 11/2024, revealed in part: "Charge RN/RN Designee, in part: Assignment for Observations will be done by the charge RN/RN Designee. The assignment sheet will reflect the time period and team members assigned to that time-period. Any changes made during the shift should be indicated on the assignment sheet accordingly.

Review of psychiatric hospital policy# NU 401 titled, "Assignment of Patient Care", reviewed on 02/2024, revealed in part: "I. Policy, in part: The DON/designee will assign patient care to appropriate staff members. II. Purpose: To define the policy for providing nursing staff assignment to meet he nursing care needs of patients. E., in part: Adjustments in the level of staffing are made based on the daily needs as determined by the ongoing assessment of the patient population treatment needs acuity and safety requirements. This assessment will occur every 4 hours and prn by the DON/designee. The daily adjustment process is the reasonability of the Director of Nursing or designee to ensure accurate staffing in relation to acuity of the unit.

Review of psychiatric hospital policy# NU 401 titled, "Assignment of Nursing Staff", reviewed on 02/2024, revealed in part: "Procedures: 1. Staffing assignments reflective of this policy will be completed at the beginning of each shift by the Charge Nurse. 2. Staffing assignments will be documented on the Staffing Assignment Sheet. 3. The name and title of the staff member to be assigned will be entered in the space provided. 4. The names of the patients assigned to the staff member will be entered in the space provided.

Review of psychiatric hospital policy# LD-015 titled, "Staffing Plan", reviewed on 08/2024, revealed in part: "Core Coverage, in part: C. When assigning the patient/staff ratio, the charge nurse or designee will consider the abilities and competencies of all nursing staff personnel. The charge nurse or designee will modify the patient/staff ratio as deemed necessary according to the current patient acuity and / or patient volume. Staffing Procedure For Inpatient Units: 1., in part: A Registered Nurse plans, assigns, supervises and evaluates the nursing care of each patient daily.

On 03/10/2025 between 8:40 AM-9:28 AM, a tour of the psychiatric hospital, guided by S23DON and S24PCNO, revealed the following:

Observation of Unit c at 8:50 AM revealed an adult unit. S25RN was the charge nurse. A review of the Shift Assignment Sheet revealed it was not completed. S25RN began to complete the Shift Assignment Sheet while surveyor on unit. S25RN completed the Shift Assignment Sheet at 8:52 AM. Of note, the completed Shift Assignment Sheet did not reveal names of patients on the sheet. Only the names of the charge nurse, the med nurse and the two behavioral health associates.

Observation of Unit d at 8:46 AM revealed an adult unit. S26RN was the charge nurse. A review of the Shift Assignment Sheet revealed it was incomplete. The assignments section listed the names of two Behavioral Health Associates but patient names were not listed. S26RN stated the assignments were completed by S27BHA. S26RN reported the Behavioral Health Associate would complete the assignments then S26RN approved the assignments and completed the rest. S26RN stated she had been busy on that morning and was unable to complete the Shift Assignment Sheet until 8:46 AM.

Observation of Unit a at 9:04 AM revealed a co-ed adolescent unit. S27RN was the charge nurse. A review of the Shift Assignment Sheet revealed it was blank. S27RN carried the Shift Assignment Sheet from the nursing station to S29BHA for her to complete the assignments at 9:05 AM.

Observation of Unit b at 9:20 AM revealed a co-ed adolescent, higher acuity and overflow unit recently opened in February 2025. S30RN was the charge nurse. A review of the Shift Assignment Sheet revealed the observation assignment section was blank. S30RN was in the process of preparing medications for patients and was unable to complete the assignment sheet while surveyor was on the unit.

On 03/10/2025 between 8:40 AM-9:28 AM, S23DON and S24CPNO were present during these observations and confirmed the above findings.

During an interview on 03/12/2025 at 3:07 PM, S18RNS confirmed the registered nurses should always complete the patient observation assignments and the Behavioral Health Associates should not complete the observation assignments.

48050

Based on record review and interview, the hospital nursing staff failed to administer medications in accordance with the accepted standards of practice. This deficient practice is evidenced by failure of the nursing staff to administer medications within the appropriate timeframe per physician order in 1 (#4) of 6 (#1-#3, #5, #6) patient medical records reviewed.
Findings:

Review of Patient #4's medication administration record revealed the following order: Hydroxyzine Pamoate (Vistaril) 50mg by mouth every 6 hours, PRN Anxiety. Further review of Patient #4's medication administration record revealed the following dates/times of administration:
11/07/2024 at 1:27 PM
11/07/2024 at 1:32 PM

Review of Patient #4's medical record failed to reveal nursing documentation that the provider was notified or that the provider approved the administration of the medication to be given early.

In an interview on 03/12/2025 at 3:00 PM, S17CD confirmed the PRN medication was given early and not as prescribed by the provider. S17CD also verified that there was no documentation by the nurse that the provider approved them to administer the medication early. At this time S1ADM also confirmed that the medication above was administered within 5 minutes of each other and not within 6 hours as prescribed by the provider.

Based on record review and interview, the psychiatric hospital failed to ensure each patient had an individualized and comprehensive treatment plan for 4 (#1, #2, #3, #4) of 6 (#1-#6) treatment plans reviewed. This deficiency is evidenced by failure to include all medical and psychiatric diagnoses and updates, as part of an individualized and comprehensive treatment plan.
Findings:

Review of psychiatric hospital's policy# PM 032, titled "Provision of Care, Treatment and Services", revised on 05/17/2017, revealed in part: "Procedure, in part: 3. The treatment plan shall involve all clinical staff/disciplines who have contact with the patient and shall include (as a minimum): a. Problems and needs relevant to admission and discharge as identified in the various assessments, expressed in behavioral and descriptive terms; d. Problems, both physical and mental, that require therapeutic management f. Treatment modalities individualized in relation to patient's needs; h. Evidence of patient's involvement in formulation of the plan; 4. Guidelines for the Interdisciplinary Treatment plans: b. The treatment plan will also identify deferred problems with rational for not addressing the deferred proble.

Patient #1
Review of Patient #1's medical record revealed and admission date of 01/30/2025, with a history of depression and anxiety. Patient ran away from school and got into trouble for hypersexual behaviors, attempting to give oral sex to multiple peers at school. Has a history of cutting herself around twice a month. Patient #1 with a history of being bullied at school and PTSD due to suffering a gunshot wound less than 30 days ago during a drive by shooting.

Review of document titled "Hospital / Licensed Provider Abuse/Neglect Initial Report" dated 01/31/2025, revealed Patient #1 was in a physical altercation on 01/31/2025 at approximately 3:10 PM that caused abrasions to both of her feet and she was placed on unit restrictions.

Review of document titled "Hospital / Licensed Provider Abuse/Neglect Initial Report" dated
02/11/2025, revealed an incident that occurred on 02/04/2025 at 9:40 PM. S11BHA entered Patient #1's room while performing Q 5 minute rounds. S11BHA's electronic observation tablet detected a signal from 2 beacons coming from the bathroom. S11BHA heard noises in the bathroom. She opened the bathroom door to find Patient #2 (12 y/o) lying on the ground with his pants down and Patient #1 (14 y/o) on top of him with her pants down and her bra open. The two appeared to be attempting to have intercourse. S11BHA immediately separated the patients.

Review of Patient #1's psychiatric progress note dated 02/05/2025 revealed the following medication: Continue Prazosin 5 mg by mouth at bedtime to help with PTSD symptoms.

Review of Patient #1's treatment plan failed to reveal Active Psychiatric Problems related to PTSD (Post-Traumatic Stress Disorder). Further review failed to reveal the treatment plan was updated to include active problems related to the altercation with another patient that occurred on 01/31/2025. Additional review failed to reveal the treatment plan was updated to include active problems related to the sexual incident that occurred on 02/04/2025.

During an interview on 03/11/2025 at 12:05 PM, S2DOR confirmed Patient #1's treatment plan failed to reveal Active Psychiatric Problems related to PTSD, the altercation with another patient and the sexual incident.

Patient #2

Review of Patient #2's medical record revealed Patient #2 was admitted on 01/29/2025 for Depression with self-harm behavior. Nursing note dated 02/04/2025 at 11:00 PM documented at 9:40 PM Patient #2 was involved in a sexual incident with a female patient. Patient #2 was on Q15 minute observations at the time of the incident. Further review revealed a Nursing Note on 02/04/2025 at 7:00 PM Patient #4 caused self-harm by punching wall/door bruising his knuckles.

Further review of Patient #2's treatment plan revealed that Patient #2's treatment plan was not updated with sexual precautions from sexual incident that occurred 02/04/2025 at 9:40 PM or updated when Patient #2 caused self-harm by punching wall/door bruising his knuckles on 02/04/2025 at 7:00 PM.

In an interview on 03/11/2025 at 4:18 PM, S17CD verified the above information.

Patient #3
Review of medical record revealed Patient #3 was admitted on 11/05/2024 with a long history of anxiety disorder, depression and ADHD (Attention Deficit hyperactivity Disorder) and attempted suicide by bashing her head into the wall 10 times in an attempt to kill herself. Patient reported having suicidal thoughts of drowning and cutting herself. Patient #3 struggled with her sexual identity and was bullied in school.

Review of document titled "Incident Report Form", dated 11/11/2024, revealed on 11/11/2024 at 7:50 PM, Patient #3 notified the nurses that during rest time she was napping in her room when she felt her roommate, Patient #4, touch her side and then reach for her pelvic area. Patient #3 then fully awakened and sat up, stopping the incident. Patient #3 was moved to another room with a peer she identified as supportive.

Review of Patient #3's physician orders revealed an order for Adderall 10 mg every day for treatment of ADHD. Further review revealed the Adderall was changed to extended release and increased to 15 mg every day to treat ADHD.

Review of Patient #3's treatment plan failed to reveal Active Psychiatric Problems related to ADHD and anxiety. Further review failed to reveal Active Psychiatric Problems related to the sexual abuse Patient #3 endured on 11/11/2024.

During an interview on 03/12/2025 at 1:41 PM, S2DOR confirmed Patient #3's treatment plan failed to reveal Active Psychiatric Problems related to ADHD, anxiety disorder and the sexual abuse that occurred on 11/11/2024.

Patient #4

Review of Patient #4's medical record revealed Patient #4 was admitted on 11/06/2024 12:59 PM with the following diagnosis Bipolar Disorder, ADHD, Depression, and Autism Disorder.

Review of Patient #4's treatment plan identifies the following psychiatric diagnoses: Bipolar disorder, Attention-Deficit Hyperactivity Disorder, Depression, and Autistic Disorder, but fails to address ADHD, Depression, and Autism on the treatment plan.

In an interview on 03/12/2025 at 3:29 PM, S17CD verifies the information documented above.


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