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Based on interview and record review, the hospital failed to ensure the grievance log was maintained for one of 10 sampled patients (Patient 5). This failure had the potential to result in the unresolved complaints or grievances for the patient.

Findings:

Review of the hospital's document titled Adolescent Program Patient Handbook (undated) showed the patients with questions about their treatments or those who feel they are being treated unfairly are encouraged to discuss their concerns with their doctors and the treatment team directly. Each patient has the rights to file a written grievance, and the form to file a written grievance maybe obtained online, from the hospital staff or from the Patient Rights Advocate.

Review of the Job Description for the Court Liaison and Patient Advocate showed the key responsibilities. The responsibilities for the Patient Advocate include to act as a in house Patients' Rights Representative and document the patient meeting in the patient grievance form.

On 7/9/24 at 1311 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated a call was made to the hosptial's Patient Advocate on 6/24, 6/25 and 6/26/24. Family Member 1 stated Family Member 1 was not receiving a return call from the hosptial's Patient Advocate.

On 7/10/24 at 1338 hours, an interview and concurrent record review was conducted with the Court Liaison/Patient Advocate. The Court Liaison/Patient Advocate was asked if the Court Liaison/Patient Advocate received a phone call from Family Member 1 on 6/24, 6/25, and 6/26/24. The Court Liaison/Patient Advocate stated the Court Liaison/Patient Advocate did not receive any. When asked if they keep a copy of the call log, the Court Liaison/Patient Advocate stated there was no call log. When asked how to prove if the concern was addressed, the Court Liaison/Patient Advocate stated they would check the grievance log. When asked if he was able to speak with Family Member 1, the Court Liaison/Patient Advocate stated no, only with the patient. The Court Liaison/Patient Advocate further stated Family Member 1 had filed a complaint with the Behavioral Health Services because no one had called her and wanted to take Patient 5 against medical advice.

However, the hospital failed to show documented evidenced of the call log for the complaints.

On 7/10/24 at 1352 hours, review of the hospital's grievance log for June abd July 2024 was conducted and showed no documented evidenced the grievance report was filed for Patient 5.

On 7/11/24 at 1545 hours, the findings were shared with the CNO, Director of Performance Improvement and Risk Management, and Nurse Manager. The CNO acknowledged the findings.

Based on observation, interview, and record review, the hospital failed to ensure the five patient access phones were in the working order on each unit. This failure posed the potential for the patients not being allowed to exercise the patient's rights.

Findings:

Review of the hospital's P&P titled Patient's Rights dated 4/2024 showed the following:

* Patients will have reasonable access to telephones, both to make and receive confidential calls or to have such calls made for them.

* Good cause for denial of patient's rights: The exercise of a specific right would be injurious to the patient or peers or there is evidence that a specific right if exercised would seriously infringe on the rights of others or that the facility would suffer serious damage if the specific right was not denied and there is no less restrictive way to prevent against those occurrences.

* Patients' rights may be denied for good cause with a provider's order. The denial of patients' rights must be reviewed and renewed every 24 hours.

On 7/10/24 at 1525 hours, a tour of Unit 2 West was conducted with the Nurse Manager. A silver public (no cost) phone for patient use was observed on the wall. The Nurse Manager stated the phone was for patient use but only during certain hours and was controlled at the nursing station by a switch. The nurses had to engage the switch for the phone to be in use. The Nurse Manager and surveyor attempted to dial out from the phone. The Nurse Manager asked the nurse at the station to turn the phone on by the switch. The Nurse Manager and surveyor watched as the nursing staff had turned on the silver phone. The Nurse Manager and surveyor tested the phone. The Nurse Manager and surveyor found the phone to have a dial tone. The Nurse Manager was asked to dial a phone number. The Nurse Manager attempted to dial the phone number but found the phone to be non-functional. The Nurse Manager verified the phone could not be used for making phone calls in its current condition but would place a ticket for repair.

On 7/10/24 at 1537 hours, a tour of Unit 2 East was conducted with the Nurse Manager. A silver public (no cost) phone for patient use was observed on the wall. The Nurse Manager stated the phone was for patient use but only during certain hours and was controlled at the nursing station by a switch. The nurses had to engage the switch for the phone to be in use. The Nurse Manager and surveyor attempted to dial out from the phone. The Nurse Manager asked the nurse at the station to turn the phone on by the switch. The Nurse Manager and surveyor watched as the nursing staff turn on the silver phone. The Nurse Manager and surveyor tested the phone. The Nurse Manager and surveyor found the phone did not have a dial tone. The Nurse Manager was asked to dial a phone number. The Nurse Manager attempted to dial the phone number but found the phone to be non-functional. The Nurse Manager verified the phone could not be used for making phone calls in its current condition but would place a ticket for repair.

On 7/10/24 at 1548 hours, a tour of Unit 1 West was conducted with the Nurse Manager. A silver public (no cost) phone for patient use was observed on the wall. The Nurse Manager stated the phone was for patient use but only during certain hours and was controlled at the nursing station by a switch. The nurses had to engage the switch to on for the phone to be in use. The Nurse Manager and surveyor attempted to dial out from the phone. The Nurse Manager asked the nurse at the station to turn the phone on by the switch. The Nurse Manager and surveyor watched as the nursing staff turn on the silver phone. The Nurse Manager and surveyor tested the phone. The Nurse Manager and surveyor found the phone did have a dial tone. The Nurse Manager was asked to dial a phone number. The Nurse Manager attempted to dial but found the phone to be non-functional. The Nurse Manager verified the phone could not be used for making phone calls in its current condition but would place a ticket for repair.

On 7/10/24 at 1559 hours, a tour of Unit 1 East was conducted with the Nurse Manager. A silver public (no cost) phone for patient use was observed on the wall. The Nurse Manager stated the phone was for patient use but only during certain hours and was controlled at the nursing station by a switch. The nurses had to engage the switch to on for the phone to be in use. The Nurse Manager and surveyor attempted to dial out from the phone. The Nurse Manager asked the nurse at the station to turn the phone on by the switch. The Nurse Manager and surveyor watched as the nursing staff turn on the silver phone. The Nurse Manager and surveyor tested the phone. The Nurse Manager and surveyor found the phone did have a dial tone. The Nurse Manager was asked to dial a phone number. The Nurse Manager attempted to dial the phone number but found the phone to be non-functional. The Nurse Manager verified the phone could not be used for making phone calls in its current condition but would place a ticket for repair.

On 7/11/24 at 1048 hours, a tour of the Specialty (Adolescent) Unit was initiated with the Nurse Manager. A silver public (no cost) phone for patient use was observed on the wall. The Nurse Manager stated the phone was for patient use but only during certain hours and was controlled at the nursing station by a switch. The nurses had to engage the switch to on for the phone to be in use. The Nurse Manager and surveyor attempted to dial out from the phone. The Nurse Manager asked the nurse at the station to turn the phone on by the switch. The Nurse Manager and surveyor watched as the nursing staff turn on the silver phone. The Nurse Manager and surveyor tested the phone. The Nurse Manager and surveyor found the phone did have a dial tone. The Nurse Manager was asked to dial a phone number. The Nurse Manager attempted to dial the phone number but found the phone to be non-functional. The Nurse Manager verified the phone could not be used for making phone calls in its current condition but would place a ticket for repair.

On 7/11/24 at 0953 hours, an interview was conducted with Patient 9. Patient 9 stated she was not able to have a confidential phone conversation as the staff always knew when she would be talking on the phone. Patient 9 stated the silver phone on the wall did not work and were known broken; and the hospital did not fix the phone. Patient 9 stated the hospital left them broken so they could control phone use. Patient 9 stated the only way to get to speak with the outside world, was to sign up for a phone time and then the nurses gave the patient a portable phone. Patient 9 stated she had to ask for the phone and didn't have free access to it. The nursing staff had controlled it. Patient 9 stated she did not like having to ask for a phone as it was intimidating. Patient 9 also stated she did not always get access to the phone when she signed up for it. Patient 9 stated she thought some of the nurses show favoritism and gave the phone to those they liked.

On 7/11/24 at 1009 hours, an interview was conducted with Patient 6. Patient 6 she was on the phone list for today and had signed up for portable phone use at two time slots. Patient 6 stated she signed up on the list for two times slots which would be at 0800 and 1800 hours as the sign stated patients had only had 10 minutes of phone time, which she felt was not sufficient for her needs. Patient 6 stated she was aware the silver phone on the wall was broken and the hospital had not fixed it. Patient 6 stated she did not like the system in place to use the phone as the patients didn't have complete privacy or anonymity. The portable phones were regulated, and nursing staff knew both who and when patients were talking on the phone.

On 7/11/24 at 1545 hours, the findings were shared with the CNO, Director of Performance Improvement and Risk Management and Nurse Manager. The CNO acknowledged the findings.

Based on observation, interview, and record review, the hospital failed to implement their P&Ps related to Restraint and Seclusion and Patient's Rights for one of 10 sampled patients (Patient 3). Patient 3 was subjected to staff excessive force and unnecessary restraints during a physical struggle with a MHW 1 when there was no evidence of imminent danger for self, staff, or others. This incident violated Patient 3's right to be free from the restraints imposed to as a mean of discipline, coercion, or convenience by staff.

Findings:

Review of the hospital's P&P titled Seclusion and Restraints revised 3/2024 showed the following:

* It is the hospital's policy to maintain a restraint free environment. The confinement of patients through the use of restraints is only used to protect a patient or others from harm when alternative less restrictive measures are determined to be ineffective and are necessary to ensure the immediate safety of the patients and others. Restraints are never to be used as a coercive, disciplinary, or retaliatory action.

* Behavioral restraint: A restraint is any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move the arms, legs, body, or head freely; or a drug or medication used to manage the patient's behavior.

Review of the hospital's P&P titled Patient's Rights revised 4/2024 showed each patient involuntary detained for evaluation or treatment shall have the following rights that cannot be denied:

- Treatment services that are the least restrictive of personal liberty.

- Dignity, privacy, and humane care.

- Be free from harm including unnecessary or excessive physical restraint, isolation, medication, abuse, or neglect.

During the hospital's tour to the "Special Unit" conducted on 7/10/24 at 1000 hours, Patient 3 was observed exiting the group meeting and sitting on a table in the day hall along with two other patients. They were coloring books.

On 7/10/24 at 1030 hours, an interview was conducted with Patient 3. Patient 3 stated she did not like the hospital due to lack of staff professionalism. Patient 3 stated the staff used inappropriate language and was aggressive with them. Patient 3 stated she was standing in front of her room on 7/7/24 approximately at 1700 hours, just looking to see what was going on with a peer in front of her room when MHW 1 grabbed her from behind and twisted her arm. Patient 3 stated she tried to break free from MHW 1 and fought MHW 1 back. Patient 3 stated she felt scared and physically hurt. Patient 3 stated she did not understand why she was treated that way when she was not doing anything wrong. "I was just standing there."

On 7/10/24 at 1445 hours, an interview with MHW 1 was conducted. MHW 1 stated on 7/7/24, all the patients in the unit were kicking the doors and walls. MHW 1 stated he asked Patient 3 to go into her room because they did not want the patients to see what was going on since they were children. MHW 1 stated Patient 3 would not go to her room and kept fighting about it. MHW 1 stated Patient 3 was watching the incident right across her room with another patient and " instigating."

When asked what was done to redirect Patient 3 back to her room, MHW 1 stated we just kept saying to go back to her room, so he had to grab Patient 3 and put Patient 3 in her room because there was someone inside the seclusion room at that time. MHW 1 stated Patient 3 was threatening, yelling, and starting to fight with him. MHW 1 stated Patient 3 just would not go back to her room, MHW 1 did not have help from other staff, and he did not know what to do as there were too many things happening at once. MHW 1 stated he could have done something different, but he did not think," it just happened all at once."

A concurrent video review and interview with MHW 1 was conducted on 7/10/24 at 1500 hours. MHW 1 confirmed he was the staff present on the video and reviewed the video recording with the survey team.

The video recording was dated 7/7/14 starting at 1700 hours. The video recording had no audio and captured the following:

- Patient 3 was observed standing in front of her room in the hallway. MHW 1 approached Patient 3 and briefly spoke to the patient, but Patient 3 was hesitating. MHW 1 was using excessive force, grabbed Patient 3 from behind and a struggle began as Patient 3 tried to break free. MHW 1 twisted Patient 3 arms during the struggle. For three intense minutes, MHW 1 and Patient 3 grappled, with Patient 3 resisting to the physical hold up and down the hallway. Eventually, MHW 1 managed to force Patient 3 to her room. There was no evidence of a valid reason or imminent danger to self or others for the physical hold.

Review of Patient 3's Kardex (patient information) dated 7/10/24, showed Patient 3 was admitted to the hospital on 7/1/24, with diagnoses of major depressive disorder (mental health condition characterized by persistent low mood or feelings of sadness).

Review of the Psychiatric Progress Note assessment dated 7/8/24 at 0940 hours, showed Patient 3 was alert and oriented to time, place, and person with appropriated thought process. Patient 3's chief of complaint was "I didn't do anything." The Psychiatric Progress Note showed per staff, last night the patient refused to go to room and was aggressive; the staff could not redirect the patient and the emergency medications were given.

Review of the Mental Health Worker's Job Description showed one of the MHW responsibilities is to follow professional crisis management procedures accurately when needed. The MHW's skills and abilities include to demonstrate the appropriate professional boundaries, treat youth with respect; demonstrate the ability to set limits for the patients, use the de-escalation techniques appropriately, exhibit calm and controlled attitude, and do not overreact to allow his own actions to further deteriorate the situation.

On 7/10/24 at 1400 hours, an interview was conducted with the Director of Performance Improvement & Risk Management. The Director of Performance Improvement & Risk Management stated she was not aware of the incident and also stated the management team did not review all incidents video footage; they reviewed the videos only if "the incident warrants an investigation."

On 7/10/24 at 1430, the Director of Performance Improvement & Risk Management, Nurse Manager, and CNO acknowledged the above findings.

Based on interview and record review, the hospital failed to ensure the physician's order of seclusion for management of violent behaviors was renewed when the physician's order was exceeding two hours as per the hospital's P&P for one of 10 sampled patients (Patient 5). This failure could lead to the unnecessary restraint use for the patient.

Findings:

Review of the hospital's P&P titled Seclusion and Restraints revised 3/2024 showed the maximum length of time of the restraint or seclusion is not exceed two hours for children and adolescent ages 9 to 17 years old. The trained RN will reassess the patient hourly and before the seclusion or restraint order expires, re-valuate the patient. If the need for seclusion or restraint continues, discuss need for other interventions and obtains a new order (Not to exceed two hours for children and adolescent ages 9 to 17 years old).

Review of Patient 5's medical record was initiated on 7/10/24. Patient 5's medical record showed Patient 5 was admitted to the hospital on 6/22/24 and discharged on 7/2/24.

Review of the Seclusion and Restraint showed on 6/28/24 at 1731 hours, the physician ordered seclusion and restraint for Patient 5. The type of restraint was "Physical Restraint (Hold)." The restraint would not be exceed two hours. The indications for the use of restraint included "Imminent Danger to self or others due to Thought Disorder."

Review of the Seclusion/Restraint Record section of the Seclusion and Restraint showed on 6/28/24 at approximately 1725 hours, Patient 5 approached the nursing station and was demanding to use the phone. The patient was told about the phone time and refused to listen. The patient began swearing the staff, refused to leave the nursing station, and refused to stand behind the red tape. The patient was threatening towards the staff. The patient was guided to the seclusion room by the staff and began fighting with the staff. The staff then restrained the patient, and the patient was taken to the seclusion room. The door of the seclusion room was locked at 1736 hours.

Review of the Seclusion/Restraint Record section of the Seclusion and Restraint showed Patient 5 was alert, agitated, and restless. The seclusion was started on 6/28/24 at 1836 hours and ended on 6/28/24 at 1950 hours. The restraint was started on 6/28/24 at 1831 hours and ended on 6/28/24 at 1835 hours.

Review of the Patient Observation Record dated 6/28/24, showed the staff performed and documented an observation every 15 minutes. The Patient Observation Record included the time, staff initials, location code activity and behavior code. Further review of the Patient Observation Record showed Patient 5 was in the seclusion room from 1800 hours to 2230 hours. Patient 5 was placed on the seclusion room more than two hours which was inconsistent with the physician's order. Patient 5 was in the seclusion room at 1800 hours which was inconsistent with the RN narrative notes.

On 7/10/24 at 1448 hours an interview and concurrent review of Patient 5's medical record was conducted with the CNO. The CNO was asked what time the seclusion should be ended for Patient 5. The CNO stated it should have been discontinued at 2000 hours and the documentation from 2000 to 2215 hours was incorrect. The CNO was informed and acknowledged the findings.

Based on interview and record review, the hospital failed to ensure the nursing staff monitored the vital signs as per the hospital's P&P for one of 10 sampled patients (Patient 5) when the patient was restrained or secluded. This failure could lead to the inappropriate use of restraints and seclusion and unsafe care for the patient.

Findings:

Review of the hospital's P&P titled Seclusion and Restraints revised 3/2024 showed the clinical staff completes documentation on the S&R flow sheet. The following patient needs will be assessed on a continuous 1:1 basis and documented in the medical record every 15 minutes:

- Staff will determine based on visual and verbal assessment if patient is continuing meet criteria based on if the patient is still exhibiting imminent danger to self or others.

- Readiness for discontinuation of S&R.

- Vital signs every 15 minutes.

Review of Patient 5's medical record was initiated on 7/10/24. Patient 5's medical record showed Patient 5 was admitted to the hospital on 6/22/24 and discharged on 7/2/24.

Review of the Seclusion and Restraint showed on 6/28/24 at 1731 hours, the physician ordered seclusion and restraint for Patient 5. The indications for the use of restraint included "Imminent Danger to self or others due to Thought Disorder."

Review of the Seclusion/Restraint Record section of the Seclusion and Restraint showed Patient 5 was alert, agitated, and restless. The seclusion was started on 6/28/24 at 1836 hours and ended on 6/28/24 at 1950 hours. The restraint was started on 6/28/24 at 1831 hours and ended on 6/28/24 at 1835 hours.

Review of the Seclusion/Restraint Record section of the Seclusion and Restraint showed on 6/28/24 at approximately 1725 hours, Patient 5 approached the nursing station and was demanding to use the phone. The patient was told about the phone time and refused to listen. The patient began swearing the staff, refused to leave the nursing station, and refused to stand behind the red tape. The patient was threatening towards the staff. The patient was guided to the seclusion room by the staff and began fighting with the staff. The staff then restrained the patient, and the patient was taken to the seclusion room. The door of the seclusion room was locked at 1736 hours.

Review of the Patient Observation Record dated 6/28/24, showed the hospital staff performed and documented an observation every 15 minutes. Further review of the Patient Observation Record showed Patient 5 was in the seclusion room from 1800 hours to 2230 hours.

Review of the Seclusion and Restraint dated 6/28/24, showed the following:

* The Seclusion/Restraint Assessment section showed the vital signs was left blank.

* The Seclusion/Restraint Treatment Team Debriefing section was left blank.

On 7/11/24 at 1105 hours, an interview and concurrent medical record review was conducted with the CNO. The CNO was asked if they needed to take and documented the patient vital signs while the patient was placed on seclusion. The CNO stated if the patient refused the vital signs, it should have been documented. The CNO was also asked how the staff knew if the patient was ready for the removal from the seclusion room. The CNO stated staff did the assessment to make sure the patient was ready; staff asked the question; and the CNO showed the assessment section of the Seclusion and Restraint form. The CNO stated there should be some notation that the patient refused, but there was no documentation. The CNO was informed and acknowledged the findings.