HospitalInspections.org

Based on surveyor observations, review of
facility incident reports and patient record review,
and confirmed in interview, the facility failed to
promote patient's right and ensure patients
received care in a safe setting for five of ten
(Patient # A, B, E, I, J) patients reviewed.

Refer to A0144

The deficient practices were identified under the
following Condition of Participation §482.13
Patient's Rights, and were determined to pose an
Immediate Jeopardy (IJ) to patient health and
safety and placed all patients in the facility at risk
for the likelihood of harm, serious injury, and
possible death.

Surveyor observations, review of records and
updated policy confirmed IJ abated on
05/03/2024.

Based on surveyor observations, review of
facility incident reports and patient record review,
and confirmed in interview, the facility failed to
ensure patients received care in a safe setting for
five of ten (Patient # A, B, E, I, J) patients
reviewed.

a) patients with history of self harm did not have
access to sharp objects to cut themselves or
access to cords for ligature risks
b) patients with history of elopement did not have
an opportunity to elope
c) patients with history of aggressive behaviors
were not able to use heavy furniture to use as
weapons to destroy property or injure staff

Findings included:

In an initial tour of the physical environment with
Staff # 3 on 05/01/2024 at 10 AM, surveyor
observed the outside courtyard with temporary
chain link fence with sandbags with plastic ties
used to weigh them down; wooden picnic tables;
and plastic trash bags in garbage bins. The
facility had 2 floors. On the second floor,
surveyor observed plastic table and chairs in the
group room and plastic trash bags in garbage
bins. Staff #3 escorted surveyor to patient room
#222. The patient room had a temporary temper
resistant covering on the window, plastic blinds
with a long cord unsecured; TV with a long cord
unsecured. Staff # 3 escorted surveyor to patient
room #106 which again the plastic blinds with
long cords unsecured; cords to and from medical
bed unsecured; floor to ceiling breakable
windows and a tall black dresser unsecured from
the wall.

An interview with Staff # 1 on 05/01/2024 at 11:30
AM confirmed that all patient rooms had similar
furniture and configuration. She also confirmed
that all rooms were left unlocked when unoccupied.

Random review of the facility incident reports from January 2024 to April 2024 revealed the following seven incidents for five patients (Patient #A, B, E, I, J) when patients used sharp objects or items with unsecured cords found in the facility for self-harm; had the opportunity to elope; and/or used furniture in rooms to use as a weapon to break windows.

Patient #A
Review of the medical chart for Patient #A revealed she was admitted on 03/18/2024 for past medical history of autism, severe and recurrent major depression, borderline personality disorder, anxiety disorder, ADHD combined, parent-child relational conflict, self-mutilation, sleep disturbances, abnormal thoughts/flashbacks/nightmares, defiant/behavioral issue/anger, hallucinations, poor impulse control.

Incident Case #10010
On 03/20/2024, "[Patient #A] attempted self harm
by wrapping chord around neck. She came to the
nursing station with sitter and pretended to throw
bandage away and then ran behind the nursing
station and grabbed the vitals machine
temperature cord and rapped around neck, after
disarming patient she then proceeded on
grabbing a pencil from the nurse. Patient was disarmed and doctor strong called at 1355 ..."

Incident Case # 10218
On 04/02/2024, "[Patient #A] was in activity room
with other patients, all of a sudden she got up
and started pulling another patient's hair, she also
tried to bite the patient. Dr. strong was called and [Patient #A] walked out of the activity
room grab the printer cord and tried to hang
herself with it. The staff succeeded to get the cord out of her hand and she headed to an empty patients room
where she tried to self harm again. This nurse held her hands to prevent her from self harm, that is when she spat on my face and directly into my eyes. I flushed my eyes at the eye wash station per protocol."

Patient # B
In review of Patient # B's medical chart, it stated she was admitted on 03/16/2024 with history of
self harm; suicidal ideation; and homicidal ideation.

The psychiatry consult assessed by Staff #19 on 3/18/2024 included Patient #B's history of illness.

"Pt is a 16 YOF w/ x of Major depressive Disorder, Self-Harm Behavior and unpredictable behavior ...and presents w/ progressively worsening behaviors. Pt endorses homicidal ideation towards peers and staff... Pt endorses SI over the last 6 months stating 'I took pills, tried to cut my wrists and tried to drown myself'. Pt also reports she 'used wood from a door' to harm herself. Pt also admits to auditory hallucinations but refuses to give examples ...to 2/9/24 d/t pt having periods of emotional dysregulation w/ picking up items and trying to remove items w/ the goal of ingesting them d/t having the intent to harm herself. Per reports, ingesting objects is a new self-harm tactic for pt that has only recently started in the past few weeks ...Per collateral pt has hx of self-harming w/ glass and scissors. Suicide precautions ordered. On 2/12/24 pt tried to swallow a toothbrush and began crying and repeatedly saying 'Do not touch me' as staff approached her. Pt wouldn't take Thorazine PO so it was given IM. Pt calm after med administration and went to her room to sleep.
Progress note from 2/13/24 indicates pt began escalating in her behaviors including banging her head against the door. She was unable to deescalate, so PRN med had to be given. Later that evening pt had to be restrained d/t severe agitation and self-harm. Pt was banging her head, kicking, and punching doors while screaming 'its my fault.' Pt spoke w/ her father on the phone and states "it did not go well". Pt required PRN meds x 2 because she was c/ o elevated anxiety and displayed poor insight. She was observed banging her head against the wall and peeling laminate off the walls. Pt rates her anxiety is 8-10/10 and depression is 6-9/10. Pt is positive for suicidal ideations w/ 7-10/10 intent to harm herself. Per pt's father the most recent behavior change is pt is swallowing objects. Pt's father explained pt mimics other people's behaviors."

In review of Staff #19's assessment on 3/18/2024, it stated "the patient claims to suffer from MDD, which is evidenced by despondency, anhedonia, feelings of isolation, and guilt. The patient reports having auditory and visual hallucinations, as well as seeing shadows. [Patient # B] claims that these symptoms began when she was three years old; she would hear a voice in her mother's kitchen calling her name and try to fight back. The patient additionally reports having nightmares at night and hypervigilance during the day ...During the evaluation, the patient denies suicidal or homicidal thoughts ...Since joining the unit, she has remained in the room and participated in group activities, with no social connections with peers. The patient has not exhibited any outbursts or indicators of irritation or fury."

Incident Case # 10405
On 04/13/2024, "[Patient #B] called [Staff #20] to room to ask for a band aid, when asked for the reason pt. showed RN her arm where she had multiple scratches to left forearm. Pt. states to self harm occurred on morning shift. Pt. gave paint cap to RN that was used for self harm. Pt. denies suicidal ideations or visual/ auditory hallucinations ..."

Incident Case # 10471
On 04/17/2024, "[Patient #B] at 1935 started to voice that she was felling anxious and hearing voices that told her to self-harm, patient broke a piece of the metallic window shade and used to cut herself in left forearm meanwhile CNA sitter [Staff #21] was 1 to 1 with the patient and patient was under her supervision. RN [Staff #22] arrived assessed the child forearm and minor cuts were observed, RN started deescalating the patient and offer to the patient options as coping mechanisms. Patient requested some ice and was given ..."

Incident Case # 10502
On 4/19/2024, "at approximately 1945, [Patient #B] request to see another nurse prior to nurse leaving. Patient disclosed to nurse that she had broke[n] a piece plastic blind off and had proceeded to cut bilateral arms and Right side of neck. Patient was placed back on a 1:1 with a CNA in her room bedside. At 2015, CNA called out for the nurse to come help her, Patient had another piece of blind and had proceeded to dig in her left. Patient and patients' room was thoroughly searched and no other plastic blinds or weapons were found."

Patient # D
In review of the psychiatry consult on 01/31/2024 after Patient #D's admission on 01/30/2024, it stated "[Patient # D] is a 15-year-old male with a history of Disruptive Mood Dysregulation Disorder Mild Intellectual Disabilities, Post-Traumatic Stress Disorder, Attention Deficit Hyperactivity Disorder history of suicidal ideations, suicide
attempts, and multiple elopements, who presents to Nexus Children's Hospital to True North Program for continued to management of aggressive behavior suicidality, elopement, and medical conditions."

Incident Case # 9395
In review of the incident report on 2/11/2024, it stated "Patient was on the playground with other patients standing by the basketball court conversing with another patient. After a while they were seen escaping alongside the wired fence."

An interview with Staff #1 on 05/02/2024 at 3:30 PM in the conference room confirmed that Patient #D had orders for a 2:1 sitter on 2/10/2024 and was still able to elope briefly in the parking lot on 2/11/2024.

Patient # I
Review of Patient # I's medical chart, he transferred into the facility on 01/26/2024 from a sister facility. His History and Physical assessed on 1/27/2024 included his history of "increased behaviors since April 2023. Behaviors include-AWOL attempts, criminal activity, self-directed violence, emergent treatment, possession of a weapon, caused property damage, used illegal substances, increased aggression, psychiatric hospitalization, suicide attempts and solicited sex from two woman on phone texts. He has not been engaging while in therapy. His participation has been superficial. Due to the increase in high-risk behavior, it is recommended that Austin have a "medication wash",
participate in individual therapy, psychiatric services, therapeutic day school, recreational activities, and behavioral monitoring in a secure environment. He was being held in a secured detention center until an appropriate placement is secured ... After admission to us at [sister facility], he had several other elopement, ate soap, and took illicit drugs found during his elopements."

In review of Patient #I's medical chart nursing notes on 2/11/2024 at 7:28 PM, Staff # 5 stated "At 1630, while patient was at the playground, patient and another patient [Patient # D] eloped from the playground. Staff went all over the area and hospital looking for patient. Nurse and another staff went to the street and was looking for patient, patient was nowhere to be found.Nurse and house supervisor called 911. The police came and also assisted in looking for patient ..." Further review of Staff # 5's nursing notes on 2/12/2023, it stated "at 1225 [AM], patient arrived at the facility and was accompanied by 2 staff. Nurse assessed patient from head to toe ..."

Patient # J
In review of Patient #J's medical chart, it stated "[Patient # J] his history of inappropriate behavior with female caregivers ...[Patient #J] had been aggressive, hypersexual, delusional, hyper religious ...currently on admission today [Patient #J] is being resistive to care, refusing to get off the floor, go into room to be assessed and demanding to call his family. "

Incident case # 10697
"[Patient J] had been sitting in the chair since 1530 unrestrained and refused to get out of the chair. When staff was able to get the patient up, he smashed a window in his room with part of his dresser, breaking the glass. Patient was restrained in the chair at 1726 and evaluated for release at 1926."

In an interview with Staff # 1 and Staff # 3 on 05/02/2024 at 12:20 PM in the conference room confirmed the above findings. They acknowledged there's a lot of work that needs to be done to ensure safety for the patients. Staff # 1 also acknowledged that many of the incidents above had no follow up and/or outcomes as the facility is currently looking for a quality risk director and is still pending review.

Based on facility policy, random review of patient charts and confirmed in interview, the facility
failed to ensure a physician ordered the use of restraints for two of ten patient records reviewed.

Findings included:

In review of the facility policy Restraints (revised 04/2023), it stated "the attending physician,
physician designee, or (QLP) shall perform a face to-face assessment of the patient at least every calendar day, at which time, the restraint shall
be either reordered or discontinued as indicated."

A random review of patient charts revealed two of ten patients (Patient #C, #E) who had restraints
administered without orders.

Patient #C
In review of the H&P assessed on 01/31/2024 when he was transferred into the facility, when patient was admitted "[Patient #C admits] with past medical history of ADHD, autism, and intermittent
explosive disorder ...Patient has a history of physical aggression and elopement. No identified
triggers. He is admitted ...for evaluation and continued management of behaviors stabilization,
behavioral health and psychological therapies and clinical monitoring."

Review of Patient #C chart revealed he had a behavioral emergency on 02/11/204. He was placed on a restraint chair at 3:43 PM and discontinued at 3:56 PM. No orders were available for review.

In review of the nurses notes on 02/11/2024, Staff #5 noted "At 1533, While patient was in the
activity area, Patient was arguing with another patient when asked to go to his room, patient got
upset and was destructive, yelling, patient also hit another patient in the activity area and also
hit a staff. patient was also hitting his head, aggressive and also yelling and using profanity.
Patient was redirected several times but was not following directions or listen.
At 1535: Therapeutic hold.
At 1537: Doctor [staff #6] notified.
At 1540: versed given via intranasal by house supervisor. Patient was still aggressive and causing self-harm.
At 1543: Restraint chair
At 1545: 2nd dose versed Intranasal given. At 1550: vital signs done every 15 minutes for one
hour.
At 1556: Nurse notified patient caseworker. Patient final calm down and joined his peers in the activity room and also participated in activities."

Patient # E
Review of Patient #E chart revealed he had a behavioral emergency on 04/17/2024. He was placed in a restraint chair at 08:03 AM and discontinued at 8:30 AM. No restraint order was available for review.

Review of the nurse's notes on 04/17/2024, Staff # 7 noted "At 0755 pt was seen by a staff member taking an item from the nurses mobile work station. Pt asked to give the item back, but ran into his room instead. Pt was upset and did not want to give the "item" back to staff. NP [Staff #8] notified of pts escalating behavior at 0755 and gave Telephone order for 5mg Zyprexa IM. Pt then
went into his bathroom and would not open to door, staff then forcibly opened the door for safety reasons and that is when the pt hit and kicked staff. 0800 Dr. Strong called, this RN, CNA [Staff #9], [Staff #10], NOA, [Staff #11], and therapy staff responded to the Dr. Strong page. Pt placed in the restraint chair at 0803 for assaulting staff, at 0806 Zyprexa 5mg IM administered by NOA to pts left deltoid. At 0808 Versed 10mg given to pt intranasally, pts left nostril began to bleed. Second dose of Versed not given due to pts nostril bleeding. At 0810 Dr. Strong Cleared. Pts vitals taken q15min, pt taken out of the restraint chair at 0835, pt fell asleep in the chair and no longer a danger to self or others ..."

In an interview with Staff #1 and Staff #4 on 05/02/2024 at 4:00 PM in the conference room confirmed the above findings.

Based on facility policy, random review of patient charts and confirmed in interview, the facility
failed to ensure a registered nurse and/or physician performed a face to face assessment within 1
hour after initiation of a restraint for two of ten patient records reviewed.

Findings included:

In review of the facility policy Restraints (revised 04/2023), it stated "upon initial restraint
application, a registered nurse must assess the mental, behavioral, and physical status of the
patient."
A random review of patient charts revealed two of ten patients (Patient #C, #E) who had restraints
administered without the face to face by an RN within 1 hour after initiation of the restraint.

Patient #C
In review of the nurses notes for Patient #C on 02/11/2024, Staff #5 noted "At 1533, While patient was in the activity area, Patient was arguing with another patient when asked to go to his room, patient got upset and was destructive, yelling, patient also hit another patient in the activity area and also hit a staff. patient was also hitting his head, aggressive and also yelling and using
profanity. Patient was redirected several times but was not following directions or listen. At 1535: Therapeutic hold.
At 1537: Doctor [staff #6] notified.
At 1540: versed given via intranasal by house supervisor. Patient was still aggressive and causing self-harm.
At 1543: Restraint chair
At 1545: 2nd dose versed Intranasal given. At 1550: vital signs done every 15 minutes for one hour.
At 1556: Nurse notified patient caseworker. Patient final calm down and joined his peers in the activity room and also participated in activities."

Review of Patient #C chart revealed he was placed on a restraint chair at 3:43 PM and discontinued at 3:56 PM. No face to face after initiation of the restraint were available for review.

Patient # E
In review of the nurses notes of Patient #E's chart on 4/16/2024, Staff # 12 noted "At 7:30 [PM]
when the night nurse received his shift when to the patient room and found a sharp blade on top of table. When we asked how he got it the patient refused to answer. Then we proceeded to a room search and we tried to take his personal item away for his safety and the patient refused it. After a few minutes trying to deescalate with the patient he became anxious and aggressive and was uncooperative. Dr Strong was called at 19:37. Midazolam (Versed) 10mg/2ml 1st nasal dose was given at 1939 and the 2nd dose at 1944. The child was placed in the chair at 1943 following the Hospital protocols, and the restriction was discontinued at 2043. Vital signs were taken every 15 minutes and in normal range. Dr Strong was cleared at 1950. RN called the patient's adopted mother and was notified. [Staff # 6] was notified at 2014. Currently the patient is stable and sleeping in his room."

Review of Patient #E chart revealed he was placed in a restraint chair at 7:43 PM and discontinued at 8:43 PM. No face to face after initiation of the restraint were available for review.

In an interview with Staff # 1 and Staff #4 on 05/02/2024 at 4:00 PM in the conference room confirmed the above findings.

Based on review of facility policy and staff records and confirmed in interview, the facility
failed to ensure staff had the education and training for non-physical intervention skills for two
of eleven staff records reviewed (Staff #13, #14).

Findings included:

In review of the facility job description for 1x1 patient sitter under position qualifications, it
stated "Attend behavioral management and
de-escalation techniques training as required by the facility (SAMA) ...".

Random review of staff records daily assignment sheets from April and May 2024 revealed two of
eleven staff were contract employees (staff #13, #14) who were assigned as a patient sitter.

Review of Staff #13 and #14 training records revealed no documentation they successfully completed the required Satori Alternatives to Managing Aggression (SAMA) prior to working as CNAs and/or sitters.

An interview with Staff # 1 on 05/01/2024 at 1:30 PM in the conference room confirmed the above findings. She stated the contract workers do not attend a routine orientation prior to working a shift.

Based on review of the facility daily assignment sheets from 4/15/2024 to 5/02/2024 and confirmed in interview, the facility failed to provide 24-hour nursing services by a registered nurse for two of seventeen days reviewed (04/28/2024 and 05/01/2024).

Findings included:

Review of the Daily Assignment sheets from 4/15/2024 and 5/2/2024 revealed two of seventeen days when only LVNs (licensed vocational nurse) were assigned to patient care (04/28/2024, 05/01/2024) for the 1st floor.
04/28/2024 - patient census 28 True North 1st floor - Staff #17, #18

05/01/2024 - patient census 27
True North 1st floor -- Staff #15, #16
In an interview with Staff #1 on 05/03/2024 at 1:20 PM in the conference room, she confirmed the above findings and confirmed Staff # 15, 16, 17, and 18 were LVNs. She was unaware that an RN had to be on each unit each day.

Based on surveyor observations, review of the facility records from 2024, and confirmed in
interview, the facility failed to ensure the condition of the physical plant were developed and
maintained to ensure the safety and well-being of patients.

Findings included:

Surveyor observations on 05/01/2024 and 05/02/2024 noted the general safety in patient In review of the facility Environmental Risks for Suicide Assessment Checklist from 4/1/2024, it stated "use the comments section to indicate any required follow-up actions identified by an 'N' for 'No' response."

In review of the checklist, the following questions had a response of 'N' with no documentation of
any follow-up actions.

"Are all chemicals, including alcohol-based hand rub, kept under direct staff observation or within
a locked room or an area inaccessible by patients? Are telephones located in corridors or common spaces for patient use securely wall-mounted, and do they feature a nonremovable shielded cord (maximum length 14 inches)?
Are only tamper-proof screws used in patient care areas?
Are all air vent covers or grills designed to resist ligature attachment and secured with
tamper-resistant fasteners?
Is window glass made of shatterproof material? Are doors, door hinges, handles, and locks designed to resist ligature attachment?
If electrically operable beds are used due to medical necessity, do they have reduced-length
cords and other tamper-resistant features, and are they free of ligature attachments?
If electrically operable beds are used due to medical necessity, are the beds listed on the
environmental risk assessment?
If pull cords on nurse call or emergency call switches are provided, are they lightweight and no longer than 4 inches?
Are mirrors and wall decorations designed to resist ligature attachment and mounted in a
tamper-resistant manner?
Are grab bars and towel bars in patient bathrooms removed or designed to resist ligature attachment?
Are toilets (including tanks and plumbing fixtures) tamper resistant and designed to resist
ligature attachment?
Are sinks (including faucets, valves, and plumbing fixtures) tamper resistant and designed to resist ligature attachment?
Are showers (including faucets and plumbing fixtures) tamper resistant and designed to resist
ligature attachment?
Are mounting brackets for TVs removed (to prevent use as ligature points)?"

In an interview with Staff #C on 05/02/2024 at 12:30 PM in the conference room confirmed that he had not implemented a plan to assess the 'no' for the above checklist. He was still 'learning' about the rules and regulations for the facility patient population since their transition in late 2023.