HospitalInspections.org

Based on policy review, medical record review, observations, internal documents review, video review, internal investigation review, employee coaching form, personnel file review, incident report review, patient safety committee investigation review, internal email review, quality/performance improvement plan review, Quality/Performance Improvement (QAPI) Council meeting minutes review, Medical Executive Committee meeting minutes review, daily assignment sheet review, employee corrective action review, medical staff Bylaws, Rules and Regulations reivew, professional service agreement review, credentialing file review, Governing Board Meeting Minutes review, Professional Practice Evaluation review, physician case load and on call schedule reviews, facility documentation review, facility COVID-19 screening tools review, weekly provider testing log review, and staff, patient, allied health provider and physician interviews, the facility's leadership failed to provide oversight and have systems in place to ensure the protection and promotion of patient's rights to provide a safe environment for behavioral health patients; failed to maintain an organized and effective quality assessment and improvement program; failed to have an organized medical staff that ensured the provision of quality medical care and services; failed to have an organized Nursing Service to meet patient care and safety needs; failed to ensure an effective infection control and prevention program that reduced the risk of exposure to COVID-19; and failed to provide oversight of active treatment for behavioral health patients. The cumulative effect of these systemic problems resulted in the hospital's inability to ensure behavioral health patients received care in a therapeutic environment and remained safe from potential harm.

The findings include:

1. Nursing staff failed to provide a safe environment for the delivery of care to a geriatric behavioral health patient resulting in an elopement in 1 of 1 geriatric elopement patients (Patient #11).

~cross refer to 482.13(c)(2) Patients' Rights Standard: Care in Safe Setting, Tag A0144

2. Facility staff failed to remove all chemicals from the patient care units; and failed to educate the staff on proper storage of chemicals for 1 of 1 self-harm patient reviewed (Patient #2).

~cross refer to 482.13(c)(2) Patients' Rights Standard: Care in Safe Setting, Tag A0144

3. The facility failed to maintain an environment free from staff to patient abuse, assure incident reports were completed in a timely manner, failed to assure complete abuse investigations were reviewed in the decision making process and failed to protect patients while allowing the staff member involved work during and after the investigation process in 1 of 2 patients involved in allegations of abuse. (Patient #6)

~cross refer to 482.13(c)(3) Patients' Rights Standard: Protect from Abuse, Tag A0145

4. Nursing staff failed to obtain a physician's order for a restrictive intervention in 1 of 5 patients (Patient #21) who required a restrictive intervention.

~cross refer to 482.13(e)(5) Patients' Rights Standard: Restraints and Seclusion, Tag A0168

5. The facility staff failed to measure, analyze and track quality indicator data for monitoring of treatment plans for compliance for 5 of 9 months (January 2021 through September 2021).

~cross refer to 482.21(a)(b)(1)(b)(2) (i)(b)(3) QAPI Standard: Data Collection and Analysis, Tag A0273

6. The facility staff failed to identify and implement measures to improve therapeutic services that were not meeting target benchmarks.

~cross refer to 482.21(b)(2)(ii),(c)(1),(c)(3) QAPI Standard: Quality Improvement Activities, Tag A0283

7. The facility failed to analyze adverse patient events to ensure corrective actions were implemented for patient safety in 3 of 5 sampled patients with incident report investigations.

~cross refer to 482.21(a), (c)(2), (e)(3) QAPI Standard: Patient Safety, Tag A0286

8. The hospital's governing body and medical staff failed to provide oversight of the quality of patient care by allowing a psychiatrist to function as the attending psychiatrist for adolescent boys via only telemedicine, while he was out of the country for extended stays. ((MD #20)

~cross refer to 482.22(b)(1)(2)(3) Medical Staff Standard: Origanization and Accountability, Tag A0347

9. The hospital's medical staff failed to evaluate the delineation of clinical privileges of Allied Health Providers (AHPs) for reappointment according to medical staff bylaws for 1 of 2 sampled AHP files reviewed (AHP # 24).

~cross refer to 482.22(a)(2) Medical Staff Standard: Credentialing, Tag A0341

10. The facility failed to provide adequate staffing to care for geriatric patients resulting in a patient elopement in 1 of 1 geriatric elopements (Patient #11).

~cross refer to 482.23(b) Nursing Services Standard: Staffing and Delivery of Care, Tag A0392

11. The nursing staff failed to monitor and supervise a geriatric patient resulting in an elopement in 1 of 1 geriatric elopement patients (Patient #11).

~cross refer to 482.23 (b)(3) Nursing Services Standard: RN Supervision, Tag A0395

12. The nursing staff failed to supervise a restrictive intervention in 1 of 5 patients (Patient #21) who required a restrictive intervention.

~cross refer to 482.23 (b)(3) Nursing Services Standard: RN Supervision, Tag A0395

13. Nursing staff failed to ensure staff assignments were made to assure the safe delivery of care for geriatric behavioral health patients in 1 of 3 geriatric patients (Patient #11).

~cross refer to 482.23 (b)(5) Nursing Services Standard: Patient Care Assignments, Tag A0397

14. The hospital staff failed to mitigate the risk of exposure to COVID-19 by failing to have a consistent process in place to screen and test physicians and allied health professionals (AHP) for COVID-19.

~cross refer to 482.42(a)(2) Infection Control Standard: Program, Tag A0749

15. The facility staff failed to ensure a Master Treatment Plan was completed within 72 hours of admission for 12 of 23 sampled patients. (Patients #20, #23, #19, #1, #14, #16, #17, #12, #4, #11, #8, #18).

~cross refer to 482.61(c)(1) Special Medical Record Requirements for Psychiatric Hospitals Standard: Treatment Plan, Tag A1640

16. The facility staff failed to document a substantiated psychiatric diagnosis (from the Comprehensive Psychiatric Evaluation) that served as the primary focus for the treatment plan for 2 of 23 sampled patients. (Patient #6 and #15)

~cross refer to 482.61(c)(1)(i) Special Medical Record Requirements for Psychiatric Hospitals Standard: Treatment Plan Substantiated Diagnosis, Tag A1641

17. The facility staff failed to develop short-term goals and failed to define target dates for short-term goals established on the Master Treatment Plan (MTP) for 3 of 11 patients with Master Treatment Plans. (Patients #2, #6, #21)

~cross refer to 482.61(c)(1)(ii) Special Medical Record Requirements for Psychiatric Hospitals Standard: Treatment Plan Goals, Tag A1642

18. The facility staff failed to ensure Nursing participation in the creation of the Master Treatment Plan (MTP) specific to interventions based on each patient's presenting problems and treatment goals and failed to ensure Psychiatrists identify treatment modalities in 3 of 11 patients sampled with MTPs ( Patient #6 # 2 and #21).

~cross refer to 482.61(c)(1) (iii) Special Medical Record Requirements for Psychiatric Hospitals Standard: Treatment Plan Modalities, Tag A1643

19. The facility staff failed to ensure documentation of an evaluation of a patient's individualized Master Treatment Plan progress toward goals for 11 of 23 sampled patients. (Patients #20, #23, #6, #19, #1, #14, #16, #17, #21, #5, #15)

~cross refer to 482.61(d) Special Medical Record Requirements for Psychiatric Hospitals Standard: Recording Progress Notes, Tag A1655

Based on policy review, medical records review, internal document review, video review, internal investigation review, employee coaching form, employee file review, incident report review, patient safety committee investigation review, internal email review, observation, and patient and staff, patient and physician interviews, the facility staff failed to promote and protect patients' rights by failing to maintain a safe environment for behavioral health patients that prevented patient elopement; identified and prevented staff to patient abuse; ensured chemicals used for cleaning were stored outside of patient care areas; and ensured a physician order was obtained for a restraint.

The findings include:

1. Nursing staff failed to provide a safe environment for the delivery of care to a geriatric behavioral health patient resulting in an elopement in 1 of 1 geriatric elopement patients (Patient #11).

~cross refer to 482.13(c)(2) Patients' Rights: Care in Safe Setting, Tag A0144

2. Facility staff failed to remove all chemicals from the patient care units; and failed to educate the staff on proper storage of chemicals for 1 of 1 self-harm patient reviewed (Patient #2).

~cross refer to 482.13(c)(2) Patients' Rights: Care in Safe Setting, Tag A0144

3. The facility failed to maintain an environment free from staff to patient abuse, assure incident reports were completed in a timely manner, failed to assure complete abuse investigations were reviewed in the decision making process and failed to protect patients while allowing the staff member involved work during and after the investigation process in 1 of 2 patients involved in allegations of abuse. (Patient #6)

~cross refer to 482.13(c)(3) Patients' Rights: Protect from Abuse, Tag A0145

4. Nursing staff failed to obtain a physician's order for a restrictive intervention in 1 of 5 patients (Patient #21) who required a restrictive intervention.

~cross refer to 482.13(e)(5) Patients' Rights: Restraints and Seclusion, Tag A0168

Based on quality/performance improvement plan review, Quality/Performance Improvement (QAPI) Council meeting minutes review, Medical Executive Committee meeting minutes review, policy and procedure review, medical records review, internal document review, video review, internal investigation review, personnel file review, employee coaching form review, corrective action review, incident report review, patient safety committee investigation review, internal email review, observation, and staff interviews, the facility's leadership staff failed to implement and maintain an effective quality assessment and performance improvement program to ensure the provision of therapeutic services and safety of patients by failing to have systems in place to measure, analyze and track treatment plan compliance; failing to implement measures to improve therapeutic services; and failing to ensure adverse events were evaluated and performed in a safe manner.

The findings include:

1. The facility staff failed to measure, analyze and track quality indicator data for monitoring of treatment plans for compliance for 5 of 9 months (January 2021 through September 2021).

~cross refer to 482.21(a)(b)(1)(b)(2) (i)(b)(3) Standard: QAPI Data Collection and Analysis, Tag A0273

2. The facility staff failed to identify and implement measures to improve therapeutic services that were not meeting target benchmarks for 5 of 9 months (January 2021 through September 2021)..

~cross refer to 482.21(b)(2)(ii),(c)(1),(c)(3) Standard: QAPI Quality Improvement Activities, Tag A0283

3. The facility failed to analyze adverse patient events to ensure corrective actions were implemented for patient safety in 3 of 5 sampled patients with incident report investigations.

~cross refer to 482.21(a), (c)(2), (e)(3) QAPI Standard: Patient Safety, Tag A0286

Based on review of medical staff Bylaws, Rules and Regulations, professional service agreement, credentialing file review, Medical Executive Committee Meeting Minutes, Governing Board Meeting Minutes, Professional Practice Evaluations, physician case load and on call schedule reviews, medical record reviews and staff, physician and allied health provider interviews, the hospital's medical staff failed to provide oversight of the quality of patient care and failed to evaluate the delineation of clinical privileges of Allied Health Providers (AHPs) for reappointment according to medical staff bylaws.

The findings include:

1. The hospital's governing body and medical staff failed to provide oversight of the quality of patient care by allowing a psychiatrist to function as the attending psychiatrist for adolescent boys via only telemedicine, while he was out of the country for extended stays for 1 of 1 physicians practicing telemedicine out of the country. (MD #20)

~cross refer to 482.22(b)(1)(2)(3) Medical Staff Standard: Origanization and Accountability, Tag A0347

2. The hospital's medical staff failed to evaluate the delineation of clinical privileges of Allied Health Providers (AHPs) for reappointment according to medical staff bylaws for 1 of 2 sampled AHP files reviewed (AHP # 24).

~cross refer to 482.22(a)(2) Medical Staff Standard: Credentialing, Tag A0341

Based on policy and procedure review, medical records review, internal document review, video review, daily assignment sheet review, internal investigation review, corrective action review, observation and staff and physician interviews, the facility's nursing staff failed to have an effective nursing service providing oversight of day to day operations by failing to ensure systems were in place to supervise and provide safe delivery of care to behavioral health patients.

The findings include:

1. The facility failed to provide adequate staffing to care for geriatric patients resulting in a patient elopement in 1 of 1 geriatric elopements (Patient #11).

~cross refer to 482.23(b) Nursing Services Standard: Staffing and Delivery of Care, Tag A0392

2. The nursing staff failed to monitor and supervise a geriatric patient resulting in an elopement in 1 of 1 geriatric elopement patients (Patient #11).

~cross refer to 482.23 (b)(3) Nursing Services Standard: RN Supervision, Tag A0395

3. The nursing staff failed to supervise a restrictive intervention in 1 of 5 patients (Patient #21) who required a restrictive intervention.

~cross refer to 482.23 (b)(3) Nursing Services Standard: RN Supervision, Tag A0395

4. Nursing staff failed to ensure staff assignments were made to assure the safe delivery of care for geriatric behavioral health patients in 1 of 3 geriatric patients (Patient #11).

~cross refer to 482.23 (b)(5) Nursing Services Standard: Patient Care Assignments, Tag A0397

5. The hospital staff failed to adhere to hospital policy regarding cell phone use on the patient units for 4 of 4 observations, and failed to obtain informed consent from a patient's guardian prior to administering a psychotropic medication in 1 of 23 sampled patients (Patient #8).

~cross refer to 482.23 (b)(6) Nursing Services Standard: Supervision of Contract Staff, Tag A0398

Based on policy and procedure review, observations, review of facility documentation, COVID-19 screening tools, weekly provider testing log, and staff interviews, the facility failed to have an effective infection control and prevention program that reduced the risk of exposure to COVID-19.

The findings include:

The hospital staff failed to mitigate the risk of exposure to COVID-19 by failing to have a consistent process in place to screen and test physicians and allied health professionals (AHP) for COVID-19 for 22 medical staff members.

~cross refer to 482.42(a)(2) Infection Control Program, Tag A0749

Based on policy review, Medical Staff Rules and Regulations review, medical record reviews and staff and allied health provider interviews, the facility failed to provide active treatment that was inclusive of individualized comprehensive treatment plans; a substantiated psychiatric diagnosis that served as the primary focus for the treatment plan; specific measurable short-term patient centered goals based on individual patient problems; specific modalities and focus of treatment based upon the patient's presenting symptoms; and documentation of an evaluation of patients' individualized treatment plan progress toward goals. The cumulative findings identified a failure to have a systemic system in place to provide active treatment to behavioral health patients.

The findings include:

1. The facility staff failed to ensure a Master Treatment Plan was completed within 72 hours of admission for 12 of 23 sampled patients. (Patients #20, #23, #19, #1, #14, #16, #17, #12, #4, #11, #8, #18).

~cross refer to 482.61(c)(1) Special Medical Record Requirements for Psychiatric Hospitals Standard: Treatment Plan, Tag A1640

2. The facility staff failed to document a substantiated psychiatric diagnosis (from the Comprehensive Psychiatric Evaluation) that served as the primary focus for the treatment plan for 2 of 23 sampled patients. (Patient #6 and #15)

~cross refer to 482.61(c)(1)(i) Special Medical Record Requirements for Psychiatric Hospitals Standard: Treatment Plan Substantiated Diagnosis, Tag A1641

3. The facility staff failed to develop short-term goals and failed to define target dates for short-term goals established on the Master Treatment Plan (MTP) for 3 of 11 patients with Master Treatment Plans. (Patients #2, #6, #21)

~cross refer to 482.61(c)(1)(ii) Special Medical Record Requirements for Psychiatric Hospitals Standard: Treatment Plan Goals, Tag A1642

4. The facility staff failed to ensure Nursing participation in the creation of the Master Treatment Plan (MTP) specific to interventions based on each patient's presenting problems and treatment goals and failed to ensure Psychiatrists identify treatment modalities in 3 of 11 patients sampled with MTPs ( Patient #6 # 2 and #21).

~cross refer to 482.61(c)(1) (iii) Special Medical Record Requirements for Psychiatric Hospitals Standard: Treatment Plan Modalities, Tag A1643

5. The facility staff failed to ensure documentation of an evaluation of a patient's individualized Master Treatment Plan progress toward goals for 11 of 23 sampled patients. (Patients #20, #23, #6, #19, #1, #14, #16, #17, #21, #5, #15)

~cross refer to 482.61(d) Special Medical Record Requirements for Psychiatric Hospitals Standard: Recording Progress Notes, Tag A1655

Based on policy review, medical records review, internal document review, video review, internal investigation review, employee coaching form, incident report review, patient safety committee investigation review, internal email review, observation, and staff and physician interviews the nursing staff failed to provide a safe environment for the delivery of care to a geriatric behavioral health patient resulting in an elopement in 1 of 1 geriatric elopement patients (Patient #11). The facility staff failed to remove all chemicals from the patient care units, and failed to educate the staff on proper storage of chemicals for 1 of 1 self-harm patient reviewed (Patient #2).

The findings include:

1. Review of the policy and procedure "Level of Observation" last reviewed 06/04/2021 revealed "PURPOSE To provide a consistent, therapeutic approach to ensure a safe environment for the patients within the facility ...PROCEDURE ...1. 15 minute Observations (Q15-minutes) a. Minimum level of observation for all patients. b. The patient is observed with visual checks every 15 minutes. c. All patients admitted to the inpatient acute units are on 15 minute observations unless otherwise ordered by the physician/provider. d. Assigned staff will document the patient's behavior, location, activity, special precautions (if indicated) and level of observation while confirming they are in no danger or distress ...2. Line of Sight (LOS) a. The patient must be in sight of a staff member at all times and 15-minute checks documented ...J. In general, a patient will have ongoing observations by Mental Health Techs (MHTs) and Nursing Staff ...O. Document time of patient observation at the time activity and behavior is observed ..."

Closed medical record review on 10/04/2021 revealed Patient #11 was a 60-year-old male admitted on 09/14/2021 with "IVC (involuntary commitment) papers taken out by his caregiver whom he tried to choke and he threatened to kill his father." Review revealed Patient #11 had a history of strokes, worsening depression, and Alzheimer's (progressive disease that destroys memory and other mental functions). Review revealed Patient #11 was transported to the referring ED (emergency department) on 09/10/2021 by law enforcement for attacking his ex-wife. Review of the referring ED provider note dated 09/10/2021 at 1530 revealed Patient #11 eloped from their ED however was found and safely returned. Review of the "Intake Screening Assessment" dated 09/14/2021 at 1647 revealed the "Elopement Risk Screen (behaviors assessed in the past 24 hours)" was zero. Patient #11 was not identified as an elopement risk. Review revealed Patient #11 was placed on Q15-minute observations on 09/14/2021 at 1815. Review of the "Medical Consult Note" dated 09/29/2021 at 1624 revealed " ...HX (history) of Dementia ...Wandered out of facility no injury or trauma ..." Review of Patient #11's "Patient Observation Rounds" sheet dated 09/28/2021 from 1600 through 1635 revealed MHT (mental health technician) #4 documented Patient #11 was outside in the courtyard. Review revealed MHT #4 documented Patient #11 was "off unit" at 1645 and back on the hall at 1655. Further review of the Patient Observation Round sheet revealed MHT #4 documented "Resident got out via the unlocked maintenance door on the patio." Review revealed Patient #11 was returned to the unit unharmed around 1651. Patient #11 was discharged on 10/11/2021.

Review of an incident report completed by RN #1 dated 09/28/2021 revealed " ...Location Details: patient was observed walking on the street, facility was notified, Supervisor, CNO (chief nursing officer) and CEO (chief executive officer) AWARE ...Details: nurses were doing group outside the courtyard, she (RN #1) left the trainee (RN #2) outside to go give 4 pm (afternoon) meds, later trainee (RN #2) came back in she was notified to live (sic) patients outside by themselves, she went out, nurse informed the trainee (RN #2) to bring them inside, then a few minutes we were notified that the patient was observed walking in the street, he was brought back to the unit, also medical doctor was informed."

Video review on 10/06/2021 at 1046 of the 900-hall outside courtyard revealed the following:
During the times 1603:17 through 1619:29- Patient #11 was visualized pacing the courtyard due to the camera position and distance limitations. The DQCR while reviewing the video stated she was unable to determine how many patients and staff were outside during the viewed time frame due to video quality and distance from the camera. She stated the camera was motioned detected, and the only available footage was the above stated time. Patient #11 was not observed during video review exiting the courtyard.

Video review on 10/06/2021 at 1055 of the 900-hall unit inside view revealed the following:
1610:00- CNA #4 was sitting at a table in the common area of the unit [unable to visualize Patient #11 from this location].
1610:30- RN #1 exited a patient room and walked to the nurse's station.
1610:37- RN #2 and a patient entered camera view from the day room area [unable to visualize the dayroom area during video review-the dayroom area has no video coverage. Also, of note the dayroom area leads outside to the courtyard]
1611:27- RN #2 entered the nurse's station.
1611:50- RN #2 exited the nurse's station and walked toward the dayroom area and out of camera view.
1612:27- RN #2 entered the camera view from the dayroom area and walked to the nurse's station.
1612:50- RN #2 exited the nurse's station and walked towards the entrance/exit doors of the unit [not located near the dayroom or courtyard area] and out of camera view.
1613:15- CNA #4 entered a patient room.
1614:41- CNA #4 exited the patient room and CNA #3 entered video review from the entrance/exit area. RN #1 was still observed at the nurse's station.
1614:52- CNA #3 entered a patient room.
1615:18- CNA #4 grabbed a clipboard from the nurse's station and sat in a chair located just outside a patient room [this patient was on line-of-sight observations].
1615:43- CNA #3 exited a patient room.
1615:55- CNA #3 exited the camera view towards the medication room [not located near the courtyard].
1617:34- RN #1 exited the nurse's station and walked towards the medication room and out of view of the camera.
1618:51- CNA #3 entered camera view from medication room area and then exits view again toward the supply room.
16:19:44- CNA #4 entered the patient room he was sitting at.
1619:55- RN #1 entered camera view and walked to the nurse's station.
1620:25- RN #1 entered the patient room where CNA #4 was sitting at the doorway.
1620:34- CNA #4 exited the patient room and sat back down in the chair.
1620:42- RN #1 exited the patient room and walked to the nurse's station.
1623:05- RN #2 entered the view of the camera from the entrance/exit door area with a backpack on and a bag in her hand and entered the nurse's station.
1623:16- CNA #3 exited the camera view towards the entrance/exit doors to the unit.
1624:59- RN #2 exited the nurse's station and walked towards the dayroom area and out of camera view.
1626:01- Three patients entered camera view from the dayroom area [none were identified as Patient #11].
1628:31- RN #2 entered back into camera view from the dayroom area and walked to the nurse's station.
1628:31 through 1645:11- RN #1, RN #2, and CNA #4 were observed on the 900-hall unit with no significant events occurring.
1645:11- RN #1 was at the nurse's station and observed to be on the phone. RN #1 stood up and walked to the opposite end of the nurse's station.
1645:35- RN #1, RN #2, CNA #3, and CNA #4 began opening patient rooms and walked around the unit looking for Patient #11.

Review of the hospital's investigative report conducted by PA #11 (Patient Advocate) revealed "Interviewed [conducted on 10/01/2021] CNA #4, he stated on 9.28.2021, he was responsible for 3 'line of sight' patients and 10 Q15 for other patients on the hall. CNA #4 stated CNA #3 was off the hall, getting supplies RN #1 was outside with the patients. CNA #4 stated he walked back and forth outside to observe patients and document on their Q15s, he had Patient #11's Q15. When everyone came inside, and they noticed that Patient #11 was not there that is when he marked Patient #11 'OU' or off unit. Stated for the 2 spaces before he marked 'OU' he did not lay eyes on Patient #11, he just marked that he observed him ...Interviewed [conducted on 10/01/2021] RN #1, she stated on 9.28.2021, she took all the patients, except for 3 of them, outside for a nursing group, after the group she returned inside to administer 4p.m. medications. RN #1 stated Patient #11 had been doing laps outside and at one point returned to the inside of the building, he did not attend group. RN #1 stated she was on the phone with the DON (Director of Nursing) when she observed RN #2 behind her, in the nurse's station, the patients were still outside, which was when she advised her to bring the patients inside in 10 minutes. RN #1 stated she was unsure what time Patient #11 exited the courtyard and the building, the receptionist called and told her a 900-hall patient had been seen walking in the street, so she asked the CNAs to ensure all patients were present and accounted for, Patient #11 was not ...within 5 mins of the notification from the receptionist Patient #11 was returned to the hall ...Interviewed [conducted on 10/04/2021] RN #2, she stated on 9.28.2021, she was outside with RN #1 and the patients ...Patient #11 and another female patient were observed doing laps around the building. RN #2 recalled she stepped inside to dispose of some trash, RN #1 exited the courtyard to do something then RN #2 stated she went inside again to dispose of trash. This time. RN #2 stated she brough (sic) in all patients, at that time she did not see Patient #11 ...RN #2 stated RN #1 received a phone call about, about (sic) a patient outside the facility, 15 or 20 minutes after they exited the courtyard and then they began to search room to room for Patient #11, he was not found in any bedroom ...Interviewed [conducted on 10/01/2021] CNA #3, she stated on 9.28.2021 she left 900 hall to secure some supplies that they had ran out of ...when she returned, she heard a 'code silver' (missing person) being called over the radio ...Conclusion: ... Also, per the video review it was determined RN #2 left the patients outside unattended for approximately 5-10 minutes. During this time RN #2 was observed on camera walking towards the bin room area ...Signed by PA #11 on 10/05/2021 and Director Quality, Compliance (DQCR) on 10/06/2021."

Review of an "Employee Coaching Form" dated 10/08/2021 for RN #1 revealed "Describe performance-related responsibilities coached ...On September 28, 2021, while conducting group in the courtyard, you left an orientee nurse alone in the courtyard with the patients. Orientees cannot assume the responsibility of patient care during their orientation period. It is expected that if you are orienting a new employee, you must remain with the patients you are responsible for supervising. This responsibility cannot be delegated to an orientee ..." Further review of the form failed to reveal RN #1 or "Supervisor" Signatures.

During an interview on 10/05/2021 at 1453 with RN #2 she reported she was a travel nurse and 09/28/2021 was her first shift on orientation. RN #2 stated she was assigned to RN #1 on the geriatric unit that day. Interview revealed none of the staff witnessed Patient #11 exit the courtyard on 09/28/2021. RN #2 stated CNA #4 was assigned to Patient #11 therefore he was the one completing the q15 minute checks. Interview revealed at one point, RN #1, RN #2, and CNA #3 were outside with approximately 6 patients, including Patient #11. RN #2 stated CNA #4 was never outside with Patient #11 and did not "hand over the clipboard" [the q15 minute observation sheets] for them to complete. Interview revealed RN #2 did "not think they [the patients] were outside by themselves." RN #2 stated "staffing was bad that day."

Interview on 10/06/2021 at 1437 with the CMO (chief medical officer) revealed it was his understanding the double doors exiting the courtyard were left unlocked by maintenance the day Patient #11 eloped. Interview revealed Patient #11 was safely returned to the hospital. Interview revealed Patient #11 didn't truly understand what he was doing as he was psychotic and confused. The CMO stated Patient #11 would push on the doors frequently as he wandered around the unit. Interview revealed staff were expected to visualize the patient and document the observation at least every 15 minutes to maintain patient safety. The CMO stated the nurse was responsible for providing supervision over the MHTs and CNAs to correctly perform the q15 minute checks, "it's their job to ensure the patients are safe."

Interview on 10/06/2021 at 1515 with CNA #3 revealed she was assigned to the geriatric unit on 09/28/2021. CNA #3 stated RN #1 and RN #2 went outside to the courtyard to conduct a nursing group and CNA #4 and herself were inside monitoring the patients that didn't go out for group. CNA #3 stated CNA #4 was responsible for all the patients q15 minute checks including three line of sights. CNA #3 explained when she worked with CNA #4, she did all the task (assisting with bathing, changing patients, making beds etc.) that needed to be done on the unit and CNA #4 did all the observations because he couldn't physically do the task. Interview revealed CNA #3 left the unit to get supplies and when she returned, she heard a code silver being called. CNA #3 stated it wasn't until someone called the unit that they realized Patient #11 was gone. CNA #3 stated Patient #11 was left outside unsupervised at some point and eloped out the double doors exiting the courtyard that maintenance had left unlocked from earlier that day. Interview revealed CNA #3 rarely got to take a lunch break due to short staffing.

Interview on 10/06/2021 at 1557 PA (Patient Advocate) #11 revealed she conducted Patient #11's elopement investigation. PA #11 stated it was determined CNA #4 had all the patients q15 minute observation sheets while CNA #3 stepped off the unit to obtain supplies. Interview revealed there was a traveler on duty that day for her first shift of orientation (RN #2). PA #11 stated RN #1 and RN #2 were outside with the patients and RN #1 came inside and left RN #2 outside with the patients. PA #11 stated the patients were left outside at some point and Patient #11 eloped out the double doors exiting the courtyard.

Interview on 10/06/2021 at 1707 with RN #1 revealed she was the RN assigned to the geriatric unit the day Patient #11 eloped. RN #1 stated she and RN #2 conducted nursing group outside in the courtyard. RN #1 stated after the nursing group was over, she came inside to make a phone call and told RN #2 she would be "right back." RN #1 stated she noticed RN #2 came inside and RN #1 told RN #2 not to leave the patients outside alone and to bring them inside. RN #1 stated none of the staff realized Patient #11 was missing until they received a phone call from the facility receptionists alerting them a geriatric patient had been located off the facility premises. RN #1 stated she checked the courtyard door and realized it was unlocked.

Interview on 10/13/2021 at 1355 with the DQCR revealed PA #11 submitted her 5-day investigation on 10/05/2021. The DQCR stated after she reviewed the report on 10/05/2021, she realized nursing staff had left Patient #11 unsupervised. The DQCR stated she notified the CEO about the lack of supervision and the CEO decided then to provide RN #1, CNA #3, and PA #11 with a written warning.

Interview on 10/14/2021 at 0957 with the DON revealed she was made aware that Patient #11 had eloped the day of the elopement. The DON stated that same day herself and the DES (Director of Environmental Services) walked the perimeter of the courtyard and discovered the door was left unlocked. The DON stated she "immediately" reviewed the video and it was identified "sometime last week" that lack of nursing supervision had contributed to Patient #11s elopement.



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2. Policy review on 10/06/2021 of "Safety Hazard Inspection Survey" review/revised 06/08/2021, revealed "Purpose A. To promote an environment for patients, staff, and visitors that is free from safety hazards and that all facility areas are following local and state regulations. B. To establish response to product, chemical, and equipment safety ..."

Open Medical record review conducted on 10/04/2021 revealed Patient (Pt) #2 was a 15-year-old female admitted to the 100-hall on 08/05//2021 with the diagnoses of major depressive disorder, recurrent severe without psychotic feature. Review of the Psychiatric Progress note dated 08/25/2021 revealed the patient "ingested some cleaning supplies that she got from the unit..."

Review of the "Incident Report (IR)" dated 08/24/2021 at 1615 revealed "patient sprayed cleaning detergent to the mouth, it was unwitnessed. The nurse Practitioner evaluated the patient and stable at this time. Vital signs 121/84, temperature 97.5, pulse 102, saturation 99%. Nurse supervisor notified."

Review of the "Patient Safety Committee investigation" dated 08/25/2021 revealed, staff statements, video review, investigative findings, and action plan. Review of the staff written statements revealed Mental Health Tech (MHT) #14 reported that Pt #2 asked for a pair of scrub bottoms. The video review revealed MHT #14 entered the bin room and Pt #2 entered behind her and grabbed the spray bottle and squeezed it into her mouth while the MHT was not looking. The video review revealed MHT #14 entered the bin room and Pt #2 was near the bin room door. The video review revealed Pt #2 stood in the bin room door, halfway inside, and walked away from the bin room door, paced up and down the hall. The video review did not show the inside of the bin room. Review of the investigative findings revealed "Staff stepped into bin room; patient held the door. The patient reached onto the shelf, per the report, and grabbed the bottle with cleaning detergent. This incident took place inside the bin room (no video footage available)." Review of the action plan revealed education was to be provided to Housekeeping and nursing staff about the storage of the chemicals.

Review of an internal email dated 08/25/2021 revealed an email was sent from the Director of Nursing (DON) to the Director of Environmental Services (DES) and the Infection Control Officer (ICO). Review of the email revealed "We need to limit cleaning with spray bottles to the housekeeping staff. Nursing staff can utilize wipes."

Observation on 10/07/2021 between 1545 and 1700 of the 700 and 800-Hall revealed a bin room on the 800-hall. The observation revealed a spray bottle labeled "Peroxide Multi Surface Cleaner and Disinfectant." Further observation revealed a nurses station was located between the 700 and 800-hall. The observation revealed four (4) spray bottles located on the floor between the copier machine and the counter. The observation revealed one bottle of Bio-Enzymatic Odor Eliminator Waterfall Mist, one bottle of Peroxide Multi Surface Cleaner and Disinfectant, one bottle of 73 Disinfecting Acid Bathroom Cleaner, and one bottle of Finito Natural Multipest Elimination.

During an interview on 10/07/2021 at 1600 with the DON during the 700- and 800-unit tour stated the cleaning supplies were not supposed to be kept in the bin rooms. The interview revealed all spray bottles with cleaning supplies should be kept in housekeeping.

Review of an internal email dated 10/08/2021 (during the survey) from the DON to the House Supervisors revealed "Housekeeping supplies are to remain in the housekeeping closet/cart. Containers such as the one illustrated below are not to be on the patient care units that include bin rooms and nurses station ..."

Interview on 10/11/2021 at 1000 with MHT #12 during the 100-Hall unit tour revealed "I have been told today that the chemicals should not be kept in the bin room. I was not told where they should be kept."

Interview on 10/11/2021 at 1000 with the DES revealed management had addressed and removed all chemical bottles from the bin rooms. The interview revealed an email was sent to all staff regarding the removal of chemicals from the bin rooms. The interview revealed the DES could not locate the email that was sent to the staff regarding the removal of the chemicals from the bin room.

Observation on 10/11/2021 between 1045 and 1150 of the 100-Hall revealed a bin room on the unit. Observation of the bin room revealed one spray bottle of Peroxide Multi Surface Cleaner and Disinfectant and one spray bottle of 73 Disinfecting Acid Bathroom Cleaner.

Follow up interview on 10/11/2021 at 1628 with the DON revealed there was no documentation of the staff education regarding not keeping chemicals in the patient care areas/bin rooms.

Interview on 10/15/2021 at 1015 with MHT #9 during tour of the 900-Hall unit revealed he had been taught to ensure all chemicals were properly labeled and inaccessible to the patients. MHT #9 stated the chemicals were kept "in the back of the locked bin rooms so patients can't reach them if they walk into the front of the bin room."

Based on facility policy review, medical record review, incident report review, video surveillance review, internal investigation review, employee file review, patient and staff interviews, the facility failed to maintain an environment free from staff to patient abuse, assure incident reports were completed in a timely manner, failed to assure complete abuse investigations were reviewed in the decision making process, and failed to protect patients while allowing the staff member involved to work during and after the investigation process in 1 of 2 patients involved in allegations of abuse. (Patient #6)

The findings include:

Review of facility policy "Patient Abuse and Neglect" reviewed/revised 6/1/2016 revealed "....Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish...III Standards...F. Pending the outcome of the investigation, the accused employee must be immediately removed from the specific patient care area. The removal might include reassignment, suspension, or re-assignment[sic] to a department where there is no patient care contact such as medical records. G. Patient abuse or neglect is considered a cause for immediate dismissal. Suspension shall occur during the investigation process if necessary..."

Review of facility policy "Patient Bill of Rights" reviewed/revised 6/1/2016 revealed "....Patient Rights: You have a right to...10. Have access to visitors, telephone calls, mail, etc. Any restrictions to access will be discussed with you and you will be involved in the decision when possible...13. Receive care in a safe setting. 14. Be free from all forms of abuse or harassment..."

Review of facility policy "Standards of Conduct" review/revised 1/22/2019 revealed " ....Gross Misconduct: Strong potential for discharge on the first offence. Listed below are examples of violations typically viewed as gross misconduct subject to immediate termination and performance deficits and conduct likely to receive corrective actions *patient abuse, neglect or willful violation of patient rights..."

Closed medical review on 10/05/2021 of Patient #6 revealed a 17 year old female admitted to the facility on 09/01/2021 for diagnoses of Major Depressive Disorder and Suicidal Ideation. Record review revealed no documented incidents with staff nor patient injury. Record review revealed Patient #6 was discharged home in the care of her grandmother on 09/27/2021.

Review of a facility incident report dated 9/16/2021(4 days after incident) revealed "Details: Peers stated Patient #6 asked night shift MHT #32 for a phone call. Per patients, staff invited patient (Patient #6) to a fight with her body language. Situation escalated to a physical altercation. Patients stated staff fought the patient."

Video surveillance (no audio) review on 10/05/2021 at 1050 revealed: Date of incident 09/12/2021
21:18:17- RN #18 enters 100 Hall from the Nurses Station, MHT #32 standing at end of hall towards nurses station facing towards patient room
21:18:19- Patient #6 in the threshold of her room at the end of the hall
21:19:04- Patient #6 stood up from sitting position walking towards where MHT #32 and RN #18 are standing
21:19:06- MHT #32 removed her jacket and threw it at RN #18
21:19:09- RN #18 motioned MHT #32 off the hall
21:19:13- unidentified staff member (nurse in orientation) pulled at MHT #32 to get her in the nurses station (unsuccessfully)
21:19:16- Patient at threshold of nurses station. RN #18 attempting to prevent altercation by standing between Patient #6 and MHT #32.
21:19:20 - MHT #32 shoved Patient #6 arm, Patient #6 swinging arms trying to hit out.
21:19:44- MHT #32 removed herself from incident by going to adjacent hall (200).

Review of facility internal investigation report dated as completed on 09/24/2021 revealed patient and staff interviews and statements. Review of the interviews/statements revealed:

Patient A interview on 09/17/2021 revealed "She stated on the night of 09/12/2021, MHT #32 told their hall they could not get phone calls and cursed at them. Per Patient A, MHT #32 took off her jacket, like she was going to fight Patient #6, and said she had been waiting on that day. Patient A stated MHT #32 hit Patient #6 and then Patient #6 hit her back."

Patient B interview on 09/17/2021 revealed "She stated on the night of 09/12/2021, she witnessed MHT #32 put her hands on Patient #6 and fight her after stating she had been waiting on this day. Patient B stated MHT #32 cursed at them and refused their phone calls. Patient B stated MHT #32 took off her jacket, Patient #6 approached her and hit MHT #32 and she hit back."

Patient C interview on 09/17/2021 revealed "She stated on 09/12/2021 MHT #32 denied their phone calls, cursed at them, and then told Patient #6 she was waiting on this moment to come, which triggered Patient #6 to fight her. Patient C did not witness MHT #32 hit Patient #6.

RN #18 interview on 09/21/2021 at 2134 revealed, "(MHT #32) refused to make phone calls for the patients because they were being rude. (Patient #6) started cursing at (MHT #32) at that point. (RN #18) stated (Patient #6) wanted to fight, and (MHT #32) provoked her in the altercation." RN #18 recalled that MHT #32 refused to leave the hall at first, refused to take time away in the med room, until another staff pulled her off the hall. Per RN #18 he was not sure if he saw MHT #32 hit Patient #6, but felt MHT #32 would have fought Patient #6 if other staff did not intervene...Per RN #18 he stated he told MHT #32 "No, let's not get into this," he felt it was a power struggle between MHT #32 and Patient #6. He stated MHT #32 told Patient #6 said just leave it to me, "I'm going to make sure I handle everything tonight, bring it on," RN #18 stated MHT #32 told Patient #6 to "bring it up here, this is what enraged Patient #6 to start charging at her." After the incident RN #18 was not feeling well so he was sent to the hospital..."

Review of the internal investigation report revealed "Conclusion: After interviews with staff and patients this investigation has been determined to be unsubstantiated for physical abuse. However, after consultation with the CNO (Chief Nursing Officer) and HRD (Human Resources Director) it was determined that staff violated HR (Human Resources) Policy 400.04 Standards of Conduct. Additionally, the CNO will follow up with RN #18 regarding the phone call issue. Recommendation: Per CNO and HRD a final written warning will be provided to MHT #32. MHT #32 will take part in additional training to include but not limited to limit setting, management of aggressive behaviors and verbal de-escalation. MHT #32 will have no contact with Patient #6 for the duration of her treatment."

Review on 10/11/2021 of MHT #32 file revealed no final written warning regarding the incident.

Interview on 10/05/2021 at 1030 with Patient #2 revealed she was present on 100 hall on the night of 09/12/2021. Interview revealed she recalled the events of that night. Interview revealed MHT #32 told us we could not have phone calls. Interview revealed Patient #6 wanted a phone call. Interview revealed MHT #32 was cursing at the patients as well as she took off her jacket and stated "I have been waiting for this day." Interview revealed nursing staff tried to get MHT #32 off the hall but she refused. Interview revealed MHT #32 did hit Patient #6.

Interview on 10/05/2021 at 2134 with RN #18 revealed he recalled the events of the night of 09/12/2021. Interview revealed MHT #32 was the only one on the hall with the patients and asked for assistance with making phone calls for patients. Interview revealed he would assist MHC #32 after completing his medication pass. Interview revealed after finishing his tasks and returning on the 100 hall he heard a comment from MHT #32 about "everyone return to your rooms, no more phone calls". Interview revealed there was a verbal altercation between MHT #32 and Patient #6. Interview revealed there were curse words used by both parties involved. Interview revealed Patient #6 stated "We all have a right to make calls." Interview revealed RN #18 felt the decision to not make phone calls by MHT #32 triggered the events. Interview revealed he asked MHT #32 to leave the hall and she refused. Interview revealed Patient #6 made a comment "I am coming down to beat your (curse word)." Interview revealed MHT #32 stated something like "ok, if you can..." then took off her jacket and threw it at him. Interview revealed he was pushed during the altercation when Patient #6 arrived at the nurses station door. Interview revealed he was transported to the hospital after the incident for high blood pressure and dizziness. Interview revealed Patient #6 apologized to him once he returned to work stating she was sorry and did not mean him any harm during the incident. Interview revealed MHT #32 has not worked on the 100 hall since the event but she has worked in other units of the hospital.

Interview on 10/06/2021 at 10 20 with PA #11 (patient advocate) revealed she conducted the investigation involving the incident on 09/12/2021. Interview revealed she interviewed the staff and patients and had them produce written statements. Interview revealed once the investigation is completed she presents the investigation report findings at patient safety meeting. Interview revealed she presented the completed report findings to the patient safety team which consists of her, DHR (human resources director), DON (chief nursing officer) and the DQCR (director of quality). Interview revealed the team met on 09/24/2021 and came up with the decision which was unsubstantiated for physical abuse. Interview revealed the decision was made on team collaboration. Interview revealed MHT #32 was not placed on leave during the investigation.

Interview on 10/06/2021 at 1515 with the DON and DHR revealed they both were not aware the patients were interview nor had consistent stories. Interview revealed they both did not have access to the patient's written statements. Interview revealed they only had staff statements during their decision making process. Interview revealed MHT #32 was given a final written warning. Interview revealed they both would have substantiated verbal abuse if all the items in the investigative report were presented. Interview revealed MHT #32 was not suspended pending investigation and has continued to work after the investigation. Interview revealed she was removed from working with Patient #6.

Interview on 10/06/2021 at 1545 with the DON revealed MHT #32 worked September 20, 24, 25, 26, and 30.

Documents received on 10/08/2021 at 1645 from the facility revealed on 10/08/2021 at 1625 DHR called and separated employment with MHT #32. A separation letter was emailed and sent in the mail.

Interview on 10/13/2021 at 1340 with DQCR revealed she was present during the Patient Safety meeting with the DON, DHR and PA #11 when the unsubstantiated decision for abuse was made. Interview revealed a review of the patient interviews and statements was included in the summary report presented at the meeting. Interview revealed the physical written statements were not presented but the information regarding them were presented. Interview revealed the DON and DHR were both focused on RN #18's statement. Interview revealed all information to make an informed decision was present at the meeting. Interviewed revealed she tried to explain the risk of the events that happened during the meeting. Interview revealed if she and PA #11 were the ones making the decisions, the abuse allegation would have been substantiated.

In summary, the facility staff failed to prevent staff to patient abuse to an adolescent female patient. A 17 year-old patient was admitted on September 1, 2021. A mental health technician was verbally abusive, cursing patients and not allowing them to make telephone calls on September 12, 2021 at 2118. The patient became upset and exhibited escalating behaviors. The mental health technician refused to leave the area when asked to do so by a nurse. The mental health technician provoked the patient resulting in a verbal and physical altercation between the mental health technician and the patient. The incident was not reported until four days after it occurred, and the mental health technician continued to work during and after the abuse investigation. Witness written statements from staff and patients reported consistent observation of staff to patient abuse. Facility staff failed to identify and prevent abuse.

Based on policy review, medical record review, video review, and staff interview, facility nursing staff failed to obtain a physician's order for a restrictive intervention in 1 of 5 patients (Patient #21) who required a restrictive intervention.

The findings include:

Review of policy titled "Seclusion and Physical or Chemical Restraint" reviewed/revised 04/28/2020 revealed, "...For a physical restraint ... episode, the Registered Nurse (RN) must obtain a telephone or written order from the client's treating psychiatrist as soon as possible, but no longer than 1 hour of implementation of an emergency safety intervention ... Immediately following release of physical restraint ... the QRN (Qualified Registered Nurse) will complete the Face to Face release assessment documenting on the RN Initial Reporting Form ... The face-to-face assessment and the restraint ... order must be documented on the Physician Order for Restrictive Interventions for Behaviors and filed in the patient's chart under Orders Tab. The restraint ... report and the incident report shall be completed by the QRN with input from the staff involved in the emergency safety intervention before the end of the shift ... All chemical/physical restraint ... will be documented by a registered nurse in the patient's medical record and will reflect justification, lesser restrictive measures attempted and failed prior to restraint ... implementation, and outcome of procedure (to include behavior at time of release..."

Closed Medical record review conducted on 10/14/2021 revealed Patient (Pt) #21 was a 12-year-old male admitted to the facility's 800 hall on 10/04/2021 with diagnoses of Post-Traumatic Stress Disorder and Disruptive Mood Regulation Disorder. Review revealed no documented evidence of the performance of, nor a provider order for a restrictive intervention on 10/05/2021.

Review of video footage of the 800 hall was conducted on 10/14/2021 at 1306. Review revealed on 10/05/2021 at 20:33:36 MHT #17 was standing at Pt #21's door, and Pt #21 attempted to exit the room and proceed across the hall towards another patient's room. MHT #17 was attempting to block Pt #21's advance. At 20:33:39 Pt # 21 attempted to lunge past MHT #17, and MHT #17 picked Pt #21 up with MHT #17's arms going under Pt #21's arm pits and across Pt #21's chest. MHT #17 carried Pt #21 back into his room, and the pair could no longer be seen on camera. At 20:35:35 a female staff member could be seen speaking to RN #18 who had entered camera view. RN #18 walked down the hall and briefly stood by Patient #21's door, did not enter the room, and walked back down the 800 hall and out of camera view.

Staff interview was conducted with MHT #17 on 10/14/2021 at 1500. Interview revealed during the evening of 10/05/2021 PT #21 was having a verbal altercation with another patient, and the Restrictive Intervention (RI) was performed when Pt #21 attempted to lunge past MHT #17 towards the other patient. Interview revealed while in Pt #21's room MHT #17 was able to call for assistance over his walkie-talkie, however no assistance ever came. Interview revealed after approximately 10 minutes, MHT #17 was able to release Pt #21 and they were able to talk about his escalating behaviors.

Telephone interview was conducted with RN #18 on 10/14/2021 at 1743. Interview revealed on the evening of 10/05/2021 several patients on the 800 hall were displaying escalating behaviors. Interview revealed RN #18 had asked a female staff member where MHT #17 was, and she reported MHT #17 was in Pt #21's room attempting to de-escalate his behaviors. At that time, RN #18 went to another patient's room to calm him down. Interview revealed, "I wasn't sure what to do at that point." Interview revealed after exiting the other patient's room, RN #18 went to Pt #21's door, which was closed, and RN #18 didn't hear anything coming from behind the door. Interview revealed RN #18 thought "if I opened the door it might escalate (Pt #21) again." Interview revealed "I didn't know what was going on with (Pt #21). If I was told something was going on in the room, I would have entered the room. I didn't see the RI and it was not reported to me the RI occurred so there was no documentation or physician order obtained."

Based on review of the Quality/Performance Improvement Plan, Quality/Performance Improvement (QAPI) Council minutes, Medical Executive Committee minutes, and staff interviews, the facility staff failed to measure, analyze and track quality indicator data for monitoring of treatment plans for compliance for 5 of 9 months (January 2021 through September 2021).

The findings include:

Review on 10/14/2021 of the "Quality/Performance Improvement Plan Overview of the Program 2021," no date provided, revealed "Performance Improvement: The systematic process of detecting and analyzing performance problems, designing, and developing interventions to address the problems, implementing the interventions, evaluating the results, and sustaining improvement." Review revealed minimum frequency of reporting to the QAPI council was monthly for at least ten times annually. Objectives, Organization and Scope of the Program: The overall objectives of the performance improvement program are as follows: ...To provide a consistent structure for monitoring and improving the organizational systems and processes to achieve patient care delivery that is appropriate, timely, effective, continuous, safe, respectful and compassionate...to provide a consistent structure for change as well as the review and design of new processes the collection and analysis of data the implementation of action plans and the evaluation of the effectiveness of improvements made in processes across the organization...MEASURE...Purpose of the Measurement (data collection) Process...To describe the stability or improvement of process...To identify areas for improvement, to determine whether changes in a process have met preestablished objectives...ASSESS...As a part of their role, leaders evaluate how effectively data and information are used throughout the hospital. That it is not useful if it is not analyzed...Once collected at the hospital the data will be compiled and assessed (analyzed) in order to identify levels of performance trends patterns and variations. ..."

Review on 10/12/2021 of the Quality/ Performance Improvement (QAPI) Council minutes revealed a "List of Performance Indicators" was approved on 01/20/2021. The list of Performance Indicators was selected based on "potential problem areas from data including some regulatory results derived in 2020 and before." The list of Performance Indicators included "Therapeutic Services: completion of elements of the treatment; completion of patient`s goals and strengths documented; treatment goals were established and documented upon admission; and completion of patients` goals in their own words; and treatment goals were updated or re-evaluated every 7 days." Review revealed the benchmark for overall score of Treatment Plans was 90%, and all elements of the treatment plan were 95% with a threshold of 90%.

Review of the QAPI council meeting minutes revealed no report/ update for Therapeutic Services on 01/20/2021; 02/17/2021; 07/21/2021; 08/2021 (no QAPI meeting held), and 09/01/2021. Review of the QAPI council meeting minutes from 01/20/2021 through 09/01/2021 revealed lack of consistent measuring (collecting), analyzing and tracking of quality indicators related to the treatment plans by failing to report in 5 out of 9 months in the QAPI council.

Interview on 10/14/2021 at 1325 with the Director of Quality revealed, there was a lack of reporting by the Therapeutic Services. Interview revealed her role was to facilitate and coordinate the quality/performance improvement activities. Interview revealed the CEO was the responsible person for ensuring all objectives were met in the Quality and Performance Improvement Council.

Interview on 10/07/2021 at 1003 with Interim Director of Clinical Services revealed she had a full caseload and had not been performing the duties and responsibilities of the Director of Clinical Services, since accepting the Interim position. Interview revealed she had not been trained or performed any medical record audits for the Quality and Performance Improvement council. Interview revealed she did not attend the Quality and Performance Improvement council meetings.

Interview on 10/14/2021 at 1050 with the DON revealed, "I don`t keep the raw data collected from the medical chart audits. I just turn in the numbers." DON revealed retraining of the nursing staff related to treatment plans were done in huddles and morning meetings. Interview revealed no documentation of the training content provided to nursing staff, and no monitoring of the nursing staff trained was done.

Interview on 10/13/2021 at 1300 with the CEO revealed, she had discussed with the Interim Director of Clinical Services the lack of performing the roles and responsibilities of the job due to therapist shortage. Interview revealed she was aware that reporting of the Clinical Services Quality Indicators for Therapeutic Services had not been reported on a regular basis in the monthly QAPI council meetings. Interview revealed "monitoring, collecting data was expected on a regular basis."

Based on review of the Quality/Performance Improvement Plan, Quality/Performance Improvement (QAPI) Council minutes, Medical Executive Committee minutes, and staff interviews, the facility staff failed to identify and implement measures to improve therapeutic services that were not meeting target benchmarks for 5 of 9 months (January 2021 through September 2021).

The findings include:

Review on 10/14/2021 of the "Quality/Performance Improvement Plan Overview of the Program 2021," no date provided, revealed "Performance Improvement: The systematic process of detecting and analyzing performance problems, designing, and developing interventions to address the problems, implementing the interventions, evaluating the results, and sustaining improvement...Objectives, Organization and Scope of the Program: The overall objectives of the performance improvement program or as follows: ...To provide a consistent structure for monitoring and improving the organizational systems and processes to achieve patient care delivery that is appropriate timely, effective, continuous, safe, respectful and compassionate...to provide a consistent structure for change as well as the review and design of new processes the collection and analysis of data the implementation of action plans and the evaluation of the effectiveness of improvements made in processes across the organization...MEASURE...Purpose of the Measurement (data collection) Process...To describe the stability or improvement of process...To identify areas for improvement, to determine whether changes in a process have met preestablished objectives...IMPROVE...The quality performance improvement council shall evaluate the effectiveness of the actions taken in remedying the problem. The hospital leadership shall intervene in the situation of failure to take actions, actions that are ineffective or that are not successful in achieving or sustaining planned improvements and action will be taken when prior actions do not achieve or sustain planned improvements..." Review revealed minimum frequency of reporting to the QAPI council was monthly for at least ten times annually. ..."

Review on 10/12/2021 of the Quality/ Performance Improvement (QAPI) Council minutes revealed a "List of Performance Indicators" was approved on 01/20/2021. The list of Performance Indicators was selected based on "potential problem areas from data including some regulatory results derived in 2020 and before." The list of Performance Indicators included Therapeutic Services: completion of elements of the treatment; completion of patient`s goals and strengths documented; treatment goals were established and documented upon admission; and completion of patients` goals in their own words; and treatment goals were updated or re-evaluated every 7 days. Review revealed the benchmark for overall score of Treatment Plans was 90%, and all elements of the treatment plan were 95% with a threshold of 90%. Review of the QAPI council meeting minutes revealed no report/ update for Therapeutic Services on 01/20/2021, 02/17/2021, 07/21/2021, 08/2021(no QAPI meeting held), and 09/01/2021.
Review revealed from 02/26/2021 through 09/01/2021 of the data for Therapy treatment plan compliance ranged from 71.5% to 74.5%, Nursing treatment plan compliance ranged from 62.7% to 67.5%, and Psychiatry treatment plan compliance ranged from 74.7% to 87.6%. Review revealed from 02/26/2021 through 09/01/2021 the conclusion/recommendations/actions remained the same " ...ongoing training by Clinical Director and DON...and...continual need for monitoring and training in this area..." Review of the QAPI council meeting minutes from 01/20/2021 through 09/01/2021 revealed, Therapeutic Services was not consistently identifying and implementing measures to improve performance indicators in the QAPI council meetings.

Review on 10/14/2021 of the Medical Executive Committee Meeting minutes revealed Therapeutic Clinical Services, that included treatment plans, were topics on the agenda. Review revealed from 02/26/2021 through 09/01/2021 the conclusion/recommendations/actions for Therapeutic Services remained the same "...ongoing training by Clinical Director and DON...and ...continual need for monitoring and training in this area..."

Interview on 10/07/2021 at 1003 with Interim Director of Clinical Services revealed she had a full caseload and had not been performing the duties and responsibilities of the Director of Clinical Services, since accepting the Interim position. Interview revealed she had not been trained or performed any medical record audits for the Quality and Performance Improvement council. Interview revealed she did not attend the Quality and Performance Improvement council meetings.

Interview on 10/14/2021 at 1050 with the DON revealed, "I don`t keep the raw data collected from the medical chart audits. I just turn in the numbers." DON revealed retraining of the nursing staff related to treatment plans were done in huddles and morning meetings. Interview revealed no documentation of the training content provided to nursing staff, and no monitoring of the nursing staff trained was done. Interview revealed no new interventions or training had been implemented based on Therapeutic Services data collected in the last three months.

Interview on 10/13/2021 at 1300 with the CEO revealed, she had discussed with the Interim Director of Clinical Services the lack of performing the roles and responsibilities of the job due to therapist shortage. Interview revealed she was aware that reporting of the Clinical Services Quality Indicators for Therapeutic Services had not been reported on a regular basis in the monthly QAPI council meetings. Interview confirmed no new action plans or improvements had been implemented in Therapeutic Services related to treatment plans in QAPI council meetings in the last three months.

Based on quality/performance improvement plan review, policy and procedure review, medical records review, internal document review, video review, internal investigation review, observation, personnel file review, employee coaching form, corrective action review, incident review, patient safety committee investigation review, and staff and patient interviews, the facility staff failed to analyze adverse patient events to ensure corrective actions were implemented for patient safety in 3 of 5 sampled patients with incident report investigations (Patients #6, #11 and #2).

The findings include:

Review on 10/14/2021 of the "Quality/Performance Improvement Plan Overview of the Program 2021," no date provided, revealed " .... "PURPOSE The purpose of this Quality/Performance Improvement Plan is to describe the program that is used to systematically design, assess, monitor, and improve processes, structures, outcomes, and patient safety ...Objectives, Organization and Scope of the Program ...To ensure that departments/services ...are properly monitoring the stability of existing processes, identifying opportunities for improvement ... Definitions: Adverse event: A patient safety event that resulted in harm to a patient served....Close Call: A patient safety event that did not reach the individual served or patient, outcome but whereby a recurrence carries a significant chance of a serious adverse outcome. Also called a "near miss" or "good catch"...HOSPITALWIDE PATIENT SAFETY PROGRAM As noted, patient safety is the intended focus of the Performance Improvement Program at [HOSPITAL]. As such, the hospital has an organization wide integrated patient safety program within its performance improvement activities. The Quality/Compliance/Risk Director is the person designated to implement the hospital wide safety program. Aspects of this program may be delegated to all departments and services within the hospital in the safety program. The scope of the program includes all safety issues ranging from near miss events ("close calls") to sentinel events...A patient safety event is defined as an event, incident, or condition that could have resulted or did result in harm to an individual served or patient. Patient safety events encompass adverse events, close calls, and sentinel events. While investigation of a close call occurs to understand how it occurred, why it occurred, any trends in occurrence, and prevention, when a sentinel event occurs, the hospital is required to conduct a thorough and credible comprehensive systematic analysis in response..."

1. Review of a facility incident report dated 09/16/2021 (4 days after incident) revealed "Details: Peers stated Patient #6 asked night shift MHT #32 for a phone call. Per patients, staff invited patient (Patient #6) to a fight with her body language. Situation escalated to a physical altercation. Patients stated staff fought the patient."

Review of facility internal investigation report revealed patient and staff interviews and statements. Review of the interviews/statements revealed:

Patient A interview on 09/17/2021 revealed "She stated on the night of 09/12/2021, MHT #32 told their hall they could not get phone calls and cursed at them. Per Patient A, MHT #32 took off her jacket, like she was going to fight Patient #6, and said she had been waiting on that day. Patient A stated MHT #32 hit Patient #6 and then Patient #6 hit her back."

Patient B interview on 09/17/2021 revealed "She stated on the night of 09/12/2021, she witnessed MHT #32 put her hands on Patient #6 and fight her after stating she had been waiting on this day. Patient B stated MHT #32 cursed at them and refused their phone calls. Patient B stated MHT #32 took off her jacket, Patient #6 approached her and hit MHT #32 and she hit back."

Patient C interview on 09/17/2021 revealed "She stated on 09/12/2021 MHT #32 denied their phone calls, cursed at them, and then told Patient #6 she was waiting on this moment to come, which triggered Patient #6 to fight her. Patient C did not witness MHT #32 hit Patient #6.

RN #18 interview on 09/21/2021 revealed "He stated MHT #32 refused to make phone calls for the patients because they were being rude. Patient #6 started cursing at MHT #32 at that point. RN #18 stated Patient #6 wanted to fight, and MHT #32 provoked her in the altercation. RN #18 recalled that MHT #32 refused to leave the hall at first, refused to take time away in the med room, until another staff pulled her off the hall. Per RN #18 he was not sure if he saw MHT #32 hit Patient #6, but felt MHT #32 would have fought Patient #6 if other staff did not intervene...Per RN #18 he stated he told MHT #32 "No, let's not get into this," he felt it was a power struggle between MHT #32 and Patient #6. He stated MHT #32 told Patient #6 said just leave it to me, "I'm going to make sure I handle everything tonight, bring it on," RN #18 stated MHT #32 told Patient #6 bring it up here, this is what enraged Patient #6 to start charging at her. After the incident RN #18 was not feeling well so he was sent to the hospital..."

Review of the internal investigation report revealed "Conclusion: After interviews with staff and patients this investigation has been determined to be unsubstantiated for physical abuse. However, after consultation with the CNO (Chief Nursing Officer) and HRD (Human Resources Director) it was determined that staff violated HR (Human Resources) Policy 400.04 Standards of Conduct. Additionally, the CNO will follow up with RN #18 regarding the phone call issue. Recommendation: Per CNO and HRD a final written warning will be provided to MHT #32. MHT #32 will take part in additional training to include but not limited to limit setting, management of aggressive behaviors and verbal de-escalation. MHT #32 will have no contact with Patient #6 for the duration of her treatment."

Review on 10/11/2021 of MHT #32 personnel file revealed no final written warning regarding the incident.

Interview on 10/05/2021 at 1030 with Patient #2 revealed she was present on 100 hall on the night of 09/12/2021. Interview revealed she recalled the events of that night. Interview revealed MHT #32 told us we could not have phone calls. Interview revealed Patient #6 wanted a phone call. Interview revealed MHT #32 was cursing at the patients as well as she took off her jacket and stated "I have been waiting for this day." Interview revealed nursing staff tried to get MHT #32 off the hall but she refused. Interview revealed MHT #32 did hit Patient #6.

Interview on 10/05/2021 at 2134 with RN #18 revealed he recalled the events of the night of 09/12/2021. Interview revealed MHT #32 was the only one on the hall with the patients and asked for assistance with making phone calls for patients. Interview revealed he would assist after completing his medication pass. Interview revealed after finishing his tasks and returning on the 100 hall he heard a comment from MHT #32 about "everyone return to your rooms, no more phone calls". Interview revealed there was a verbal altercation between MHT #32 and Patient #6. Interview revealed there were curse words used by both parties involved. Interview revealed Patient #6 stated "We all have a right to make calls." Interview revealed RN #18 felt the decision to not make phone calls by MHT #32 triggered the events. Interview revealed he asked MHT #32 to leave the hall and she refused. Interview revealed Patient #6 made a comment "I am coming down to beat your (curse word)." Interview revealed MHT #32 stated something like "ok, if you can..." then took off her jacket and threw it at him. Interview revealed he was pushed during the altercation when Patient #6 arrived at the nurses station door. Interview revealed he was transported to the hospital after the incident for high blood pressure and dizziness. Interview revealed Patient #6 apologized to him once he returned to work stating she was sorry and did not mean him any harm during the incident. Interview revealed MHT #32 has not worked on the 100 hall since the event but she has worked in other units of the hospital.

Interview on 10/06/2021 at 1020 with PA #11 (patient advocate) revealed she conducted the investigation involving the incident on 09/12/2021. Interview revealed she interviewed the staff and patients and had them produce written statements. Interview revealed once the investigation was completed she presents the investigation report findings at patient safety meeting. Interview revealed she presented the completed report findings to the patient safety team which consists of her, DHR (human resources director), DON (Director of Nursing) and the DQCR (director of quality). Interview revealed the team met on 09/24/2021 and came up with the decision which was unsubstantiated for physical abuse. Interview revealed the decision was made on team collaboration. Interview revealed MHT #32 was not placed on leave during the investigation.

Interview on 10/06/2021 at 1515 with the DON and DHR revealed they both were not aware the patients were interviewed nor had consistent stories. Interview revealed they both did not have access to the patient's written statements. Interview revealed they only had staff statements during their decision making process. Interview revealed MHT #32 was given a final written warning. Interview revealed they both would have substantiated verbal abuse if all the items in the investigative report were presented. Interview revealed MHT #32 was not suspended pending investigation and has continued to work after the investigation. Interview revealed she was removed from working with Patient #6.

Interview on 10/06/2021 at 1545 with the DON revealed MHT #32 worked September 20, 24, 25, 26, and 30.

Documents received on 10/08/2021 at 1645 from the facility revealed on 10/08/2021 at 1625 DHR called and separated employment with MHT #32. A separation letter was emailed and sent in the mail.

Interview on 10/13/2021 at 1340 with DQCR revealed she was present during the Patient Safety meeting with the DON, DHR and PA #11 when the unsubstantiated decision for abuse was made. Interview revealed a review of the patient interviews and statements was included in the summary report presented at the meeting. Interview revealed the physical written statements were not presented but the information regarding them was presented. Interview revealed the DON and DHR were both focused on RN #18's statement. Interview revealed all information to make an informed decision was present at the meeting. Interview revealed she tried to explain the risk of the events that happened during the meeting. Interview revealed if she and PA #11 were the ones making the decisions, the abuse allegation would have been substantiated.



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2. Closed medical record review on 10/04/2021 revealed Patient #11 was a 60-year-old male admitted on 09/14/2021 with "IVC (involuntary commitment) papers taken out by his caregiver whom he tried to choke and he threatened to kill his father." Review revealed Patient #11 was transported the referring local ED (emergency department) on 09/10/2021 by law enforcement for attacking his ex-wife. Review of the referring ED provider note dated 09/10/2021 at 1530 revealed Patient #11 eloped from their ED however was found and safely returned. Review of the "Intake Screening Assessment" dated 09/14/2021 at 1647 revealed the "Elopement Risk Screen (behaviors assessed in the past 24 hours)" was zero therefore Patient #11 was not identified as an elopement risk. Review revealed Patient #11 was placed on Q15-minute observations on 09/14/2021 at 1815. Review of the "Medical Consult Note" dated 09/29/2021 at 1624 revealed " ...HX (history) of Dementia ...Wandered out of facility no injury or trauma ..." Review of Patient #11's "Patient Observation Rounds" sheet dated 09/28/2021 from 1600 through 1635 revealed MHT (mental health technician) #4 documented Patient #11 was outside in the courtyard. Review revealed MHT #4 documented Patient #11 was "off unit" at 1645 and back on the hall at 1655. Further review of the Patient Observation Round sheet revealed MHT #4 documented "Resident got out via the unlocked maintenance door on the patio." Review revealed Patient #11 was returned to the unit unharmed around 1651. Patient #11 was discharged on 10/11/2021.

Review of an incident report completed by RN #1 dated 09/28/2021 revealed " ...Location Details: patient was observed walking on the street, facility was notified, Supervisor, CNO (Chief Nursing Officer) and CEO (chief executive officer) AWARE ...Details: nurses were doing group outside the courtyard, she (RN #1) left the trainee (RN #2) outside to go give 4 pm (afternoon) meds, later trainee (RN #2) came back in she was notified to to live (sic) patients outside by themselves, she went out, nurse informed the trainee (RN #2) to bring them inside, then a few minutes we were notified that the patient was observed walking in the street, he was brought back to the unit, also medical doctor was informed."

Video review on 10/06/2021 at 1046 of the 900-hall outside courtyard revealed the following:
1603:17 through 1619:29- Patient #11 was visualized pacing the courtyard. [Unable to determine how many patients and staff were outside during the viewed time frame due to video quality and distance from the camera. Also, the camera is motioned detected, and the only available footage was the above stated time]. Patient #11 was not observed during video review exiting the courtyard.

Video review on 10/06/2021 at 1055 of the 900-hall unit inside view revealed the following:
1610:00- CNA #4 [CNA #4 was assigned to Patient #11 which was outside at this point] was sitting at a table in the common area of the unit [unable to visualize Patient #11 from this location]. Further review of the video revealed CNA #4 remained inside the 900-hall unit for the duration of Patient #11's outside time and RN #1, RN #2, and CNA #3 were noted to be inside the 900-hall and/or out of camera view away from the courtyard area [they would be unable to visualize the courtyard from their point of exit of video view] for the duration of Patient #11's outside time. Review revealed at 1645 was when RN #1 received a phone call and staff began to search the unit for Patient #11.

Review of the hospital's investigative report initiated by PA #11 (Patient Advocate) on 09/29/2021 (the next day following Patient #11's elopement) revealed Patient #11 was in the geriatric unit courtyard attending a nursing group conducted by RN #1. Review revealed RN #1 left the patients in the courtyard with RN #2, (travel nurse which was on her first day of orientation) a "trainee" while RN #1 completed a medication administration. Review revealed RN #2 subsequently left the patients outside unattended. Review revealed it was not until RN #1 received a phone call alerting her that Patient #11 had been located off the hospital premises and safely returned. Review revealed the Director of Environmental Services (DES) and CNO (Chief Nursing Officer) were notified and determined the double doors leading out of the courtyard were left unlocked by a maintenance tech from earlier that morning. Review revealed immediate actions were "Maintenance technician was immediately terminated for not following safety protocol for ensuring exterior doors are secured after vendors exits. All Maintenance technicians have been retrained on the safety and security of building protocol."

Review of the hospital's updated investigative report by PA #11 (Patient Advocate) revealed
it was determined during video review, RN #2 left the patients outside unattended for approximately 5-10 minutes. Review revealed CNA #4 was interviewed on 10/01/2021 by PA #11 and stated he was responsible for "3 line of sight patients and 10 Q15 for other patients on the hall." Review revealed CNA #4 falsified Patient #11's q15 observation sheet the day he eloped and marked him as outside when he actually did not observe him. Review revealed additional actions were implemented by the CEO on 10/04/2021 (after the survey team entered and 6 days after Patient #11 eloped) which included CNA #4 was terminated, RN #2 was no longer allowed to work at the hospital, RN #1 and CNA #3 were to receive "written write up", and staff were "receiving re-education on Patient Observation starting on 10/05/2021 (one day after the survey team entered and 7 days after Patient #11 eloped), second shift." Further review revealed screamer alarms (audible alarms) had been installed on the gate at the geriatric courtyard, twice daily perimeter security checks by maintenance were being completed, a new policy on physical security and management was being drafted, vender safety checklist was initiated, and EOC (environment of care) daily, weekly and monthly checks were being implemented to include checking perimeter doors. Review revealed the report was closed by PA #11 on 10/04/2021, signed by her on 10/05/2021, revised and signed by DQCR on 10/06/2021 (after the survey team was on site and 8 days after the patient eloped).

Observation on 10/05/2021 at 0953 during tour with the DES of the geriatric courtyard double doors revealed a red screamer alarm mounted above the doors. Observation during testing of the screamer alarm revealed the alarm had an audible alarm when the double doors were opened.

Interview on 10/05/2021 at 0956 with the DES revealed immediately following Patient #11's elopement, the maintenance tech was terminated due to leaving the door unlocked after the vender left. The DES stated all his staff had completed re-education on 10/01/2021 on ensuring the perimeter door securement. The DES stated the screamer alarms were installed over both the geriatric and adolescent courtyard doors on 10/01/2021. Interview revealed perimeter checks had been added to the maintenance daily check-offs, a draft policy had been started to include perimeter checks and will be reviewed in Octobers (10/21/2021) EOC meeting, new hire training had been updated to discuss securing the doors with all new hires, "security competencies" check offs had been added to include door security, a "vendor safety check list" had been updated to include checking outside doors and will now be completed by maintenance anytime a vender entered the building. During interview the DES provided the surveyor with documentation supporting the implemented process changes.

Review on 10/06/2021 of CNA #4's personnel file revealed he was terminated on 10/04/2021 for "falsification of records."

Review on 10/07/2021 of RN #1's personnel file failed to reveal a written warning related to Patient #11's elopement.

Review on 10/07/2021 of RN #2's personnel file failed to reveal any documentation that RN #2 was no longer allowed to work at the facility.

Review on 10/11/2021 of CNA #3's personnel file failed to reveal a written warning related to Patient #11's elopement.

Review of the "Corrective Action Report" dated 10/04/2021 for CNA #4 revealed "On 9/28/2021 CNA #4 falsified 2 Q15 checks. He stated he observed a patient that he could not have observed because the patient eloped. The patient eloped for 29 minutes. CNA #4 did not notice the patient was missing. It came to the attention of the facility by other means. CNA #4 was notified by the facility that the patient was missing." Signed by the DON and DHR (Director of Human Resources) on 10/04/2021.

Review of an "Employee Coaching Form" dated 10/08/2021 [10 days following Patient #11's elopement] for RN #1 revealed "Describe performance-related responsibilities coached ...On September 28, 2021, while conducting group in the courtyard, you left an orientee nurse alone in the courtyard with the patients. Orientees cannot assume the responsibility of patient care during their orientation period. It is expected that if you are orienting a new employee, you must remain with the patients you are responsible for supervising. This responsibility cannot be delegated to an orientee ..." Further review of the form failed to reveal RN #1 or "Supervisor" Signatures.

Interview on 10/05/2021 at 1453 with RN #2 revealed she was a travel nurse and 09/28/2021 was her first shift on orientation. RN #2 stated she was assigned to RN #1 on the geriatric unit that day. Interview revealed none of the staff witnessed Patient #11 exit the courtyard on 09/28/2021. RN #2 stated CNA #4 was assigned to Patient #11 therefore he was the one completing the Q15 minute checks. Interview revealed at one point, RN #1, RN #2, and CNA #3 were outside with approximately 6 patients, including Patient #11. RN #2 stated CNA #4 was never outside with Patient #11 and did not "hand over the clipboard" [the q15 minute observation sheets] for them to complete. Interview revealed RN #2 did "not think they [the patients] were outside by themselves."

Interview on 10/06/2021 at 1515 with CNA #3 revealed she was assigned to the geriatric unit on 09/28/2021. CNA #3 stated RN #1 and RN #2 went outside to the courtyard to conduct a nursing group and CNA #4 and herself were inside monitoring the patients that didn't go out for group. CNA #3 stated CNA #4 was responsible for all the patients q15 minute checks including three line of sights. Interview revealed CNA #3 left the unit to get supplies and when she returned, she heard a code silver being called. CNA #3 stated it wasn't until someone called the unit that they realized Patient #11 was gone. CNA #3 stated Patient #11 was left outside unsupervised at some point and eloped out the double doors exiting the courtyard that maintenance had left unlocked from earlier that day. Interview revealed CNA #3 had not received any reeducation or corrective action regarding Patient #11s elopement.

Interview on 10/06/2021 at 1557 PA (Patient Advocate) #11 revealed she conducted Patient #11's elopement investigation. PA #11 stated it was determined CNA #4 had all the patients q15 minute observation sheets while CNA #3 stepped off the unit to obtain supplies. Interview revealed there was a traveler on duty that day for her first shift of orientation (RN #2). PA #11 stated RN #1 and RN #2 were outside with the patients and RN #1 came inside and left RN #2 outside with the patients. PA #11 stated the patients were left outside at some point and Patient #11 eloped out the double doors exiting the courtyard. PA #11 stated she notified the CEO of the incident on 09/29/2021 and her (CEO) immediate actions were to place CNA #4 on leave and terminate the maintenance tech that left the door unlocked. PA #11 stated she completed her investigation and submitted it to the CEO on 10/04/2021 and the CEO added written warnings for RN #1, CNA #3, and herself; termination for CNA #4 and RN #2; and reeducation for staff starting on 10/05/2021 on patient observations. PA #11 stated the DQCR (Director of Quality) reviewed and changed the report on 10/06/2021. Interview revealed PA #11 "did not feel like the RNs were at fault." Interview revealed PA #11 conducted all elopement investigations and submits the report to her supervisor, DQCR for final review.

Interview on 10/06/2021 at 1707 with RN #1 revealed she was the RN assigned to the geriatric unit the day Patient #11 eloped. RN #1 stated she and RN #2 conducted nursing group outside in the courtyard. RN #1 stated after the nursing group was over, she came inside to make a phone call and told RN #2 she would be "right back." RN #1 stated she noticed RN #2 had come inside and RN #1 told RN #2 not to leave the patients outside alone and to bring them inside. RN #1 stated none of the staff realized Patient #11 was missing until they received a phone call from the facility receptionists alerting them a geriatric patient had been located off the facility premises. Interview revealed RN #1 had not received any reeducation or corrective action related to Patient #11's elopement.

Interview on 10/07/2021 at 1306 with DHR (Director of Human Resources) revealed she notified RN #2's travel agency (date unknown) that she would no longer be allowed to work at the facility. DHR stated she was unaware of any corrective actions for RN #1 or CNA #3.

Interview on 10/12/2021 at 1444 with the CEO revealed following Patient #11's elopement, staff took "immediate actions." The CEO stated she pulled a team together and they reviewed the video footage. The CEO stated the DES (Director of Environmental Services) reported the courtyard doors were left unlocked and the DON reported Patient #11s q15 minute checks were falsified. The CEO stated as the investigation developed, staff realized there were additional staff that required corrective actions. Interview revealed it ultimately "falls on my shoulders" to ensure the facility followed through with the corrective actions.

Interview on 10/13/2021 at 1355 with the DQCR revealed PA #11 submitted her 5-day investigation on 10/05/2021. The DQCR stated after she reviewed the report, she realized nursing staff had left Patient #11 unsupervised. The DQCR stated she notified the CEO on 10/05/2021 about the lack of supervision and the CEO decided then to provide RN #1, CNA #3, and PA #11 with a written warning. The DQCR stated she revised the report on 10/06/2021 to remove PA #11 from the corrective actions list because she did not feel she had any involvement with Patient #11's elopement.

Interview on 10/13/2021 at 1459 with the DON revealed CNA #3 did not receive a corrective action and should have not been on the 5-day investigative report as receiving a corrective action.

Follow-up interview on 10/14/2021 at 0957 with the DON revealed she was made aware that Patient #11 had eloped the day of the elopement. The DON stated that same day herself and the DES walked the perimeter of the courtyard and discovered the door was left unlocked. The DON stated she "immediately" reviewed the video. The DON stated the maintenance tech was immediately terminated and it was identified "sometime last week" that lack of nursing supervision had contributed to Patient #11's elopement. The DON stated RN #1's employee coaching form was dated for 10/08/2021 however RN #1 had not been back to work to sign it. Interview revealed the DON could not recall if she had a discussion with anyone else but maybe with the DHR about corrective actions for RN #1. The DON stated there was an immediate action to terminate CNA #4 once they realized he had falsified Patient #11's q15 minute checks.



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3. Policy review on 10/06/2021 of "Safety Hazard Inspection Survey" review/revised 06/08/2021, revealed "Purpose A. To promote an environment for patients, staff, and visitors that is free from safety hazards and that all facility areas are following local and state regulations. B. To establish response to product, chemical, and equipment safety ..."

Open Medical record review conducted on 10/04/2021 revealed Patient (Pt) #2 was a 15-year-old female admitted to the 100-hall on 08/05//2021 with the diagnoses of major depressive disorder, recurrent severe without psychotic feature. Review of the Psychiatric Progress note dated 08/25/2021 revealed the patient "ingested some cleaning supplies that she got from the unit ..."

Review of the "Incident Report (IR)" dated 08/24/2021 at 1615 revealed "patient sprayed cleaning detergent to the mouth, it was unwitnessed. The nurse Practitioner evaluated the patient and stable at this time. Vital signs 121/84, temperature 97.5, pulse 102, saturation 99%. Nurse supervisor notified."

Review of the "Patient Safety Committee investigation" dated 08/25/2021 revealed, staff statements, video review, investigative findings, and action plan. Review of the staff statements revealed Mental Health Tech (MHT) #14 reported that Patient #2 asked for a pair of scrub bottoms. The review revealed MHT #14 entered the bin room and Patient #2 entered behind her and grabbed the spray bottle and squeezed it into her mouth while the MHT was not looking. The video review revealed MHT #14 entered the bin room and Patient #2 was near the bin room door. The review revealed Patient #2 stood in the bin room door, halfway inside, and walked away from the bin room door, paced up and down the hall. The review did not show the inside of the bin room. Review of the investigative findings revealed "Staff stepped into bin room; patient held the door. The patient reached onto the shelf, per the report, and grabbed the bottle with cleaning detergent. This incident took place inside the bin room (no video footage available)." Review of the action plan revealed education was to be provided to Housekeeping and nursing staff about the storage of the chemicals.

Review of an internal email dated 08/25/2021 revealed an email was sent from the Director of Nursing (DON) to the Director of Environmental Services (DES) and the Infection Control Officer (ICO). Review of the email revealed "We need to limit cleaning with spray bottles to the housekeeping staff. Nursing staff can utilize wipes."

Observation on 10/07/2021 between 1545 and 1700 of the 700 and 800-Hall revealed a bin room on the 800-hall. The observation revealed a spray bottle labeled "Peroxide Multi Surface Cleaner and Disinfectant." Further observation revealed a nurses station was located between the 700 and 800-hall. The observation revealed four (4) spray bottles located on the floor between the copier machine and the counter. The observation revealed one bottle of Bio-Enzymatic Odor Eliminator Waterfall Mist, one bottle of Peroxide Multi Surface Cleaner and Disinfectant, one bottle of 73 Disinfecting Acid Bathroom Cleaner, and one bottle of Finito Natural Multipest Elimination.

Interview on 10/07/2021 at 1600 with the DON during the 700- and 800-unit tour revealed the cleaning supplies were not supposed to be kept in the bin rooms. The interview revealed all spray bottles with cleaning supplies should be kept in housekeeping.

Review of an internal email dated 10/08/2021 (during the survey) from the DON to the House Supervisors revealed "Housekeeping supplies are to remain in the housekeeping closet/cart. Containers such as the one illustrated below are not to be on the patient care units that include bin rooms and nurses station ..."

Interview on 10/11/2021 at 1000 with the DES revealed management had addressed and removed all chemical bottles from the bin rooms. The interview revealed an email was sent to all staff regarding the removal of chemicals from the bin rooms. The interview revealed the DES could not locate the email that was sent to the staff regarding the removal of the chemicals from the bin room.

Interview on 10/11/2021 at 1000 with MHT #12 during the 100-Hall unit tour revealed "I have been told today that the chemicals should not be kept in the bin room. I was not told where they should be kept."

Observation on 10/11/2021 between 1045 and 1150 of the 100-Hall revealed a bin room on the unit. Observation of the bin room revealed one spray bottle of Peroxide Multi Surface Cleaner and Disinfectant and one spray bottle of 73 Disinfecting Acid Bathroom Cleaner.

Follow up interview on 10/11/2021 at 1628 with the DON revealed there was no documentation of the staff education regarding not keeping chemicals in the patient care areas/bin rooms.

Based on review of medical staff Bylaws, credentialing file reviews, medical record reviews and staff and Allied Health Provider interview, the facility medical staff failed to evaluate the delineation of clinical privileges of Allied Health Providers (AHPs) for reappointment according to medical staff bylaws for 1 of 2 sampled AHP files reviewed (AHP # 24).

The findings include:

Review of the hospital's "Bylaws of the (Name of Hospital) Hospital 2021" adopted 2021 revealed "... Section 1. ACTIVE MEDICAL STAFF... Allied Health Professionals ("AHP") may exercise only the privileges granted to them. In determining all need for and type of privileges for AHPs, consideration must be given to federal and state laws and regulations governing scope of practice and supervision. Licensure shall not be the sole criterion for determining the need and scope of services. [FOR STATES REQUIRING COLLABORATIVE AGREEMENTS: AHPs may, under a collaborative practice agreement with a physician and, as privileged, serve under the supervision of a physician member of the Medical Staff, but they are not allowed to admit or discharge patients.]..."

Review on 10/08/2021 of AHP #24's credential file revealed "SPECIALTY OF CERTIFIED PHYSICIAN ASSISTANT DELINEATION OF CLNICAL PRIVILEGES... Scope of service and Responsibility... The PA-C will collaborate with the supervising physician in managing care, and discharging patients from the hospital/ facility..." Review revealed AHP #24 appointment period for clinical privileges is for 05/04/2020- 04/30/2022 and approved on 06/17/2020.

1. Closed medical record review of Patient #5 revealed "Nursing Orders- General Planned Discharge for 09/27/2021 Date: 09/27/21 Comments: Patient may discharge home today". Entered by AHP #24 Ordered by AHP #24 at 1009 eSigned by AHP #24 at 1009. Record review revealed Patient #5 was discharged from the facility on 09/27/2021 at 1408.

2. Closed medical record review of Patient #6 revealed "Nursing Orders- General Planned Discharge for 09/27/2021 Date: 09/27/21 Comments: Patient to be discharged today to go to Grandma's via Sheriff transport". Entered by AHP #24 Ordered by AHP #24 at 1025 eSigned by AHP #24 at 1025. Record review revealed Patient #6 was discharged from the facility on 09/27/2021 at 2100.

3. Closed medical record review of Patient #15 revealed "Nursing Orders- General Planned Discharge for 10/02/2021 Date: 10/02/21 Comments: Patient may discharge home today under the care and custody of parents". Entered by AHP #24 Ordered by AHP #24 at 847 eSigned by AHP #24 at 847. Record review revealed Patient #5 was discharged from the facility on 10/02/2021 at 1240.

Interview on 10/08/2021 at 0930 with AHP #24 revealed she does have access to the facility's Medical Staff By-Laws. Interview revealed until about a month ago she would admit patients to the facility. Interview revealed she was told she no longer admits patients. Interview revealed she does currently write discharge orders for patients.

Interview on 10/12/2021 at 1330 with MD #25 revealed he was aware that AHP's do not admit and discharge. Interview revealed he has been the on-call physician for the past few weeks as well as on call for the month of October to cover admissions. Interview revealed "this is a by-law issue that needs to be changed."

Based on review of medical staff Bylaws, Rules and Regulations, professional service agreement, credentialing file review, Medical Executive Committee Meeting Minutes, Governing Board Meeting Minutes, Professional Practice Evaluations, physician case load and on call schedule reviews, medical record reviews and staff and physician interviews, the hospital's governing body and medical staff failed to provide oversight of the quality of patient care by allowing a psychiatrist to function as the attending psychiatrist for adolescent boys via only telemedicine, while he was out of the country for extended stays for 1 of 1 physicians practicing telemedicine out of the country. (MD #20)

The findings include:

Review of the 2021 Medical Staff Bylaws revealed, "...Telemedicine - means the practice of medicine through the use of electronic communication or other communication technologies to provide or support clinical care at a distance and for the purpose of improving patient care, treatment and services. The physician may have either total or shared responsibility for patient care, treatment, and services and can write orders and direct care, treatment, and services through a telemedicine link. ... Each member of the medical staff will: a. provide his/her patients with professional care that meets generally accepted standards of quality, provide for continuous care for his/her patients, and participate in all quality improvement activities of the hospital and medical staff. ... d. prepare and complete in a timely manner medical records ... Section 3. TELEMEDICINE STAFF ... Tele-Medicine Medical Staff duties and responsibilities include admission, consultation, or ongoing care with patients as delineated in their individual privilege list. ... (Facility Name), as the originating site, retains responsibility for overseeing safety and quality of services provided. ... Tele-Medicine staff are subjected to medical staff quality reviews including Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE). The performance of their services rendered shall be evaluated as part of privileging and reappraisal conducted at the time of reappointment, renewal, or the revision of privileges. ... Article VIII: CLINICAL PRIVILEGES Section 1. DELINEATION OF CLINICAL PRIVILEGES ... b. New Clinical Privileges: Additional clinical privileges and classes of clinical privileges not presently listed on staff clinical privilege forms may be added upon determination by the Board that: ... 5. adequate monitoring of such clinical privileges could be achieved by the staff without undue burden; and the provision of such privileges would not unduly complicate patient care or expose the hospital staff to liability. ... Section 2. FOCUSED PROFESSIONAL PRACTICE EVALUATION All clinical privileges are granted under a period of Focused Professional Practice Evaluation (FPPE) to ensure and assess the practitioner's ability and competency to perform the privileges granted by the Board. The initial FPPE period will be for a period of 10 cases or six (6) months (whichever comes sooner) and can be extended for an additional six (6) month period if deemed necessary. Failure to advance the appointee from FPPE to OPPE (Ongoing Professional Practice Evaluation) shall be deemed a termination of his/her medical staff appointment. ... "

Review of the Medical Staff Rules and Regulations 2021 revealed, "All hospital Medical Staff and non-employee medical personnel working in the hospital shall adhere to the Rules and Regulations of the Medical staff as delineated below: ... Medical Record Requirements ... 6. The attending Medical Staff member is responsible for preparing the admission note and preliminary treatment plan and psychiatric evaluation ... Treatment Plan 8. The multi-disciplinary team shall develop an Individual Comprehensive Treatment Plan that is based on a comprehensive assessment of the patient's needs. This plan will be reviewed within 72 hours of admission and at least weekly. The attending physician/practitioner will be directly and actively involved in the development of the plan and approve it, noting this approval by signing the Master Treatment Plan and Treatment Plan updates. ... Adherence to Medical Staff and Facility Requirements ... 12. each Attending Medical Staff member on the Active Medical Staff shall attend treatment team meetings conducted concerning his/her patient and, for acute care patients is responsible for completing progress notes at least six days per week and other such notes as clinically indicated during the patient's length of stay. ... This will be monitored by the Medical Director with verbal reports, as necessary, made to the Medical Staff Meetings. ... Care of the Patient ... 16. ... The patient's progress in meeting goals and the efforts of staff members to help the patient should be regularly recorded. These progress notes will be used as a basis for reviewing treatment plans as outlined above and should refer to goals and objectives of the Individual Comprehensive Treatment Plan. ..."

Review of a Professional Service Agreement between the facility and MD #20 with an effective date of 01/01/2020 revealed "... Physician shall retain responsibility for all medical care provided to Hospital patients. ... Physician shall maintain proper clinical records and such reports as may be required by the Hospital ... "

Review of MD #20's credentialing file revealed an initial appointment to active medical staff on 08/03/2018. Review of the file revealed a letter from the CEO dated 08/06/2020 that stated MD #20 had been approved for a two year re-appointment with clinical privileges in Psychiatry from 08/06/2020 through 07/31/2022. Review of the "DELINEATION OF CLINICAL PRIVILEGES" revealed a a request for renewal of privileges (reappointment) signed by MD #20 on 07/22/2021. Review revealed, "Current clinical competence is assessed prior to granting privileges initially and is reassessed when renewing privileges at reappointment for maintenance of privileges. ... FPPE is conducted during the period after granting new/additional privileges." Review of the "Tele-psychiatry Core Privileges" included "Psychiatric Evaluation and Treatment; Psychiatric medication management; Psychiatric consultations, Follow-up on labs, EKG's and other orders; Continuity of Care; Psychiatric consultations to PCP (primary care provider) and specialty care providers." Review of the file revealed a letter from the CEO dated 07/24/2021 that stated MD #20 had been approved for a two year re-appointment with clinical privileges in Psychiatry and Tele-psychiatry from 07/24/2021 through 07/31/2023.

Review of Medical Executive Committee Ad-Hoc Meeting Minutes signed by the CEO on 07/23/2021 revealed MD #20 was approved for Tele-psychiatry privileges in addition to his current core privileges for Adolescents, Adults and Geriatrics for the remainder of his current two-year appointment, which expires July 31, 2022. The notes recorded MD #20 had a current license, DEA, current BLS (basic life support), and TB and flu vaccine. Review revealed the Chief Medical Officer (CMO) and the Medical Director approved these privileges.

Review of Governing Board Ad-Hoc Meeting Minutes signed by the CEO on 07/23/2021 recorded approval for MD #20 for Tele-psychiatry privileges in addition to his core privileges for Adolescents, Adults, and Geriatrics for the remainder of his current two-year appointment, which expires July 31, 2022. The notes recorded MD #20 had a current license, DEA, current BLS (basic life support), and TB and flu vaccine. Review revealed the approval was granted by the CEO, CMO, and three additional Governing Board members.

Review of MD #20's Focused Professional Practice Evaluation (FPPE) revealed letters from the Medical Director regarding results of MD #20's FPPE reviews and status. Review of a letter dated 03/11/2019 revealed 3 chart reviews were completed on 08/19/2018; 2 reviews done on 11/11/2018; 9 reviews on 02/08/2019; and 1 review on 02/01/2019. Review revealed 7 areas were identified as needing improvement. Review revealed FPPE was continued. Review of a letter dated 01/22/2020 revealed a total of 7 chart reviews were completed, with 5 reviews done on 01/17/2020; 1 review on 12/15/2019; and 1 review on 12/08/2019. Review revealed 4 areas were identified as needing improvement. Review revealed FPPE was continued. Review of a letter dated 02/18/2020 revealed a total of 5 chart reviews were completed on 01/25/2020. Review revealed 3 areas were identified as needing improvement. Review revealed FPPE was continued. Review of a letter dated 03/25/2021 revealed a total of 5 chart reviews were completed on 03/05/2021. Review revealed 5 areas were identified as needing improvement. Review revealed FPPE was continued. Review of a letter dated 05/18/2021 revealed a total of 5 chart reviews were completed on 04/29/2021. Review revealed no areas were identified as needing improvement. Review revealed MD #20 advanced to OPPE (Ongoing Professional Practice Evaluation).

Review of physician case load numbers revealed MD # 20 had an average census of 24 patients in August 2021; an average census of 22 patients in September; and an average census of 20 patients in October as of 10/13/2021.

Review of the physician on call schedule from June 2021 through October 4, 2021 revealed MD #20 was on call daily for adolescent boys and/or PRTF (psychiatric residential treatment facility) from June 1, 2021 through October 4, 2021. Review revealed MD #20 also covered call for geriatric patients on 07/03/2021; 07/04/2021; 07/10/2021; and 07/11/2021. Review of the call schedule revealed another provider was also listed as "ON CALL" daily. Sometimes this "ON CALL" person was a physician and sometimes it was a Nurse Practitioner or Physician's Assistant.

Telephone interview on 10/12/2021 with the Medical Director (MD #25) revealed the "ON CALL" person listed on the on call schedule usually covered on call needs during the night with the physician listed for adolescent boys, girls, or geriatrics as the back up coverage when a physician was needed.

Interview on 10/13/2021 at 1000 with the CEO revealed she was made aware from MD #20 that he was going out of the country on vacation and would be gone for about 30 days and wanted to use tele-psychiatry during this time. She reported MD #20 was the attending psychiatrist for the adolescent boys and PRTF (capacity of 24 acute and 12 PRTF patients). She reported he should see his patients via video daily six days a week and attend treatment team meetings on Monday, Wednesday and Friday. She reported he would document his notes electronically. The CEO reported that he sees all his patient via telepsych and speaks to the families. The CEO reported MD #20 was gone for about a month, then returned for a couple of weeks and reported that he was going back out of the country indefinitely. The CEO reported that MD #20 does participate in on call coverage.

The CEO confirmed the dates MD #20 was out of the country on 10/13/2021 at 1430. She reported that MD #20's last worked before going out of the country was July 27, 2021. He was gone through September 9, 2021 (44 days); then left on September 22, 2021 and was gone indefinitely.

Review of 10 sampled adolescent boys medical records revealed 8 of the 10 records failed to have Master Treatment Plans documented.

A. Open medical record review on 10/12/2021 revealed Patient #23, a 13 year-old male admitted to the facility on 09/01/2021. Record review revealed no Master Treatment Plan has been created as of record review date. (41 days after admission)

B. Closed medical record review conducted on 10/04/2021 revealed Patient #1 was a 13-year-old male who was admitted to the facility on 08/29/2021 and discharged on 09/09/2021 (11 days). Review revealed no evidence the Master Treatment Plan was created for Patient #1.

C. Open medical record review conducted on 10/06/2021 revealed Patient #14 was a 15-year-old male who was admitted to the facility on 09/07/2021. Review revealed no evidence the Master Treatment Plan was created for Patient #14 as of the record review date (29 days).

D. Open medical record review conducted on 10/08/2021 revealed Patient #16 was a 12-year-old male who was admitted to the facility on 09/07/2021. Review revealed no evidence the Master Treatment Plan was created for Patient #16 as of the record review date (31 days).

E. Closed medical record review conducted on 10/11/2021 revealed Patient #17 was a 15-year-old male who was admitted to the facility on 08/30/2021 and discharged from the facility on 10/08/2021 (39 days). Review revealed no evidence the Master Treatment Plan was created for Patient #17.

F. Closed medical record review on 10/06/2021 revealed Patient #4 was a 17-year-old male who was admitted to the facility on the 800-Hall on 09/07/2021. Review of the record revealed no evidence an initial Master Treatment Plan (MTP) was created for Patient #4. Review revealed Patient #4 eloped on 09/12/2021 (5 days) and did not return to the facility per parent request.

G. Closed medical record review on 10/04/2021 revealed Patient #8 was a 17-year-old male involuntarily committed to the facility on 09/03/2021 and discharged on 09/30/2021 (27 days). Medical record review failed to reveal evidence of a Master Treatment Plan for Patient #8.

H. Open medical record review on 10/11/2021 revealed Patient #18 was a 15-year-old male admitted to the facility on 09/24/2021. Medical record review failed to reveal evidence of a Master Treatment Plan for Patient #18 as of the record review date (17 days).

Telephone interview on 10/06/2021 at 1415 with MD #20 revealed he "sees patients everyday and talks to the nurses everyday so the treatment team meeting does not matter, but it is a regulation that has to be followed."

The CEO was asked on 10/15/2021 at 1110 for any quality monitoring regarding MD #20 since he had been out of the country and conducting all treatment via tele-medicine. The CEO reported the Quality Department would have monitoring of the physicians regarding completion of the medical record requirements. Interview revealed MD #20 would not have been reviewed individually for medical record components like History and Physical, discharge summary or psychiatric evaluations.

The Quality Director (DQCR) was asked on 10/15/2021 at 1120 for any quality monitoring regarding MD #20 since he had been out of the country and conducting all treatment via tele-medicine. Interview with the Quality Director revealed the last audit of physicians completion of medical records was done in May of 2020 when the person in the medical records department that was doing those audits left. Interview revealed there were no current audits done related to physician compliance with completion of medical records components. Interview confirmed there had been no monitoring conducted of MD #20 since he had been practicing tele-medicine beginning in July, 2021.

Interview on 10/11/2021 at 1215 with the CMO revealed he was not included in any discussion regarding MD #20 going out of the country. The CMO reported that he was told after it had already been approved by the CEO. He reported that he had resigned his position and had resigned from the medical staff and planned to leave in November. He reported concerns with quality and safety related to inadequate staff and management. He reported treatment teams and therapy is not being done. Many staff were leaving, including therapy staff, nurses and mental health technicians. He stated he was not included in medical decisions that affected patient care. The CMO reported he was told by the CEO that he had to do all QPE (Qualified Physician's Examination) for all involuntary admissions because there were no other physicians available to do them. He reported he was told by the CEO that he needed to see 30 patients and do treatment teams and meet with families. He felt this was too much to do safely and he could not provide quality care. The CMO stated he had concerns with "inadequate clinical services, inadequate therapy services, and a shortage of staff nurses." He stated, "there is really poor communication and collaboration with the medical team. Patient's are not getting any treatment, only tele-psych and no therapy. It's a hotel. It's not a hospital"

Based on policy and procedure review, medical records review, video review, daily assignment sheet review, internal investigation review, and staff interviews the facility failed to provide adequate staffing to care for geriatric patients resulting in a patient elopement in 1 of 1 geriatric elopements (Patient #11).

The findings include:

Review of the policy titled "Nursing Staffing Policy" reviewed 06/07/2021 revealed "POLICY: The Director of Nursing (DON) will be responsible for assessing and evaluating the nursing staffing needs of all units. Staffing needs will be based on patient-nurse ratio, acuity, safety concerns, staff mix and availability ...6 ...f. The DON will retain staffing schedules and daily staffing sheets ..."

Review of the policy and procedure "Level of Observation" last reviewed 06/04/2021 revealed "PURPOSE To provide a consistent, therapeutic approach to ensure a safe environment for the patients within the facility...PROCEDURE...1. 15 minute Observations (Q15-minutes) a. Minimum level of observation for all patients. b. The patient is observed with visual checks every 15 minutes.. d. Assigned staff will document the patient's behavior, location, activity, special precautions (if indicated) and level of observation while confirming they are in no danger or distress...2. Line of Sight (LOS) a. The patient must be in sight of a staff member at all times and 15-minute checks documented...O. Document time of patient observation at the time activity and behavior is observed ..."

Closed medical record review on 10/04/2021 revealed Patient #11 was a 60-year-old male admitted on 09/14/2021 with "IVC (involuntary commitment) papers taken out by his caregiver whom he tried to choke and he threatened to kill his father." Review revealed Patient #11 had a history of strokes, worsening depression, and Alzheimer's (progressive disease that destroys memory and other mental functions). Review revealed Patient #11 was placed on Q15-minute observations on 09/14/2021 at 1815. Review of the "Medical Consult Note" dated 09/29/2021 at 1624 revealed "...HX (history) of Dementia ...Wandered out of facility no injury or trauma ..." Review of Patient #11's "Patient Observation Rounds" sheet dated 09/28/2021 from 1600 through 1635 revealed MHT (mental health technician) #4 documented Patient #11 was outside in the courtyard. Review revealed MHT #4 documented Patient #11 was "off unit" at 1645 and back on the unit at 1655. Further review of the Patient Observation Round sheet revealed MHT #4 documented "Resident got out via the unlocked maintenance door on the patio." Review revealed Patient #11 was returned to the unit unharmed around 1651. Patient #11 discharged on 10/11/2021.

Video review on 10/06/2021 at 1046 of the 900-hall outside courtyard revealed the following:
1603:17 through 1619:29- Patient #11 was visualized pacing the courtyard. [Unable to determine how many patients and staff were outside during the viewed time frame due to video quality and distance from the camera. Also, the camera is motioned detected, and the only available footage was the above stated time]. Patient #11 was not observed during video review exiting the courtyard.

Video review on 10/06/2021 at 1055 of the 900-hall unit inside view revealed the following:
1610:00- CNA #4 [CNA #4 was assigned to Patient #11 which was outside at this point] was sitting at a table in the common area of the unit [unable to visualize Patient #11 from this location]. Further review of the video revealed CNA #4 remained inside the 900-hall unit for the duration of Patient #11's outside time and RN #1, RN #2, and CNA #3 were noted to be inside the 900-hall and/or out of camera view away from the courtyard area [they would be unable to visualize the courtyard from their point of exit of video view] for the duration of Patient #11's outside time. Review revealed at 1645 was when RN #1 received a phone call and staff began to search the unit for Patient #11.

Review of the "Daily Assignment Sheet" [printed computer version] dated 09/28/2021 revealed the total census for the 900-hall was 13. Assigned staff were RN #1, CNA #3, and CNA #4 [RN #2 was not on the assignment sheet]. Further review revealed there were three patients on line-of-sight and ten patients on standard q15-minute checks. Request for the assignment sheet completed by RN #1 on 09/28/2021 was made however, the DON was unable to provide a copy.

Review of the hospital's investigative report conducted by PA #11 (Patient Advocate) revealed "Interviewed [conducted on 10/01/2021] CNA #4, he stated on 9.28.2021, he was responsible for 3 'line of sight' patients and 10 Q15 for other patients on the hall. CNA #4 stated CNA #3 was off the hall, getting supplies RN #1 was outside with the patients...Interviewed [conducted on 10/01/2021] RN #1, she stated on 9.28.2021, she took all the patients, except for 3 of them, outside for a nursing group, after the group she returned inside to administer 4p.m. medications...RN #1 stated she was on the phone with the CNO (chief nursing officer) when she observed RN #2 behind her, in the nurse's station, the patients were still outside, which was when she advised her to bring the patients inside in 10 minutes..."

Interview on 10/05/2021 at 1453 with RN #2 revealed she was a travel nurse and 09/28/2021 was her first shift on orientation. RN #2 stated she was assigned to orient with RN #1 on the geriatric unit that day. Interview revealed none of the staff witnessed Patient #11 exit the courtyard on 09/28/2021. RN #2 stated CNA #4 was assigned to Patient #11 therefore he was the one completing the q15 minute checks. Interview revealed at one point, RN #1, RN #2, and CNA #3 were outside with approximately 6 patients, including Patient #11. RN #2 stated CNA #4 was never outside with Patient #11 and did not "hand over the clipboard" [the q15 minute observation sheets] for them to complete. Interview revealed RN #2 did "not think they [the patients] were outside by themselves." RN #2 stated "staffing was bad that day." Interview revealed RN #2 was assigned to a unit by herself the following day after one 12-hour shift of orientation.

Interview on 10/06/2021 at 1515 with CNA #3 revealed she was assigned to the geriatric unit on 09/28/2021. CNA #3 stated RN #1 and RN #2 went outside to the courtyard to conduct a nursing group and CNA #4 and herself were inside monitoring the patients that didn't go out for group. CNA #3 stated CNA #4 was responsible for all the patients (13 total) q15 minute checks including three line of sights. Interview revealed CNA #3 left the unit to get supplies and when she returned, she heard a code silver (missing person) being called. CNA #3 stated it wasn't until someone called the unit that they realized Patient #11 was gone. Interview revealed CNA #3 rarely got to take a lunch break due to short staffing. Interview revealed there were supposed to be two staff members with the patients outside at all times.

Interview on 10/06/2021 at 1557 PA (Patient Advocate) #11 revealed she conducted Patient #11's elopement investigation. PA #11 stated it was determined CNA #4 had all the patients q15 minute observation sheets while CNA #3 stepped off the unit to obtain supplies. Interview revealed there was a traveler on duty that day for her first shift of orientation (RN #2). PA #11 stated RN #1 and RN #2 were outside with the patients and RN #1 came inside and left RN #2 outside with the patients. PA #11 stated the patients were left outside at some point and Patient #11 eloped out the double doors exiting the courtyard.

Interview on 10/06/2021 at 1707 with RN #1 revealed she was the RN assigned to the geriatric unit the day Patient #11 eloped. RN #1 stated she and RN #2 conducted nursing group outside in the courtyard. RN #1 stated after the nursing group was over, she came inside to make a phone call and told RN #2 she would be "right back." RN #1 stated she noticed RN #2 came inside and RN #1 told RN #2 not to leave the patients outside alone and to bring them inside. RN #1 stated none of the staff realized Patient #11 was missing until they received a phone call from the facility receptionist alerting them a geriatric patient had been located off the facility premises. RN #1 stated she checked the courtyard door and realized it was unlocked. RN #1 stated CNA #4 was assigned to complete Patient #11s q15 minute checks. RN #1 stated the day Patient #11 eloped, there were three patients on line-of-sight and ten on standard q15 minute checks. RN #1 stated lack of staff contributed to Patient #11s elopement that day.

Interview on 10/11/2021 at 1500 with the DON revealed, the nursing staffing [MHT`s, CNA`s, and Nurses] minimum pattern was one RN and one MHT per hall for acute adolescents and one RN and one to two CNA`s for acute geriatrics. The CNA`s to geriatric patient ratio was 1:8. Interview revealed there was "no algorithm" or matrix for staffing ratio`s at the facility. Interview revealed "behaviors, like falls risk, or a patient up all night, helped decide staffing needs."

Interview on 10/07/2021 at 1157 with the CMO (Chief Medical Officer) revealed the workload for nurses were "too great" due to staff shortages. Interview revealed nurses were leaving (resigning) because it was "too risky." Interview revealed "There were not enough technicians" [MHTs and CNAs] to care for the patients. Interview revealed he had "expressed concerns" to administration, specifically the Chief Executive Officer.

Based on policy review, medical records review, internal document review, video review, internal investigation review, employee coaching form, and staff and physician interviews the nursing staff failed to monitor and supervise a geriatric patient resulting in an elopement in 1 of 1 geriatric elopement patients (Patient #11); and failed to supervise a restrictive intervention in 1 of 5 patients (Patient #21) who required a restrictive intervention.

The findings include:

1. Review of the policy and procedure "Level of Observation" last reviewed 06/04/2021 revealed "PURPOSE To provide a consistent, therapeutic approach to ensure a safe environment for the patients within the facility ...PROCEDURE ...1. 15 minute Observations (Q15-minutes) a. Minimum level of observation for all patients. b. The patient is observed with visual checks every 15 minutes. c. All patients admitted to the inpatient acute units are on 15 minute observations unless otherwise ordered by the physician/provider. d. Assigned staff will document the patient's behavior, location, activity, special precautions (if indicated) and level of observation while confirming they are in no danger or distress ...2. Line of Sight (LOS) a. The patient must be in sight of a staff member at all times and 15-minute checks documented ...J. In general, a patient will have ongoing observations by Mental Health Techs (MHTs) and Nursing Staff ...O. Document time of patient observation at the time activity and behavior is observed ..."

Closed medical record review on 10/04/2021 revealed Patient #11 was a 60-year-old male admitted on 09/14/2021 with "IVC (involuntary commitment) papers taken out by his caregiver whom he tried to choke and he threatened to kill his father." Review revealed Patient #11 had a history of strokes, worsening depression, and Alzheimer's (progressive disease that destroys memory and other mental functions). Review revealed Patient #11 was transported to the referring ED (emergency department) on 09/10/2021 by law enforcement for attacking his ex-wife. Review of the referring ED provider note dated 09/10/2021 at 1530 revealed Patient #11 eloped from their ED however was found and safely returned. Review of the "Intake Screening Assessment" dated 09/14/2021 at 1647 revealed the "Elopement Risk Screen (behaviors assessed in the past 24 hours)" was zero therefore Patient #11 was not identified as an elopement risk. Review revealed Patient #11 was placed on Q15-minute observations on 09/14/2021 at 1815. Review of the "Medical Consult Note" dated 09/29/2021 at 1624 revealed " ...HX (history) of Dementia ...Wandered out of facility no injury or trauma ..." Review of Patient #11's "Patient Observation Rounds" sheet dated 09/28/2021 from 1600 through 1635 revealed MHT (mental health technician) #4 documented Patient #11 was outside in the courtyard. Review revealed MHT #4 documented Patient #11 was "off unit" at 1645 and back on the hall at 1655. Further review of the Patient Observation Round sheet revealed MHT #4 documented "Resident got out via the unlocked maintenance door on the patio." Review revealed Patient #11 was returned to the unit unharmed around 1651. Patient #11 was discharged on 10/11/2021.

Review of an incident report completed by RN #1 dated 09/28/2021 revealed " ...Location Details: patient was observed walking on the street, facility was notified, Supervisor, CNO (chief nursing officer) and CEO (chief executive officer) AWARE ...Details: nurses were doing group outside the courtyard, she (RN #1) left the trainee (RN #2) outside to go give 4 pm (afternoon) meds, later trainee (RN #2) came back in she was notified to to live (sic) patients outside by themselves, she went out, nurse informed the trainee (RN #2) to bring them inside, then a few minutes we were notified that the patient was observed walking in the street, he was brought back to the unit, also medical doctor was informed."

Video review on 10/06/2021 at 1046 of the 900-hall outside courtyard revealed the following:
1603:17 through 1619:29- Patient #11 was visualized pacing the courtyard. [Unable to determine how many patients and staff were outside during the viewed time frame due to video quality and distance from the camera. Also, the camera is motioned detected, and the only available footage is the above stated time]. Patient #11 was not observed during video review exiting the courtyard.

Video review on 10/06/2021 at 1055 of the 900-hall unit inside view revealed the following:
1610:00- CNA #4 was sitting at a table in the common area of the unit [unable to visualize Patient #11 from this location].
1610:30- RN #1 exited a patient room and walked to the nurse's station.
1610:37- RN #2 and a patient entered camera view from the day room area [unable to visualize the dayroom area during video review-the dayroom area has no video coverage. Also, of note the dayroom area leads outside to the courtyard]
1611:27- RN #2 entered the nurse's station.
1611:50- RN #2 exited the nurse's station and walked toward the dayroom area and out of camera view.
1612:27- RN #2 entered the camera view from the dayroom area and walked to the nurse's station.
1612:50- RN #2 exited the nurse's station and walked towards the entrance/exit doors of the unit [not located near the dayroom or courtyard area] and out of camera view.
1613:15- CNA #4 entered a patient room.
1614:41- CNA #4 exited the patient room and CNA #3 entered video review from the entrance/exit area. RN #1 was still observed at the nurse's station.
1614:52- CNA #3 entered a patient room.
1615:18- CNA #4 grabbed a clipboard from the nurse's station and sat in a chair located just outside a patient room [this patient was on line-of-sight observations].
1615:43- CNA #3 exited a patient room.
1615:55- CNA #3 exited the camera view towards the medication room [not located near the courtyard].
1617:34- RN #1 exited the nurse's station and walked towards the medication room and out of view of the camera.
1618:51- CNA #3 entered camera view from medication room area and then exits view again toward the supply room.
16:19:44- CNA #4 entered the patient room he was sitting at.
1619:55- RN #1 entered camera view and walked to the nurse's station.
1620:25- RN #1 entered the patient room where CNA #4 was sitting at the doorway.
1620:34- CNA #4 exited the patient room and sat back down in the chair.
1620:42- RN #1 exited the patient room and walked to the nurse's station.
1623:05- RN #2 entered the view of the camera from the entrance/exit door area with a backpack on and a bag in her hand and entered the nurse's station.
1623:16- CNA #3 exited the camera view towards the entrance/exit doors to the unit.
1624:59- RN #2 exited the nurse's station and walked towards the dayroom area and out of camera view.
1626:01- Three patients entered camera view from the dayroom area [none were identified as Patient #11].
1628:31- RN #2 entered back into camera view from the dayroom area and walked to the nurse's station.
1628:31 through 1645:11- RN #1, RN #2, and CNA #4 were observed on the 900-hall unit with no significant events occurring.
1645:11- RN #1 was at the nurse's station and observed to be on the phone. RN #1 stood up and walked to the opposite end of the nurse's station.
1645:35- RN #1, RN #2, CNA #3, and CNA #4 began opening patient rooms and walked around the unit looking for Patient #11.

Review of the hospital's investigative report conducted by PA #11 (Patient Advocate) revealed "Interviewed [conducted on 10/01/2021] CNA #4, he stated on 9.28.2021, he was responsible for 3 'line of sight' patients and 10 Q15 for other patients on the hall. CNA #4 stated CNA #3 was off the hall, getting supplies RN #1 was outside with the patients. CNA #4 stated he walked back and forth outside to observe patients and document on their Q15s, he had Patient #11's Q15. When everyone came inside, and they noticed that Patient #11 was not there that is when he marked Patient #11 'OU' or off unit. Stated for the 2 spaces before he marked 'OU' he did not lay eyes on Patient #11, he just marked that he observed him ...Interviewed [conducted on 10/01/2021] RN #1, she stated on 9.28.2021, she took all the patients, except for 3 of them, outside for a nursing group, after the group she returned inside to administer 4p.m. medications. RN #1 stated Patient #11 had been doing laps outside and at one point returned to the inside of the building, he did not attend group. RN #1 stated she was on the phone with the CNO (chief nursing officer) when she observed RN #2 behind her, in the nurse's station, the patients were still outside, which was when she advised her to bring the patients inside in 10 minutes. RN #1 stated she was unsure what time Patient #11 exited the courtyard and the building, the receptionist called and told her a 900-hall patient had been seen walking in the street, so she asked the CNAs to ensure all patients were present and accounted for, Patient #11 was not ...within 5 mins of the notification from the receptionist Patient #11 was returned to the hall ...Interviewed [conducted on 10/04/2021] RN #2, she stated on 9.28.2021, she was outside with RN #1 and the patients ...Patient #11 and another female patient were observed doing laps around the building. RN #2 recalled she stepped inside to dispose of some trash, RN #1 exited the courtyard to do something then RN #2 stated she went inside again to dispose of trash. This time. RN #2 stated she brough (sic) in all patients, at that time she did not see Patient #11 ...RN #2 stated RN #1 received a phone call about, about (sic) a patient outside the facility, 15 or 20 minutes after they exited the courtyard and then they began to search room to room for Patient #11, he was not found in any bedroom ...Interviewed [conducted on 10/01/2021] CNA #3, she stated on 9.28.2021 she left 900 hall to secure some supplies that they had ran out of ...when she returned, she heard a 'code silver' (missing person) being called over the radio ...Conclusion: ... Also, per the video review it was determined RN #2 left the patients outside unattended for approximately 5-10 minutes. During this time RN #2 was observed on camera walking towards the bin room area ...Signed by PA #11 on 10/05/2021 and Director Quality, Compliance (DQCR) on 10/06/2021."

Review of an "Employee Coaching Form" dated 10/08/2021 for RN #1 revealed "Describe performance-related responsibilities coached ...On September 28, 2021, while conducting group in the courtyard, you left an orientee nurse alone in the courtyard with the patients. Orientees cannot assume the responsibility of patient care during their orientation period. It is expected that if you are orienting a new employee, you must remain with the patients you are responsible for supervising. This responsibility cannot be delegated to an orientee ..." Further review of the form failed to reveal RN #1 or "Supervisor" Signatures.

Interview on 10/05/2021 at 1453 with RN #2 revealed she was a travel nurse and 09/28/2021 was her first shift on orientation. RN #2 stated she was assigned to RN #1 on the geriatric unit that day. Interview revealed none of the staff witnessed Patient #11 exit the courtyard on 09/28/2021. RN #2 stated CNA #4 was assigned to Patient #11 therefore he was the one completing the q15 minute checks. Interview revealed at one point, RN #1, RN #2, and CNA #3 were outside with approximately 6 patients, including Patient #11. RN #2 stated CNA #4 was never outside with Patient #11 and did not "hand over the clipboard" [the q15 minute observation sheets] for them to complete. Interview revealed RN #2 did "not think they [the patients] were outside by themselves." RN #2 stated "staffing was bad that day."

Interview on 10/06/2021 at 1437 with the CMO (chief medical officer) revealed it was his understanding the double doors exiting the courtyard were left unlock by maintenance the day Patient #11 eloped. Interview revealed Patient #11 was safely returned to the hospital. Interview revealed Patient #11 didn't truly understand what he was doing as he was psychotic and confused. The CMO stated Patient #11 would push on the doors frequently as he wandered around the unit. Interview revealed staff were supposed to visualize the patient and document the observation at least every 15 minutes to maintain patient safety. The CMO stated the nurse was responsible for provided supervision over the MHTs and CNAs to correctly perform the q15 minute checks, "it's their job to ensure the patients are safe."

Interview on 10/06/2021 at 1515 with CNA #3 revealed she was assigned to the geriatric unit on 09/28/2021. CNA #3 stated RN #1 and RN #2 went outside to the courtyard to conduct a nursing group and CNA #4 and herself were inside monitoring the patients that didn't go out for group. CNA #3 stated CNA #4 was responsible for all the patients q15 minute checks including three line of sights. CNA #3 explained when she worked with CNA #4, she did all the task (assisting with bathing, changing patients, making beds etc.) that needed to be done on the unit and CNA #4 did all the observations because he couldn't physically do the task. Interview revealed CNA #3 left the unit to get supplies and when she returned, she heard a code silver being called. CNA #3 stated it wasn't until someone called the unit that they realized Patient #11 was gone. CNA #3 stated Patient #11 was left outside unsupervised at some point and eloped out the double doors exiting the courtyard that maintenance had left unlocked from earlier that day. Interview revealed CNA #3 rarely got to take a lunch break due to short staffing.

Interview on 10/06/2021 at 1557 PA (Patient Advocate) #11 revealed she conducted Patient #11's elopement investigation. PA #11 stated it was determined CNA #4 had all the patients q15 minute observation sheets while CNA #3 stepped off the unit to obtain supplies. Interview revealed there was a traveler on duty that day for her first shift of orientation (RN #2). PA #11 stated RN #1 and RN #2 were outside with the patients and RN #1 came inside and left RN #2 outside with the patients. PA #11 stated the patients were left outside at some point and Patient #11 eloped out the double doors exiting the courtyard.

Interview on 10/06/2021 at 1707 with RN #1 revealed she was the RN assigned to the geriatric unit the day Patient #11 eloped. RN #1 stated she and RN #2 conducted nursing group outside in the courtyard. RN #1 stated after the nursing group was over, she came inside to make a phone call and told RN #2 she would be "right back." RN #1 stated she noticed RN #2 came inside and RN #1 told RN #2 not to leave the patients outside alone and to bring them inside. RN #1 stated none of the staff realized Patient #11 was missing until they received a phone call from the facility receptionists alerting them a geriatric patient had been located off the facility premises. RN #1 stated she checked the courtyard door and realized it was unlocked.

Interview on 10/13/2021 at 1355 with the DQCR revealed PA #11 submitted her 5-day investigation on 10/05/2021. The DQCR stated after she reviewed the report on 10/05/2021, she realized nursing staff had left Patient #11 unsupervised. The DQCR stated she notified the CEO about the lack of supervision and the CEO decided then to provide RN #1, CNA #3, and PA #11 with a written warning.

Interview on 10/14/2021 at 0957 with the DON revealed she was made aware that Patient #11 had eloped the day of the elopement. The CNO stated that same day herself and the DES (Director of Environmental Services) walked the perimeter of the courtyard and discovered the door was left unlocked. The DON stated she "immediately" reviewed the video and it was identified "sometime last week" that lack of nursing supervision had contributed to Patient #11s elopement.



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2. Review of policy titled "Seclusion and Physical or Chemical Restraint" reviewed/revised 04/28/2020 revealed, "...Immediately following release of physical restraint ... the QRN (Qualified Registered Nurse) will complete the Face to Face release assessment documenting on the RN (Registered Nurse) Initial Reporting Form ... The face-to-face assessment and the restraint ... must be documented on the Physician Order for Restrictive Interventions for Behaviors and filed in the patient's chart under Orders Tab. The restraint ... report and the incident report shall be completed by the QRN with input from the staff involved in the emergency safety intervention before the end of the shift ... All chemical/physical restraint ... will be documented by a registered nurse in the patient's medical record and will reflect justification, lesser restrictive measures attempted and failed prior to restraint ... implementation, and outcome of procedure (to include behavior at time of release..."

Closed Medical record review conducted on 10/14/2021 revealed Patient #21 was a 12-year-old male admitted to the facility's 800 hall on 10/04/2021 with diagnoses of Post-Traumatic Stress Disorder and Disruptive Mood Regulation Disorder. Review revealed no documented evidence of the performance of, nor a provider order for a restrictive intervention on 10/05/2021.

Review of video footage of the 800 hall was conducted on 10/14/2021 at 1306. Review revealed on 10/05/2021 at 20:33:36 MHT (mental health tech) #17 was standing at Patient #21's door, and Pt #21 attempted to exit the room and proceed across the hall towards another patient's room. MHT #17 was attempting to block Patient #21's advance. At 20:33:39 Patient #21 attempted to lunge past MHT #17, and MHT #17 picked Patient #21 up with MHT #17's arms going under Patient #21's arm pits and across Patient #21's chest. MHT #17 carried Patient #21 back into his room, and the pair can no longer be seen on camera. At 20:35:35 a female staff member can be seen speaking to RN #18 who had entered camera view. RN #18 walked down the hall and briefly stood by Patient #21's door, did not enter the room, and walked back down the 800 hall and out of camera view.

Staff interview was conducted with MHT #17 on 10/14/2021 at 1500. Interview revealed during the evening of 10/05/2021 Patient #21 was having a verbal altercation with another patient, and the Restrictive Intervention (RI) was performed when Patient #21 attempted to lunge past MHT #17 towards the other patient. Interview revealed while in Patient #21's room MHT #17 was able to call for assistance over his walkie-talkie, however no assistance ever came. Interview revealed after approximately 10 minutes, MHT #17 was able to release Patient #21 and they were able to talk about his escalating behaviors.

Telephone interview was conducted with RN #18 on 10/14/2021 at 1743. Interview revealed on the evening of 10/05/2021 several patients on the 800 hall were displaying escalating behaviors. Interview revealed RN #18 had asked a female staff member where MHT #17 was, and she reported MHT #17 was in Patient #21's room attempting to de-escalate his behaviors. At that time, RN #18 went to another patient's room to calm him down. Interview revealed, "I wasn't sure what to do at that point." Interview revealed after exiting the other patient's room, RN #18 went to Pt #21's door, which was closed, and RN #18 didn't hear anything coming from behind the door. Interview revealed RN #18 thought "if I opened the door it might escalate (Patient #21) again." Interview revealed "I didn't know what was going on with (Patient #21). If I was told something was going on in the room, I would have entered the room. I didn't see the RI and it was not reported to me the RI occurred so there was no documentation or physician order obtained."

Based on policy and procedure review, medical records review, video review, daily assignment sheet review, internal investigation review, and staff interviews, nursing staff failed to ensure staff assignments were made to assure the safe delivery of care for geriatric behavioral health patients in 1 of 3 geriatric patients (Patient #11).

The findings include:

Review of the policy and procedure "Level of Observation" last reviewed 06/04/2021 revealed "PURPOSE To provide a consistent, therapeutic approach to ensure a safe environment for the patients within the facility ...PROCEDURE ...1. 15 minute Observations (Q15-minutes) a. Minimum level of observation for all patients. b. The patient is observed with visual checks every 15 minutes. c. All patients admitted to the inpatient acute units are on 15 minute observations unless otherwise ordered by the physician/provider. d. Assigned staff will document the patient's behavior, location, activity, special precautions (if indicated) and level of observation while confirming they are in no danger or distress ...2. Line of Sight (LOS) a. The patient must be in sight of a staff member at all times and 15-minute checks documented ...J. In general, a patient will have ongoing observations by Mental Health Techs (MHTs) and Nursing Staff ...O. Document time of patient observation at the time activity and behavior is observed ..."

Closed medical record review on 10/04/2021 revealed Patient #11 was a 60-year-old male admitted on 09/14/2021 with "IVC (involuntary commitment) papers taken out by his caregiver whom he tried to choke and he threatened to kill his father." Review revealed Patient #11 had a history of strokes, worsening depression, and Alzheimer's (progressive disease that destroys memory and other mental functions). Review revealed Patient #11 was placed on Q15-minute observations on 09/14/2021 at 1815. Review of the "Medical Consult Note" dated 09/29/2021 at 1624 revealed " ...HX (history) of Dementia ...Wandered out of facility no injury or trauma ..." Review of Patient #11's "Patient Observation Rounds" sheet dated 09/28/2021 from 1600 through 1635 revealed MHT (mental health technician) #4 documented Patient #11 was outside in the courtyard. Review revealed MHT #4 documented Patient #11 was "off unit" at 1645 and back on the hall at 1655. Further review of the Patient Observation Round sheet revealed MHT #4 documented "Resident got out via the unlocked maintenance door on the patio." Review revealed Patient #11 was returned to the unit unharmed around 1651. Patient #11 was discharged on 10/11/2021.

Video review on 10/06/2021 at 1046 of the 900-hall outside courtyard revealed the following:
1603:17 through 1619:29- Patient #11 was visualized pacing the courtyard. [Unable to determine how many patients and staff were outside during the viewed time frame due to video quality and distance from the camera. Also, the camera is motioned detected, and the only available footage was the above stated time]. Patient #11 was not observed during video review exiting the courtyard.

Video review on 10/06/2021 at 1055 of the 900-hall unit inside view revealed the following:
1610:00- CNA #4 [CNA #4 was assigned to Patient #11 which was outside at this point] was sitting at a table in the common area of the unit [unable to visualize Patient #11 from this location]. Further review of the video revealed CNA #4 remained inside the 900-hall unit for the duration of Patient #11's outside time and RN #1, RN #2, and CNA #3 were noted to be inside the 900-hall and/or out of camera view away from the courtyard area [they would be unable to visualize the courtyard from their point of exit of video view] for the duration of Patient #11's outside time. Review revealed at 1645 was when RN #1 received a phone call and staff began to search the unit for Patient #11.

Review of the "Daily Assignment Sheet" [printed computer version] dated 09/28/2021 revealed the total census for the 900-hall was 13. Assigned staff were RN #1, CNA #3, and CNA #4 [RN #2 was not on the assignment sheet]. Further review revealed there were three patients on line-of-sight and ten patients on standard q15-minute checks. Request for the assignment sheet completed by RN #1 on 09/28/2021 was made however, the DON was unable to provide a copy.

Review of the hospital's investigative report conducted by PA (Patient Advocate) #11 revealed "Interviewed [conducted on 10/01/2021] CNA #4, he stated on 9.28.2021, he was responsible for 3 'line of sight' patients and 10 Q15 for other patients on the hall. CNA #4 stated CNA #3 was off the hall, getting supplies RN #1 was outside with the patients..."

Interview on 10/05/2021 at 1453 with RN #2 revealed she was a travel nurse and 09/28/2021 was her first shift on orientation. RN #2 stated she was assigned to orient with RN #1 on the geriatric unit that day. Interview revealed none of the staff witnessed Patient #11 exit the courtyard on 09/28/2021. RN #2 stated CNA #4 was assigned to Patient #11 therefore he was the one completing the Q15 minute checks. RN #2 stated CNA #4 was never outside with Patient #11 and did not "hand over the clipboard" [the q15 minute observation sheets] for them to complete.

Interview on 10/06/2021 at 1515 with CNA #3 revealed she was assigned to the geriatric unit on 09/28/2021. CNA #3 stated RN #1 and RN #2 went outside to the courtyard to conduct a nursing group and CNA #4 and herself were inside monitoring the patients that didn't go out for group. CNA #3 stated CNA #4 was responsible for all the patients q15 minute checks including three line of sights. CNA #3 explained when she worked with CNA #4, she did all the task (assisting with bathing, changing patients, making beds etc.) that needed to be done on the unit and CNA #4 did all the observations because he couldn't physically do the task. Interview revealed CNA #3 left the unit to get supplies and when she returned, she heard a code silver being called. CNA #3 stated it wasn't until someone called the unit that they realized Patient #11 was gone.

Interview on 10/06/2021 at 1557 PA (Patient Advocate) #11 revealed she conducted Patient #11's elopement investigation. PA #11 stated it was determined CNA #4 had all the patients q15 minute observation sheets while CNA #3 stepped off the unit to obtain supplies. Interview revealed there was a traveler on duty that day for her first shift of orientation (RN #2). PA #11 stated RN #1 and RN #2 were outside with the patients and RN #1 came inside and left RN #2 outside with the patients. PA #11 stated the patients were left outside at some point and Patient #11 eloped out the double doors exiting the courtyard.

Interview on 10/06/2021 at 1707 with RN #1 revealed she was the RN assigned to the geriatric unit the day Patient #11 eloped. RN #1 stated she and RN #2 conducted nursing group outside in the courtyard. RN #1 stated after the nursing group was over, she came inside to make a phone call and told RN #2 she would be "right back." RN #1 stated she noticed RN #2 came inside and RN #1 told RN #2 not to leave the patients outside alone and to bring them inside. RN #1 stated none of the staff realized Patient #11 was missing until they received a phone call from the facility receptionist alerting them a geriatric patient had been located off the facility premises. RN #1 stated CNA #4 was assigned to complete Patient #11s q15 minute checks. RN #1 stated she was supposed to round on the q15 minute checks throughout her shift and she had noticed on that day CNA #4 was behind on his q15 minute checks. RN #1 stated she told CNA #4 he needed to document in "real time." RN #1 stated when making patient assignments, she attempted to group "line-of-sights" together and assign all them to one CNA or MHT (mental health tech) and have the other q15 minute checks grouped together and assigned to a different CNA or MHT. RN #1 stated the day Patient #11 eloped, she had three patients on line-of-sight and ten on standard q15 minute checks. RN #1 did not recall how she made the assignment the day of Patient #11's elopement, but she did recall CNA #4 was assigned to Patient #11.

Based on hospital policy review, observations, and staff and physician interviews, the hospital staff failed to adhere to hospital policy regarding cell phone use on the patient units for 4 of 4 observations, and failed to obtain informed consent from a patient's guardian prior to administering a psychotropic medication in 1 of 23 sampled patients (Patient #8).

The findings include:

A. Policy review on 10/13/2021 of "Telephone & Personal Electronic Device Usage" effective date 01/22/2019, revealed, " ...Purpose: To provide guidelines regarding personal calls and the use of electronic devices while at work. Policy: ...No cell phones are allowed on patient units ... Procedure: ...6. ...No cell phones are allowed on patient units at any time. 7. Employees may not wear wired earphones or Bluetooth devices while on duty at any time..."

1. Observation on 10/12/2021 between 1305 and 1345 of the 100-Hall revealed a group therapy session conducted by Therapist #10 and attended by Mental Health Tech (MHT) #12 and two adolescent girl patients. The observation revealed MHT #12 was looking down at her cell phone in multiple occasions and placed the cell phone in her pocket at the end of the group session.

Interview on 10/12/2021 at 1347 with MHT #12 revealed the cell phone was used for timekeeping during patient observation. The interview revealed there was a wall clock on the unit, it was removed during renovation about two months ago. The interview revealed there was a clock in the nursing station, but it was not visible to the staff on the unit. The interview revealed the use of cell phones on the unit was not acceptable.

2. Observation on 10/13/2021 at 1350 during a unit tour of the 100-Hall revealed MHT #14 exited the bin room with a cell phone in hand and placed it in her pockets.

Interview on 10/13/2021 with MHT #14 at 1350 revealed MHT #14 utilized her cell phone for timekeeping on the unit. The interview revealed, "everyone on the floor has their cell phone on them." The interview revealed MHT #14 was not aware of any polity regarding cell phone use.

Interview on 10/13/2021 at 1352 with Registered Nurse (RN) #15 revealed the MHTs should use their watch for timekeeping. The interview confirmed that that the use of a watch was not required as part of the staff uniform. The interview revealed there should be no cell phones in the patient care area.

3. Observation on 10/13/2021 between 1345 and 1515 of the 700-Hall revealed a group session conducted by Case Manager (CM) #13 and attended by MHT #16 and five (5) adolescent boy patients. The observation revealed CM #13 removed a cell phone from his pocket and announced the time of 2:40 pm to the group. The observation revealed MHT #16 had a set of Bluetooth devices in his ears.

Interview on 10/13/2021 at 1505 with CM #13 revealed he has been on staff since 2017. The interview revealed the staff was not supposed to use their cell phones on the unit. The interview revealed his cell phone should be kept in his office or his car. The interview revealed CM #13 left his watch at home and needed to keep up with time. The interview confirmed that the policy was not followed.

Interview on 10/13/2021 at 1507 with MHT #16 revealed he has been on staff for three weeks. The interview revealed the staff should not use a cell phone in the patient area. Interview revealed MHT #16 used his cell phone to tell time for documentation. The interview confirmed that MHT #16 had a cell phone in his pocket and had forgotten that he had the Bluetooth device in his ears.



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4. Observation on 10/13/2021 at 1442 during a unit tour of the 900-Hall revealed RN #8 was standing at the nurses station and had a cell phone in her scrub pocket.

Interview on 10/13/2021 at 1442 with RN #8 revealed she had her cellphone in her pocket. RN #8 stated cell phones were not allowed in the patient care areas.

Interview on 10/13/2021 at 1535 with the Director of Nursing (DON) revealed "Cell phone should not be visible in the patient area." The interview revealed there should be a clock in every unit. The interview revealed management would figure out timekeeping in areas like the courtyard.



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B. Review of the facility policy titled "Informed Consent for Medications" last revised 07/2021 revealed "PURPOSE To delineate the process for the provision of Informed Consent to patients at (facility name) prior to their receipt of psychotropic medications ...POLICY 1. (Facility name) recognizes that, as part of their patient rights, the patient has a right to explanations of care...and benefits of medications...This right extends to the parent or conservator of a minor...2. Prior to their initiation, the patient is to receive informed consent for psychotropic medications to be prescribed for their treatment of their psychiatric illness or psychiatric symptoms...PROCEDURE...2. Following the provision of informed consent by the patient's physician/provider, if not accomplished by the physician/provider, the nurse will be directed by the physician/provider to secure evidence of the patient's informed consent through the patient's signature on the form entitled: 'Medication Consent Form'...9. The...nurse will follow the same processes for the parent or conservator of minors..."

Review of a closed medical record on 10/04/2021 revealed Patient #8 was a 17-year-old male involuntarily committed to the hospital on 09/03/2021 with suicide ideation (thoughts of killing self). Medical record review revealed Patient #8 had a history of Major depressive disorder and Attention-deficit hyperactivity disorder. Review of a document titled "Informed Consent & Medication Education For Patient Education [sic]" revealed the medications "Depakote Sprinkles (mood stabilizer medication) 125mg (milligrams) and Remeron (antidepressant medication) 15mg" were written on the form. Review revealed the word "DENIED" was written vertically and extended from the bottom of the form to the top of the form. Review revealed the name of Patient #8's mother, a telephone number and the words "DAD Refused" were written on the bottom of the form. Review of a form titled "MEDICATION ADMINISTRATION PRIOR TO OBTAINING PARENTAL/GUARDIAN CONSENT" revealed the word "DENIED" written vertically and extended from the bottom to the top of the form. Review of Patient #8's "Medication Administration Record" revealed documentation that divalproex sodium (generic Depakote) 125mg was administered on 09/05/2021 at 0743; 09/05/2021 at 2032; 09/06/2021 at 0910; 09/08/2021 at 2021; 09/09/2021 at 2217; 09/13/2021 at 2021; 09/14/2021 at 0846; and 09/24/2021 at 2136 (administered eight times). Review revealed divalproex sodium 250mg was administered on 09/14/2021 at 2006 (administered one time). Review revealed divalproex sodium 500mg was administered on 09/23/2021 at 2039 (administered one time).
Review revealed divalproex sodium (generic Depakote) was administered a total of ten times without informed consent from the patient's legal guardian. Review of Patient #8's "Medication Administration Record" revealed documentation that mirtazapine (generic Remeron) 15mg was administered on 9/04/2021 at 2136; 09/08/2021 at 2021; 09/09/2021 at 2218; 09/13/2021 at 2021; 09/14/2021 at 2006; and 09/23/2021 at 2039 (administered six times). Medical record reveiew revealed mirtazapine (generic Remeron) was administered six times without informed consent from the patient's legal guardian. Medical record review revealed Patient #8 discharged home on 09/30/2021.

Telephone interview with Registered Nurse (RN) #29 on 10/12/2021 at 1045 revealed she was told in shift report that Patient #8 had been consented to receive the ordered medications, but could not recall if she verified by checking for written consent on the patient's chart. Interview revealed RN #29 administered the medications as ordered. Interview revealed once RN #29 returned to work the next week, she was made aware that Patient #8's parent had not consented to the patient receiving medications. Interview revealed the hospital's policy was to verify patient or guardian consent prior to administering medications.

Telephone interview with the attending Psychiatrist (MD #20) on 10/06/2021 at 1415 revealed he was not made aware Patient #8 received psychotropic medications without parental consent.

Interview with the Director of Nursing on 10/12/2021 at 1452 revealed that hospital policy was that nursing staff had to obtain consent from the patient's parent or guardian prior to administering psychotropic medications. Interview revealed the nursing staff did not follow the hospital's policy and administered medications to Patient #8 without parental consent.

Based on review of policy and procedures, observations, COVID-19 screening tools, electronic mail review, employee flyer review, weekly provider testing log, and staff interviews, the hospital staff failed to mitigate the risk of exposure to COVID-19 by failing to have a consistent process in place to screen and test physicians and allied health professionals (AHP) for COVID-19 for 22 medical staff members.

The findings include:

Review of the Infection Prevention and Control policy, Management of Coronavirus (2019n-CoV) reviewed/revised 07/30/2020 revealed, "... II. PURPOSE: To quickly identify healthcare personnel, patients, visitors and vendors reasonable suspected of being infected with coronavirus and to follow Center for Disease Control guidelines for containing the infection thereby minimizing exposure and preventing transmission of coronavirus within the facility and community and to ensure facility policies and practices are in place to minimize exposures to respiratory pathogens. ... III. APPLICATION This policy shall apply to all personnel, patients/clients, visitors and vendors of (facility name). ... V. PROCEDURES: All patients, visitors, and vendors shall be screened for possible coronavirus infection upon arrival to the facility using the Center for Disease Control recommended screening tool. Employees shall be screened on a daily basis and as needed per the CDC recommendations. Screenings shall include the following clinical features and epistemology risks: 1. fever 2. Signs/symptoms of lower respiratory illness or GI symptoms (e.g. cough, shortness of breath, nausea/ vomiting or diarrhea) 3. Close contact with a laboratory confirmed 2019-nCoV patient within 14 days of symptom onset 4. A history of travel within 14 days of symptom onset A. Personnel All personnel shall contact their immediate supervisor if any of the above noted clinical features ... B. Admissions ... All potential patients/clients shall be screened via telephone for coronavirus symptoms prior to accepting the patient/client for admission. 2. Upon arrival to the facility, all potential patients/clients shall be screened by the assessor for coronavirus symptoms or signs of infection as part of the admission process. C. Inpatient Screening Process 1. Following admission to an inpatient unit, patients will be screened twice daily with temperature checks. 2. Nurses will also complete daily screening process with patients to assess for signs/symptoms of lower respiratory illness or GI symptoms ... 5. Visitors and Vendors All visitors and vendors will be required to complete an assessment from upon entry into the facility. ... 7. Management of Exposed Healthcare Employees 1. Movement and monitoring decisions for healthcare providers potentially exposed to 2019-n-CoV should be made in consultation with public health authorities Wake County Human Services ..."

Interview during the entrance conference on 10/04/2021 at 1130 with the CEO revealed the 100 hall was a COVID-19 positive unit and that there were currently 4 adolescent girls that were COVID-19 positive on that unit.

Observations upon arrival to the facility daily on 10/04/2021 through 10/15/2021 revealed a staff member at the reception desk repeatedly ask a series of questions, take temperatures and document on a screening form for each visitor that arrived. Observation revealed the Chief Medical Officer and other facility staff members in the same line to get screened by the receptionist prior to going into the clinical area. Observation upon arrival to the facility on Monday 10/11/2021 at 0900 revealed two females in the lobby who were conducting COVID-19 testing for staff members upon their arrival to work.

Interview on 10/11/2021 at 1120 with the facility's Infection Control Officer (ICO) revealed a contract company came to the facility to conduct weekly testing of employees for COVID-19. Interview revealed the results were sent to the Human Resources Department. Interview revealed the facility usually received results in 48 hours and if there was a positive the ICO would initiate a contact investigation. Interview revealed the employee would be out of work for 10 - 20 days. Interview revealed patients were required to be tested 48 hours prior to admission and the patients also had weekly COVID-19 testing completed. The ICO reported all staff and patients were tested weekly on Mondays. Interview revealed the facility was on their fourth outbreak (2 or more positive results) and had worked with the county health department through each of the outbreaks.

Interview on 10/13/2021 at 1000 with the CEO revealed MD #20 had been out of the country and returned to work in the facility, then left to go back out of the country. When asked about testing for MD #20 after he returned to the facility after being out of the country, the CEO stated, "Our physicians should be tested weekly." Evidence of MD #20s COVID-19 status after his travel out of the country was requested.

Interview on 10/13/2021 at 1430 with the CEO revealed the date that MD #20 had last worked at the facility prior to going out of the country was July 27, 2021, then returned to work in the facility on September 9, 2021 and left again to go out of the country indefinitely on September 22, 2021.

Interview on 10/13/2021 at 1610 with the CEO revealed, "Physician's are not required to do COVID-19 testing unless there is an exposure. They would be responsible to let us know that. That includes travel out of the country." Interview confirmed there was no COVID-19 testing for MD #20 after his travel out of the country and prior to returning to conduct patient care at the facility on September 9, 2021.

Review of a "Patient COVID-19 Screening Assessment" tool used by staff to assess patients for COVID-19 revealed the first question is "Have you traveled out of the country or to a high-risk state in the last month?" The tool has a series of six questions and includes the patient's temperature.

Review of a "Visitor/Vendor Screening Assessment" tool used by the receptionist to screen visitors and vendors for COVID-19 revealed the first question is "Have you traveled out of the United States in the last month?" The tool has a series of six questions and includes the visitor or vendors temperature.

Review of an "Employee Screening for Coronavirus (COVID-19):" tool revealed it included the date, staff name, role, time, temperature, date supervisor notified. It included a YES or NO answer to the following two questions: "Any symptoms (may be intermittent): ~Fever or chills ~Cough ~Shortness of breath or difficulty breathing ~Fatigue ~Muscle or body aches ~Headache ~New loss of taste or smell ~Sore throat ~Congestion or runny nose ~Nausea or vomiting ~Diarrhea If yes, contact RN Supervisor immediately (If Supervisor already notified, please include date supervisor notified.). " Review revealed the second question on the tool was "Have you had prolonged contact with anyone who has tested positive for COVID-19? (Less than 6 feet for a total of 15 min) If yes, contact RN Supervisor Immediately with additional information: When, Where, etc." Review of the Employee Screening Tool revealed no question regarding travel out of the country.

Review of the completed "Employee Screening for Coronavirus (COVID-19): screening tool dated 09/10/2021 revealed MD #20 was listed on the form timed at 1024. His temperature was recorded (afebrile) and he answered "NO" to questions 1 and question 2 on the form (no symptoms and no known exposure). He circled YES to donning a mask.

Interview on 10/14/2021 at 1320 with the ICO revealed she was not sure if physicians or Allied Health Providers (AHPs) were tested for COVID-19. The ICO stated, "They should be tested." The ICO stated the Medical Staff person (named) handled all of the provider testing and that would go through her. The ICO staff member reported there was no policy regarding the weekly testing of patients and staff. She reported that after the third outbreak of COVID-19 at the facility, the health department asked them to do weekly testing and the facility has been doing it since that time. The ICO staff member stated she would provide the email from the county health department that recommended testing and that would provide a date when they started the testing.

Interview on 10/14/2021 at 1415 with the CEO revealed there was no policy for weekly testing for COVID-19 and that the testing was based on the state/county email recommendation for weekly testing for all. The CEO stated "The physicians, per Human Resources, are not required to have weekly testing. Providers are screened on arrival. There is no requirement to have weekly testing." Interview confirmed that the providers (physicians and Allied Health Providers) do have direct contact with the patients.

Review of an electronic mail dated 02/09/2021 at 1054 AM revealed the Wake County Health Department sent the email to the ICO. Review of the email revealed, ""Wake County follows the same guideline for all residential facilities, not just nursing homes. The amount of weekly testing goes by the county positivity rate. Currently, Wake Counties positivity rate is between 7% and 8%, so there should be weekly testing at the facility for all. ..."

The ICO provided a flyer that was sent to all employees dated 02/26/2021 at 6:09 PM that stated "COVID TESTING MONDAY NEW TIME 7AM - 11AM."

Interview on 10/14/2021 at 1440 with the Director of Human Resources (DHR) revealed she received the results from the COVID-19 tests weekly the following week after testing was done and she kept a spreadsheet of the results. She reported any positive results are reported back in 1 - 2 days and she notified the CEO, DON and ICO of any positive results. Interview revealed if physicians or AHPs are employees, they get tested for COVID-19 weekly. If physicians or AHPs are contracted staff, she did not know if they got tested.

Review of weekly provider testing from February 8, 2021 through October 4, 2021 was reviewed. Review of the list revealed MD #20 was "not at the facility" each week beginning 07/08/2021 through 10/11/2021. Review of the log for the weeks of 09/09/2021 through 09/27/2021 when MD #20 was back in the facility listed the physician as "not at the facility". Review of the log for MD #20 revealed he had testing the week of 02/22/2021 and 05/10/2021 (prior to going out of the country). The remainder of the weeks listed MD #20 as "DID NOT TEST."

In summary, weekly testing was completed for patients, staff and employed physicians and AHPs. Weekly testing was not completed for contracted physicians or AHPs. Both employed and contracted physicians and AHPs have direct contact with patients and have the potential for exposing others to COVID-19. Screening tools were used to screen visitors that included travel out of the country. Screening tools used for employees, physicians and AHPs did not include travel out of the country. There was no screening for MD #20 that included a question about travel out of the country. There was no testing for MD #20 that was done after he returned to the facility following travel out of the country. There failed to be a consistent process in place for screening and testing care givers in the facility. The hospital staff failed to mitigate the risk of exposure to COVID-19.

Based on medical record review and staff interview, the facility staff failed to develop short-term goals and failed to define target dates for short-term goals established on the Master Treatment Plan (MTP) for 3 of 11 patients with Master Treatment Plans. (Patients #2, #6, #21)

The findings include:

Review of facility policy "Treatment Plan Acute Inpatient" reviewed/revised 12/2016 revealed "PROCEDURE: Master Treatment Plan 1. Each clinical team member of the treatment team should review and contribute to the Master Treatment Plan. The Master Treatment Plan should be completed within 72 hours of the patient's admission..."

Review of policy titled "Clinical Team Responsibilities" effective 05/01/2020 revealed, "This policy and procedure is designed to delineate the duties and responsibilities of various members of the Interdisciplinary Treatment Team and their roles in the treatment planning process. POLICY The following delineation of duties and responsibilities will be followed at (Named Facility) ... Psychiatrist ... Attends and participates in treatment team meetings ... Documents goals and appropriate interventions in the Treatment Plan ... Nurses ... The RN (Registered Nurse) assigned to the patient documents the patient's response to the Inpatient Treatment Program and role in the milieu ... The patient's RN attends scheduled treatment planning sessions to discuss the patient's progress or lack of progress toward goals ... The RN participates in treatment planning process, initiates and reviews goals and individualized interventions and updates target dates and interventions as indicated ... The RN ... communicate problems or concerns to the treatment team and attending MD (Medical Doctor) ... Therapy Services/Clinical Services ... Participate in Treatment Team Meetings and documents appropriate goals and individualized interventions in the Treatment Plan ..."

1. Open medical record review on 10/04/2021 revealed Patient #2 was a 15-year-old female who was admitted to the facility on the 100-Hall on 08/05/2021 with a diagnosis of major depressive disorder, recurrent severe without psychotic feature. Review of an Initial Interdisciplinary Treatment Plan revealed, "... SHORT TERM GOALS / INTERVENTIONS - NURSING ... Date/Initials (blank/blank) Goals (blank)." The review revealed there were no nursing short-term goals developed and documented for the Initial Interdisciplinary Treatment Plan for Patient #2.

Interview on 10/14/2021 at 1000 with the Interim Director of Clinical Services revealed generally a therapist initiates the creation of a treatment plan, and the team creating the treatment plan consists of a physician or mid-level provider, a therapist, a nurse, a recreational therapist, and sometimes a utilization review staff member and the patient and/or their family or guardian.



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2. Closed medical review on 10/05/2021 of Patient #6 revealed a 17 year old female admitted to the facility on 09/01/2021 for diagnoses of Major Depressive Disorder and Suicidal Ideation. Review of the "Initial Interdisciplinary Treatment Plan" created on 09/02/2021 revealed, "... SHORT TERM GOALS / INTERVENTIONS - NURSING ... Date/Initials ( left blank/ left blank) Goals (left blank)." The review revealed there were no nursing short-term goals developed and documented for the "Interdisciplinary Treatment Plan" for Patient #6. Review of the MTP revealed no nursing participation in the development of the plan on 09/02/2021.

Interview on 10/07/2021 at 1000 with the IDTS revealed treatment teams meet Mondays, Wednesdays and Fridays. Interview revealed Interview revealed the team coordinates and contributes to the treatment plan to include short term goals and interventions. Interview revealed she has not seen nursing representation at the team meetings since June.


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3. Closed Medical record review conducted on 10/14/2021 revealed Pt #21 was a 12-year-old male admitted to the facility's 800 hall on 10/04/2021 with diagnoses of Post-Traumatic Stress Disorder and Disruptive Mood Regulation Disorder. Review of a Master Treatment Plan revealed, "...SHORT-TERM GOALS / INTERVENTIONS - THERAPY SERVICES ... Date/Initials 10-6-2021 (Initialed by Therapist #10) (Pt #21 Named) will ID (identify) at least 3 triggers for increased agitation. 10-6-2021 (Initialed by Therapist #10) (Pt #21 Named) will ID at least 3 positive self-soothing strategies to use when feeling suicidal. Interventions ... Date/Initials 10-6-2021 (Initials) Therapy services staff will facilitate daily process groups to provide (Pt #21 Named) the opportunity to explore topics related to agitation. Therapy services staff will facilitate daily process groups to provide (Pt #21 Named) the opportunity to ID self soothing (sic) techniques to cope with thoughts of suicide ... SHORT TERM GOALS / INTERVENTIONS - NURSING ... Date/Initials 10/8/21 (Initialed by RN #19) #1 (Pt #21 Named) will immediately report to staff when having suicidal thoughts. #2 (Pt #2 Named) will be compliant with prescribed medications to help control his mood and behaviors till (sic) discharge. Interventions Date/Initials 10/8/21 (Initialed by RN #19) #1 Nursing staff will provide education on the benefits and side effects of medications. #2 Nursing staff will monitor patient q (every) 15 minutes checks to ensure safety till discharge ... SHORT-TERM GOALS / INTERVENTIONS - PSYCHIATRIC PROVIDER Date/Initials 10/6/21 (no initials) #1 medication management Target Date 10/ (blank) ... #2 psychotherapy Target Date 10/ (blank) ... Interventions (blank) ... (electronically signed by MD #20) Date/Time 10/6/21 1930." Review revealed there was no target date documented for any of the short-term goals and interventions.

Staff interview was conducted with the Interim Director of Clinical Services on 10/14/2021 at 1002. Interview revealed patient's short-term goals and interventions should have documented target dates.

Based on facility policy review, medical record review and staff interview, the facility staff failed to ensure Nursing participation in the creation of the Master Treatment Plan (MTP) specific to interventions based on each patient's presenting problems and treatment goals and failed to ensure Psychiatrists identify treatment modalities in 3 of 11 patients sampled with MTPs ( Patient #6 # 2 and #21).

The findings include:

Review of policy titled "Clinical Team Responsibilities" effective 05/01/2020 revealed, "This policy and procedure is designed to delineate the duties and responsibilities of various members of the Interdisciplinary Treatment Team and their roles in the treatment planning process. POLICY The following delineation of duties and responsibilities will be followed at (Named Facility) ... Psychiatrist ... Attends and participates in treatment team meetings ... Documents goals and appropriate interventions in the Treatment Plan ... Nurses ... The RN (Registered Nurse) assigned to the patient documents the patient's response to the Inpatient Treatment Program and role in the milieu ... The patient's RN attends scheduled treatment planning sessions to discuss the patient's progress or lack of progress toward goals ... The RN participates in treatment planning process, initiates and reviews goals and individualized interventions and updates target dates and interventions as indicated ... The RN ... communicate problems or concerns to the treatment team and attending MD (Medical Doctor) ... Therapy Services/Clinical Services ... Participate in Treatment Team Meetings and documents appropriate goals and individualized interventions in the Treatment Plan ..."

1. Closed medical review on 10/05/2021 of Patient #6 revealed a 17 year old female admitted to the facility on 09/01/2021 for diagnoses of Major Depressive Disorder and Suicidal Ideation. Review of the "Initial Interdisciplinary Treatment Plan" created on 09/02/2021 revealed, "... SHORT TERM GOALS / INTERVENTIONS - NURSING ... Date/Initials ( left blank/ left blank) Goals (left blank)." The review revealed there were no nursing interventions or short-term goals developed and documented for the "Interdisciplinary Treatment Plan" for Patient #6. Review of the MTP revealed no nursing participation in the development of the plan on 09/02/2021.

Interview on 10/07/2021 at 1000 with the IDTS revealed treatment teams meet Mondays, Wednesdays and Fridays. Interview revealed Interview revealed the team coordinates and contributes to the treatment plan to include short term goals and interventions. Interview revealed she has not seen nursing representation at the team meetings since June.



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2. Open medical record review on 10/04/2021 revealed Patient #2 was a 15-year-old female who was admitted to the facility on the 100-Hall on 08/05/2021 with a diagnosis of major depressive disorder, recurrent severe without psychotic feature. Review of an Interdisciplinary Treatment Plan revealed, "... SHORT TERM GOALS / INTERVENTIONS - NURSING ... Date/Initials (blank/blank) ...Interventions (blank)." The review revealed there were no nursing interventions documented on the Master Treatment Plan for Patient #2.

Interview on 10/07/2021 at 1000 with the Interim Director of Clinical Services revealed treatment teams meet Mondays, Wednesdays and Fridays. Interview revealed the team coordinates and contributes to the treatment plan to include short term goals and interventions. Interview revealed she has not seen nursing representation at the team meetings since June.

Follow up interview on 10/14/2021 at 1000 with the Interim Director of Clinical Services revealed generally a therapist initiates the creation of a treatment plan, and the team creating the treatment plan consists of a physician or mid-level provider, a therapist, a nurse, a recreational therapist, and sometimes a utilization review staff member and the patient and/or their family or guardian.



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3. Closed Medical record review conducted on 10/14/2021 revealed Patient #21 was a 12-year-old male admitted to the facility's 800 hall on 10/04/2021 with diagnoses of Post-Traumatic Stress Disorder and Disruptive Mood Regulation Disorder. Review of a Master Treatment Plan revealed, " ...SHORT-TERM GOALS / INTERVENTIONS - PSYCHIATRIC PROVIDER Date/Initials 10/6/21 (no initials) #1 medication management Target Date 10/ (blank) ... #2 psychotherapy Target Date 10/ (blank) ... Interventions (blank) ... (electronically signed by MD #20) Date/Time 10/6/21 1930."

Staff interview was conducted with the Interim Director of Clinical Services on 10/14/2021 at 1002. Interview revealed interventions should be specified on the Master Treatment Plan.

Based on the facility's policy, Medical Staff Rules and Regulations, medical record review and staff and allied health provider interviews, the facility staff failed to ensure documentation of an evaluation of a patient's individualized Master Treatment Plan progress toward goals for 11 of 23 sampled patients. (Patients #20, #23, #6, #19, #1, #14, #16, #17, #21, #5, #15)

The findings include:

Review of facility policy "Treatment Plan Acute Inpatient" review/revised 12/2016 revealed "... Each patient admitted to the psychiatric unit shall have an individualized person centered treatment plan which is based on interdisciplinary clinical assessments. The multidisciplinary team is headed by the physician and consists of nursing, therapists, recreational therapists, utilization management, milieu management, clinical directors, director of nursing, and other health professionals as indicated. ... Each clinical team member of the treatment team should review and contribute to the Master Treatment Plan. ... In order to determine the effectiveness of the interdisciplinary person centered treatment plan, weekly reviews are done by the interdisciplinary team. This review will provide valuable information about the patient progress, need for continued treatment, and revision of interventions as well as discharge planning. The major areas addressed will be: 1. Reason for continued hospitalization. 2. Progress on identified goals and objectives. ... The patient's progress, as well as revision to the treatment plan based on these summaries, are reflected in the treatment plan update. ..."

Review of facility "Medical Staff Rules and Regulations 2021" revealed "....Treatment Plan 8. The multi-disciplinary team shall develop an Individual Comprehensive Treatment Plan that is based on a comprehensive assessment assessment of the patient's needs. This plan will be reviewed within 72 hours of admission and at least weekly... "

1. Open medical record review on 10/12/2021 revealed Patient #20, a 16 year old female admitted to the facility on 09/24/2021 for diagnoses of Disruptive Mood Dysregulation Disorder, Major Depressive Disorder and Post-Traumatic Stress Disorder. Record review revealed no evidence of a Master Treatment Plan. Review revealed an "Interdisciplinary Treatment Plan Update" was completed on 10/11/2021 (17 days after admission). Review revealed the treatment plan update was completed without a documented Master Treatment Plan.

Interview on 10/12/2021 at 1120 with AHP #26 revealed treatment plans should be completed in its entirety. Interview revealed diagnoses, interventions, and goals should all be documented. Interview revealed she knew what the patients diagnoses were even though they were not documented on the plans and would provide updates. Interview revealed for her, the MTP was not needed to complete weekly updates.

Interview on 10/12/2021 at 1200 with Therapist #10 revealed treatment team meetings were conducted on Mondays, Wednesdays and Fridays. Interview revealed treatment plan updates were to be completed at least weekly on patients with documentation of the patient's progress toward goals.

2. Open medical record review on 10/12/2021 revealed Patient #23, a 13 year old male admitted to the facility on 09/01/2021 for diagnoses of Disruptive Mood Dysregulation Disorder, Restlessness and Agitation, Suicidal Ideations and Violent Behavior. Record review revealed "Interdisciplinary Treatment Plan Updates" were completed on 09/16/2021 (15 days after admission), 09/28/2021(12 days later), 10/01/2021 and 10/08/2021. Review revealed treatment plan updates were completed without a documented Master Treatment Plan.

Interview on 10/12/2021 at 1120 with AHP #26 revealed treatment plans should be completed in its entirety. Interview revealed diagnoses, interventions, and goals should all be documented. Interview revealed she knew what the patients diagnoses were even though they were not documented on the plans and would provide updates. Interview revealed for her, the MTP was not needed to complete weekly updates.

Interview on 10/12/2021 at 1200 with Therapist #10 revealed treatment team meetings were conducted on Mondays, Wednesdays and Fridays. Interview revealed treatment plan updates were to be completed at least weekly on patients with documentation of the patient's progress toward goals.

3. Closed medical review of Patient #6 revealed a 17 year old female admitted to the facility on 09/01/2021 for diagnoses of Major Depressive Disorder and Suicidal Ideation. Review revealed the "Initial Interdisciplinary Treatment Plan" was created on 09/02/2021. Record review revealed "Interdisciplinary Treatment Plan Updates" were completed on 09/08/2021 and 09/13/2021. Review revealed Patient #6 was discharged on 09/27/2021 (14 days after last update was completed).

Interview on 10/12/2021 at 1200 with Therapist #10 revealed treatment team meetings were conducted on Mondays, Wednesdays and Fridays. Interview revealed treatment plan updates were to be completed at least weekly on patients with documentation of the patient's progress toward goals.



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4. Open medical record review on 10/12/2021 revealed Patient #19, a 15 year old female admitted to the facility on 09/10/2021 for diagnoses of attention deficit hyperactivity disorder, disruptive mood dysregulation disorder, major depressive disorder and post-traumatic stress disorder. Record review revealed no evidence of a Master Treatment Plan. Review revealed an "Interdisciplinary Treatment Plan Update" was completed on 10/01/2021 (21 days after admission) and 10/11/2021 (31 days after admision). Review revealed the treatment plan update was completed without a documented Master Treatment Plan or identified problem areas or goals.

Interview on 10/12/2021 at 1120 with AHP #26 revealed treatment plans should be completed in its entirety. Interview revealed diagnoses, interventions, and goals should all be documented. Interview revealed she knew what the patients diagnoses were even though they were not documented on the plans and would provide updates. Interview revealed for her, the MTP was not needed to complete weekly updates.

Interview on 10/12/2021 at 1200 with Therapist #10 revealed treatment team meetings were conducted on Mondays, Wednesdays and Fridays. Interview revealed treatment plan updates were to be completed at least weekly on patients with documentation of the patient's progress toward goals.



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5. Closed medical record review conducted on 10/04/2021 revealed Patient #1 was a 13-year-old male who was admitted to the facility on 08/29/2021 with a diagnosis of Disruptive Mood Dysregulation Disorder. Patient #1 was discharged from the facility on 09/09/2021. Review revealed there were no weekly treatment plan updates during the admission, other than recreational therapy updates. (41 days of admission)

Staff interview was conducted with the Interim Director of Clinical Services (IDCS) on 10/14/2021 at 1002. Interview confirmed there were no complete weekly treatment plan updates for Patient #1. Interview revealed the Interdisciplinary Treatment Team (ITT) was scheduled to meet every Monday, Wednesday, and Friday of each week. Interview revealed the treatment plan should be updated at least weekly.

6. Open medical record review conducted on 10/06/2021 revealed Patient #14 was a 15-year-old male who was admitted to the facility on 09/07/2021 with a diagnosis of Suicidal Ideation. Review revealed there were no weekly treatment plan updates during the admission, other than recreational therapy updates. (29 days after admission)

Staff interview was conducted with the IDCS on 10/14/2021 at 1002. Interview confirmed there were no complete weekly treatment plan updates for Pt #14. Interview revealed the ITT was scheduled to meet every Monday, Wednesday, and Friday of each week. Interview revealed the treatment plan should be updated at least weekly.

7. Open medical record review conducted on 10/08/2021 revealed Patient #16 was a 12-year-old male who was admitted to the facility on 09/07/2021 with diagnoses of Disruptive Mood Regulation Disorder and Major Depressive Disorder. Review revealed there were no weekly treatment plan updates during the admission, other than recreational therapy updates. (30 days after admission)

Staff interview was conducted with the IDCS on 10/14/2021 at 1002. Interview confirmed there were no complete weekly treatment plan updates for Patient #16. Interview revealed the ITT was scheduled to meet every Monday, Wednesday, and Friday of each week. Interview revealed the treatment plan should be updated at least weekly.

8. Closed medical record review conducted on 10/11/2021 revealed Patient #17 was a 15-year-old male who was admitted to the facility on 08/30/2021 with a diagnosis of Suicidal Thoughts with Plan and Bipolar Disorder. Patient #17 was discharged from the facility on 10/08/2021. Review revealed there were no weekly treatment plan updates during the admission, other than recreational therapy updates. (41 days of admission)

Staff interview was conducted with the IDCS on 10/14/2021 at 1002. Interview confirmed there were no complete weekly treatment plan updates for Patient #17. Interview revealed the ITT was scheduled to meet every Monday, Wednesday, and Friday of each week. Interview revealed the treatment plan should be updated at least weekly.

9. Closed Medical record review conducted on 10/14/2021 revealed Patient #21 was a 12-year-old male admitted to the facility's 800 hall on 10/04/2021 with diagnoses of Post-Traumatic Stress Disorder and Disruptive Mood Regulation Disorder. Review of an ITT Treatment Plan update performed on 10/11/2021 at 1448 revealed, "pt progressing as expected - danger to self and others. Therapist has been talking with (Patient #21 Named) about coping skills to use when angry. (Patient #21 Named) appears to have the insight to know coping skills and there has been discussion on (Patient #21 Named) d/c (discharge) plan for him to transition to level 3 GH (Group Home). (Patient #21 Named) family has been involved in tx (treatment) (signed by Therapist #10) 10/11/21 Patient about to attack the nurse yesterday after he had an altercation with his roommate. Patient needed long time (sic) to calm down. (MD #20 Named) aware. Patient taking all his meds as prescribed by MD (Medical Doctor) and eating fair amount of food with each meal (note unsigned) (Patient #21 Named) regularly attends RT (Recreational Therapy) groups. He initiates involvement in the activity and typically remains engaged for the duration of the session. (Patient #21 Named) has shown frustration at times with the activity and peers, requiring redirection (signed by RT #21)." Review revealed no physician participated in this treatment plan update.

Video review and staff interview confirmed Patient #21 required a restrictive intervention on 10/05/2021 that was not documented.

Staff interview was conducted with the Director of Nursing on 10/15/2021 at 1524. Interview revealed if a patient had experienced a restrictive intervention, it should be addressed in the weekly treatment plan update. Interview revealed physicians should take part in the weekly treatment plan update.



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10. Closed medical record review on 10/04/2021 revealed Patient #5 was a 14-year-old female who was admitted to the facility on the 100-Hall on 09/09/2021 with a diagnosis of auditory hallucination and suicidal ideation. Patient #5 was discharged from the facility on 09/27/2021. The review revealed there were no weekly treatment plan updates during the admission (18 days of admission).

Interview on 10/14/2021 at 1000 with the Interim Director of Therapy Services (IDTS) revealed the Interdisciplinary Treatment Team (IDTT) was scheduled to meet every Monday, Wednesday, and Friday of each week. The interview revealed the treatment plan should be updated at least weekly.

11. Closed medical record review on 10/08/2021 revealed Patient #15 was a 14-year-old female who was admitted to the facility on the 100-Hall on 08/31/2021 with a diagnosis of bipolar disorder, unspecified. The review revealed the Master Treatment Plan was conducted on 09/01/2021 and updated on 09/06/2021, 09/10/2021, and 09/27/2021 (17 days later).

Interview on 10/14/2021 at 1000 with the IDTS revealed the Interdisciplinary Treatment Team (IDTT) was scheduled to meet every Monday, Wednesday, and Friday of each week. The interview revealed the treatment plan should be updated at least weekly.

NC00181690; NC00181705; NC00181654; NC00181802; NC00181784; NC0081821; NC00181590; NC00181721; NC00181753; NC00182206; NC00181731

Based on medical record review and staff interviews, the facility staff failed to coordinate transportation for an involuntarily committed patient being transferred to another facility for 1 of 9 discharged patients. (Patient #8)

The findings include:

Closed medical record review revealed Patient #8 was a 17-year-old male involuntarily committed to the hospital on 09/03/2021 with suicide ideation (thoughts of killing self). Medical record review revealed Patient #8 had a history of Major depressive disorder and Attention-deficit hyperactivity disorder. Review of the "Final Ancillary Orders" revealed an order to "Discharge to: Other-HHH (Hospital B); Comments: Pt is being transferred to HHH per CEO [sic]...for further care" signed by the Chief Medical Officer on 09/24/2021 at 1556. Medical record review revealed Patient #8 did not discharge from the facility on 09/24/2021. Review of a "Therapy Services Progress Note" dated 09/27/2021 at 1230 revealed "...Social worker spoke with (named employee) at (Hospital B) to discuss acute to acute transfer for this client. Social worker made contact and (Hospital B employee) shared that they do not have any open acute beds for this client today. (Hospital B employee) shared to make attempt to transfer tomorrow. (Hospital B employee) share [sic] that in order for the client to be accepted a bed needs to be open." Review of a "Therapy Services Progress Note" signed on 09/28/2021 at 1109 revealed "...Social worker contacted (Hospital B) on 9.28.21. Social worker spoke with (Hospital B) admission department to staff this case. (Hospital B) shared that they do not have a bed for this client today. (Hospital B) shared to call tomorrow 9/29 to inquire as to bed availability..." Medical record review revealed Patient #8 discharged home with his parent on 09/30/2021.

Interview on 10/07/2021 at 1140 with the Director of Utilization Review (URD) revealed on 09/24/2021 she received notification of a request to transfer Patient #8 to Hospital B for continued treatment. Interview revealed the Admissions & Referrals Specialist (A&R) #30 contacted Hospital B and Patient #8 was accepted for admission on 09/24/2021. Interview revealed Case Manager (CM) #13 was tasked to coordinate transportation from local law enforcement to transport Patient #8 from the facility to Hospital B. Interview revealed law enforcement did not pick-up Patient #8 on 09/24/2021 and the patient remained in the facility until he discharged home.

Interview on 10/07/2021 at 1550 with CM #13 revealed on 09/24/2021 he was notified by the URD that Patient #8 was being transferred to Hospital B and that he needed to schedule transportation. Interview revealed CM #13 contacted the Johnston County Sheriff's Department and requested transport to pick up an IVC patient from the facility and transport him to Hospital B. Interview revealed CM #13 informed the Johnston County Sheriff's Department Patient #8 would be ready for transport in one hour. Interview revealed at approximately 1440, CM #13 notified the URD that Johnston County Sheriff's transport would be at the facility in one hour to pick up Patient #8 and transport him to Hospital B. Interview revealed CM #13 was working from home on 09/24/2021 and was not informed Patient #8 had not been picked up by the sheriff's department. Interview revealed Patient #8's therapist would have been responsible for following up with the sheriff's department to further coordinate transportation.

An interview was requested with Therapist #31 who was unavailable for interview.

Interview on 10/07/2021 at 1005 with the Interim Director of Clinical Services revealed Therapist #31 was Patient #8's assigned therapist. Interview revealed Therapist #31 was responsible for coordinating Patient 8's discharge plan and following up with the sheriff's department after Patient #8 was not picked up from the facility. Interview revealed there was no documentation to indicate that Therapist #31 followed up with the Johnston County Sheriff's department.

Based on policy and procedure review, Medical Staff Rules and Regulations review, medical record reviews and staff interviews, the facility staff failed to ensure a Master Treatment Plan was completed within 72 hours of admission for 12 of 23 sampled patients. (Patients #20, #23, #19, #1, #14, #16, #17, #12, #4, #11, #8, #18).

The findings include:

Review of facility policy "Treatment Plan Acute Inpatient" reviewed/revised 12/2016 revealed "PROCEDURE: Master Treatment Plan 1. Each clinical team member of the treatment team should review and contribute to the Master Treatment Plan. The Master Treatment Plan should be completed within 72 hours of the patient's admission..."

Review of facility "Medical Staff Rules and Regulations 2021" revealed "....Treatment Plan 8. The multi-disciplinary team shall develop an Individual Comprehensive Treatment Plan that is based on a comprehensive assessment of the patient's needs. This plan will be reviewed within 72 hours of admission and at least weekly... "

1. Open medical record review on 10/12/2021 revealed Patient #20, a 16 year old female admitted to the facility on 09/24/2021 for diagnoses of Disruptive Mood Dysregulation Disorder, Major Depressive Disorder and Post-Traumatic Stress Disorder. Record review revealed no Master Treatment Plan has been created as of record review date. (18 days after admission)

Staff interview was conducted with the Interim Director of Therapy Services (IDTM) on 10/14/2021 at 1002. Interview revealed generally a therapist initiates the creation of a Master Treatment Plan, and the team creating the treatment plan consists of a physician or mid-level provider, a therapist, a nurse, a recreational therapist, and sometimes a utilization review staff member and the patient and/or their family or guardian. Interview revealed the Master Treatment Plan should be created within 72-hours of a patient's admission. Interview revealed due to staff turnover there has not been consistent therapist coverage in the facility. Interview revealed "If we don't have the form the question is 'Was treatment team conducted?' Unfortunately, I don't think treatment team was actually done."

2. Open medical record review on 10/12/2021 revealed Patient #23, a 13 year old male admitted to the facility on 09/01/2021 for diagnoses of Disruptive Mood Dysregulation Disorder, Restlessness and Agitation, Suicidal Ideations and Violent Behavior. Record review revealed no Master Treatment Plan has been created as of record review date. (41 days after admission)

Staff interview was conducted with the Interim Director of Therapy Services (IDTM) on 10/14/2021 at 1002. Interview revealed generally a therapist initiates the creation of a Master Treatment Plan, and the team creating the treatment plan consists of a physician or mid-level provider, a therapist, a nurse, a recreational therapist, and sometimes a utilization review staff member and the patient and/or their family or guardian. Interview revealed the Master Treatment Plan should be created within 72-hours of a patient's admission. Interview revealed due staff turnover there has not been consistent therapist coverage in the facility. Interview revealed "If we don't have the form the question is 'Was treatment team conducted?' Unfortunately, I don't think treatment team was actually done."



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3. Open medical record review on 10/12/2021 revealed Patient #19, a 15 year old female admitted to the facility on 09/10/2021 for diagnoses of attention deficit hyperactivity disorder, disruptive mood dysregulation disorder, major depressive disorder and post-traumatic stress disorder. Record review revealed no Master Treatment Plan has been created as of record review date (32 days after admission).

Staff interview was conducted with the Interim Director of Therapy Services (IDTM) on 10/14/2021 at 1002. Interview revealed generally a therapist initiates the creation of a Master Treatment Plan, and the team creating the treatment plan consists of a physician or mid-level provider, a therapist, a nurse, a recreational therapist, and sometimes a utilization review staff member and the patient and/or their family or guardian. Interview revealed the Master Treatment Plan should be created within 72-hours of a patient's admission. Interview revealed due to staff turnover there has not been consistent therapist coverage in the facility. Interview revealed "If we don't have the form the question is 'Was treatment team conducted?' Unfortunately, I don't think treatment team was actually done."



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4. Closed medical record review conducted on 10/04/2021 revealed Patient #1 was a 13-year-old male who was admitted to the facility on 08/29/2021 with a diagnosis of Disruptive Mood Dysregulation Disorder. Patient #1 was discharged from the facility on 09/09/2021. Review revealed no evidence the Master Treatment Plan was created for Patient #1. (11 days of admission)

Staff interview was conducted with the Interim Director of Clinical Services (IDCS) on 10/14/2021 at 1002. Interview confirmed there was no Master Treatment Plan created for Patient #1. Interview revealed generally a therapist initiates the creation of a Master Treatment Plan, and the team creating the treatment plan consists of a physician or mid-level provider, a therapist, a nurse, a recreational therapist, and sometimes a utilization review staff member and the patient and/or their family or guardian. Interview revealed the Master Treatment Plan should be created within 72-hours of a patient's admission. Interview revealed due staff turnover there has not been consistent therapist coverage in the facility. Interview revealed "If we don't have the form the question is 'Was treatment team conducted?' Unfortunately, I don't think treatment team was actually done."

5. Open medical record review conducted on 10/06/2021 revealed Patient #14 was a 15-year-old male who was admitted to the facility on 09/07/2021 with a diagnosis of Suicidal Ideation. Review revealed no evidence the Master Treatment Plan was created for Patient #14 as of record review date. (29 days after admission)

Staff interview was conducted with the IDCS on 10/14/2021 at 1002. Interview confirmed there was no Master Treatment Plan created for Patient #14. Interview revealed generally a therapist initiates the creation of a Master Treatment Plan, and the team creating the treatment plan consists of a physician or mid-level provider, a therapist, a nurse, a recreational therapist, and sometimes a utilization review staff member and the patient and/or their family or guardian. Interview revealed the Master Treatment Plan should be created within 72-hours of a patient's admission. Interview revealed due staff turnover there has not been consistent therapist coverage in the facility. Interview revealed "If we don't have the form the question is 'Was treatment team conducted?' Unfortunately, I don't think treatment team was actually done."

6. Open medical record review conducted on 10/08/2021 revealed Patient #16 was a 12-year-old male who was admitted to the facility on 09/07/2021 with diagnoses of Disruptive Mood Regulation Disorder and Major Depressive Disorder. Review revealed no evidence the Master Treatment Plan was created for Patient #16 as of record review date. (31 days after admission)

Staff interview was conducted with the IDCS on 10/14/2021 at 1002. Interview confirmed there was no Master Treatment Plan created for Patient #16. Interview revealed generally a therapist initiates the creation of a Master Treatment Plan, and the team creating the treatment plan consists of a physician or mid-level provider, a therapist, a nurse, a recreational therapist, and sometimes a utilization review staff member and the patient and/or their family or guardian. Interview revealed the Master Treatment Plan should be created within 72-hours of a patient's admission. Interview revealed due staff turnover there has not been consistent therapist coverage in the facility. Interview revealed "If we don't have the form the question is 'Was treatment team conducted?' Unfortunately, I don't think treatment team was actually done."

7. Closed medical record review conducted on 10/11/2021 revealed Patient #17 was a 15-year-old male who was admitted to the facility on 08/30/2021 with a diagnosis of Suicidal Thoughts with Plan and Bipolar Disorder. Patient #17 was discharged from the facility on 10/08/2021. Review revealed no evidence the Master Treatment Plan was created for Patient #17. (39 days of admission)

Staff interview was conducted with the IDCS on 10/14/2021 at 1002. Interview confirmed there was no Master Treatment Plan created for Patient #17. Interview revealed generally a therapist initiates the creation of a Master Treatment Plan, and the team creating the treatment plan consists of a physician or mid-level provider, a therapist, a nurse, a recreational therapist, and sometimes a utilization review staff member and the patient and/or their family or guardian. Interview revealed the Master Treatment Plan should be created within 72-hours of a patient's admission. Interview revealed due staff turnover there has not been consistent therapist coverage in the facility. Interview revealed "If we don't have the form the question is 'Was treatment team conducted?' Unfortunately, I don't think treatment team was actually done."



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8. Open medical record review on 10/06/2021 revealed Patient #12 was a 14-year-old female who was admitted to the facility on the 100-Hall on 09/17/2021 with a diagnosis of Suicidal Ideation. Review of the record revealed no evidence a Master Treatment Plan was created for Patient #12 as of record review date (19 days after admission).

Staff interview was conducted with the Interim Director of Clinical Services on 10/14/2021 at 1002. Interview revealed generally a therapist initiates the creation of a treatment plan, and the team creating the treatment plan consists of a physician or mid-level provider, a therapist, a nurse, a recreational therapist, and sometimes a utilization review staff member and the patient and/or their family or guardian. The interview revealed the Master Treatment Plan should be created within 72-hours of a patient's admission. The interview revealed due to staff turnover there has not been consistent therapist coverage in the facility. Interview revealed "If we don't have the form the question is 'Was treatment team conducted?' Unfortunately, I don't think treatment team was actually done."



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9. Closed medical record review on 10/06/2021 revealed Patient #4 was a 17-year-old male who was admitted to the facility on the 800-Hall on 09/07/2021 with a diagnosis of Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Review of the record revealed no evidence an initial Master Treatment Plan (MTP) was created for Patient #4. Review revealed Patient #4 eloped on 09/12/2021(5 days after admission) and did not return to the facility per parent request.

Interview on 10/13/2021 at 0903 with Therapist #10 revealed she was Patient #4's assigned therapist. Interview confirmed Patient #4 did not receive a MTP during his admission. Interview revealed Therapist #10 was on orientation the week Patient #7 was admitted. Therapist #10 stated her first day of employment was 09/07/2021.

Staff interview was conducted with the Interim Director of Therapy Services (IDTM) on 10/14/2021 at 1002 revealed generally a therapist initiated the creation of a treatment plan, and the team creating the treatment plan consisted of a physician or mid-level provider, a therapist, a nurse, a recreational therapist, and sometimes a utilization review staff member and the patient and/or their family or guardian. The interview revealed the Master Treatment Plan should be created within 72-hours of a patient's admission. The interview revealed due to staff turnover there has not been consistent therapist coverage in the facility. Interview revealed "If we don't have the form the question is 'Was treatment team conducted?' Unfortunately, I don't think treatment team was actually done."

10. Open medical record review on 10/04/2021 revealed Patient #11 was a 60-year-old male who was admitted to the facility on the 900-Hall on 09/14/2021 due to worsening aggression and homicidal threats. Review of the record revealed no evidence an initial Master Treatment Plan (MTP) was created for Patient #11. Review revealed Patient #11 discharged on 10/10/2021. (26 days of admission)

Interview on 10/08/2021 at 1002 with Therapist #6 revealed she was Patient #11's assigned therapist. Interview confirmed Patient #11 did not receive a MTP during his admission.

Staff interview was conducted with the Interim Director of Therapy Services (IDTM) on 10/14/2021 at 1002 revealed generally a therapist initiated the creation of a treatment plan, and the team creating the treatment plan consisted of a physician or mid-level provider, a therapist, a nurse, a recreational therapist, and sometimes a utilization review staff member and the patient and/or their family or guardian. The interview revealed the Master Treatment plan should be created within 72-hours of a patient's admission. The interview revealed due to staff turnover there has not been consistent therapist coverage in the facility. Interview revealed "If we don't have the form the question is 'Was treatment team conducted?' Unfortunately, I don't think treatment team was actually done."



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11. Review of a closed medical record on 10/04/2021 revealed Patient #8 was a 17-year-old male involuntarily committed to the facility on 09/03/2021 with suicide ideation (thoughts of killing self). Medical record review revealed Patient #8 had a history of Major depressive disorder and Attention-deficit hyperactivity disorder. Record review failed to reveal evidence of a Master Treatment Plan for Patient #8. Record review revealed Patient #8 discharged home on 09/30/2021. (27 days of admission)

Staff interview was conducted with the Interim Director of Clinical Services on 10/14/2021 at 1002. Interview revealed generally a therapist initiates the creation of a Master Treatment Plan, and the team creating the treatment plan consists of a physician or mid-level provider, a therapist, a nurse, a recreational therapist, and sometimes a utilization review staff member and the patient and/or their family or guardian. Interview revealed the Master Treatment Plan should be created within 72-hours of a patient's admission. Interview revealed due staff turnover there has not been consistent therapist coverage in the facility. Interview revealed "If we don't have the form the question is 'Was treatment team conducted?' Unfortunately, I don't think treatment team was actually done."

12. Open medical record review on 10/11/2021 revealed Patient #18 was a 15-year-old male admitted to the facility on 09/24/2021 with suicide ideation. Medical record review revealed Patient #18 had a history of Schizophrenia, Bipolar disorder Type 1 and Attention-deficit hyperactivity disorder. Record review failed to reveal evidence of a Master Treatment Plan for Patient #18 as of record review date. (17 days after admission)

Staff interview was conducted with the Interim Director of Clinical Services on 10/14/2021 at 1002. Interview revealed generally a therapist initiates the creation of a Master Treatment Plan, and the team creating the treatment plan consists of a physician or mid-level provider, a therapist, a nurse, a recreational therapist, and sometimes a utilization review staff member and the patient and/or their family or guardian. Interview revealed the Master Treatment Plan should be created within 72-hours of a patient's admission. Interview revealed due staff turnover there has not been consistent therapist coverage in the facility. Interview revealed "If we don't have the form the question is 'Was treatment team conducted?' Unfortunately, I don't think treatment team was actually done."

Based on policy review, medical record review and staff interview the facility failed to document a substantiated psychiatric diagnosis (from the Comprehensive Psychiatric Evaluation) that served as the primary focus for the treatment plan for 2 of 23 sampled patients. (Patient #6 and #15)

The findings include:

Review of the policy "Treatment Plan Acute Inpatient" review/revised 12/2016 revealed "... Each patient admitted to the psychiatric unit shall have an individualized person centered treatment plan which is based on interdisciplinary clinical assessments. The multidisciplinary team is headed by the physician and consists of nursing, therapists, recreational therapists, utilization management, milieu management, clinical directors, director of nursing, and other health professionals as indicated. ... Each clinical team member of the treatment team should review and contribute to the Master Treatment Plan. ...

1. Closed medical record review on 10/05/2021 revealed Patient #6 was a 17 year old female who was admitted to the facility on 09/01/2021 with diagnoses of Major Depressive Disorder and Suicidal Ideation. Review of the Master Treatment Plan revealed, "Diagnosis Mental Health and Physical Disorder" was left blank. Review revealed the substantiated diagnosis was not documented on the Master Treatment Plan .

Interview on 10/12/2021 at 1120 with AHP #26 revealed treatment plans should be completed in its entirety. Interview revealed diagnoses, interventions, and goals should all be documented. Interview revealed she knows what the patients diagnoses are even though they are not documented on the plans and will provide updates. Interview revealed for her, the MTP is not needed to complete weekly updates.



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2. Closed medical record review on 10/08/2021 revealed Patient #15 was a 14-year-old female who was admitted to the facility on the 100-Hall on 08/31/2021 with a diagnosis of bipolar disorder, unspecified. Review revealed Patient #15 was discharged from the hospital on 10/02/2021. Review of the Master Treatment Plan revealed, "Diagnosis Mental Health and Physical Disorder" was left blank. The review revealed Patient #15's diagnosis was not documented on the Master Treatment Plan .

Interview on 10/14/2021 at 1000 with the Interim Director of Clinical Services revealed generally a therapist initiates the creation of a treatment plan, and the team creating the treatment plan consists of a physician or mid-level provider, a therapist, a nurse, a recreational therapist, and sometimes a utilization review staff member and the patient and/or their family or guardian.