HospitalInspections.org

Based on observation, interview, and record review, the facility failed to provide care in a safe setting for 22 of 22 patients (Patient #2 through Patient #23). This was evidenced by the facility's failure to ensure that the environment was free of objects that could be used to harm self or others - a box of 8-inch wooden pencils was on the shelf in the day room.

Findings were:

Observation of the day room on 4/22/2025 at 10:45 AM and on 4/23/2025 at 11:00 AM revealed a box of 8-inch wooden pencils that were accessible to all 22 patients on the unit.

In an interview with Staff B (DON) on 4/23/2025 at 11:00 AM, she stated the pencils could be used as weapons to harm self or others.

Based on interview and record review, the facility failed to obtain an order for a physical restraint for 1 of 1 patients (Patient #1). This was evidenced by the facility's failure to ensure that an order was obtained for a physical escort of the patient from one side of the building through the nurse's station.

Findings were:

Review of the definition of a restraint in A0159 - Patient Rights: Restraint or Seclusion 482.13(e)(1)(i)(A) showed: a restraint is any manual method, physical or mechanical ... [that] immobilizes or reduces the ability of a patient to move his or her arms, body, or head freely.

Review of the definition of a physical escort in A0161 - Patient Rights: Restraint or Seclusion 482.13(e)(1)(i)(A) showed: a physical escort would include a "light" grasp to escort the patient to a desired location. If the patient can easily remove or escape the grasp, this would not be considered physical restraint. However, if the patient cannot easily remove or escape the grasp, this would be considered physical restraint, and all the requirements would apply.

Record review of the Initial Psychiatric Evaluation with History and Physical Examination by Staff C (Attending MD) dated 10/23/2024 at 10:30AM showed a 21-year-old male with Prader-Willi Syndrome [a genetic disorder characterized by behavioral problems - such as temper outbursts - and mild to moderate intellectual impairment and learning disabilities]. He presented with "violent meltdowns, injuring self and others." He had "caused thousands of dollars' worth of damage ... attached a housemate ... struck the House Manager with a 2 x 4 board ... [and] tore the door off its hinges." IQ = 43. "Everyone is afraid of him ... [he] becomes very violent."

Record review of the Nurse Progress Note by Staff Q (RN) dated 10/30/2024 at 8:05 AM showed: "At 0530am, patient [Patient #1] started screaming so loud. When staff tried to intervene, patient became more agitated and even screaming louder ... was punching holes in the wall and destroying walls till the fire alarm started to go off ... order to put patient in seclusion ... It took 4 staff to transfer patient to seclusion room because patient was resisting ... was hitting head on window in seclusion room and punching the walls and tearing it apart."

Record review of the Seclusion/Restraint/Emergency Medication Administration form by Staff Q dated 10/30/2024 at 6:30 AM showed: "Unable to get vital signs. Patient assaultive and aggressive ... physical aggression, destruction of property, physical threats, explosive outbursts ... significant damage to treatment environment severe agitation/anxiety, danger to self."

Record review of Seclusion Restraint Debriefing form by Staff R dated 10/31/2024 at 1:30 PM showed that Patient #1 stated that staff hurt him and "dropped him and dragged him. He also alleged he was dragged by his legs."

In an interview with Staff G (MHT) on 4/23/2025 at 10:10 AM, she stated she was not working on 10/31/2024 when the incident with Patient #1 happened. She also stated that patients should never be taken through the nurse's station during a physical escort. She concluded by saying that patients should never be physically escorted "hanging upside down."

In an interview with Staff B (DON) on 4/23/2025 at 9:10 AM, she stated that she reviewed the surveillance footage of the incident involving Patient #1 along with Staff A (Administrator) and Staff F (IT). She also stated that part of the restraint and escort of the patient to the seclusion room was out of view of the camera, adding that the patient was carried through the nurse's station to shorten the distance. She described the patient as very anxious and over-stimulated. She referred to the physical escort as a physical hold. She stated that an order for the physical restraint was not gotten from the doctor.

In an interview with Staff F (IT) on 4/23/2025 at 9:55 AM, he stated he did not have access to the surveillance footage because the system had already recorded over it, adding that the system keeps footage about three months.

Based on interview, observation, and record review, the facility failed to ensure that a registered nurse assigned nursing personnel to provide nursing care for 22 of 22 patients (Patient #2 through Patient #23). This was evidenced by the facility's failure to ensure that:
1) Nursing care was assigned to a registered nurse.
2) Observation rounds were assigned to nursing staff.

Findings were:

Record review of policy, "Patient Care Assignments," last reviewed 4/2025, showed:
"A Registered Nurse (RN) must assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available.
A RN must make all Patient Care Assignments and Nursing Assignment Sheets at the start of every shift ...
PROCEDURE
Patient Care Assignments: After receiving the report and before delivering patient care, one RN per shift will complete the Patient Care Assignment sheet as follows: ...
2. Assign a primary care nurse to each patient next to the patient's room number ...
Nursing Department Assignment Sheet: ...
3. Delegate duties to psychiatric technicians to ensure patient needs are met.
4. Assign rounding periods of four hours for each technician.
5. Stagger other technician tasks ... to ensure continuous patient care throughout the shift."

In an interview with Staff A (Administrator) and Staff B (DON) on 4/22/2025 at 12:45 PM, they stated that each of the two RNs (Staff M and Staff N) had half of the patients but that the Nursing Assignment Sheet dated 4/22/2025 for 7AM-7PM did not identify which patients had been signed to each nurse. They also stated that the duties of each MHT [Mental Health Technician] had not been assigned on the Nursing Assignment Sheet.

Record review of the Nursing Assignment Sheet dated 4/22/2025 for 7AM-7PM showed two RNs (Staff M and Staff N), and three MHT (Staff G, H, and Staff O). Twenty-two current patients had not been assigned to the RNs. 10-minute rounds, environmental rounds, 1:1 observation, smoke breaks, vital sign checks, glucometer checks, groups, patient phone monitor, breakfast/lunch/dinner monitor, daily refrigerator logs, and weekly eye wash logs had not been assigned to a staff member.