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Based on record review and interview facility staff failed to remove medication from patient access when completing the intake process for 1 of 4 Patient (#7), which resulted in Pt. #7 being transported by EMS (Emergency Medical Services) for treatment of a drug overdose, and failed to document 15-minute checks were completed for 1 of 4 Patient (#7) in a total of 4 patients during admission to the facility.

Findings Include:

Facility staff failed keep a patient safe by removing medication from patient access and failed to document 15-minute safety checks per policy. See tag A-0144.






52395

Based on record review and interview the facility failed to document refusal of food and fluids and failed to assess nutrition and fluid status in 14 of 16 patients which resulted in Patient (Pt.) #4 requiring transfer to a higher level of care for dehydration and failed to assess 1 (Pt. #1) of 16 medical records for the reason for and after giving as needed medications. This failure to assess nutrition and fluid status and failure to assess the reason for and after giving as needed medications has the potential to impact all patients hospitalized at the facility.


Findings Include:

The facility failed to follow their daily nursing assessment policy, failed to assess Pt. #24 for suicide risk and failed to assess nutrition and fluid status as per policy. See Tag A-395

The facility failed to follow their medication administration policy, failed to assess Pt. #1 for the reason for and after giving as needed medications. See Tag A-405

Based on record review and interview the facility failed to have a process to evaluate the facility discharge program for 1 of 1 discharge programs reviewed, failed to follow their discharge policy to provide complete discharge information for 1 Patient (Pt.#1) out of 16 records reviewed and failed to provide discharge transfer information for 3 Patients (Pt. #2, #4 and #24) out of 3 records reviewed transferring to a higher level of care.

Findings:

The facility failed to have a process to evaluate the discharge program for 1 of 1 discharge programs reviewed. See Tag A-803.

The facility failed to provide complete discharge education and transfer information per policy. See Tag A-813.

Based on record review and interview facility staff failed to keep a patient safe by removing medication from patient access when completing the intake process for 1 of 4 Patient (#7) which resulted in Pt. #7 being transported by EMS for treatment for a drug overdose, and failed to document 15-minute checks were completed for 1 of 4 Patients (#7) in a total of 4 patients during admission to the facility.

Findings Include:

A review of the facility form titled, "Client Rights" effective 09/2024 revealed, "When you receive inpatient ... services for mental illness ... you have the following rights ... Your surroundings must be kept safe and clean ..."

A review of the facility policy #17598868 titled, "Admission Process for the Voluntary and Involuntary Patient" dated 02/13/2025 revealed, "B. Arrival and Admission of Voluntary Patients: 1. Patient presents to the hospital's Intake Department. 2. The patient will place their belongings in a bag and give the belongings to the in the Intake staff. Once completed the patient does not regain access to belongings until discharge or until the belongings inventory is completed for admission to ensure the safety of the patient and others."

A review of facility policy #14948866 titled, "Belongings Management Process" dated 10/09/2024 revealed, "B. Belongings Management 1. Upon entering the Intake Area, the patient will place all belongings in the a (sic) locked area provided by [Psych Hospital]. This includes luggage, clothing, purses, backpacks, bags, and any other item brought into the hospital. 3. After an admission order has been received, the patient's belongings are retrieved from the locked area ... 4. Medications are placed in a drop safe by the Intake Staff to be removed and reviewed by pharmacy before being stored on the unit for storage ..."

A review of facility policy #16358123 titled, "Patient Observation Rounds/Level of Observation" dated 08/06/2024 revealed, "It is the policy of [Hospital] to uphold the right of our patients to receive care in a safe and therapeutic environment. Patients are routinely observed in compliance with physician orders and/or prescribed protocols. Staff members assigned to each patient will provide monitoring, precautions, oversight and intervention to provide for their safety and security ... 1. Patient Observation Rounds will begin upon patient arrival to [Hospital] ... 2. Transfer admissions will be brought directly to the Intake Department where Patient Observation rounds will be immediately initiated by the Intake Staff utilizing a paper rounding sheet until the patient has been established to the hospital at which time a beacon (tamper resistant bracelet worn by patients to record safety rounds) will be paired and placed on the patient and Patient Observation Rounds will be transferred to the ObservSMART tablet ... 5. Level of Observation: 1. Q (every) 15 minutes Observations. Staff assigned to complete patient observation rounds will: a. Log in to the ObservSMART tablet and review their rounding assignment and begin documenting observations ... c. Observe each patient a minimum of every 15 minutes ... and document observation on the observSMART tablet."

A review of Patient #7's "Direct Admission Assessment" form dated 03/24/2025 at 12:55 PM revealed, "Voluntary admission of a 15-year-old female with complaints of suicidal ideation. Plan to jump out of a window. History of PTSD (Post Traumatic Stress Disorder), depression, anxiety and self-harm."

A review of facility "Incident Report" for Patient #7 revealed, "Date of Incident: 03/24/2025 Time: 2:10 PM ... As the writer was walking patient to unit 5, she endorsed not feeling good. Shortly after pt (patient) projectile vomited and told this writer that she tried to overdose. Writer inquired about when, the patient said when she was in the assessment room. Patient was helped to the unit EMS were called. Meds (medications) were found in brown paper bag that was given to patient at unknown time."

A review of the video of Patient #7 in the intake department in the assessment room on 03/24/2025 beginning at 1:22 PM was completed. The video of Patient #7 revealed the following: Patient #7 was sitting in the assessment room in a chair. There was a large brown bag sitting on the table. The door of the assessment room was propped open with a chair. Patient #7 was observed at:
1:22 PM- eating snacks
1:26 PM- left room to get more snacks
1:28 PM- left room to use bathroom
1:32 PM- observed looking in brown paper bag sitting on table in assessment room. Patient #7 grabbed gallon bag filled with bottles of medication. Looked at bottles of medication and put them back into brown bag.
1:33 PM- observed removing medications from brown paper bag, taking medication out of gallon bag, and taking pills out of medication containers and setting medications on table.
1:34 PM- medications containers were placed back into brown paper bag. Patient #7 grabbed the medication sitting on the table and put them in her mouth.
1:35 PM- Intake coordinator T walked into room and provided Patient #7 a journal and a stress ball.
1:36 PM- Intake coordinator T provided Patient #7 a cup of water.
1:37 PM- Patient #7 resting head on table.
1:38 PM- standing and throwing ball against wall.
1:41 PM- sitting in chair eating snacks.
1:43 PM- removed a book from the brown paper bag.
1:47 PM- resting in chair
2:08 PM- Patient #7 left the room with Intake Coordinator T.
2:15 PM- Arrived at adolescent unit- 15-minute checks began with beacon.

A review of Patient #7's "15-minute check form" that is completed in the intake department included checks being completed every 15 minutes from 03/24/2025 at arrival time of 12:00 PM through 1:15 PM (documentation indicated the beacon was placed on Patient #7 at 1:20 PM). Review of Patient #7's "Behavioral Health- Patient Observation Sheet" revealed, 15-minute checks starting at 2:15 PM through 3:30 PM. There was no documentation of 15-minute checks from 1:20 PM through 2:15 PM.

During an interview on 04/22/2025 at 8:59 AM, Director of Intake I stated when a new admit is brought to the facility a metal detector is used to check person and clothing. Medications are taken and placed in a white bag, folded over and stapled. The white bag is then placed in the safe for pharmacist to pick up.

During an interview on 04/22/2025 at 9:23 AM, Lead Receptionist J stated when a patient is brought in the front entrance a wand is used to check for contraband. Belongings are locked up in a locker including medication.

During an interview on 04/22/2025 at 9:46 AM, Intake Coordinator L stated the staff is trained on the intake process including checking the belongings of all patients. Intake Coordinator L stated when patients bring in medication they need to be taken and placed in a white bag and put in the safe. The patient should never be left alone with medication.

During an interview on 04/23/2025 at 8:15 AM, Intake Coordinator L stated she was working when Patient #7 was admitted to the facility. Patient #7 was brought to the facility by family. They entered the building through the main lobby. [Patient #7] was a direct admit from a hospital. Intake Coordinator L stated she went through her belongings, the patient only had a bra, underwear and a book. The belongings were placed in a brown paper bag. Intake Coordinator L stated the family member had a gallon bag a medication. They were encouraged to take them home, but they were adamant about the medications being left at the facility. Intake Coordinator L stated she was not aware that the medications had been placed in the brown paper bag with the other belongings. Intake Coordinator L stated she picked up the paper bag and gave the bag to the patient as she thought the bag only contained the few pieces of clothing and a book.

During an interview on 04/23/2025 at 12:01 PM, Intake Coordinator T stated she was working in the intake area when Patient #7 was admitted to the facility. Intake Coordinator T stated she that patients do not typically have personal items in the assessment room during the intake process. Intake Coordinator T stated she didn't look in the brown bag, so she was not aware that medications were mixed with personal belongings. Intake Coordinator T stated medications are usually separated from the patient immediately and put in a small white paper bag and stored in the pharmacy drop safe. Intake Coordinator T stated it was also brought to her attention that 15-minute checks were not documented on Patient #7 per facility policy.

During an interview on 04/24/2025 at 11:07 AM, Director of Intake I stated the staff identified that proper rounding was not documented on Patient #7.

Based on record review and interview the facility failed to assess 1 of 8 Patients (Pt. #24) for suicide risk, failed to document refusal of food and fluids and failed to assess nutrition and fluid status in 14 of 16 patients (Pt. #1, #2, #3, #4, #5, #6, #9, #10, #11, #17, #18, #19, #20 and #24). This failure to assess nutrition and fluid status has the potential to impact all patients hospitalized at the facility and resulted in Pt. #4 requiring transfer to a higher level of care for dehydration.

Summary:
Pt. #4 was a 21 year old admitted involuntarily as a Chapter 51 (temporary legal hold) on 3/17/2025 and was discharged on 03/24/2025. Pt. #4 had a diagnosis of bipolar disorder (mental disorder with severe mood swings) and suicidal tendency.

Pt. #24 was a 41 year old admitted involuntarily as a Chapter 51 on 02/17/2025 and discharged on 02/26/2025. Pt. #24 had a history of seizures, depression, paranoia and suicide intent.

Findings:

Review of facility policy #14954290, last reviewed 07/31/2024 titled, "Initial Nursing Admission Assessment," revealed, "Upon admission...each patient will be assessed by a registered nurse within eight (8) hours of admission to identify patient health care needs, and to guide the delivery of nursing care based on an analysis of information gathered....The Registered Nurse....interviews the patient, and collects and interprets data including...height, weight, vital signs, nutritional status...additional assessment data: Self-Injury/Suicide Assessment...when a patient is unable or unwilling to participate in the initial nursing assessment process, the nurse will gather as much information as possible to determine an initial plan of care and treatment. A unit nurse will then check every shift for patient's ability to provide information enabling the nurse to complete the incomplete portions of the "Nursing Assessment."

Review of facility policy #14954192, last reviewed 07/31/2024 titled, "Daily Nursing Assessment and Progress Note," revealed, "Nursing staff members are responsible for documenting clinical observations and care that he/she delivers/provides to each patient. Documentation by Nursing staff members shall be thorough, concise, accurate and will reflect the nursing process and the individual patients' response to the goals and interventions...what to chart....symptoms: using the person's own words, communication gestures, or non-verbal cues as much as possible...observations...interventions...illnesses and unusual health situations..nursing assessment; nursing care provided...any changes in condition in vital signs, refusal of meals, fluids."

Review of facility policy #14949628, last reviewed 07/17/2024 titled, "Proper use and Monitoring of Physical/Chemical Restraints and Seclusion," revealed, "The patient shall be assessed and monitored every 15 minutes while in....seclusion by the RN assigned/trained staff..fluids...shall be offered at least every two hours...meals shall be offered at regular meal times."

Review of facility policy #15186182, last reviewed 02/07/2024 titled, "Nutritional Assessment/Consult," revealed, "Nutrition screening will be completed for all patients at the hospital within eight (8) hours of admission by nursing."

Review of facility policy #14954445, last reviewed 07/16/2024 titled, "Medical Risk-Acute Change of Condition," revealed, "To identify warning signs of clinical deterioration in a patient's medical condition in order to provide early response to treatment that may patient [sic] mortality...When the clinical nursing staff identify symptoms in a patient that constitute a medical risk/acute change of condition they will proceed with the following steps:...Nursing staff will document the symptoms and interventions in the patient's clinical record to include:...chronology of events including the onset of symptoms, vital signs, description of symptoms and condition. Measures taken or treatment implemented...notify the patient's parent/guardian or emergency contact of the change in patient status."

Failure to assess suicide risk:

Review of Pt. #4's medical record revealed the suicide assessment completed on 03/17/2025 at 9:10 PM revealed entire assessment was documented as UTA.

Review of Pt. #24's medical record revealed a history of seizures, depression, paranoia and suicide intent, no suicide assessment was completed.

Failure to assess food and fluids:

Review of Pt. #4's nursing admission assessment no date or time of completion revealed multiple sections of UTA (Unable to Assess), no evidence of a nutrition assessment was completed and no evidence of vital signs being taken until 3/19/2025 at 9:11 AM. (48 hours after Pt. #4 was admitted). There was no evidence Pt. #4 was monitored for food or fluids or assessed for symptoms of dehydration throughout their hospitalization.

Review of Patient #4's medical record revealed Pt. #4 was placed in seclusion for sexual aggression, inappropriate behavior, agitation, bizarre and uncooperative behaviors on:
03/21/2025 from 12:55-1:50 PM a total of 55 minutes
03/21/2025 from 4:05 - 6:46 PM a total of 2 hours and 40 minutes
03/22/2025 from 4:52-6:18 PM a total of 1 hour and 26 minutes
03/22/2025 from 8:02 -10:43 PM a total of 2 hours and 41 minutes
03/23/2025 from 9:35 - 11:45 AM a total of 2 hours and 10 minutes
There is no documentation present if Pt. #4 received or was offered fluids or meals while they were in seclusion. There is no documentation of food or fluid consumption or refusal of food or fluids present in Pt. #4's medical record throughout their hospitalization at the facility from 03/17/2025-03/24/2025 (7 days).

Pt. #24 was hospitalized from 02/17/2025 through 02/26/2025 (9 days) and no evidence of food or fluid consumption was documented during their hospitalization. Pt. #24 required an IM injection of Thorazine and Ativan on 02/24/2025 and was placed in seclusion for 57 minutes and was not offered fluids while in seclusion Pt. #24 had a seizure while hospitalized and was transferred for a higher level of care on 02/25/2025 and then returned to the facility. Review of Pt. #24's medical record revealed no nutrition assessment was completed.

Review of medical records for Patients #1, #2, #3, #4, #5, #6, #9, #10, #11, #17, #18, #19 #20 and #24 revealed no evidence of patients being assessed for food or fluid consumption or refusal of food throughout their hospitalizations and no admission nutrition assessments were completed.

On 04/24/2025 at 2:26 PM in an interview with Chief Nursing Officer (CNO) V when asked if they would expect to see something documented about refusal of food or fluids, V stated, "I would."

On 04/24/2025 at 3:20 PM in an interview with CNO V when asked if it was accurate there was no documentation of meal consumption, V stated, "There is no documentation of meal consumption, agree that is concerning."

On 04/30/2024 at 12:13 PM in an interview with Nursing Manager EE when asked what is the expectation to use UTA when assessing a patient, EE stated, "We don't have anything that talks about it, staff should always redo it, I don't believe we should ever see a UTA."

Based on Record Review and interview the facility failed to assess 1 (Pt. #1) of 16 medical records reviewed for the reason for and after giving as needed medications.

Summary:

Patient #1 was a 14 year old admitted voluntarily on 02/26/25 through 03/12/2025 following a suicide attempt. Pt. #1 had a history of multiple hospitalizations for suicide attempts, depression, anxiety and anger management.

Findings:

Review of Facility policy #15018754 titled, "Medication Administration," effective date 01/10/2024 revealed, "All indications for the use of the medication will be documented appropriately in the Medication Administration Record...PRN [as needed] medications require reassessment to determine effectiveness of medication with measurable results....This should be documented on the MAR (Medication Administration Record)."

Review of Pt. #1's Medication Administration Record (MAR) revealed Pt. #1 had Vistaril 25 mg as needed for anxiety up to 4 doses daily, Zyprexa 5 mg as needed for mood every 8 hours as needed up to 3 doses daily and Melatonin 3 mg for sleep as needed at bedtime. Pt. #1 received the following PRN medications:

Vistaril 25 mg oral was given as needed on 2/27/25 at 1:44 PM, 2/28/25 at 1:51 PM, 3/3/25 at 9:15 AM, 3/4/25 at 4:18 PM, 3/7/25 at 5:01 PM, 3/8/25 at 9:25 AM, 3/9/25 at 10:07 AM, 3/10/25 at 10:28 AM and 9:23 PM, 3/11/25 at 7:29 PM and on 3/12/25 at 9:00 AM
Zyprexa 5 mg oral was given as needed on 2/27/25 at 1:45 PM, 2/28/25 at 1:51 PM, 3/3/25 at 4:19 PM, 3/4/25 at 9:12 PM, 3/8/25 at 9:33 AM and 5:27 PM, 3/11/25 at 7:29 PM and 3/12/25 at 9:55 AM
Melatonin 3 mg oral was given as needed on 2/28/25 at 8:47 PM, 3/5/25 at 8:29 PM, 3/7/25 at 8:47 PM, 3/8/25 at 8:48 PM and 3/10/25 at 9:23 PM.

Review of Pt. #1's medical record, medication administration record revealed no evidence of indications for or reassessment completed or documented when PRN medications were administered during their hospitalization.

On 04/22/2025 at 3:44 PM in an interview with Registered Nurse GG, GG stated that patients are assessed with the morning and afternoon medication passes and as needed for PRN medications.

Based on Record Review and Interview the facility failed to have a process to evaluate the facility discharge program for 1 of 1 discharge programs reviewed.

Findings:

Review of Facility Discharge program revealed no evidence of a policy or procedure that addresses periodic review of patient discharge plans including those readmitted within 30 days of a previous admission.

On 04/30/2025 at 4:21 PM in an interview with Chief Clinical Officer FF who oversees social services and discharge planning, when asked how the discharge process is reviewed for effectiveness, FF stated, "I review with the staff involved, we do discharge audits every month to make sure everything is done." When asked if this review includes a review of the 30 day admissions, and if there is a process to review the 30 day readmissions, FF stated, "No. We discuss it clinically."

Chief Clinical Officer FF was unable to provide any documentation about how they evaluate the discharge program.

Based on record review and interview the facility failed to provide a medication list upon discharge for 1 Patient (Pt. #1) out of 12 records reviewed and failed to provide discharge transfer information for 3 Patients (Pt. #2, #4 and #24) out of 4 records reviewed transferring to a higher level of care.

Summary:
Patient #1 was a 14 year old admitted voluntarily on 02/26/25 through 03/12/2025 following a suicide attempt. Pt. #1 had a history of multiple hospitalizations for suicide attempts, depression, anxiety and anger management.

Patient #2 was a 15 year old admitted involuntarily on 03/05/2025 through 03/10/2025 following an unsuccessful suicide attempt to shoot herself. Pt. #2 was recently discharged in February 2025 from this facility for similar concerns. Pt. #2 was discharged on 03/10/2025 to another psychiatric facility for a higher level of care due to repeated suicide attempts and behaviors while hospitalized.

Patient #4 was a 21 year old admitted involuntarily as a Chapter 51 (temporary legal hold) on 3/17/2025 and was discharged on 03/24/2025. Patient #4 had a diagnosis of bipolar disorder (mental disorder with severe mood swings) and suicidal tendency.

Patient #24 was a 41 year old admitted involuntarily on 02/17/2025 through 02/26/2025 with a history of seizures, depression, paranoia and suicide intent.

Findings:

Review of facility policy #14949024, last reviewed 01/30/2024 titled, "Discharge Planning Process," revealed, "The development of a Discharge Plan begins upon admission and is a continuous process...The individual's demonstrated readiness for discharge should be linked to the achievement of the multidisciplinary treatment goals....the multidisciplinary treatment team will develop aftercare plans on all individuals...The discharge/aftercare plan should: Prepare the individual and family for the transition to the next level of care...address the individual's and family's need for instructions about continued treatment...delineate how progress made in the current level of care will continue after discharge...identify the responsibility for ensuring that the prescribed follow-up care is accomplished...include timely and direct communication with and transfer of information to other programs, agencies or individuals that will be providing continuing care...The discharge/aftercare plan should define the following:...the level of care which the individual will be discharged to...a listing of all medications that the individual is to continue taking after discharge and...method for obtaining medications...follow up appointments...referrals...Discharge/aftercare plans and information on prescribed medications are communicated to the individual and family...and documented appropriately in the individuals electronic medical record. Discharge/aftercare plans are to be signed by the individual to acknowledge receipt and understanding of the information. The individual receives the original copy of the form at time of discharge/transfer. The Social Worker....designee will also fax or mail a copy of the forms to the next provider of care. This will occur for all internal transfers from one level of care to another....and for all referrals to providers in the community responsible for continuing care...All documentation related to discharge planning will be reflected in the individual's medical record."

Review of facility policy #14726135, last reviewed 07/10/2024 titled, "Discharge Process-Department Roles," revealed, "The discharge procedure is a multidisciplinary task that is to be completed by the members of the treatment team. This includes communicating the coordination of discharge planning with the individual, their family, natural supports and other person who may be involved in their care....The nurse will assist the individual in....reviewing and understanding discharge instructions and aftercare plan...reviewing and understanding the discharge medications/medication reconciliation.

Review of Pt. #1's medical record discharge summary on 03/12/2025 revealed Pt. #1 signed their discharge plan which included a listing of follow up appointments, crisis safety plan, Columbia suicide assessment, and health related social needs screening, there was no evidence of a signed discharge medication list provided to Pt. #1.

Review of Pt. #2's medical record revealed they were a 15 year old with a history of suicide attempts and multiple attempts while hospitalized. Pt. #2's discharge summary completed by Doctor AA on 03/10/2025 at 2:00 PM revealed, "According to nursing reports, patient tried to kill herself on the unit yesterday evening...required medical intervention and was transferred for acute medical stabilization...at the time of discharge, lethality was denied and psychosis resolving. Mood and anxiety were well managed...patient was seen and evaluated on the day of discharge and deemed to be absent credible lethality and had achieved the maximum benefit from an inpatient hospitalization, so was discharged. Patient transferring to [a higher level of care facility]. Review revealed no evidence of a transfer form, or information sent to the receiving facility indicating Pt. #2's condition or why they were transferred.

Review of Pt. #4's Discharge Summary on 3/24/2025 revealed, "At the time of discharge, pt had been moved to a higher acuity unit due to psychotic behaviors, had apparently become dehydrated and was sent out to a medical facility for treatment and observation where he was admitted." Discharge diagnosis were, "Bipolar disorder, current episode manic, severe with psychotic features." Review of Pt. #4's discharge paperwork revealed pages 3-5 were missing and there was no evidence of a completed transfer form , MOT (Memorandum of Transfer) or status of patient's medical condition at the time of transfer.

Review of Pt. #24's medical record revealed a history of seizures, depression, paranoia and suicide intent. Pt. #24 was hospitalized from 02/17/2025 through 02/26/2025. Pt. #24 had a seizure while hospitalized and was transferred for a higher level of care on 02/25/2025. There was no evidence of a transfer form being completed when a higher level of care was required.

On 04/22/2025 at 2:39 PM in an interview with Social Work/Discharge Planner P, when asked what patients receive when they are discharged home, Discharge Planner P stated, "They get a copy of all of the discharge planning information, medications, it is reviewed with the patient and family by the nurse."

On 04/30/2025 at 3:40 PM in an interview with Director of Risk H, when asked if a memorandum of transfer form should be used with for patients transferring to a facility or higher level of care, H said, "Yes." When asked if it was correct that [Pt. #2, #4 and #23] were missing transfer forms when they were discharged or transferred, Director of Risk H stated, "That would be correct."