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Based on observation, interview and record review, the hospital failed to ensure a safe environment was provided for 10 of 20 patients (Patient #6, #7, #8, #9, #14, #31, #32, #39, #40 and Patient #44) and

1) Patient #14, a 10 year old pediatric patient, was assaulted by Patient #39, a 14 year old adolescent, and Patient #40, a 16 year old adolescent. Patient #14 was sent to the medical hospital for a head injury.

2) Patient rounds records did not accurately document behavior/location and/or were left incomplete for 8 of 20 patients (Patient #6, #7, #8, #9, #14, #31, #32, and Patient #44)

3) An oxygen tank identified and documented by staff as being full was empty and oxygen was not available in case of an emergency.

4) Four electrical cords, a plastic trash bag, and a substance (Sani Wipes) that required poison control interventions in case of ingestion were in close proximity and accessible to patients eating their lunch meal on 04/21/15.

(refer to A144)

Based on record review and interview, the hospital's performance improvement

1) failed to track adverse patient events for 4 of 4 patients (Patient #14, #39, #40 and Patient #47).

Patient #39 and #40, adolescents, assaulted Patient #14, a pediatric patient.

Patient #47) threw a lit cigarette at a patient.


2) failed to investigate why more than 20 patient's urine specimens were left on the hospital adolescent unit for an unknown time without timely processing by the lab.

Refer to A0286

Based on observation, interview and record review, the hospital failed to ensure nursing services was adequately supervised and met the care needs of patients.

1) Registered nurses failed to assess, reassess patients with medical needs. Patient #14 was sent to the acute care hospital and upon return was not assessed.

2) Patient #41 fell on his left wrist/hand and no assessment was completed after the event was reported to the nurse on 04/20/15. Patient #41 did not receive treatment for a fracture until 04/24/15.

3) Nurse staffing on the adolescent unit and adult unit on 03/22/15, and 04/20/15. Patient #14, a pediatric patient, was assaulted by a 14 and 16 year old adolescent. One technician was in charge of the 14 patients. The adult psychiatric unit had a total of 16 patients with one technician. One of the sixteen patients was on (HLO) hightened level of observation every five minute checks and the technician was responsible for all 16 patients observation rounds.

(refer to 0392 and 0395)

Based on observation, interview and record review, the hospital failed to ensure a safe environment was provided for 10 of 20 patients (Patient #6, #7, #8, #9, #14, #31, #32, #39, #40 and Patient #44).

1) Patient #14, a 10 year old pediatric patient, was assaulted by Patient #39, a 14 year old adolescent and Patient #40, a 16 year old adolescent. Patient #14 was sent to the medical hospital for a head injury.

2) Patient rounds records did not accurately document behavior/location and/or were left incomplete for 8 of 20 patients (Patient #6, #7, #8, #9, #14, #31, #32, and Patient #44)

3) An oxygen tank identified and documented by staff as being full was empty and oxygen was not available in case of an emergency.

4) Four electrical cords, a plastic trash bag, and a substance (saniwipes) that required poison control interventions in case of ingestion were in close proximity and accessible to patients eating their lunch meal on 04/21/15.

Findings included:

1) Patient #14's Integrated Assessment dated 03/08/15, timed at 0100, showwed, "10 year old female in foster care...anger issues with Mother and Dad...reports she sometimes does not use coping skills...history of mood disorder, anxiety...history of cutting self mutilation..."

The Group Notes dated 03/21/15, timed at 1100, showed, "Attentive...hears other patients being mean...says she is afraid of another patient..."

The Multidisciplinary Progress Notes dated 03/22/15, timed at 2000, showed, "Female peer slapped patient in the face, she (Patient #14) fell to the floor, when she stood up the female with another female peer jumped her (Patient #14) and hit her (Patient #14) on the floor...neuro checks started...called Dr...send to ER (emergency room) for medical clearance of any injuries... Social Worker guardian called and notified...stated he will press charges for assault against the two female patients...gave report to (hospital)...2015...transport arrives to take patient to hospital..."

The Multidisciplinary Progress Notes dated 03/22/15 (03/23/15) timed at 0330 showed, "Hospital called to give report...patient on way back to unit with minor injury to head...suggests Ibuprofen for headache..."

On 04/23/15, at 0844, Personnel #33 was interviewed. Personnel #33 was asked if she had reviewed the assault incident involving Patient #14 and the injuries suffered on 03/22/15, and whether the assault was investigated. Personnel #33 stated she was unaware of the assault and stated she picked up the reports.

On 04/23/15, at 0915, Personnel #2 was interviewed. The surveyor asked Personnel #2 if an investigation had been completed in regard to the assault on Patient #14 who suffered at the hands of a 14 and 16 year old adolescent. Personnel #2 stated that the event had not been investigated and was unaware that a pediatric patient was assaulted. Personnel #2 was asked if she had any documentation on the two adolescents who assaulted Patient #14. Personnel #2 said she did not know who the two patients were.

On 04/24/15, a confidential Interview was conducted. The interviewee stated that the adolescent girls and pediatric patients are housed together. The interviewee said that the documentation in the medical record did not accurately reflect what happened. The interviewee stated that Patient #14 was slapped in the face which caused Patient #14 to fall and hit her head on the door. The two girls then attacked Patient #14 while she was on the floor. The interviewee stated the girls were separated and while walking in front of the nursing station one of the two girls slapped Patient #14 again. The interviewee said there was only one technician for 14 patients.


Patient #39's Integrated Assessment dated 03/16/15, timed at 22:02, showed, "14 year old...urges for self-injury...history of PTSD (post traumatic stress disorder), Bipolar...family conflict...hitting, slapping."

The 03/22/15, Multidisciplinary Progress Note timed at 23:50, showed, "Met with patient...agitated, aggressive/combative around unit...re-directable...will continue to monitor." No details were documented regarding the assault on Patient #14.


Patient #40's Integrated Assessment dated 03/21/15, timed at 15:30, showed, "16 year old accompanied by police...increased appetite due to pregnancy...involved in human trafficking (witness)...runaway...three months pregnant...wanted to hurt herself...admit for safety."

The Multidisciplinary Progress Note dated 03/22/15, timed at 23:00, showed, "Met with patient...agitated, behavioral aggression, combative period, yelling, cursing...fighting with peers...redirected, q15 (every fifteen minute) for safety." No details were documented regarding the assault on Patient #14.

Hospital Policy TMHS.NURS.067 dated 02/2015, and titled Patient Rights and Responsibility noted that "without limitations patient shall be entitled to care in a safe and sanitary setting."


2) A. Patient #14's Multidisciplinary Progress Notes dated 03/22/15, timed at 2000, showed, "Female peer slapped patient in the face, she (Patient #14) fell to the floor, when she stood up the female with another female peer jumped her (Patient #14) and hit her on the floor...neuro checks started...called Dr...send to ER (emergency room) for medical clearance of any injuries... Social Worker guardian called and notified...stated he will press charges for assault against the two female patients...gave report to (hospital)...2015...transport arrives to take patient to hospital..."

Patient #14's Precaution Checklist (close observation 15 minute checks for assault) dated 03/22/15 (the day of assault), timed from 2045 through 2345 revealed the following documentation:

The precaution checklist timed from 2045 through 2100 showed, "Quiet in patient room."

The precaution checklist timed from 2115 through 2145 showed, "Interacting socially in the large lounge."

The precaution checklist timed from 2200 through 2345 showed, "Sleeping in patient room."

The above precaution checklist did not accurately document the location/behavior of the patient as Patient #14 was transferred to the acute care hospital on 03/22/15, at 2015.

On 04/30/15, at 1450, Personnel #37 was interviewed. Personnel #37 reviewed Patient #14's medical record and verified the rounds records were not accurate.


B. Patient #31's Notification of Emergency Detention dated 04/24/15, timed at 0855, showed, "Stating he wanted to kill himself...anger problems."

The APOWW Pre-Assessment Screening dated 04/22/15 (04/24/15) timed at 2200 showed, "Patient arrived on unit at 2055."

The Precaution Checklist for 04/25/15, showed, "Discharged 0030." No precaution checklist was found for 04/24/15, from 2055 to 2345.

On 05/01/15, at approximately 1000, Patient #31's medical record was reviewed with Personnel #3. Personnel #3 verified the rounds records were not completed for 04/24/15.


C. Patient #32's Notification of Emergency Detention dated 04/24/15, showed, "Patient #32 was becoming violent with neighbors and stated he wanted to die...would make police kill him..."

The 04/24/15, Precaution Checklist showed, "1600 to 1645" was left blank with no documentation regarding behavior/location.

On 05/01/15, at approximately 1015 (Patient #32's) medical record was reviewed with Personnel #3. Personnel #3 verified the rounds records were not completed for 04/24/15.


The policy and procedure entitled, "Patient Observation/Levels of Observation" with a current effective date of 03/2015, showed, "Purpose to ensure patient safety...to provide a process for observing and documenting patient location and behavior...document patient location and behavior when the observation occurs on the patient observation form...while monitoring hallways and patient care areas ensure patients are not entering rooms not assigned to them...not in rooms or areas that are designated "off limits" areas to patients...not left in "Treatment Areas" without direct staff supervision...levels of observation...all in-patient admissions as well as APOWWs will be on close observation with a minimum of observation to be completed every 15 minutes (give or take 5 minutes)...documentation of patient's behavior will be documented on the patient observation form...(Patient Observation Checklist)....Heightened Level of Observation (HLO) 5 minute close observation...where a patient is visualized and monitored for safety at least every five minutes..."


D) Patient #44 nursing documentation dated 04/19/15, showed the patient had eloped at 1400, and returned to the unit at 14:30. Patient #44's 15 minute precaution checklist dated 04/19/15, showed the patient was 'sleeping in [the] large lounge" between 14:00 and 1430. Personnel #3 and Personnel #14 acknowledged the above findings on 04/28/15, at approximately 15:30.


E) Patients #6's, #7's, #8's, and #9's behavior and location were observed documented on 04/20/15, at 1315, on the patient's precaution checklists. The time slots for 1245, 1300 and 1315 were left blank. One mental health technician was in charge of 16 patients including Patient #50 who was on every five-minute (HLO) (high level observation) checks.

Patient #6's Physician's Preadmission examination orders dated 04/19/15, placed the patient under an order of protective custody for safety on 04/09/15. The patient's precaution checklist dated 04/20/15, showed the patient was on close observation and 15 minute checks.


Patient #7's Physician's Orders dated 04/18/15, placed the patient on suicide precautions. The patient's precaution checklist dated 04/20/15, showed Patient #7 was on fifteen minute checks for suicide.


Patient #8's Physician Orders dated 03/26/15, ordered the patient to be on suicide precautions. Patient #8's precaution checklist dated 04/20/15, noted the patient was on close observation for suicide precautions.


Patient #9's Admission Physician Orders dated 04/14/15, the patient was ordered to be on 15 minute checks and suicide precautions. The patient's precaution checklist dated 04/20/15, noted the patient was on 15 minute checks.


Patient #50's Preadmission Examination Orders dated 04/17/15, showed the patient's admission diagnosis of Major Depressive Disorder, Recurrent,with psychotic features. Patient #50 was placed on suicide precautions. The Physician Daily Progress Note dated 04/20/15 at 1230 showed the patient heard voices telling the patient to kill herself, was suicidal, had scratched herself the previous day and "could not promise no harm." The physician placed the patient on high level of observation.


During an interview on 04/20/15, at 1345, Personnel #3 acknowledged the above findings and stated the 15-minute observation checklists "should not be behind."

On 04/23/15, (confidential interview) Personnel #17 acknowledged that the unit did not have enough staff.


3) Observations on 04/20/15, at 1020, in the Trauma Unit Exam Room showed an oxygen tank placed in an area identified as storage for full oxygen tank was sealed with plastic. Personnel #4 stated it was full. Upon surveyor request, Personnel #6 opened the seal, tested the tank and stated, "It registers empty."

Personnel #2 stated during an interview on 04/20/15, at 1225, that nurses "were trained to turn on the oxygen to make sure the tanks are full. It is on their [the nurses'] competency checklist."

Personnel #3 was interviewed on 04/20/15, at 1235, and asked how nurses knew an oxygen tank was full. Personnel #3 replied that if the plastic seal was on the tank "it should be full."


4) Observations on 04/21/15, at 12 noon, in the hospital's dining room showed nine adolescent patients eating lunch. In close proximity and accessible to the patients, an unlocked door led to a room identified by Personnel #12 as staff dining room. The staff dining room contained the following items: a large plastic bag in a trash can, four electrical cords of about three feet of length each connecting steam tables with their electric outlets, and a container of 100 count saniwipes which carried the warning to call poison control in case of ingestion.

Personnel #12 acknowledged the above observations on 04/21/15 at approximately 1210.

Based on record review and interview, the hospital's performance improvement failed to

1) Track adverse patient events for 4 of 4 patients (Patients #14, #39, #40 and Patient #47). Patient #39 and Patient #40, adolescents, assaulted Patient #14, a pediatric patient.

Patient #47 threw a lit cigarette at a patient.


2) Investigate why more than 20 patients' urine specimens were left in the adolescent unit's refrigerator for an unknown length of time without timely processing by the lab technician.


Findings included:

1) Patient #14'sThe Multidisciplinary Progress Notes dated 03/22/15, timed at 2000, reflected, "Female peer slapped patient in the face, she (Patient #14) fell to the floor, when she (Patient #14) stood up the female with another female peer jumped her (Patient #14) and hit her on the floor...neuro checks started...called Dr...send to ER (emergency room) for medical clearance of any injuries... Social Worker guardian called and notified...stated he will press charges for assault against the two female patients...gave report to (hospital)...2015...transport arrives to take patient to hospital..."

On 04/23/15, at 0844, Personnel #33 was interviewed. Personnel #33 was asked if she had reviewed the assault incident involving Patient #14 and the injuries suffered on 03/22/15, and whether the assault was investigated. Personnel #33 stated that she was unaware of the assault and stated that she just picked up the reports. Personnel #33 denied an investigation of the incident which involved (Patient #14) being slapped.

On 04/23/15, at 0915, Personnel #2 was interviewed. The surveyor asked Personnel #2 if an investigation had been completed in regard to the assault which Patient #14 suffered at the hands of a 14 and 16 year old adolescent. Personnel #2 stated that the event had not been investigated and was unaware that a pediatric patient was assaulted. Personnel #2 was asked if she had any documentation on the two adolescents who assaulted Patient #14. Personnel #2 said that she did not know who the two patients were.

On 04/24/15, a confidential Interview was conducted. The interviewee stated that the adolescent girls and pediatric patients are housed together. The interviewee said that the documentation in the medical record did not accurately reflect what happened. The interviewee stated that Patient #14 was slapped in the face which caused Patient #14 to fall and hit her head on the door. The two girls then attacked Patient #14 while she was on the floor. The interviewee stated the girls were separated and while walking in front of the nursing station one of the two girls slapped Patient #14 again. The interviewee said there was only one technician for 14 patients.


Patient #39's 03/22/15 Multidisciplinary Progress Note timed at 2350, reflected, "Met with patient...agitated, aggressive/combative around unit...re-directable...will continue to monitor." No details were documented regarding the assault on Patient #14.


Patient #40's Multidisciplinary Progress Note dated 03/22/15, timed at 2300, reflected, "Met with patient...agitated, behavioral aggression, combative period, yelling, cursing...fighting with peers...redirected, q15 (every fifteen minute) for safety." No details were documented regarding the assault on Patient #14.


Patient #47's Admitting Diagnosis dated 04/19/15, at 1500, reflected the patient was hospital admitted with diagnoses including Paranoid Schizophrenia.

Patient #47's Multidisciplinary Progress Notes dated 04/19/15, at 1320 reflected Patient #47 had "thoughts of harming self and others....became very anxious, agitated, and threatening other patients on the unit because he threw a lit cigarette at a patient in the smoke room..."

On 04/23/15, at 1450, Hospital Personnel #2 denied an investigation of the incident was done because "the nurse decided that it did not need to be investigated since nobody got hurt." Personnel #2 stated an investigation would be initiated.


2) On 04/23/15, at 1040, the surveyor observed 22 urine collection cups with yellow liquid in the refrigerator located at the hospital's Burkett I Treatment Room. Personnel #46 acknowledged that there were no accompanying lab requisition sheets with the specimen cups "because the computer was down last night and the lab person did not pick up the urine this morning because they did not have paper work."Personnel #46 stated one of the specimens was provided by (Patient #40) who was discharged.

On 04/23/15, at 1315, Personnel #2 denied having received notification that 22 specimen cups had not been picked up by the lab technician.

Record review of the hospital's performance improvement documentation reflected every second hospital incident in 02/2015, was documented as physical confrontation. Personnel #14 acknowledged the data on 04/23/15, at 0920.

Personnel #2 was asked about an improvement plan for physical confrontation and stated on 04/23/15, at 0930 that "a PI [performance improvement] team is being developed."

Based on observations, interviews and record review, the hospital failed to ensure nursing services had an adequate number of nursing personnel to provide care/supervision
for 2 of 4 units (Adolescent/Child Unit and Adult Psych Unit ) in that

1) 1 of 1 patient (Patient #14), a 10 year old pediatric patient, was assaulted by Patient #39, a 14 year old adolescent, and Patient #40, a 16 year old adolescent. Patient #14 was sent to acute care hospital for a head injury, and

2) 4 of 4 patients (Patients #6, #7, #8, and Patient #9) on the hospital's Adult Psych Unit did not have their behaviors and locations documented on their precaution sheets for 45 minutes on 04/20/15. One technician was in charge of 15 patients on 15 minute precautions and one acutely suicidal patient (Patient #50) on high level of observation (5 minute checks).


Findings included:

1) On 03/22/15, Patient #14, a 10 year old pediatric patient, was assaulted by Patient #39, a 14 year old adolescent patient, and Patient #40, a 16 year old adolescent patient. Patient #14 was sent to acute care hospital for a head injury.

The daily patient checklist dated 03/22/15, for adolescent/child (girls) revealed, 14 total patients listed on the daily patient checklist. Three (30 of the fourteen (14) patients were APOWW's. One MHT was assigned to all 14 patients. One nurse was assigned for the adolescent/girls unit. Fourteen patients were on close observations (15 minute checks), seven patients were on assault precautions, two patients were on (SAO) sexually acting out precautions and six patients on suicide precautions.

On 04/24/15, a confidential Interview was conducted. The interviewee stated that the adolescent girls and pediatric patients are housed on the same unit. The interviewee stated that there was only one MHT (mental health technician) for 14 adolescent/children and one nurse on 03/22/15. The interviewee stated this included any APOWW's (apprehension by peace officer without warrant) on the unit. The interviewee stated the staffing is unsafe.


2) Patients #6's, #7's, #8's, and #9's behavior and location were observed documented on 04/20/15, at 1315, on the patient's precaution checklists. The time slots for 1245, 1300 and 1315 were left blank. One mental health technician was in charge of 16 patients including Patient #50 who was on every five-minute observation checks.

Patient #6's checklist dated 04/20/15, reflected the patient was on close observation and 15 minute checks.

Patient #7's precaution checklist dated 04/20/15, reflected Patient #7 was on suicide precautions.

Patient #8's precaution checklist dated 04/20/15 noted the patient was on close observation for suicide.

Patient #9's precaution checklist dated 04/20/15 noted the patient was on 15 minute checks.

Patient #50 was on high level of observation (every 5 minutes) for previous self-harming behavior.

During an interview on 04/20/15, at 1345, Personnel #3 acknowledged the above findings and stated the 15-minute observation checklists "should not be behind."

On 04/23/15, (confidential interview) Personnel #17 acknowledged that the unit did not have enough staff.

The hospital policy entitled, "Staffing Plan" with an effective date of 02/2015, reflected, "To provide the appropriate number of staff necessary to provide patient care...staffing assignments based on the programmatic and acuity needs..."

Based on observation, interview and record review, the hospital failed to ensure a Registered Nurse (RN) evaluated/re-assessed the care needs for:

1) 3 of 3 patients (Patient #14, #39 and Patient #40) who were in a physical altercation. The RN did not complete neuro-checks, vital signs upon Patient #14's, a 10 year old child, return from the acute carel hospital. The RN failed to document Patient #39's, a 14 year old adolescent, and Patient #40's, a 16 year old adolescent, involvement in the assault on (atient #14. No details regarding the event, skin assessment, vital signs were documented for Patient #39 and Patient #40.


2) 1 of 1 patient (Patient #41) sustained a fractured left wrist on 04/20/15. Although the technician reported the event to the RN, the RN did not document an initial assessment and/or ongoing assessment of the site until after the patient returned from the ER (emergency room) on 04/24/15, at 2330.


Findings included:

1) Patient #14's Integrated Assessment dated 03/08/15, timed at 0100, reflected, "10 year old female in foster care...anger issues with Mother and Dad...reports she sometimes does not use coping skills...history of mood disorder, anxiety...history of cutting self mutilation..."

The Group Notes dated 03/21/15, timed at 1100, reflected, "Attentive...hears other patients being mean...says she is afraid of another patient..."

The Multidisciplinary Progress Notes dated 03/22/15, timed at 2000, reflected, "Female peer slapped patient in the face, she (Patient #14) fell to the floor, when she stood up the female with another female peer jumped her (Patient #14) and hit her on the floor...neuro checks started...called Dr...send to ER (emergency room) for medical clearance of any injuries... Social Worker guardian called and notified...stated he will press charges for assault against the two female patients...gave report to (hospital)...2015...transport arrives to take patient to hospital..."

The Multidisciplinary Progress Notes dated 03/22/15 (03/23/15) timed at 0330 reflected, "Hospital called to give report...patient on way back to unit with minor injury to head...suggests Ibuprofen for headache..." No neuro-checks, vital signs and/or re-assessment was documented for the 10 year old child.

The acute care hospital's discharge instructions dated 03/23/15, with a print timed at 0405, reflected, "Head Injury (Child: No Wake-Up)...your child has had a mild head injury...sometimes symptoms of a more serious problem (bruising or bleeding in the brain) may appear later...during next 24 hours watch for warning signs...home care...next 24 hours someone must stay with your child to check for signs below...if there is swelling of the face, scalp, apply an ice pack for 20 minutes every 1-2 hours until swelling starts to go down...do not use aspirin or ibuprofen after a head injury...you may use Tylenol...for next 24 hours do not give medicines that might make your child sleepy...no strenuous activities..."

On 04/23/15, at 1321, Personnel #3 was interviewed. Personnel #3 reviewed Patient #14's medical record. Personnel #3 verified that no vital signs, assessment, neuro-checks were completed for (Patient #14) upon return from the hospital.


Patient #39's Integrated Assessment dated 03/16/15, timed at 2202, reflected, "14 year old...urges for self-injury...history of PTSD (post traumatic stress disorder), Bipolar...family conflict...hitting, slapping."

The 03/22/15, Multidisciplinary Progress Note timed at 2350, reflected, "Met with patient...agitated, aggressive/combative around unit...re-directable...will continue to monitor." No vital signs, assessment and/or details were documented for (Patient #39).

On 04/23/15, at 1330, Personnel #3 was interviewed. Personnel #3 reviewed Patient #39's medical record. Personnel #3 verified that no vital signs and assessment was completed for (Patient #39).


Patient #40's Integrated Assessment dated 03/21/15, timed at 1530, reflected, "16 year old accompanied by police...increased appetite due to pregnancy...involved in human trafficking (witness)...runaway...three months pregnant...wanted to hurt herself...admit for safety."

The Multidisciplinary Progress Note dated 03/22/15, timed at 2300, reflected, "Met with patient...agitated, behavioral aggression, combative period, yelling, cursing...fighting with peers...redirected, q15 (every fifteen minute) for safety." No vital signs, assessment was documented for Patient #40.

On 04/23/15, at 1345, Personnel #3 was interviewed. Personnel #3 reviewed Patient #40's medical record. Personnel #3 verified that no vital signs and assessment was completed for Patient #40.


2) Patient #41's Integrated Assessment dated 04/03/15, timed 1530, reflected, "13 year old male...suicidal thoughts...drug use...threatened to kill himself at school...wants to beat up people...abusive towards mom."

The 04/20/15, Precaution Checklist reflected, "1600 to 1645...interacting socially outside."

The 04/20/15, Multidisciplinary Progress Note timed at 1900, reflected, "Presents with bright affect...will continue to monitor." No nursing documentation in regard to Patient #41's left wrist injury.

The 04/20/15 Physician's Orders timed at 2300, reflected, "Consult Dr...to rule out left hand fracture...",

The 04/21/15, Physician's Orders timed at 0935, reflected, "X-Ray left wrist...Ibuprofen 400 mg (milligrams) po (by mouth) TID (three times a day) as needed for left wrist pain."

The 04/21/15, Consultation timed at 1400, reflected, "I fell on it yesterday playing football...swelling left wrist...increased pain to palpation...decreased range of motion secondary to pain."

The 04/22/15, Multidisciplinary Progress Note timed at 2100, reflected, "Compliance with medications...attempted to call the labs for x-ray results...x-ray did not answer will give report to morning nurses...will monitor for changes in mood and behavior."

The Faxed Radiology Report dated 04/23/15, timed at 2327, reflected, "There is acute impacted fracture involving left distal radius with mild displacement...there is associated tissue swelling..."

The Multidisciplinary Progress Notes dated 04/23/15, timed at 1700, reflected, "Denies depression...will continue to monitor for changes in mood and behavior." No nursing documentation regarding the condition of the left wrist including vital signs.

The 04/24/15, Consultation reflected, "ED (emergency department) for fracture stabilization."

The 04/24/15, Multidisciplinary Progress Note timed at 1800, reflected, "MD ordered patient to be transferred to ER (emergency room)...patient transferred to hospital..."

The 04/24/15, Multidisciplinary Progress Notes timed at 2330, reflected, "Patient returned from hospital...with splint to left forearm...no signs and symptoms of compartment syndrome...HS (hour of sleep) medications and went to bed." No vital signs were documented and no further treatment orders were documented upon (Patient #41's) return.

The acute care hospital's instructions dated 04/24/15, reflected, "Fracture forearm...keep arm elevated, apply ice pack over injured area for 20 minutes every 1-2 hours the first day...continue with ice packs 3-4 times a day for the next two days...keep cast/splint dry...follow-up with your doctor in one week...to be sure the bone is healing properly...fracture of radius and ulna, left, closed, initial encounter."

On 04/28/15, at 1550, Personnel #40 was interviewed. Personnel #40 was asked how Patient #41 sustained a fractured left wrist. Personnel #40 stated that on the afternoon of 04/20/15, Patient #41 was outside playing football and he fell on his left arm/wrist. Personnel #40 stated that he reported the event to the nurse upon return to the unit.

On 04/30/15, at approximately 1000, Personnel #47 was interviewed. Personnel #47 was asked to review Patient #41's medical record. Personnel #47 stated that she remembered the day shift nurse tell her the patient had hurt his wrist/hand. Personnel #47 was asked if she assessed Patient #41's wrist/hand. Personnel #47 said that was all she remembered.

On 04/30/15, at 1110, Personnel #3 was interviewed. Personnel #3 was asked to review Patient #41's medical record. Personnel #3 said that she could find nothing about nursing assessing the condition of the patient's hand after he fell on it.

The Hospital Policy entitled "Assessment and Reassessment of Patients" dated 02/2015, noted the procedure that "the registered nurse will assess each patient at a minimum every shift and more often as deemed necessary. Assessment will include their mental and physical status...more frequent assessments of patients may be needed when the patient is having a physical problem..."

Based on observations, interviews and record review, the hospital failed to ensure nursing services had an adequate number of nursing personnel to provide care/supervision
for 2 of 4 units (Adolescent/Child Unit and Adult Psych Unit ) in that

1) 1 of 1 patient (Patient #14), a 10 year old pediatric patient, was assaulted by Patient #39 a 14 year old adolescent, and Patient #40, a 16 year old adolescent. Patient #14 was sent to an acute care hospital for a head injury,

2) 4 of 4 patients (Patients #6, #7, #8, and Patient #9) on the hospital's Adult Psych Unit did not have their behaviors and locations documented on their precaution sheets for 45 minutes on 04/20/15. One technician was in charge of 15 patients on 15 minute precautions and one acutely suicidal patient (Patient #50) on high level of observation (5 minute checks).


Findings included:

1) Patient #14's Integrated Assessment dated 03/08/15, timed at 0100, reflected, "10 year old female in foster care...anger issues with Mother and Dad...reports she sometimes does not use coping skills...history of mood disorder, anxiety...history of cutting self mutilation..."

The Multidisciplinary Progress Notes dated 03/22/15, timed at 2000, reflected, "Female peer slapped patient in the face, she (Patient #14) fell to the floor, when she stood up the female with another female peer jumped her (Patient #14) and hit her on the floor...neuro checks started...called Dr...send to ER (emergency room) for medical clearance of any injuries... Social Worker guardian called and notified...stated he will press charges for assault against the two female patients...gave report to (hospital)...2015...transport arrives to take patient to hospital..."

The Multidisciplinary Progress Notes dated 03/22/15 (03/23/15) timed at 0330 reflected, "Hospital called to give report...patient on way back to unit with minor injury to head..."


Patient #39's Integrated Assessment dated 03/16/15, timed at 2202, reflected, "14 year old...urges for self-injury...history of PTSD (post traumatic stress disorder), Bipolar...family conflict...hitting, slapping."

The 03/22/15, Multidisciplinary Progress Note timed at 2350, reflected, "Met with patient...agitated, aggressive/combative around unit...re-directable...will continue to monitor." No vital signs, assessment and/or details were documented for Patient #39.


Patient #40's Integrated Assessment dated 03/21/15, timed at 1530, reflected, "16 year old accompanied by police...increased appetite due to pregnancy...involved in human trafficking (witness)...runaway...three months pregnant...wanted to hurt herself...admit for safety."

The Multidisciplinary Progress Note dated 03/22/15, timed at 2300, reflected, "Met with patient...agitated, behavioral aggression, combative period, yelling, cursing...fighting with peers...redirected, q15 (every fifteen minute) for safety."

The daily patient checklist dated 03/22/15, for adolescent/child (girls) revealed, 14 total patients listed on the daily patient checklist. Three of the fourteen patients were APOWW's. One MHT was assigned to all 14 patients. One nurse was assigned for the adolescent/girls unit. Fourteen patients were on close observations (15 minute checks), seven patients were on assault precautions, two patients were on (SAO) sexually acting out precautions and six patients on suicide precautions.

On 04/24/15, confidential Interview was conducted. The interviewee stated that the adolescent girls and pediatric patients are housed on the same unit. The interviewee stated that there was only one MHT (mental health technician) for 14 adolescent/children and one nurse on 03/22/15. The interviewee stated this included any APOWW's (apprehension by peace officer without warrant) on the unit. The interviewee stated the staffing is unsafe.


2) Patients #6's, #7's, #8's, and #9's behavior and location were observed documented on 04/20/15, at 1315 on the patient's precaution checklists. The time slots for 1245, 1300 and 1315 were left blank. One mental health technician was in charge of 16 patients including Patient #50 who was on every five-minute observation checks.


Patient #6's Physician's Preadmission examination orders dated 04/19/15, reflected admission diagnoses included Schizophrenia. The patient was placed under an order of protective custody for safety on 04/09/15. The patient's precaution checklist dated 04/20/15, reflected the patient was on close observation and 15 minute checks.


Patient #7's Physician's Orders dated 04/18/15, reflected admitting diagnoses included severe Major Depressive Disorder and the patient was placed on suicide precautions. The patient's precaution checklist dated 04/20/15 reflected Patient #7 was on suicide precautions.


Patient #8's Physician Orders dated 03/26/15, reflected the patient's admitting diagnosis of severe, recurrent Major Depressive Disorder. The patient was ordered to be on suicide precautions. (Patient #8's) precaution checklist dated 04/20/15, noted the patient was on close observation for suicide precautions.


Patient #9's Admission Physician Orders dated 04/14/15, reflected admitting diagnoses included Bipolar Disorder and Depressive Episode. The patient was ordered to be on 15 minute checks and suicide precautions. The patient's precaution checklist dated 04/20/15 noted the patient was on 15 minute checks.


Patient #50's Preadmission Examination Orders dated 04/17/15, reflected the patient's admission diagnosis of Major Depressive Disorder, Recurrent,with psychotic features. Patient #50 was placed on suicide precautions. The Physician Daily Progress Note dated 04/20/15, at 1230, reflected the patient heard voices telling the patient to kill herself, was suicidal, had scratched herself the previous day and "could not promise no harm." The physician placed the patient on high level of observation.


During an interview on 04/20/15, at 1345, Personnel #3 acknowledged the above findings and stated the 15-minute observation checklists "should not be behind."

On 04/23/15 (confidential interview) Personnel #17 acknowledged that the unit did not have enough staff.

The hospital policy entitled, "Staffing Plan" with an effective date of 02/2015 reflected, "To provide the appropriate number of staff necessary to provide patient care...staffing assignments based on the programmatic and acuity needs..."


The failure to ensure adequate staffing to provide care and services to patients presents the likelihood of harm and injuries to all patients.