HospitalInspections.org

Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights.

Findings include:

1. The facility failed to ensure documentation of 15-minute observational checks of patients to ensure safety of the patients (See A144).

Based on document review and interview for 2 of 10 (Pt #1 and Pt #4) records reviewed,it was determined that the facility failed to ensure documentation of 15-minute observational checks of patients to ensure safety of the patients.

Findings include:

1. The policy "Patient Observation (revised 09/2024)" was reviewed. The policy indicated "Nurse/Lead Mental Health Technician (MHT) ...Ensures the patient observations occur a minimum of every 15 minutes, 24 hours per day, seven days a week, for every patient and are documented concurrently on the Observation Flow Record ...MHT (or any employee assigned to Observation) ...Observe each patient, a minimum of every 15 minutes, individualizing according to precaution level and concurrently document observation on the Observation Flow Record."

2. Pt #1's record was reviewed. Pt #1 was a 6-year-old patient admitted to the facility on 5/5/25 at 3:16 PM, with a diagnosis of "disruptive mood dysregulation disorder." A patient progress note from 5/6/2025 at 4:15 PM stated "Pt was in rec (recreational) therapy group when (Pt #1) stood up and flashed (Pt#1's) genitals to 3 adolescent girls. Pt removed from group... Nurse Manager and Case Manager notified." Pt #1 was subsequently moved to a single room in the "swing hall" on 5/6/25. The Patient Progress Note for Pt #1, dated 5/8/25, 12:50 PM, stated "Pt reported that (Pt #1) and a peer (referring to Pt #4) were ripping our scrub pants and showing each others private parts' last night (5/7/25) in peers (referring to Pt #4's) room. Unknown time but roughly 1800-2300 (6:00 PM - 11:00 PM). Pt able to tell story multiple times this AM and is consistent. Peer denies this happening. Staff reports that (staff member) witnessed Pt going into peers room this AM. Pt redirected out and doors were locked once hygiene time was completed." Pt #1 was discharged on 5/8/2025 at approximately 10:00 PM. Per the Discharge Summary dated 5/8/2025, at 7:38 PM, it was noted "On 5/8/2025, alleged report of patient along with another underage peer 'touching each other's private part' reported to Administration which is being investigated. Guardian was notified, mother decided to pick up patient today, which will be granted as he is not suicidal, not homicidal, not psychotic. In addition, we are not administering any medication at this time as consent has been revoked, further intervention to follow on an outpatient basis."

3. Pt #4's record was reviewed. Pt #4 was a 12-year old admitted to the facility on 5/7/2025 with a diagnosis of "disruptive mood dysregulation disorder." A "Nurse to Nurse Form" (nurse report from outside hospital that transferred Pt #4 to the facility) dated 5/7/25 at 9:30 AM indicated, "Sexually inappropriate ...comments about (family member) licking butt hole ... open DCFS case about sexually inappropriate comments ... no sex victim precautions at this (point)." Pt #4 was admitted to the pediatric unit at 1:36 PM. On 5/7 at 8:45 PM, Pt #4 was moved to the swing unit due to a physical altercation with a peer (not Pt #1). The Patient Progress Note for Pt #4, dated 5/8/2025, 6:57 PM stated "At 17:00 (5:00 PM) Peer (in reference to Pt #1) reported to staff that the previous night between 19:00 - 23:00 (7:00 PM and 11:00 PM) Pts had ripped each other's pants and showed each other their genitals, kissed each other, and licked each others genitals. AOC (Administrator on Call), Risk Manager, CNO (Chief Nursing Officer) and CEO (Chief Executive Officer) notified at 17:09 - 17:14 (5:09 PM - 5:14 PM). Physician notified at 17:30 (5:30 PM). Guardian notified at 17:52 (5:52 PM). DCFS was also notified of incident. Pt later was on the phone with (family member) and stated 'I didn't think a 6 yo (year old) would make this much noise.'"

4. The Observation Flow Records for Pt #1 and Pt #4 for 5/7/2025 were reviewed with Chief Nursing Officer (E #1). The flow sheets lacked documentation of observation at 7:00 PM, 7:15 PM and 7:30 PM for both Pt #1 and Pt #4.

5. An interview was conducted on 6/18/2025 at approximately 11:00 AM, with the Quality Assurance Coordinator (E #6). E #6 stated "during the investigation, staff expressed possible red flags that though there were no previous reported incidents prior to (Pt #1) arriving at the facility."

6. An interview was conducted on 6/18/2025 at 1:00 PM with E #1. E #1 verbally agreed the checks should have been completed and were not. E #1 stated, "Staff are to document and notify supervisor if the checks are not completed. I cannot find any documentation as to why the checks were not completed and do not see any notification documented."