HospitalInspections.org

Based upon review of 12 of 18 medical records, Quality Assurance/Performance Improvement data, nurse staffing ratios, observations, and staff interviews, the hospital failed to meet the Condition of Participation for Patient Rights as evidenced by:

1) Failing to provide care in a safe setting to ensure that sexual contact was not allowed for 12 of 18 patients (#'s 2, 6-11, 14-18) who were inpatients on the Adult Psychiatric Unit, the Adolescent Unit, and the Youth Enhanced Unit and failure to provide adequate staff on the Adult Psychiatric Unit on 2/17/14 for patient #13 who was on 1:1 observations, and patient #12 and two random patients who were on Constant Visual Observations. (Tag A144) and,

2) Failing to ensure additional staff were on the Adult Psychiatric Unit, the Adolescent Unit, and the Youth Enhanced Unit to ensure all patients were free of abuse and neglect:

a) Adequate staff failed to be available on the Adult Psychiatric Unit on 2/17/14 in order to provide 1:1 observations (prior to 10:37 a.m.) for patient #13, and Constant Visual Observations for three patients (#12 and 2 random patients) with only 2 staff members available to monitor 15 patients;

b) Adequate staff failed to be available on the Adolescent Unit on 01/26/14 when there were 2 random patients (census 43) who were ordered 1:1 observations;

c) Adequate staff failed to be available on the Youth Enhanced Unit on 1/26/14 for physician ordered observations levels (1:1; Close Visual Observation-CVO) for 2 of 8 patients (#2, #7), who were allowed to engage in alleged sexual misconduct;

d) Adequate staff failed to be available on 12/25/13 during the 3:00 p.m. to 11:00 p.m. shift when there were 6 patient admissions to the Adult Psychiatric Unit raising the staffing level from 2 staff members to 3. (During this shift, patient #16 (female) alleged a sexual encounter occurred where male patient #17 came into her room and had sex with her);

e) Failure to ensure all incidents of sexual misconduct were investigated and reported to the state agency (Health Standards Section) within 24 hours in accordance with the policy and procedure for 12 of 18 medical record reviews (Patient #s 2, 6-11, 14-18).

See Tag 145.

Based upon interview and review of the grievance policy and procedure, grievances filed from November 2013 to February 13, 2014, the hospital failed to ensure that the grievance policy and procedure identified reasonable time frames for a response to complaints. According to the grievance policy and procedure, the grievance would be first reported to the grievance committee, which according to interview was held every three months, then a response would be forwarded to the complainant.

Findings:

Review of policy #RI.012 titled "Patient Grievance Procedures", part II. Procedure revealed "3.3 A grievance, such as a patients rights violation will be addressed by the patient advocate and will be reported on in the Grievance Committee Review committee meeting. A written response will be provided to the patient within 7 days of the committee's review..."

Interview with S2 Risk Manager/Quality Assurance Director (RM/QA) on 02/14/14, at 9:05 a.m., revealed she was also the patient advocate and received the patient grievances. When asked when the Grievance Committee Review held their meetings, S2 RM/QA replied "every three months" and after the meeting the patient was then notified of their findings of the complaint investigation.

Based upon review of 1 of 18 medical records (#16), Quality Assurance/Performance Improvement data, Hospital Abuse/Neglect Initial Report forms, and interviews, the hospital failed to ensure that the practitioners who provide care to the patients comply with directives related to the execution of a legal guardianship and inform the designated individual(s) (parents of patient #16) of an incident which occurred between female patient #16 and male patient #17.

Findings:

Review of the medical record for patient #16, a 27 year old female, revealed that the patient was admitted to the hospital on 12/21/13 for violent and aggressive behaviors and suicidal ideation. According to the initial screening exam and the initial nursing assessment, documentation revealed that patient #16's mother and father were identified as the patient's legal guardians.

On 12/26/13, patient #16 (female) reported that a sexual encounter had occurred between herself and patient #17 (male). Review of the form titled Hospital Abuse/Neglect Initial Report, completed by S2 Risk Manager/Quality Assurance Director (RM/QM) revealed documentation that patient #16 refused to have her parents notified of the incident.

Review of the information provided by the Hospital Complaint Program Manager revealed a document titled "LETTERS OF CO-GUARDIANSHIP AND CO-CONSERVATORSHIP" dated 12/13 2004. This document identified "Full power and authority in the premises, including all the powers and duties of a guardian. The following rights and duties of a conservator, as set forth in K.S.A 59-3078 (Supp. 2002) and amendments thereto, are hereby assigned to (mother and father of patient #16), to be exercised jointly or individually." This document was submitted and approved through the District Court in the state of Kansas.

Even though the hospital identified patient #16's parents had legal guardianship, there was no documented evidence that the hospital staff requested further information regarding the guardianship. The parents of patient #16 were not notified at the time of the sexual encounter between their daughter and male patient #17. According to the documented grievances, patient #16 called her parents and told them of the sexual encounter while still an inpatient in the hospital.

Based upon review of Quality Assurance/Performance Improvement data, 12 of 18 medical records, policy and procedures, and staff interviews, the hospital failed to ensure patients received care in a safe setting. This was evidenced by the hospital's failure to ensure:

I) the staff monitored patients to ensure that sexual contact was not allowed for 12 of 18 patients (#'s 2, 6-11, 14-18) hospitalized on the Adult Psychiatric Unit, the Adolescent Unit, and the Youth Enhanced Unit, and

II) adequate staff were present on the Adult Psychiatric Unit on 2/17/14 to ensure that physician ordered Constant Visual Observations were implemented for patients #12, #13, and two random patients. Findings:

I) Review of the Quality Assurance Reports of incidents from November 2013 to February 14th, 2014 revealed:

A) 12/25/13 an allegation of sexual misconduct occurred between patients #16 (female) and #17 (male); reported on 12/26/13.

B) 01/25/14 an allegation of sexual misconduct between patients #15 (male) and #9 (male); reported on 01/27/14.

C) 01/26/14 an allegation of sexual misconduct between patients #2 (male) and #7 (male); reported on 01/29/14.

D) 02/03/14 an allegation of sexual misconduct between patients #18 and #10; reported on 02/03/14.

E) 12/04/13 an allegation of sexual misconduct between patients #6 (male) and #8 (male); reported on 12/05/13.

F) 11/28/13 an allegation of sexual misconduct between patients #14 (female) and #11 (female); reported on 11/29/13.


A) Review of patient #16's medical record (female patient) revealed the patient was admitted, 12/21/13, with the diagnoses of Mood Disorder, Obsessive-Compulsive Disorder, Autism, and Rule Out Bipolar Disorder.

Review of patient #17's medical record (male patient) revealed the patient was admitted to the hospital on 12/02/13 for Suicidal and Homicidal Ideations, and auditory and visual hallucinations and diagnosed with Bipolar Disorder.

Further review of patient #16's (female patient) medical record revealed that the patient reported on 12/26/13, at 9:30 a.m., "something happened last night at shower time. I went into shower and I guess someone came in and had sex with me." At 9:40 a.m., the patient recanted her statement after staff told her they would review the video tape.

Review of patient #17's (male patient) medical record revealed according to the Nursing Progress Notes dated 12/25/13, timed 12:00 p.m., revealed "(patient #17) has spastic uncontrolled movements. Intrusive behavior, makes sexually inappropriate comments. Poor impulse control, needs frequent redirection...". According to the incident report, patient #17 was observed on video tape to enter patient #16's room and stay for approximately 30 minutes. Interview with S2 RM/QA Director on 2/14/14, at 9:05 a.m., revealed when the video tape of this incident was reviewed during the 3:00 p.m. to 11:00 p.m. shift, it did show patient #17 go into patient #16's room and stayed for approximately 30 minutes. S2 RM/QA Director further stated she interviewed patient #17 regarding the sexual encounter and the patient admitted to her that he did have sex with patient #16.

Review of the 15 minute observation Rounds Sheet for patient #17 on 12/25/13, for the 3:00 p.m. to 11:00 p.m. shift, revealed from 2:15 p.m. to 3:00 p.m. S26 Licensed Practical Nurse (LPN) documented the patient was in his room lying down and from 3:15 p.m. to 10:00 p.m., S26 LPN documented the patient was in the day room Even though the RN documented patient #17 was making inappropriate sexual comments during the day of 12/25/13 there failed to be documented evidence that the staff protected patient #16 from the sexual advances of patient #17 by allowing this patient access to patient #16's room.

There was no further documentation of a follow-up investigation regarding the incident between patient #16 and patient #17 until the video tape was actually reviewed in January 2014. According to a plan of correction submitted by S2 RM/QA Director it was revealed S1 RN/DON, S2 RM/QA Director, Nurse Manager for Youth Services, and the Weekend Nursing Supervisor met on 1/10/14 to review the findings of the sexual encounter between patient #16 and patient #17. It was at this time that a plan of correction was developed. According to their findings, it was found the nursing staff on the Adult Psychiatric Unit did not follow policy and procedure related to observations of the patients on the unit. There failed to be further documentation the incident between patients #16 and #17 was investigated at the time of occurrence.


B) Review of patient #9's medical record revealed: 9 year old male admitted 01/22/14, at 3:00 a.m., under a Physician Emergency Certificate (PEC) and Coroner's Emergency Certificate (CEC), and discharged 02/17/14. Patient #9 was admitted with the diagnoses of Bipolar Mood Disorder, Type I, Mixed, Severe with Psychosis; Impulse Control Disorder, NOS; ADHD; Oppositional Defiant Disorder; Relational Problems, NOS; and Rule Out Posttraumatic Stress Disorder. Patient #9 has a history of multiple inpatient psychiatric admissions--last admit was 12/20/13. History of being "bullied" by peers at school. Initial Nursing Assessments revealed history of Suicidal Ideation, Homicidal Ideation, Self Mutilation, Depression, auditory hallucinations, and sexual abuse.

Review of Seclusion/Restraint Orders revealed Patient #9 required:
01/29/14 Seclusion;
02/01/14 physical hold;
02/02/14 physical hold and seclusion;
02/03/14 Seclusion;
02/04/14 physical hold and Seclusion;
02/09/14 physical hold and Seclusion;
02/10/14 mechanical restraint;
02/12/14 physical hold;
02/13/14 physical hold;
02/16/14 physical hold and seclusion for hitting, spitting, trying to bite staff and peers, scratching himself, cursing at peers and staff.

Review of Nursing Progress Notes, 01/26/14 6:04pm, revealed S23 RN documented, "(patient #9's) mother spoke with me via phone, states '(patient #9) told me [a peer's name] (identified as patient #15) touched his private parts, and he wouldn't make something like that up' Ensured mother they are no longer roommates, that was changed today due to an incident during the first shift (7a-3p) when (patient #9) was angry and agitated at the same peer..." Patient #9 was placed on 1:1 observation 01/26/14 at 9:00 p.m. per physician's order.

Review of Physician's Orders, dated 01/23/14 2:50 pm, revealed S10 Psychiatrist documented "Transfer to CEU (Children's Enhanced Unit)...". Continued review of Physician's Orders revealed, on 01/26/14 9:33 p. m., S24 RN documented (a telephone order from S11 Psychiatrist) "Place on 1:1, Place on SAP precautions (sexually acting out)...also recommends enough staff to watch patients, 6 ft peer restriction from (patient #15)"

Review of the medical record for patient #15 revealed the patient was admitted to the hospital on 1/20/14 for homicidal ideation and violent behavior and diagnosed with Mood Disorder and Impulse Control Disorder. According to the admission orders from S11 psychiatrist, the precautions were: Elopement, Behavioral, Suicidal, Violence/Assaultive, and Sexual: Victim. Review of the Nursing Progress Notes dated 1/26/14, at 7:00 p.m., S23 RN documented "(Patient #15) is irritable, escalates quickly, but responds to redirection if he is given 1:1 attention regarding incident leading up to outburst. Defiant at first, but once engaged, calms down quickly." 7:30 p.m. "(Patient #15) replied when asked about incident, 'He asked me to do it and I did." Review of the physician orders revealed on 1/26/14 at 9:33 p.m., a telephone order from S11 Psychiatrist was obtained and revealed "Place on SAP precautions (sexually acting out).. 6 ft. peer restriction from (patient #9)". Even though S11 Psychiatrist ordered sexual precautions, there was no documented evidence that a safe environment was provided for patient #15 to ensure there were no sexual encounters.
There failed to be further evidence that this incident was investigated and reported other than the initial documentation of the incident.


C) Review of patient #2's medical record revealed: 13 year old male admitted, 01/21/14, under a PEC (Physician Emergency Certificate) for "explosive behavior ...threatening to kick his brother and tear down the house, being mean to family dog" . Patient #2 was discharged 01/31/14 with appointments for outpatient psychiatric follow up.

Review of Patient #2's Psychiatric Evaluation, dated 01/22/14, revealed S8 Psychiatrist documented: " ...LEGAL DIFFICULTIES: The patient has multiple arrests for aggression toward others ...MENTAL STATUS EXAM: ...Thought content is positive for harmful behavior toward others ... denied suicidal ideation ... DIAGNOSTIC IMPRESSIONS: Axis I: Bipolar Disorder, Type I, Mixed, Severe; Axis II: Deferred; Axis III: Noonan syndrome; Axis IV: Psychological Stressors - Extreme..."

Review of a Family Session form, dated 01/30/14, revealed S8 LMSW (Licensed Masters Social Worker), documented in the summary note, " ...has a hx (history) of fire setting and cruelty to animals. GM (grandmother) reports pt (patient) burned the school library and was kicked out of school ...has been diagnosed (with) Explosive Behavior Disorders, ADHD, and Mild MR (mental retardation) ...reports a hx of sexual abuse by older half brother ... "

Review of Physician admission orders, dated 01/21/14, revealed S17 RN documented the following verbal orders: " ...Precautions: Elopement, Suicidal, and Violence/Assaultive... "

Review of Patient #7's medical record revealed: 16 year old male admitted, 01/23/14, with diagnoses of Medication Non-compliance and Mood Instability. Patient #7 was discharged on 01/28/14 into the custody of the local police for an existing arrest warrant for assault with a dangerous weapon.

Review of the information obtained during admission, 01/23/14, revealed S20 Counselor documented S25 Psychiatrist was notified of the following: " Risk Factors Noted " : Elopement; Sexually Acting Out - Victim; and Behavior Precautions. The date and time was documented by S20 Counselor as 01/23/14 at 2:00pm.

Review of Physician's Orders, dated 01/23/14, revealed RN S24 documented the following telephone orders, Admit to Adolescent Unit, Precautions: Behavioral, Elopement, Sexually Acting Out.

Review of a report to the Child Protective Service (CPS), dated 01/31/14, revealed S18 RN documented, (page 2), " (name Patient #2) came to me and stated ' my roommate made me touch and suck his penis ' . " S18 RN documented, " on 1-28-14 @ around 6:30pm, (name Patient #2) came to me as Charge Nurse and stated, ' I have something to tell you ' . "

Review of a form titled "Rounds Sheet" revealed from 01/21/14 through 01/31/14 there failed to be documented evidence of any type of incident. Review of a form titled "Interdisciplinary Notes" , dated 1/27/14 at 9:30pm, revealed S12 RN Manager Youth Services documented Patient #2 required restraining and was placed in "time out" for banging on the walls of his room and disrupting the unit with his yelling.

Reviews of the "Rounds Sheets" for Patients #2 and #7 revealed on the alleged night, 01/26/14, the MHT (Mental Health Technician) documented both patients were in the "patient room" "lying down." (Note: Patient #2 and #7 had been assigned to the same patient room).

Review of video evidence, performed by S2 QA Director/Risk Manager, revealed on the night of the allegation (01/26/14), the MHT assigned to observe Patients #2 and #7 was himself observed sitting at a table in the dayroom of the Youth Enhanced Unit (YEU) and did not get up and physically look into the patients' room even though he documented on the Rounds Sheets (these were observation forms utilized by the hospital), that Patient #2 and #7 's location was "patient room" and activity was recorded as "lying down" . The hospital staff failed to ensure these 2 patients were kept safe and not victimized sexually as per Patient #2's allegation.


D) Review of the medical record for patient #18 revealed this 11 year old patient was admitted to the hospital on 1/22/14, with the diagnoses of AXIS I: Bipolar Disorder, Impulse Control Disorder and AXIS II: Mental Retardation, Mild. According to the physician admission orders, precautions were to include: Sexual: victim. Review of the Interdisciplinary Notes dated 2/2/14, and timed at 9:55 a.m., revealed the RN documented "Patient #18 comes walking out of his room behind his roommate directed to day room. (patient #18) stopped in hall and nurse asked 'What happened?' (patient #18) states, 'He asked me if I wanted to have sex, and I said NO.' Staff prompted (patient #18) to continue telling story by asking 'Then what,' (patient #18) replied 'He sucked my penis.' Roommate denies this allegation."

Review of Patient #10's medical record revealed an 8 year old male admitted, 01/20/14, with diagnoses of Homicidal Ideation, Mood Disorder, Impulse Control Disorder, history of severe, violent behavior towards others. Parents state Patient #10 was destroying property, cursing at his parents and uncontrollable; increasingly worse over last week and refuses to take his medications. Review of Interdisciplinary Notes, dated 02/02/14, 8:00pm, S24 RN documented, "...observed pt laying on floor, fully covered in blanket and hiding his head under his pillow. Staff asked, 'what happened?' He scooted in opposite direction, away from staff. Advised he would not be in trouble, but encouraged to behave, he said, 'ok. I asked him if he wanted to do sex. He said No, No, No.' Pt denies any further contact..."

There was no documented evidence that the hospital investigated this incident other than what nurse's documented in the patients' medical records.


E) Review of patient #6's medical record revealed an admission date of 01/21/14, with diagnoses of Homicidal Ideation and Depressive Mood. Review of patient #8's medical records revealed an admission date of 01/23/14, under a Formal Voluntary Admission. Diagnoses documented were Medication Non-compliance and Depression.

Review of an incident report revealed patient #6 reported to a staff member that patient #8 "was lying on top of me while I was in bed, I told her to get off". Continued review of the incident report revealed patient #8 had gotten off of patient #6, went over to her own bed, then came back over to patient #6's bed and sat on the edge; then got off patient #6's bed and left the room.

Review of the Rounds Sheets and Nursing Progress Notes revealed no documentation relative to staff actions in relation to patient complaints/concerns to ensure all patients were safe and not subject to unwanted touching/harassment/abuse.

There was no evidence of further investigation to ensure Patient #8 did not repeat these behaviors with other patients.


F) Review of the medical record for patient #14 revealed according to the Interdisciplinary Notes dated 11/28/13, at 5:45 a.m., the Registered Nurse (RN) documented "Upon routine nursing rounds, (patient #14) was found in a male peers room 170 bed A, lying in bed with male peer in left lateral recumbent position. (Patient #14) was fully dressed but pressed against male peer. Staff called her name and escorted her to nurses station where she began apologizing profusely stating 'I just wanted to tell him good morning and my feet were on the floor'...". Review of the rounds sheet dated 11/28/13, revealed the same RN documented at 5:45 a.m. that patient (patient #14) was in her room lying down.

Review of the medical record for patient #11 revealed the following documentation on the Interdisciplinary Notes dated 11/28/13, 5:45 p.m., "Upon routine nursing rounds a female peer was found in (patient #11)'s bed in room 170-A. (Patient #11) was asleep in bed, lateral recumbent position, and appeared to be unaware of patient's presence when startled. When brought down to nurses station, (patient #11) stated 'I was sleeping and I didn't know she was there. I did not ask her to come in my room, she knows the rules...'". Review of the Rounds Sheet dated 11/28/13 revealed at 5:45 a.m., the RN documented patient #11 was asleep in his room.

There was no documented evidence that this incident was investigated and identified the discrepancy between the RN's documentation on the Interdisciplinary Notes and the Rounds Sheet and the staff's failure to ensure female/males patients were not allowed in each others rooms during the 11:00 p.m. to 7:00 a.m. shift.


II) Observations made on the Adult Psychiatric Unit (ADU) on 2/17/14, at 1:20 p.m., revealed according to the eraser board located in the nursing station, there was a total of 15 patients on the unit.

One patient (#13) was listed as a 1:1 (one staff member/one patient) and three patients were identified as CVO (Constant Visual Observation) (patient #10 and two random patients).

Two staff members were on the unit, one RN and one LPN. At the time of observations, the 1:1 patient (#13) was sitting at a table in the day room. The RN was sitting in a chair at the day room door approximately 8 feet away from the patient. Interview with S14 RN during the observations revealed when asked if patient #1 was a 1:1, S14 RN replied "let me look at my sheet". S14 RN then stated "yes, she is 1:1". When asked what 1:1 level meant, S14 RN indicated the patient was to be within arms length. Review of patient #13's medical record revealed the 1:1 had been discontinued on 2/17/14 at 10:37 a.m.; however, S14 RN was unaware that the order had been changed almost three hours earlier. When asked about the staff members on the unit, S14 RN stated that the unit also had a Mental Health Technician; however, this MHT was on break. When asked about the patients who were on Constant Visual Observation, S14 RN stated two of these patients, one of whom had received an injection, were in their rooms lying down and the third patient was in the day room attending group therapy with the counselor.

Observations made, 02/19/14, at 11:00am, on the Adolescent Unit (ADO) revealed according to the census board at the nurses station there were 21 females. Further review of the census board revealed 5 females, out of the 21, were identified as Constant Visual Observation (CVO). There were 2 staff members on the female hall of the ADO. The RN was conducting an assessment on a patient and the MHT (Mental Health Technician) had a patient in a room conducting a search.

The nurse staffing level on 2/17/14, failed to ensure enough staff were available to provide Constant Visual Observations as ordered by the physician and to ensure all patients remained safe.

Review of a Nursing Staffing schedule, dated 01/26/14, revealed on the Adolescent Unit (ADOL), the staffing was 4 Registered Nurses (RN) and 2 Mental Health Technicians (MHT) for a census of 43 which met the staffing grid requirement. However, the hospital failed to ensure adequate numbers of nursing staff were present to ensure the safety of all patients as there were 2 patients on 1:1 (1:1 observation required one staff member with the patient, at arms length at all times). The hospital failed to adjust staffing to ensure staff members were added to provide the supervision of patients ordered to be on a 1:1 observation level.

Review of a Nursing Staffing schedule, dated 01/26/14, revealed on the Youth Enhanced Unit (YEU - Adolescent patients were transferred to this unit when they required a higher/more intensive observation/treatment), the staffing was 3 (no breakdown of RN-LPN-MHT) and census was 8 the staffing was appropriate for the census according to the staffing grid; however, there was one patient who was ordered on 1:1 observation, so an additional staff member should have been present. The hospital failed to adjust staffing to ensure staff members were added to provide the supervision of patients ordered to be on a 1:1 observation level.





22538

Based upon observations, review of medical records, policies and procedures, QA Incident Report data/reports, staffing schedules/grids, nursing supervisor reports and interviews the hospital failed to ensure all patientts were free of abuse and neglect. This was evidenced by the failure to ensure:

1) additional staff were present on the Adult Psychiatric Unit on 2/17/14 to provide physician ordered observation levels for 4 of 15 patients (#12, #13 and 2 random patients);

2) additional staff were present on the Adolescent Unit on 01/26/14 when there were 2 random patients (census 43) who were ordered 1:1 observations;

3) additional staff were present on the Youth Enhanced Unit on 1/26/14 for physician ordered observations levels (1:1; Close Visual Observation-CVO) for 2 of 8 patients (#2, #7), who were allowed to engage in alleged sexual misconduct;

4) failure to provide additional staff on 12/25/13 during the 3:00 p.m. to 11:00 p.m. shift when there were 6 patient admissions to the Adult Psychiatric Unit raising the staffing level from 2 staff members to 3. (During this shift, patient #16 (female) alleged a sexual encounter occurred where patient #17 (male) came into her room and had sex with her); and

5) all incidents of sexual misconduct were investigated and reported to the state agency (Health Standards Section) within 24 hours in accordance with the policy and procedure for 12 of 18 medical record reviews (Patient #s 2, 6-11, 14-18).

Findings:

Review of a hospital policy, titled "Safety Rounds/Accountability", #TX.064, revealed:

"I. POLICY: ...to provide a safe, secure environment..by ensuring accountability for their well-being.

II. PROCEDURE: Guidelines for monitoring...patients...follows: SAFETY ROUNDS PROCEDURE: The charge nurse assigns...patient observation rounds...

1. Every patient not on Constant Observation or one to one (1:1) precaution will be monitored at least every 15 minutes. All CO and 1:1 patients will be monitored constantly but documented every 15 minutes...

2...any point in time that the patient is not visible through video monitoring, staff will physically go and visualize the patient...

8. Visually observe patients when behind closed doors by: 8.1 Knocking on bedroom...door. 8.2 Announce...stepping into room for rounds. 8.3 Open the door and visually observe the safety of the patient...

10...If the patient is...therapist's office or is in with a physician, the staff will notate that the patient is in the meeting but must check on the patient every 15 minutes. The exception is any 1:1 or CVO (constant visual observation) patient that must be either within arm's reach at all times or within the line of vision at all times...ROOMS: ...2. When patients are in their rooms, a staff member...to be stationed in center of the hallways to monitor patients and prevent inappropriate patient contact...will station self in the hallways at all times. 3. Patient bedroom doors to stay open when patients are in their rooms, except when patients are taking showers, to allow for appropriate staff monitoring..."


Observations on 2/17/14, at 1:20 p.m., on the Adult Psychiatric Unit revealed according to the patient list, there were 15 adult female and male patients on the unit. Of these 15 patients, 1 was identified as being 1:1 (patient #13), and patient #12 and 2 random patients were identified as being on Close Visual Observation.

At the time of the observation, staff present on the Adult Unit were one Licensed Practical Nurse, who was in and out of the medication room, and one Registered Nurse who was sitting next to the door of the group therapy room. Patient #13, who was the 1:1 was sitting at a table in the middle of the group therapy room and S14 RN was approximately 8 feet away from the patient. Other than the Counselor conducting therapy, there were no other direct staff in the group therapy room.

Interview with S14 RN on 2/17/14, at 1:40 p.m., revealed when asked about the 1:1 ordered for patient #13, S14 RN stated "let me look at my sheet" then stated "yes patient #13 is a 1:1" When asked what 1:1 observation meant, S14 RN motioned and replied "at arms length".

Review of patient #13's medical record revealed on 2/17/14, the psychiatrist wrote an order dated 2/17/14 and timed 10:37 a.m. for the 1:1 observation to be discontinued; however, S14 RN failed to be aware that her patient's 1:1 observation level had been discontinued.

Further observations on 2/17/14 revealed patient #12, on Close Visual Observations (CVO) was in her room lying down. The 2 random patients who were on CVO were also in their rooms lying down. Further interview with S14 RN during the observation revealed the staff assigned to the Adult Psychiatric Unit was an RN, an LPN, and a Mental Health Technician (MHT); however, the MHT was off the unit on break which left only the RN and LPN to monitor 15 patients.

Review of the staffing ratio grid requirements revealed for 15 patients there were to be 3 staff members present on the Adult Psychiatric Unit; however the hospital failed to provide additional staff to provide the 1:1 observation (1:1 observation required one staff member with the patient, at arms length at all times) for patient #13 on 2/17/14 prior to the order being discontinued at 10:37 a.m. and the Constant Visual Observations for patient #12 and 2 random patients. At 1:30 p.m., the nursing staff failed to call for additional staff when the MHT went on break, leaving only two staff members on the unit to monitor 15 patients.


2) Review of a census and staffing form, dated 01/26/14, revealed there were 43 patients on the Adolescent Unit. According to the nursing staffing schedule there were 4 Registered Nurses (RNs) and 2 Mental Health Technicians (MHTs) assigned the Adolescent Unit. Review of the staffing grid indicated this was the required number of staff (6 total) for the census (43). However, the staffing grid did not take into consideration the need for additional staff when the acuity was increased (i.e. 1:1 observation ordered on 2 patients, which indicated the need for 2 additional staff members in order to ensure patient and staff safety).


3) Review of patient #2's medical record revealed: 13 year old male admitted, 01/21/14, under a PEC (Physician Emergency Certificate) for "explosive behavior ...threatening to kick his brother and tear down the house, being mean to family dog" . Patient #2 was discharged 01/31/14 with appointments for outpatient psychiatric follow up.

Review of Patient #2's Psychiatric Evaluation, dated 01/22/14, revealed S8 Psychiatrist documented: " ...LEGAL DIFFICULTIES: The patient has multiple arrests for aggression toward others ...MENTAL STATUS EXAM: ...Thought content is positive for harmful behavior toward others ... denied suicidal ideation ... DIAGNOSTIC IMPRESSIONS: Axis I: Bipolar Disorder, Type I, Mixed, Severe; Axis II: Deferred; Axis III: Noonan syndrome; Axis IV: Psychological Stressors - Extreme..."

Review of a Family Session form, dated 01/30/14, revealed S8 LMSW (Licensed Masters Social Worker), documented in the summary note, " ...has a hx (history) of fire setting and cruelty to animals. GM (grandmother) reports pt (patient) burned the school library and was kicked out of school ...has been diagnosed (with) Explosive Behavior Disorders, ADHD, and Mild MR (mental retardation) ...reports a hx of sexual abuse by older half brother ... "

Review of Physician admission orders, dated 01/21/14, revealed S17 RN documented the following verbal orders: " ...Precautions: Elopement, Suicidal, and Violence/Assaultive... "

Review of Patient #7's medical record revealed: 16 year old male admitted, 01/23/14, with diagnoses of Medication Non-compliance and Mood Instability. Patient #7 was discharged on 01/28/14 into the custody of the local police for an existing arrest warrant for assault with a dangerous weapon.

Review of the information obtained during admission, 01/23/14, revealed S20 Counselor documented S25 Psychiatrist was notified of the following: "Risk Factors Noted" : Elopement; Sexually Acting Out - Victim; and Behavior Precautions. The date and time was documented by S20 Counselor as 01/23/14 at 2:00pm.

Review of Physician's Orders, dated 01/23/14, revealed RN S24 documented the following telephone orders, Admit to Adolescent Unit, Precautions: Behavioral, Elopement, Sexually Acting Out.

Review of a report to the Child Protective Service (CPS), dated 01/31/14, revealed S18 RN documented, (page 2), "(name Patient #2) came to me and stated 'my roommate made me touch and suck his penis' . " S18 RN documented, "on 1-28-14 @ around 6:30pm, (name Patient #2) came to me as Charge Nurse and stated, 'I have something to tell you'."

Review of a form titled "Rounds Sheet" revealed from 01/21/14 through 01/31/14, there was no documented evidence of any type of incident. Review of a form titled "Interdisciplinary Notes," dated 1/27/14, at 9:30pm, revealed S12 RN Manager Youth Services documented Patient #2 required restraining and was placed in "time out" for banging on the walls of his room and disrupting the unit with his yelling.

Reviews of the "Rounds Sheets" for Patients #2 and #7 revealed on the alleged night, 01/26/14, the MHT (Mental Health Technician) documented both patients were in the "patient room" "lying down." (Note: Patient #2 and #7 had been assigned to the same patient room).

Review of video evidence, performed by S2 QA Director/Risk Manager, revealed on the night of the allegation (01/26/14), the MHT assigned to observe Patients #2 and #7 was himself observed sitting at a table in the dayroom of the Youth Enhanced Unit (YEU) and did not get up and physically look into the patients' room even though he documented on the Rounds Sheets (these were observation forms utilized by the hospital), that Patient #2 and #7's location was "patient room" and activity was recorded as "lying down" . The hospital staff failed to ensure these 2 patients were kept safe and not victimized sexually as per Patient #2's allegation.

Review of a Nursing Staffing schedule, dated 01/26/14, revealed on the Adolescent Unit (ADOL), the staffing was 4 Registered Nurses (RN) and 2 Mental Health Technicians (MHT) for a census of 43 which met the staffing grid requirement; however, there number of nursing staff present was not adequate to ensure the safety of all patients as there were 2 patients on 1:1 (1:1 observation required one staff member with the patient, at arms length at all times), there should have been additional staff members present to care for the 2 patients on 1:1 observation.

Review of a Nursing Staffing schedule, dated 01/26/14, revealed on the Youth Enhanced Unit (YEU--Adolescent patients were transferred to this unit when they required a higher/more intensive observation/treatment), the staffing was 3 (no breakdown of RN-LPN-MHT) and census was 8. The staffing was appropriate for the census according to the staffing grid. However, there was one patient who was ordered on 1:1 observation, so an additional staff member should have been present.

Interviews, 02/19/14, at 11:15 a.m., with S1 Director of Nursing revealed when asked if there had been adequate nursing staff present, she replied the staffing was based on the staffing grid. Unfortunately, the hospital failed to provide additional staff members on the ADOL and YEU for 01/26/14 for monitoring of patients who were ordered 1:1.

There number of staff present was not adequate to ensure the safety of all patients as evidenced by the alleged sexual misconduct that was allowed to occur between patients #2 and #7 when they were patients on the YEU.


4) Review of the Quality Assurance/Performance Improvement data revealed on 12/26/13, an allegation of a sexual incident had been reported between female patient #16 and male patient #17.

Review of the medical record for patient #16 revealed on 12/26/13 the patient reported to the nurse that during the 3:00 p.m. to 11:00 p.m. shift of 12/25/13, a male patient (#17) had come into her room and had sex with her while she was in the shower.

Review of the nurse staffing form dated, 12/25/13, it was revealed at the beginning of the 7:00 a.m. to 3:00 p.m. and the 3:00 p.m. to 11:00 p.m. (when patient #16 identified the sexual encounter occurred) shifts it was identified there were 7 patient on the Adult Psychiatric Unit. At the beginning of the 11:00 p.m. to 7:00 a.m. shift, it was identified there were 13 patients on the Adult Psychiatric Unit, which meant during the 3:00 p.m. to 11:00 p.m. shift there were 6 patient admissions. According to the staffing form, during the 3:00 p.m to 11:00 p.m. shift, there was one LPN and one RN. According to the staffing grid requirements, when the patient level was at 13, an additional staff member should have been added in order to provide enough staff to monitor the patients.

There was no further documentation of a follow-up investigation regarding the incident between patient #16 and patient #17 until the video tape was actually reviewed in January 2014. According to a plan of correction submitted by S2 RM/QA it was revealed S1 RN/DON, S2 RM/QA, Nurse Manager for Youth Services, and the Weekend Nursing Supervisor met on 1/10/14, to review the findings of the sexual encounter between patient #6 and patient #17. It was at this time that a plan of correction was developed. According to their findings, it was found that the nursing staff on the Adult Psychiatric Unit did not follow policy and procedure related to observations of the patients on the unit. There was no further documentation that the incident between patients #16 and #17 was investigated when it was reported by patient #16.


5) Review of incident reports related to sexual misconduct between patients reviewed through the QA/PI Program revealed the following:

A) 02/03/14--allegation of sexual misconduct between patients #18 and #10; reported on 02/03/14.

Review of the medical record for patient #18 revealed this 11 year old patient was admitted to the hospital on 1/22/14 with the diagnoses of AXIS I: Bipolar Disorder, Impulse Control Disorder and AXIS II: Mental Retardation, Mild. According to the physician admission orders, precautions were to include: Sexual: victim. Review of the Interdisciplinary Notes dated 2/2/14 and timed at 9:55 a.m. revealed the RN documented "Patient #18 comes walking out of his room behind his roommate directed to day room. (Patient #18) stopped in hall and nurse asked 'What happened?' (Patient #18) states, 'He asked me if I wanted to have sex, and I said NO.' Staff prompted (patient #18) to continue telling story by asking 'Then what,' (patient #18) replied 'He sucked my penis.' Roommate denies this allegation."

Review of Patient #10's medical record revealed an 8 year old male admitted, 01/20/14, with diagnoses of Homicidal Ideation, Mood Disorder, Impulse Control Disorder, history of severe, violent behavior towards others. Parents state Patient #10 was destroying property, cursing at his parents and uncontrollable; increasingly worse over last week and refuses to take his medications. Review of Interdisciplinary Notes, dated 02/02/14, 8:00pm, S24 RN documented, "...observed pt laying on floor, fully covered in blanket and hiding his head under his pillow. Staff asked, 'what happened?' He scooted in opposite direction, away from staff. Advised he would not be in trouble, but encouraged to behave, he said, 'ok. I asked him if he wanted to do sex. He said No, No, No.' Pt denies any further contact..."


B) 12/04/13--allegation of sexual misconduct between patients #6 and #8; reported on 12/05/13;

Review of patient #6's medical record revealed an admission date of 01/21/14, with diagnoses of Homicidal Ideation and Depressive Mood.

Review of patient #8's medical records revealed an admission date of 01/23/14, under a Formal Voluntary Admission. Diagnoses documented were Medication Non-compliance and Depression.

Review of an incident report revealed patient #6 reported to a staff member that patient #8 "was lying on top of me while I was in bed, I told her to get off". Continued review of the incident report revealed patient #8 had gotten off of patient #6, went over to her own bed, then came back over to patient #6's bed and sat on the edge; then got off patient #6's bed and left the room.

Review of the Rounds Sheets and Nursing Progress Notes revealed there was no documentation relative to staff actions in relation to patient complaints/concerns to ensure all patients were safe and not subject to unwanted touching/harassment/abuse.

There was no evidence of a further investigation to ensure Patient #8 did not repeat these behaviors with other patients.


C) 01/25/14 an allegation of sexual misconduct between patients #9 and #15 and was reported on 01/27/14.

Review of patient #9's medical record revealed: 9 year old male admitted 01/22/14 at 3:00am, under a Physician Emergency Certificate (PEC) and Coroner's Emergency Certificate (CEC), and discharged 02/17/14.

Patient #9 was admitted with the diagnoses of Bipolar Mood Disorder, Type I, Mixed, Severe with Psychosis; Impulse Control Disorder, NOS; ADHD; Oppositional Defiant Disorder; Relational Problems, NOS; and Rule Out Posttraumatic Stress Disorder.

Patient #9 has a history of multiple inpatient psychiatric admissions--last admit was 12/20/13. History of being "bullied" by peers at school. Initial Nursing Assessments revealed history of Suicidal Ideation, Homicidal Ideation, Self Mutilation, Depression, auditory hallucinations, and sexual abuse.

Review of Seclusion/Restraint Orders revealed Patient #9 required:
01/29/14 Seclusion;
02/01/14 physical hold;
02/02/14 physical hold and seclusion;
02/03/14 Seclusion;
02/04/14 physical hold and Seclusion;
02/09/14 physical hold and Seclusion;
02/10/14 mechanical restraint;
02/12/14 physical hold;
02/13/14 physical hold;
02/16/14 physical hold and seclusion for hitting, spitting, trying to bite staff and peers, scratching himself, cursing at peers and staff.

Review of Nursing Progress Notes, 01/26/14, 6:04 pm, revealed S23 RN documented, "(patient #9's) mother spoke with me via phone, states '(patient #9) told me [a peer's name] (identified as patient #15) touched his private parts, and he wouldn't make something like that up' Ensured mother they are no longer roommates, that was changed today due to an incident first shift (7a-3p) when (patient #9) was angry and agitated at the same peer..." Patient #9 was placed on 1:1 observation 01/26/14 at 9:00 p.m. per physician's order.

Review of Physician's Orders, dated 01/23/14 2:50pm, revealed S10 Psychiatrist documented "Transfer to CEU (Children's Enhanced Unit)...". Continued review of Physician's Orders revealed, on 01/26/14 9:33 p. m., S24 RN documented (a telephone order from S11 Psychiatrist) "Place on 1:1, Place on SAP precautions (sexually acting out)...also recommends enough staff to watch patients, 6 ft peer restriction from (patient #15)"

Review of the medical record for patient #15 revealed the patient was admitted to the hospital on 1/20/14 for homicidal ideation and violent behavior and diagnosed with Mood Disorder and Impulse Control Disorder. According to the admission orders from S11 psychiatrist, the precautions were: Elopement, Behavioral, Suicidal, Violence/Assaultive, and Sexual: Victim.

Review of the Nursing Progress Notes dated 1/26/14, at 7:00 p.m., S23 RN documented "(Patient #15) is irritable, escalates quickly, but responds to redirection if he is given 1:1 attention regarding incident leading up to outburst. Defiant at first, but once engaged, calms down quickly." 7:30 p.m. "(Patient #15) replied when asked about incident, 'He asked me to do it and I did."

Review of the physician orders revealed on 1/26/14, at 9:33 p.m., a telephone order from S11 Psychiatrist was obtained and revealed "Place on SAP precautions (sexually acting out).. 6 ft. peer restriction from (patient #9)". Even though S11 Psychiatrist ordered sexual precautions, there was no documented evidence that a safe environment was provided for patient #15 to ensure there were no sexual encounters.

There was no further evidence this incident had been investigated and reported other than the initial documentation of the incident.

There was no documented evidence the hospital investigated this incident other than what nurse's documented in the patients' medical records.


D) 11/28/13--allegation of sexual misconduct between patients #14 and #11, reported on 11/29/13.

Review of the medical record for patient #14 revealed according to the Interdisciplinary Notes dated 11/28/13, at 5:45 a.m., the Registered Nurse (RN) documented "Upon routine nursing rounds, (patient #14) was found in a male peers room 170 bed A, lying in bed with male peer in left lateral recumbent position. (Patient #14) was fully dressed but pressed against male peer. Staff called her name and escorted her to nurses station where she began apologizing profusely stating 'I just wanted to tell him good morning and my feet were on the floor'...".

Review of the rounds sheet dated 11/28/13, revealed the same RN documented at 5:45 a.m. the patient (patient #14) was in her room lying down. Review of the medical record for patient #11 revealed the following documentation on the Interdisciplinary Notes dated 11/28/13, 5:45 p.m. "Upon routine nursing rounds a female peer was found in (patient #11)'s bed in room 170-A. (Patient #11) was asleep in bed lateral recumbent position and appeared to be unaware of patient's presence when startled. When brought down to nurses station, (patient #11) stated 'I was sleeping and I didn't know she was there. I did not ask her to come in my room, she knows the rules...'". Review of the Rounds Sheet dated 11/28/13 revealed at 5:45 a.m., the RN documented patient #11 was asleep in his room.

Interview, 02/19/14, at 9:30am, with S2 RM/QA Director revealed when asked if the above incidents of sexual misconduct were investigated, she replied, "not all of them". When questioned why they were not all investigated, S2 RM/QA Director replied she really did not have an answer. Continued interview with S2 RM/QA Director revealed the incident of sexual misconduct between Patient #s 16 and 17, had been investigated and was reported to the State Agency; however, the investigation was not conducted when it was discovered and reported on 12/26/13 and was not reported to the State Agency within the required 24 hours of discovery.

Review of the incident between patient #2 and patient #7 revealed the incident occurred on 1/26/13; however, the incident was not reported to the state agency until 2/3/14. The sexual incidents for patients identified as A, B, C, and D were not reported.

The surveyors discovered the telephone number identified in the Grievance Policy was incorrect. The telephone number listed for reporting allegations of abuse/neglect to the state agency (Health Standards Section) was for a Bahamas vacation.

Based upon review of medical records, policies/procedures, QA Incident Report data, reports, staffing schedules/grids and interviews, the hospital failed to meet the Condition of Participation for Nursing Services as evidenced by the failure of the Director of Nursing to ensure:

I.) there were enough staff members present on the units to provide patients with nursing care/monitoring based on their various acuities as evidenced by:

1) Failure to adequately staff the Adult Psychiatric Unit on 2/17/14 to ensure 4 of 15 patients were provided monitoring in accordance with the physician orders (#12, #13, and 2 random patients);

2) Failure to adequately staff the Youth Enhanced Unit for 2 of 8 patients (#2, #7) who were allowed to engage in sexual misconduct when #7 was ordered on 1:1 observation; and

3) Failure to obtain additional staff on the Adolescent Psychiatric Unit, 1/26/14, for 2 random patients who had physician orders for 1:1 observation. (A0392); and


II.) The RNs performed on-going evaluations of nursing care for 12 of 18 patients (Patient #s 2, 6-11, 14-18) who had physician orders for specific precautions (i.e. Suicide, Behavioral, Assault, Sexual Acting Out, Elopement, etc.), who were allowed to engage in alleged sexual misconduct. See Tag A395.

Based upon observations, review of nurse staffing schedules, the hospital's staffing grid, medical records, and interviews, the hospital failed to ensure there were enough staff members present on the units to provide patients with nursing care/monitoring based on their various acuities, as evidenced by:

1) Failure to adequately staff the Adult Psychiatric Unit on 2/17/14 to ensure 4 of 15 patients were provided monitoring in accordance with the physician orders (#12, #13, and 2 random patients);

2) Failure to adequately staff the Youth Enhanced Unit for 2 of 8 patients (#2, #7) who were allowed to engage in sexual misconduct when #7 was ordered on 1:1 observation; and

3) Failure to obtain additional staff on the Adolescent Psychiatric Unit, 1/26/14, for 2 random patients who had physician orders for 1:1 observation.

Findings:

1) Observations on 2/17/14, at 1:20 p.m., on the Adult Psychiatric Unit revealed according to the patient list, there were 15 adult female and male patients on the unit. Of these 15 patients, 1 was identified as being 1:1 (patient #13), and patient #12 and 2 random patients were identified as being on Close Visual Observation.

At the time of the observation, staff present on the Adult Unit were one Licensed Practical Nurse, who was in and out of the medication room, and one Registered Nurse who was sitting next to the door of the group therapy room. Patient #13, who was the 1:1 was sitting at a table in the middle of the group therapy room and S14 RN was approximately 8 feet away from the patient. Other than the Counselor conducting therapy, there were no other direct staff in the group therapy room.

Interview with S14 RN on 2/17/14, at 1:40 p.m., revealed when asked about the 1:1 ordered for patient #13, S14 RN stated "let me look at my sheet" then stated "yes patient #13 is a 1:1" When asked what 1:1 observation meant, S14 RN motioned and replied "at arms length".

Review of patient #13's medical record revealed on 2/17/14, the psychiatrist wrote an order dated 2/17/14 and timed 10:37 a.m. for the 1:1 observation to be discontinued; however, S14 RN failed to be aware that her patient's 1:1 observation level had been discontinued.

Further observations on 2/17/14, revealed patient #12, on Close Visual Observations (CVO) was in her room lying down. The 2 random patients who were on CVO were also in their rooms lying down.

Further interview with S14 RN during the observation revealed that the staff assigned to the Adult Psychiatric Unit was an RN, an LPN, and a Mental Health Technician (MHT); however, the MHT was off the unit on break which left only the RN and LPN to monitor 15 patients.

Review of the staffing ratio grid requirements revealed for 15 patients there were to be 3 staff members present on the Adult Psychiatric Unit. However, the hospital failed to provide additional staff to provide the 1:1 observation (1:1 observation required one staff member with the patient, at arms length at all times) for patient #13 on 2/17/14 prior to the order being discontinued at 10:37 a.m. and the Constant Visual Observations for patient #12 and 2 random patients. At 1:30 p.m., the nursing staff failed to call for additional staff when the MHT when on break, leaving only two staff members on the unit to monitor 15 patients.



2) Review of the hospital's nurse staffing schedule, dated 01/26/14, revealed the following: Youth Enhanced Unit (YEU--Adolescent patients were transferred to this unit when they required a higher/more intensive observation/treatment), the staffing was 3 (no breakdown of RN-LPN-MHT) and census was 8. The staffing was appropriate for the census according to the staffing grid. However, there was one patient (#7) who was physician ordered on 1:1 observation, so an additional staff member should have been present. (NOTE: Physician ordered 1:1 observation required one staff member with the patient at all times).


3) Review of the hospital's nurse staffing schedule, dated 01/26/14, revealed the following: Adolescent Unit (ADOL), the nurse staffing schedule reflected there were 4 Registered Nurses (RNs), and 2 Mental Health Technicians (MHTs) assigned on 01/26/14, with a census of 41. According to the nurse staffing grid, this was appropriate. However, the grid did not take into consideration the increased acuities (i.e. Close Visual Observation--CVO; 1:1 observation) of 2 random patients

Interview, 02/19/14, at 11:15am, with S1 Director of Nursing revealed when asked if there had been adequate nursing staff present to provide on-going nursing re-assessments and monitoring, she replied the staffing was based on the staffing grid.

Review of the hospital's staffing grid failed to account for increased acuity in patients, i.e. 1:1 observations, Close Visual Observations; although the Director of Nursing based nursing staff on the staffing grid, they failed to ensure patient acuity was also included in the determination of additional staff.

Based upon reviews of medical records, policies/procedures, QA Incident Report data, reports, staffing schedules/grids and interviews, the Director of Nursing failed to ensure RNs performed on-going evaluations of nursing care for each patient as evidenced by 12 of 18 patients (Patient #s 2, 6-11, 14-18) who had physician orders for specific precautions (i.e. Suicide, Behavioral, Assault, Sexual Acting Out, Elopement, etc.), who were allowed to engage in alleged sexual misconduct.

Findings:

Review of Patient #s 2, 6-11 and 14-18's medical records revealed their individual physician/psychiatrist had ordered specific precautions upon the patients' admission. Review of the Interdisciplinary Treatment Plans revealed none of the physician ordered precautions had been care planned. Further reviews of Patient #s 2, 6-11 and 14-18's medical records revealed that the RNs failed to reassess and address the issues of the patients' sexual misconduct in order to provide for each patients' individual needs, care and safety.

Review of a hospital policy, titled "Safety Rounds/Accountability", #TX.064, revealed:

"I. POLICY: ...to provide a safe, secure environment..by ensuring accountability for their well-being.

II. PROCEDURE: Guidelines for monitoring...patients...follows: SAFETY ROUNDS PROCEDURE: The charge nurse assigns...patient observation rounds...

1. Every patient not on Constant Observation or one to one (1:1) precaution will be monitored at least every 15 minutes. All CO and 1:1 patients will be monitored constantly but documented every 15 minutes...

2...any point in time that the patient is not visible through video monitoring, staff will physically go and visualize the patient...

8. Visually observe patients when behind closed doors by: 8.1 Knocking on bedroom...door. 8.2 Announce...stepping into room for rounds. 8.3 Open the door and visually observe the safety of the patient...

10...If the patient is...therapist's office or is in with a physician, the staff will notate that the patient is in the meeting but must check on the patient every 15 minutes. The exception is any 1:1 or CVO (constant visual observation) patient that must be either within arm's reach at all times or within the line of vision at all times...ROOMS: ...2. When patients are in their rooms, a staff member...to be stationed in center of the hallways to monitor patients and prevent inappropriate patient contact...will station self in the hallways at all times. 3. Patient bedroom doors to stay open when patients are in their rooms, except when patients are taking showers, to allow for appropriate staff monitoring..."

Review of incident reports revealed:

11/28/13--allegation of sexual misconduct between patients #14 and #11, reported on 11/29/13.

12/04/13--allegation of sexual misconduct between patients #6 and #8; reported on 12/05/13.

12/25/13 an allegation of sexual misconduct occurred between patients #16 and #17, and reported on 12/26/13.

01/25/14 an allegation of sexual misconduct between patients #15 and #9 and was reported on 01/27/14.

01/26/14--allegation of sexual misconduct between patients #2 and #7; reported on 01/29/14.

02/03/14--allegation of sexual misconduct between patients #18 and #10; reported on 02/03/14.


Interview, 02/19/14, at 11:15am, with S1 Director of Nursing revealed when asked if there had been adequate nursing staff present to provide on-going nursing re-assessments, she replied the staffing was based on the staffing grid.

Review of the hospital's staffing grid failed to account for increased acuity in patients, i.e. 1:1 observations, Close Visual Observations; although the Director of Nursing based nursing staff on the staffing grid, they failed to ensure patient acuity was also included in the determination of additional staff.

Based on review of medical records and interviews, the hospital failed to ensure every patient received a treatment plan that stated the specific purpose and focus of the treatment modalities as evidenced by:

1) 10 of 18 patients (Patient #s 1,2,7-10,15-18) with generalized treatment plans that did not address specific modalities and interventions for Elopement, Suicidal, Homicidal, Cognitive Impairment, Violence/Assaultive and/or Sexual Acting Out Precautions which were ordered by the Psychiatrist and

2) lack of focus on the Treatment Plans for 10 of 18 patients (#1, 2, 7-10, 15-18).

Findings:

Review of Patient # 2's medical record revealed a 13 year old male admitted under a Physician Emergency Certificate (PEC), dated 01/20/2014, for "history of explosive behavior", ADHD (attention deficit hyperactivity disorder), "threatening to kick his brother and tear down the house, being mean to family dog".

Patient #2 was admitted under the orders of S9 Psychiatrist with a diagnosis of Major Depressive Disorder (MDD). S9 Psychiatrist had ordered the following Precautions: Elopement, Suicidal, and Violence/Assaultive.

Review of a form titled "Brentwood Hospital Hand-Off Communication" revealed under a section titled "Risk Factors Noted" S16 Counselor had identified the following Risks: Homicide: Ideation/Intent/Plan/Attempt; Violent; Sexually Acting Out Precautions: Victim--prior victimization suspected; and Potential for Aggression Precautions.

Review of Patient #2's Initial Psycho-Social and Nursing Assessments revealed both S16 Counselor and S17 Registered Nurse (RN) had identified Patient #2 as a victim of sexual abuse (history of being raped by his half-brother when he was 11).

Review of Patient #2's Interdisciplinary Treatment Plan, dated 01/21/14, revealed the problems identified were: #1 Homicidal Ideation; #2 Depressed Mood; and #3 Asthma.

The Treatment Team failed to formulate and implement a Treatment Plan that addressed behaviors exhibited by Patient #2 when he reported to S18, on 01/30/14, that another patient (identified as Patient #7) had "made him touch his penis and suck it". The Treatment Plan was simply "naming" modalities (i.e., individual therapy, group therapy, occupational therapy, medication education) The focus of the treatment was not included.

Review of Patient #7's medical record revealed a 16 year old male admitted, 01/23/14, under a Formal Voluntary Admission (FVA) for Mood Instability.

Review of a Hand-Off Communication sheet, dated 01/23/14, revealed S20 Counselor documented Risk Factors Noted were Elopement Precautions, Sexually Acting Out Precautions--Victim - prior victimization suspected, and Behavior Problems.

Continued review of Patient #7's medical record revealed Social Services had identified Patient #7 had been physically and sexually abused by his biological parents until age 3 when he was removed from his biological parents and subsequently was adopted. S20 Counselor documented Patient #7 had alleged that his adoptive father was also sexually abusing him.

Review of Physician Admission Orders, 01/23/14, revealed the following Precautions were ordered: Elopement, Behavioral, and Sexual - Victim.

Review of Patient #7's Interdisciplinary Treatment Plan, dated 01/23/14, revealed the problems identified were: #1 Anxiety and #2 Medication non-compliance.

The Treatment Team failed to develop and implement a Treatment Plan that addressed risk factors identified upon admission by S20 Counselor which were Behavior Problems and Sexually Acting Out.

Review of Patient #s 1, 8-10, 15-18 revealed all had physician orders for varied precautions (i.e. Assault, Behavior, Cognitive, Elopement, Suicide, Sexual Acting Out, etc.).

Reviews of Patient #s 1, 8-10, and 15-18 revealed their individual Treatment Plans did not address the physician ordered precautions and all lacked specific treatment modalities to be utilized in the Treatment Plans.

Interview with S11 Psychiatrist on 01/19/14, at 9:20 am, confirmed that the Treatment Plans were not developed relative to the physician ordered precautions nor were specific treatment modalities identified and implemented.

Based upon observations, reviews of medical records, policies/procedures, QA Incident Report data, reports, staffing schedules/grids and interviews, the Director of Nursing failed to ensure additional staff was present when increased observations were ordered for patients as evidenced by 12 of 18 patients (#2, 6-11, 14-18) who were allowed to engage in alleged sexual misconduct.

Findings:

Review of Patient #s 2, 6-11, 14-18's medical records revealed that their individual physician/psychiatrist had ordered specific precautions (Elopement, Behavioral, Assaultive, Sexual Acting Out), upon the patients' admission.

Review of the Interdisciplinary Treatment Plans revealed none of the physician ordered precautions were care planned.

Review of a hospital policy, titled "Safety Rounds/Accountability", #TX.064, revealed:

"I. POLICY: ...to provide a safe, secure environment..by ensuring accountability for their well-being.

II. PROCEDURE: Guidelines for monitoring...patients...follows: SAFETY ROUNDS PROCEDURE: The charge nurse assigns...patient observation rounds...

1. Every patient not on Constant Observation or one to one (1:1) precaution will be monitored at least every 15 minutes. All CO and 1:1 patients will be monitored constantly but documented every 15 minutes...

2...any point in time that the patient is not visible through video monitoring, staff will physically go and visualize the patient...

8. Visually observe patients when behind closed doors by: 8.1 Knocking on bedroom...door. 8.2 Announce...stepping into room for rounds. 8.3 Open the door and visually observe the safety of the patient...

10...If the patient is...therapist's office or is in with a physician, the staff will notate that the patient is in the meeting but must check on the patient every 15 minutes. The exception is any 1:1 or CVO (constant visual observation) patient that must be either within arm's reach at all times or within the line of vision at all times...ROOMS: ...2. When patients are in their rooms, a staff member...to be stationed in center of the hallways to monitor patients and prevent inappropriate patient contact...will station self in the hallways at all times. 3. Patient bedroom doors to stay open when patients are in their rooms, except when patients are taking showers, to allow for appropriate staff monitoring...


Review of incident reports revealed:

11/28/13--allegation of sexual misconduct between patients #14 and #11, reported on 11/29/13.

12/04/13--allegation of sexual misconduct between patients #6 and #8; reported on 12/05/13.

12/25/13 an allegation of sexual misconduct occurred between patients #16 and #17, and reported on 12/26/13.

01/25/14 an allegation of sexual misconduct between patients #15 and #9 and was reported on 01/27/14.

01/26/14--allegation of sexual misconduct between patients #2 and #7; reported on 01/29/14.

02/03/14--allegation of sexual misconduct between patients #18 and #10; reported on 02/03/14.


Observations on 2/17/14, at 1:20 p.m., on the Adult Psychiatric Unit revealed, according to the patient list, that there were 15 adult female and male patients on the unit. Of these 15 patients, 1 was identified as being 1:1 (patient #13), and patient #12 and 2 random patients were identified as being on Close Visual Observation.

At the time of the observation, staff present on the Adult Unit were one Licensed Practical Nurse, who was in and out of the medication room, and one Registered Nurse who was sitting next to the door of the group therapy room. Patient #13, who was the 1:1 was sitting at a table in the middle of the group therapy room and S14 RN was approximately 8 feet away from the patient. Other than the Counselor conducting therapy, there were no other direct staff in the group therapy room.

Interview with S14 RN on 2/17/14, at 1:40 p.m., revealed when asked about the 1:1 ordered for patient #13, S14 RN stated "let me look at my sheet" then stated "yes patient #13 is a 1:1" When asked what 1:1 observation meant, S14 RN motioned and replied "at arms length".

Review of patient #13's medical record revealed on 2/17/14, the psychiatrist wrote an order dated 2/17/14 and timed 10:37 a.m. for the 1:1 observation to be discontinued; however, S14 RN failed to be aware that her patient's 1:1 observation level had been discontinued.

Further observations on 2/17/14, revealed patient #12, on Close Visual Observations (CVO) was in her room lying down. The 2 random patients who were on CVO were also in their rooms lying down.

Further interview with S14 RN during the observation revealed the staff assigned to the Adult Psychiatric Unit was an RN, an LPN, and a Mental Health Technician (MHT), however, the MHT was off the unit on break which left only the RN and LPN to monitor 15 patients.

Review of the staffing ratio grid requirements revealed for 15 patients there were to be 3 staff members present on the Adult Psychiatric Unit. However, the hospital failed to provide additional staff to provide the 1:1 observation (1:1 observation required one staff member with the patient, at arms length at all times) for patient #13 on 2/17/14, prior to the order being discontinued at 10:37 a.m. and the Constant Visual Observations for patient #12 and 2 random patients. At 1:30 p.m., the nursing staff failed to call for additional staff when the MHT when on break, leaving only two staff members on the unit to monitor 15 patients.

Review of a Nursing Staffing schedule, dated 01/26/14, revealed on the Adolescent Unit (ADOL), the staffing was 4 Registered Nurses (RN) and 2 Mental Health Technicians (MHT) for a census of 43 which met the staffing grid requirement. However, the number of nursing staff present was not adequate to ensure the safety of all patients as there were 2 random patients on 1:1 (1:1 observation required one staff member with the patient, at arms length at all times), there should have been additional staff members present to care for the 2 random patients on 1:1 observation.

Review of a Nursing Staffing schedule, dated 01/26/14, revealed on the Youth Enhanced Unit (YEU--Adolescent patients were transferred to this unit when they required a higher/more intensive observation/treatment), the staffing was 3 (no breakdown of RN-LPN-MHT) and census was 8. The staffing was appropriate for the census, according to the staffing grid. However, there was one patient (#7) who was ordered on 1:1 observation, so an additional staff member should have been present.

Interviews, 02/19/14, at 11:15am, with S1 Director of Nursing revealed when asked if there had been adequate nursing staff present, she replied the staffing was based on the staffing grid.

The staffing grid utilized by the hospital failed to take into account increased acuity levels on patients and failed to ensure additional staff were working to provide the monitoring required for patients to remain safe.

The hospital failed to provide additional staff members on the ADOL and YEU on 01/26/14 for monitoring of patients who were ordered 1:1 and Constant Visual Observation..

The number of staff present was not adequate to ensure the safety of all patients as evidenced by the alleged sexual misconduct that was allowed to occur between patients.

Based upon review of Quality Assurance/Performance Improvement data, 12 of 18 medical records, policy and procedures, and staff interviews, the hospital failed to ensure patients received care in a safe setting. This was evidenced by the hospital's failure to ensure:

I) the staff monitored patients to ensure that sexual contact was not allowed for 12 of 18 patients (#'s 2, 6-11, 14-18) hospitalized on the Adult Psychiatric Unit, the Adolescent Unit, and the Youth Enhanced Unit, and

II) adequate staff were present on the Adult Psychiatric Unit on 2/17/14 to ensure that physician ordered Constant Visual Observations were implemented for patients #12, #13, and two random patients. Findings:

I) Review of the Quality Assurance Reports of incidents from November 2013 to February 14th, 2014 revealed:

A) 12/25/13 an allegation of sexual misconduct occurred between patients #16 (female) and #17 (male); reported on 12/26/13.

B) 01/25/14 an allegation of sexual misconduct between patients #15 (male) and #9 (male); reported on 01/27/14.

C) 01/26/14 an allegation of sexual misconduct between patients #2 (male) and #7 (male); reported on 01/29/14.

D) 02/03/14 an allegation of sexual misconduct between patients #18 and #10; reported on 02/03/14.

E) 12/04/13 an allegation of sexual misconduct between patients #6 (male) and #8 (male); reported on 12/05/13.

F) 11/28/13 an allegation of sexual misconduct between patients #14 (female) and #11 (female); reported on 11/29/13.


A) Review of patient #16's medical record (female patient) revealed the patient was admitted, 12/21/13, with the diagnoses of Mood Disorder, Obsessive-Compulsive Disorder, Autism, and Rule Out Bipolar Disorder.

Review of patient #17's medical record (male patient) revealed the patient was admitted to the hospital on 12/02/13 for Suicidal and Homicidal Ideations, and auditory and visual hallucinations and diagnosed with Bipolar Disorder.

Further review of patient #16's (female patient) medical record revealed that the patient reported on 12/26/13, at 9:30 a.m., "something happened last night at shower time. I went into shower and I guess someone came in and had sex with me." At 9:40 a.m., the patient recanted her statement after staff told her they would review the video tape.

Review of patient #17's (male patient) medical record revealed according to the Nursing Progress Notes dated 12/25/13, timed 12:00 p.m., revealed "(patient #17) has spastic uncontrolled movements. Intrusive behavior, makes sexually inappropriate comments. Poor impulse control, needs frequent redirection...". According to the incident report, patient #17 was observed on video tape to enter patient #16's room and stay for approximately 30 minutes. Interview with S2 RM/QA Director on 2/14/14, at 9:05 a.m., revealed when the video tape of this incident was reviewed during the 3:00 p.m. to 11:00 p.m. shift, it did show patient #17 go into patient #16's room and stayed for approximately 30 minutes. S2 RM/QA Director further stated she interviewed patient #17 regarding the sexual encounter and the patient admitted to her that he did have sex with patient #16.

Review of the 15 minute observation Rounds Sheet for patient #17 on 12/25/13, for the 3:00 p.m. to 11:00 p.m. shift, revealed from 2:15 p.m. to 3:00 p.m. S26 Licensed Practical Nurse (LPN) documented the patient was in his room lying down and from 3:15 p.m. to 10:00 p.m., S26 LPN documented the patient was in the day room Even though the RN documented patient #17 was making inappropriate sexual comments during the day of 12/25/13 there failed to be documented evidence that the staff protected patient #16 from the sexual advances of patient #17 by allowing this patient access to patient #16's room.

There was no further documentation of a follow-up investigation regarding the incident between patient #16 and patient #17 until the video tape was actually reviewed in January 2014. According to a plan of correction submitted by S2 RM/QA Director it was revealed S1 RN/DON, S2 RM/QA Director, Nurse Manager for Youth Services, and the Weekend Nursing Supervisor met on 1/10/14 to review the findings of the sexual encounter between patient #16 and patient #17. It was at this time that a plan of correction was developed. According to their findings, it was found the nursing staff on the Adult Psychiatric Unit did not follow policy and procedure related to observations of the patients on the unit. There failed to be further documentation the incident between patients #16 and #17 was investigated at the time of occurrence.


B) Review of patient #9's medical record revealed: 9 year old male admitted 01/22/14, at 3:00 a.m., under a Physician Emergency Certificate (PEC) and Coroner's Emergency Certificate (CEC), and discharged 02/17/14. Patient #9 was admitted with the diagnoses of Bipolar Mood Disorder, Type I, Mixed, Severe with Psychosis; Impulse Control Disorder, NOS; ADHD; Oppositional Defiant Disorder; Relational Problems, NOS; and Rule Out Posttraumatic Stress Disorder. Patient #9 has a history of multiple inpatient psychiatric admissions--last admit was 12/20/13. History of being "bullied" by peers at school. Initial Nursing Assessments revealed history of Suicidal Ideation, Homicidal Ideation, Self Mutilation, Depression, auditory hallucinations, and sexual abuse.

Review of Seclusion/Restraint Orders revealed Patient #9 required:
01/29/14 Seclusion;
02/01/14 physical hold;
02/02/14 physical hold and seclusion;
02/03/14 Seclusion;
02/04/14 physical hold and Seclusion;
02/09/14 physical hold and Seclusion;
02/10/14 mechanical restraint;
02/12/14 physical hold;
02/13/14 physical hold;
02/16/14 physical hold and seclusion for hitting, spitting, trying to bite staff and peers, scratching himself, cursing at peers and staff.

Review of Nursing Progress Notes, 01/26/14 6:04pm, revealed S23 RN documented, "(patient #9's) mother spoke with me via phone, states '(patient #9) told me [a peer's name] (identified as patient #15) touched his private parts, and he wouldn't make something like that up' Ensured mother they are no longer roommates, that was changed today due to an incident during the first shift (7a-3p) when (patient #9) was angry and agitated at the same peer..." Patient #9 was placed on 1:1 observation 01/26/14 at 9:00 p.m. per physician's order.

Review of Physician's Orders, dated 01/23/14 2:50 pm, revealed S10 Psychiatrist documented "Transfer to CEU (Children's Enhanced Unit)...". Continued review of Physician's Orders revealed, on 01/26/14 9:33 p. m., S24 RN documented (a telephone order from S11 Psychiatrist) "Place on 1:1, Place on SAP precautions (sexually acting out)...also recommends enough staff to watch patients, 6 ft peer restriction from (patient #15)"

Review of the medical record for patient #15 revealed the patient was admitted to the hospital on 1/20/14 for homicidal ideation and violent behavior and diagnosed with Mood Disorder and Impulse Control Disorder. According to the admission orders from S11 psychiatrist, the precautions were: Elopement, Behavioral, Suicidal, Violence/Assaultive, and Sexual: Victim. Review of the Nursing Progress Notes dated 1/26/14, at 7:00 p.m., S23 RN documented "(Patient #15) is irritable, escalates quickly, but responds to redirection if he is given 1:1 attention regarding incident leading up to outburst. Defiant at first, but once engaged, calms down quickly." 7:30 p.m. "(Patient #15) replied when asked about incident, 'He asked me to do it and I did." Review of the physician orders revealed on 1/26/14 at 9:33 p.m., a telephone order from S11 Psychiatrist was obtained and revealed "Place on SAP precautions (sexually acting out).. 6 ft. peer restriction from (patient #9)". Even though S11 Psychiatrist ordered sexual precautions, there was no documented evidence that a safe environment was provided for patient #15 to ensure there were no sexual encounters.
There failed to be further evidence that this incident was investigated and reported other than the initial documentation of the incident.


C) Review of patient #2's medical record revealed: 1

Based upon observations, review of medical records, policies and procedures, QA Incident Report data/reports, staffing schedules/grids, nursing supervisor reports and interviews the hospital failed to ensure all patientts were free of abuse and neglect. This was evidenced by the failure to ensure:

1) additional staff were present on the Adult Psychiatric Unit on 2/17/14 to provide physician ordered observation levels for 4 of 15 patients (#12, #13 and 2 random patients);

2) additional staff were present on the Adolescent Unit on 01/26/14 when there were 2 random patients (census 43) who were ordered 1:1 observations;

3) additional staff were present on the Youth Enhanced Unit on 1/26/14 for physician ordered observations levels (1:1; Close Visual Observation-CVO) for 2 of 8 patients (#2, #7), who were allowed to engage in alleged sexual misconduct;

4) failure to provide additional staff on 12/25/13 during the 3:00 p.m. to 11:00 p.m. shift when there were 6 patient admissions to the Adult Psychiatric Unit raising the staffing level from 2 staff members to 3. (During this shift, patient #16 (female) alleged a sexual encounter occurred where patient #17 (male) came into her room and had sex with her); and

5) all incidents of sexual misconduct were investigated and reported to the state agency (Health Standards Section) within 24 hours in accordance with the policy and procedure for 12 of 18 medical record reviews (Patient #s 2, 6-11, 14-18).

Findings:

Review of a hospital policy, titled "Safety Rounds/Accountability", #TX.064, revealed:

"I. POLICY: ...to provide a safe, secure environment..by ensuring accountability for their well-being.

II. PROCEDURE: Guidelines for monitoring...patients...follows: SAFETY ROUNDS PROCEDURE: The charge nurse assigns...patient observation rounds...

1. Every patient not on Constant Observation or one to one (1:1) precaution will be monitored at least every 15 minutes. All CO and 1:1 patients will be monitored constantly but documented every 15 minutes...

2...any point in time that the patient is not visible through video monitoring, staff will physically go and visualize the patient...

8. Visually observe patients when behind closed doors by: 8.1 Knocking on bedroom...door. 8.2 Announce...stepping into room for rounds. 8.3 Open the door and visually observe the safety of the patient...

10...If the patient is...therapist's office or is in with a physician, the staff will notate that the patient is in the meeting but must check on the patient every 15 minutes. The exception is any 1:1 or CVO (constant visual observation) patient that must be either within arm's reach at all times or within the line of vision at all times...ROOMS: ...2. When patients are in their rooms, a staff member...to be stationed in center of the hallways to monitor patients and prevent inappropriate patient contact...will station self in the hallways at all times. 3. Patient bedroom doors to stay open when patients are in their rooms, except when patients are taking showers, to allow for appropriate staff monitoring..."


Observations on 2/17/14, at 1:20 p.m., on the Adult Psychiatric Unit revealed according to the patient list, there were 15 adult female and male patients on the unit. Of these 15 patients, 1 was identified as being 1:1 (patient #13), and patient #12 and 2 random patients were identified as being on Close Visual Observation.

At the time of the observation, staff present on the Adult Unit were one Licensed Practical Nurse, who was in and out of the medication room, and one Registered Nurse who was sitting next to the door of the group therapy room. Patient #13, who was the 1:1 was sitting at a table in the middle of the group therapy room and S14 RN was approximately 8 feet away from the patient. Other than the Counselor conducting therapy, there were no other direct staff in the group therapy room.

Interview with S14 RN on 2/17/14, at 1:40 p.m., revealed when asked about the 1:1 ordered for patient #13, S14 RN stated "let me look at my sheet" then stated "yes patient #13 is a 1:1" When asked what 1:1 observation meant, S14 RN motioned and replied "at arms length".

Review of patient #13's medical record revealed on 2/17/14, the psychiatrist wrote an order dated 2/17/14 and timed 10:37 a.m. for the 1:1 observation to be discontinued; however, S14 RN failed to be aware that her patient's 1:1 observation level had been discontinued.

Further observations on 2/17/14 revealed patient #12, on Close Visual Observations (CVO) was in her room lying down. The 2 random patients who were on CVO were also in their rooms lying down. Further interview with S14 RN during the observation revealed the staff assigned to the Adult Psychiatric Unit was an RN, an LPN, and a Mental Health Technician (MHT); however, the MHT was off the unit on break which left only the RN and LPN to monitor 15 patients.

Review of the staffing ratio grid requirements revealed for 15 patients there were to be 3 staff members present on the Adult Psychiatric Unit; however the hospital failed to provide additional staff to provide the 1:1 observation (1:1 observation required one staff member with the patient, at arms length at all times) for patient #13 on 2/17/14 prior to the order being discontinued at 10:37 a.m. and the Constant Visual Observations for patient #12 and 2 random patients. At 1:30 p.m., the nursing staff failed to call for additional staff when the MHT went on break, leaving only two staff members on the unit to monitor 15 patients.


2) Review of a census and staffing form, dated 01/26/14, revealed there were 43 patients on the Adolescent Unit. According to the nursing staffing schedule there were 4 Registered Nurses (RNs) and 2 Mental Health Technicians (MHTs) assigned the Adolescent Unit. Review of the staffing grid indicated this was the required number of staff (6 total) for the census (43). However, the staffing grid did not take into consideration the need for additional staff when the acuity was increased (i.e. 1:1 observation ordered on 2 patients, which indicated the need for 2 additional staff members in order to ensure patient and staff safety).


3) Review of patient #2's medical record revealed: 13 year old male admitted, 01/21/14, under a PEC (Physician Emergency Certificate) for "explosive behavior ...threatening to kick his brother and tear down the house, being mean to family dog" . Patient #2 was discharged 01/31/14 with appointments for outpatient psychiatric follow up.

Review of Patient #2's Psychiatric Evaluation, dated 01/22/14, revealed S8 Psychiatrist documented: " ...LEGAL DIFFICULTIES: The patient has multiple arrests for aggression toward others ...MENTAL STATUS EXAM: ...Thought content is positive for harmful behavior toward others ... denied suicidal ideation ... DIAGNOSTIC IMPRESSIONS: Axis I: Bipolar Disorder, Type I, Mixed, Severe; Axis II: Deferred; Axis III: Noonan syndrome; Axis IV: Psychological Stressors - Extreme..."

Review of a Family Session form, dated 01/30/14, revealed S8 LMSW (Licensed Masters Social Worker), documented in the summary note, " ...has a hx (history) of fire setting and cruelty to animals. GM (grandmother) reports pt (patient) burned the school library and was kicked out of school ...has been diagnosed (with) Explosive Behavior Disorders, ADHD, and Mild MR (mental retardation) ...reports a hx of sexual abuse by older half brother ... "

Review of Physician admission orders, dated 01/21/14, revealed S17 RN documented the following verbal orders: " ...Precautions: Elopement, Suicidal, and Violence/Assaultive... "

Review of Patient #7's medical record revealed: 16 year old male admitted, 01/23/14, with diagnoses of Medication Non-compliance and Mood Instability. Patient #7 was discharged on 01/28/14 into the custody of the local police for an existing arrest warrant for assault with a dangerous weapon.

Review of the information obtained during admission, 01/23/14, revealed S20 Counselor documented S25 Psychiatrist was notifi