HospitalInspections.org

Based on review of documents and staff interviews, it was determined the Hospital failed to report patient abuse by a staff member to the appropriated agencies as required by law. Failure to report patient abuse as mandated by law poses a high potential risk of harm to patients if the facility does not take the appropriate actions to report and protect individuals abused while receiving services within the facility.

Cross reference: A0043, A0057, A0115

Findings include:

Policy titled "Abuse, Assault or Neglect of a Patient," revealed: "...Any incident of suspected abuse, neglect, or exploitation of a patient by a staff member is to be reported to the Administrator on Call (AOC)...The employee will be immediately sent home from the facility and placed on unpaid administrative leave. An investigation will commence immediately, but no later than 24 hours after the report...At the conclusion of the investigation if the facility has reasonable suspicion that the employee did, in fact, perpetrate abuse in any form, he or she will be terminated for cause and not eligible for re-hire...The Director of Quality and Compliance will have the obligation to report all substantiated cases of abuse, neglect, or exploitation by staff to any applicable department of protective services as well as any applicable licensed services...The hospital CEO or designee will have the obligation to speak with the patient, guardian, and/or family members/caregivers, with appropriate consent, regarding the circumstances of the abuse, neglect, or exploitation. The initial interaction must occur immediately, but no later that twenty-four (24) hours after the occurrence. The patient, guardian, family and/or caregivers will be updated with the results of investigation no later than twenty-four (24) hours after the conclusion of the investigation...."

Policy titled "Abuse and Neglect, Identification and Reporting of," revealed: "...All staff members employed by the hospital are considered mandated reporters by the State of Arizona and therefore have a legal and ethical obligation to act upon any suspicion of abuse, neglect, or exploitation. Department of Protective Services must be notified within twenty-four (24) hours of discovery by the Social Worker...Documentation of the reporting must be made in the patient's medical record by the mental health professional who contacted DPS and/or DCS...If desired by the patient or guardian, or requested by the community agency contacted, hospital staff may also contact local law enforcement...Documentation in the medical record shall include the following reportable information: a. Notification to patient and guardian of obligation to report the information. b. Time and place of alleged incidents (if known). c. Persons involved. d. Supporting evidence. e. Detailed description of the incident. f. Detailed description of who was notified and when (to include APS personnel with name, date, time as well as those listed above).... "

While on survey at facility on 04/24/2024 the SA reviewed hospital documentation of a camera review on 04/24/2024, of a seclusion episode involving Patient #5, on 04/20/2024, revealed: " ...(Employee #9) puts [his] hands on pt first, grabs by arm. Pt exculated {sic}...Techs holding (Employee #9) back...(Employee #9) assaults patient.... "

Hospital documentation revealed Employee #9 was seen on video showing "aggression" towards Patient #5. The documentation also revealed the DON would be performing employee interviews, and HR, along with Employee #1, were "handling the suspension of (Employee #9)."

Further hospital documentation revealed Employee #9 was placed on administrative leave pending an investigation, and then terminated, when the investigation was completed, due to the interaction with Patient #5 seen during the camera review.

Patient #5's medical record was reviewed and revealed no documentation of assault or abuse, nor documentation of notification to the Department of Child Services (DCS), or to Patient #5's guardian.

Documentation of notification of Patient #5's guardian and DCS, of the abuse and assault incident was requested during state survey on 04/24/2024 from Employee #1, and was not provided.

Employee #2 confirmed in an interview on 06/04/2024, while reviewing a video on 04/24/2024, of a seclusion episode on 04/20/2024, for Patient #5, Employee #9 was seen assaulting Patient #5. Employee #2 also confirmed the abuse was not reported to Patient #5's guardian or to DCS.

Based on the review of documents and staff interviews, it was determined that the Governing Body failed to ensure that the hospital operations, functions, and responsibilities are able to provide a safe and healthy environment for the patient population. These deficient practices pose a potential risk for patients of receiving inadequate care and treatment timely, which could lead to avoidable lengthy patient admissions, unwarranted development of disease complications, and probable poor patient prognosis.

Findings include:

Hospital document titled, "Medical Staff Bylaws", revealed: "...Governing Board means the group that has ultimate authority and responsibility for establishing policy; maintaining quality of care, treatment or services; and providing for organization management and planning...."

Cross reference: A0057, A0115
A-0021: The Hospital failed to report patient abuse by a staff member to the appropriated agencies as required by law.

Cross reference: A0057, A0115
A-0144: The Hospital failed to ensure four (4) adolescent patients were not able to elope from the hospital during the night.

Cross reference: A0057, A0115
A-0145: The Hospital failed:

1. To report patient abuse by a staff member to the appropriated agencies as required by law. Failure to report patient abuse as mandated by law poses a high potential risk of harm to patients if the facility does not take the appropriate actions to report and protect individuals abused while receiving services within the facility.

2 To ensure staff did not abuse a patient (Patient #8) by administering a chemical restraint unnecessarily and swearing at the patient. This deficient practice poses the potential risk to the health and safety to patients, by restraining patients unnecessarily with no danger of imminent harm, a Endotherapy and unsafe environment, intimidation of patients and is a violation of patient rights.

Cross reference: A0057, A0115
A-0154: The Hospital failed to ensure staff did not utilize a chemical restraint as a means of coercion, discipline, convenience or retaliation for one (1) patient (Patient #8).

Cross reference: A0057
A-0392: The Hospital failed to ensure there were sufficient numbers of nursing personnel to assist patients to prevent four (4) patients from eloping from the hospital.

Cross reference: A0057
A-0534: The Hospital failed to ensure medical staff authenticated a telephone order for a chemical restraint for one (1) patient (Patient #8) within the required 48 hour timeframe.

The cumulative effect of these systemic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Governing Body.

Based on review of documents and staff interview, it was determined the Administrator failed to manage the daily operation of the hospital. This deficient practice poses a risk to the health and safety of patients when leadership does not provide proper guidance, enforcement of policies and procedures and provide resources to provide care to meet the needs of patients.

Findings include:

Policy titled, "Written Plan of Service and Staff Composition: Leadership", revealed: "...Chief Executive Officer, (CEO) role: The CEO is responsible for leading the development and execution of the hospital's long term strategy with a view to creating shareholder value. The CEO acts as a direct liaison between the Board and management of the hospital and communicates to the Board on behalf of the hospital leadership. The CEO is responsible administratively for the development and implementation of each offered service. In collaboration with the Medical Director, and Director of Social Services, the CEO shares the responsibility for the overall function of each offered service. He/she serves as the liaison with outside agencies and provides/ensures community involvement. The CEO reports to the governing board...."

Hospital document titled, "Medical Staff Bylaws", revealed: "...Chief Executive Officer is the individual responsible for the overall administrative management of the Hospital...."

During the survey it was determined the CEO failed to perform the core functions of the CEO as demonstrated by the following:

Cross reference: A0043, A0115
A-0021: The Hospital failed to report patient abuse by a staff member to the appropriated agencies as required by law.

Cross reference: A0043, A0057, A0115
A-0144: The Hospital failed to ensure four (4) adolescent patients were not able to elope from the hospital during the night.

Cross reference: A0043, A0057, A0115
A-0145: The Hospital failed:

1. To report patient abuse by a staff member to the appropriated agencies as required by law. Failure to report patient abuse as mandated by law poses a high potential risk of harm to patients if the facility does not take the appropriate actions to report and protect individuals abused while receiving services within the facility.

2 To ensure staff did not abuse a patient (Patient #8) by administering a chemical restraint unnecessarily and swearing at the patient. This deficient practice poses the potential risk to the health and safety to patients, by restraining patients unnecessarily with no danger of imminent harm, a nontherapeutic and unsafe environment, intimidation of patients and is a violation of patient rights.

Cross reference: A0043, A0057, A0115
A-0154: The Hospital failed to ensure staff did not utilize a chemical restraint as a means of coercion, discipline, convenience or retaliation for one (1) patient (Patient #8).

Cross reference: A0043, A0057
A-0392: The Hospital failed to ensure there were sufficient numbers of nursing personnel to assist patients to prevent four (4) patients from eloping from the hospital.

Cross reference: A0043, A0057, A0115
A-0534: The Hospital failed to ensure medical staff authenticated a telephone order for a chemical restraint for one (1) patient (Patient #8) within the required 48 hour timeframe.


Employee #3 confirmed the Chief Executive Officer (CEO) is responsible for the management of the hospital. Employee #3 confirmed that the CEO was on leave at the time of the survey and was not to be disturbed.

The cumulative effect of these systematic problems resulted in the CEO's inability to ensure the facility provided quality health care in a safe environment.

Based on review of hospital policies and procedures, hospital documents, medical records, observations, and staff interviews, it was determined that the hospital failed to comply with protecting and promoting each patient's rights as evidenced by the hospital's failure to:

Repeat deficiency from event SLZZ11 02/03/2023

Findings include:

The Condition level deficiency is the result of the standard deficiencies found under the Conditions of Patient Right in the following citations:

Cross reference: A0043, A0057, A0115
A-0021: The Hospital failed to report patient abuse by a staff member to the appropriated agencies as required by law.

Cross reference: A0043, A0057, A0115
A-0144: The Hospital failed to ensure four (4) adolescent patients were not able to elope from the hospital during the night.

Cross reference: A0043, A0057, A0115
A-0145: The Hospital failed:

1. To report patient abuse by a staff member to the appropriated agencies as required by law. Failure to report patient abuse as mandated by law poses a high potential risk of harm to patients if the facility does not take the appropriate actions to report and protect individuals abused while receiving services within the facility.

2 To ensure staff did not abuse a patient (Patient #8) by administering a chemical restraint unnecessarily and swearing at the patient. This deficient practice poses the potential risk to the health and safety to patients, by restraining patients unnecessarily with no danger of imminent harm, a nontherapeutic and unsafe environment, intimidation of patients and is a violation of patient rights.

Cross reference: A0043, A0057, A0115
A-0154: The Hospital failed to ensure staff did not utilize a chemical restraint as a means of coercion, discipline, convenience or retaliation for one (1) patient (Patient #8).

The cumulative effect of these systemic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Patient Rights and provide a safe environment for patients to protect them from harm.

Based on review of documents and staff interviews, it was determined the Hospital failed to ensure four (4) adolescent patients were not able to elope from the hospital during the night. This deficient practice poses a risk to the health and safety of patients if hospital services are not provided in a safe, secure environment.

Repeat deficiency from event# SLZZ11 02/03/2023

Cross reference: Cross reference: A0043, A0057, A0115

Findings include:

A request was made for a policy on accompanying patients to the patio. None was provided.

Policy titled, "Patient Rights", revealed: "...Patients Rights according to federal and state guidelines include the following at a minimum: j. The right to receive care in a safe setting...."

Policy titled, "Elopement/AMA", revealed: "...Elopement: Patients who leave the hospital without a discharge order are considered to have "eloped". Staff shall make every effort to locate the patient and make notifications to designated persons regarding the elopement...At the time of discovering a patient is missing, a staff member will call a code orange over the radio and repeat it three times...Staff will search the hospital and immediate hospital grounds...In the event that the patient leaves the hospital grounds the Surprise police are to contacted immediately...Staff will notify the following of the patient's elopement* Attending/Covering Physician* CEO/AOC*CNO* Police*Guardian or Emergency Contact...Documentation of the elopement consists of: Documenting the sequence of events in the Incident Reporting System, including date, time, and circumstances under which the patient was noted missing, If patient is locate but not returned the disposition of the patient and If the patient is located and returned, staff shall: Document the time, condition of the patient and circumstances of the return of the patient...An RCA surrounding the event will be completed...."

Policy titled, "Code Orange-Missing Patient/Elopement", revealed: "...Code Orange-Elopement: In the event a patient is observed eloping, staff should announce: CODE ORANGE ELOPEMENT, the location of the elopement and whether it is adult or adolescent male or female, three times via the radio...."

Document titled, "Incident report", revealed: "...Location: Lotus Unit (RN) called for assistance with four patients being unruly and belligerent with staff. Upon arrival to the unit noted 4 patients in the hallway upset and refusing to enter their rooms. (Patient #3) was so upset s/he stated s/he could not even talk about it. S/he was upset because s/he felt the staff on duty were being disrespectful to hem/her and the other kids. Pt was harming by banging fists into the wall. Pt was asked if s/he would calm down if we called the provider and got something to help him/her relax. Pt stated s/he would because it;s just too much here and they (staff on duty) make it harder. (RN) stated s/he had already given Patient #3 the "max" there was nothing else s/he could do. Call placed to DR. with the above and informed [him] that the pt had already received a Benadryl 50 mg and Vistaril 50 mg but still extremely agitated. [Dr. Carr] ordered Zyprexa 10 mg PO to be given. Pt took the medication but was still irate. Explained to the pt that it would take a little while to take effect. Pt was about to start banging the wall again, when it was suggested s/he try walking around the courtyard to get some fresh air. Pt agreeable. The other three patients also wanted to go so they included. All four patients did start to calm down and were expressing their concerns as they walked around, at 1305 (RN) on Phoenix unit came out and sat on a chair outside. The kids started saying they did not want her/him out there with them. They all started to escalate and start cursing and asking for her/him to leave, I informed them that s/he was just making sure all was safe. All four patients began to retaliate the decision was made to go back in side, when Patient #3 began kicking at the doors to the back wall across the glass doors of the hallway. The other kids also began kicking the doors because the two nurses and the BHT the patients were upset with were coming up the hallway towards them. They continued to kick in the doors until the doors busted open and all 4 patients escaped. A CODE support was called however the kids busted the door open before staff could arrive. [Dave] CEO was called with the above. Surprise PD was called. Pts [father] was called and informed...."

Hospital document titled, "Incident report", revealed: "...Lotus unit...While conducting 0100 HRS Q 15 rounding supervisor on duty opened the patio door from the outside hand gesturing for me to come to the door. At which time s/he shouted inside the hallway requesting both RNs in the hall to leave the hall. however, (RN from Phoenix unit) was the only RN in the hall. I approached the door entrance speaking directly to (Patient #4) I asked (Patient #4) to not disrespect me verbally as I had not shown disrespect to [her] during redirectives. Patient #4 placed [her] head on the outside exit door sighing "UGH". Patient #4 proceeded to take [her] foot kicking the bottom of the exit door. The door moves slightly outward, Supervisor hand gestured for me to leave closing the door...."

Hospital document titled, "Video Review", revealed: "...(Location Lotus unit) 00:24:55 pts down hall, in and out of rooms...00:28:29 Back to rooms...00:28:38 House supervisor shows up...00:29:30 patients in hall with RN and House supervisor escalating...00:33:57 2 patients at nurse station with house supervisor...00:39:09 House supervisor goes to take one patient our to courtyard, other patients in rooms, s/he allows for them to come first patient goes and gets 4th patient from room...00:40:03 RN from Phoenix unit goes outside...00:40:22 RN From Phoenix unit leaves courtyard with house supervisor and patients...00:44:41 RN enters hallway while supervisor and patients remain in corridor...00:46:07 patient starts to kick at exterior door...00:47:04 door starts to give way and all the patients begin kicking at door...00:48:31 Door gives way and all 4 elope...00:50 CODE called..."

Hospital document titled, "Follow up for Nursing Leadership", revealed: "...On 05/28/2024 at 00:40 am four adolescent patients were taken outside of lotus unit by acting House Supervisor (name). The patients walked around courtyard #2 for approximately five minutes. At 00:44:48 the adolescents were being escorted back to the unit from the courtyard and entered breezeway leading from courtyard #2 to Lotus unit exit door. Adolescent patients paused in breezeway. Adolescent patient #1 began hitting at fire exit door in breezeway which exits the west end and leads outside facility. Patient #2 walks over to the same door and begins pushing/kicking at door. Patient #3 starts hitting/pushing door approximately 30 seconds later. HS is seen standing next to the door and appears to be talking to patients. At 00:48 the exit door fails at the bottom corner end. A space is created in which the adolescents slide through one after the other and AWOL from facility...HS failed to ensure the safety of staff and patients. Error in judgement AEB by allowing patients outside without proper staffing to ensure safety. HS failed to call code during three minutes of patients attempting to elope...Monitoring and safety of patients inadequate...."

Hospital document titled, "Written Warning Form", revealed: "...Performance/Behaviors Observed: RN failed to ensure the safety of staff and patients. Error in judgement AEB by allowing patients outside without proper staffing to ensure safety...."

Review of Patient #2 nurse note dated 05/28/2024 revealed: "..At approximately 2300 patient came to nursing counter stating they did not want to go to their room to sleep. Pt and other 3 patients were grilling the RNS about their badges and how they worked...The patients were seen by this RN at various times whispering to each other in the hallway, they would go back to their rooms and peek out of the doors and signal the other patient then would come back out into the hallways and walk toward the exit doors to rear of unit and were repeatedly redirected back to the front of the unit...pt and other 3 patients became agitated...0040 house sup came to floor to speak with one of the patients...the hours charge took over control of the patients telling this RN "I got this" as the charge nurse walked toward the back door of the building with the other patients involved exiting their rooms and following the house charge and patient outside to the courtyard...The writer determined this was a safety issue and sent another nurse out to the courtyard...0046 the house charge attempted to bring the patients back into the unit. they came through the doors exiting the courtyard into and outdoor hallway...the patients began kicking and pushing on the door that led to the outside they attempted to break the door free for approximately 2 minutes as the house charge asked them to come in but they refused...0048 all four patients broke the door open and ran out of the hospital. As the pts AWOL the house charge called for code support...."

Employee #2 confirmed during an interview conducted on 06/05/2024 that the four patients eloped from the hospital while outside in the courtyard accompanied by only one employee. Employee #2 confirmed the hospital has no policy regarding staff accompanying patients to the courtyard. Employee #2 confirmed the house supervisor did not call for code support until after the patients had eloped from the hospital.

Based on review of documents and staff interviews, it was determined the Hospital failed:

1. To report patient abuse by a staff member to the appropriated agencies as required by law. Failure to report patient abuse as mandated by law poses a high potential risk of harm to patients if the facility does not take the appropriate actions to report and protect individuals abused while receiving services within the facility.

2 To ensure staff did not abuse a patient (Patient #8) by administering a chemical restraint unnecessarily and swearing at the patient. This deficient practice poses the potential risk to the health and safety to patients, by restraining patients unnecessarily with no danger of imminent harm, a nontherapeutic and unsafe environment, intimidation of patients and is a violation of patient rights.

Repeat deficiency from event# SLZZ11 02/03/2023

Cross reference: Cross reference: A0043, A0057, A0115

Findings include:

Policy titled "Abuse, Assault or Neglect of a Patient," revealed: "...Any incident of suspected abuse, neglect, or exploitation of a patient by a staff member is to be reported to the Administrator on Call (AOC)...The employee will be immediately sent home from the facility and placed on unpaid administrative leave. An investigation will commence immediately, but no later than 24 hours after the report...At the conclusion of the investigation if the facility has reasonable suspicion that the employee did, in fact, perpetrate abuse in any form, he or she will be terminated for cause and not eligible for re-hire...The Director of Quality and Compliance will have the obligation to report all substantiated cases of abuse, neglect, or exploitation by staff to any applicable department of protective services as well as any applicable licensed services...The hospital CEO or designee will have the obligation to speak with the patient, guardian, and/or family members/caregivers, with appropriate consent, regarding the circumstances of the abuse, neglect, or exploitation. The initial interaction must occur immediately, but no later that twenty-four (24) hours after the occurrence. The patient, guardian, family and/or caregivers will be updated with the results of investigation no later than twenty-four (24) hours after the conclusion of the investigation...."

Policy titled "Abuse and Neglect, Identification and Reporting of," revealed: "...All staff members employed by the hospital are considered mandated reporters by the State of Arizona and therefore have a legal and ethical obligation to act upon any suspicion of abuse, neglect, or exploitation. Department of Protective Services must be notified within twenty-four (24) hours of discovery by the Social Worker...Documentation of the reporting must be made in the patient's medical record by the mental health professional who contacted DPS and/or DCS...If desired by the patient or guardian, or requested by the community agency contacted, hospital staff may also contact local law enforcement...Documentation in the medical record shall include the following reportable information: a. Notification to patient and guardian of obligation to report the information. b. Time and place of alleged incidents (if known). c. Persons involved. d. Supporting evidence. e. Detailed description of the incident. f. Detailed description of who was notified and when (to include APS personnel with name, date, time as well as those listed above).... "

Policy titled, "Rights and Responsibilities of the Individual", revealed: "...Patient Rights according to federal and state guidelines include the following at a minimum: ...b. The right to receive considerate, respectful care in the least restrictive environment which preserves your dignity and contributes to a positive self-image regardless of race, ethnicity, sexual orientation, culture, religion. gender identity, age, marital status, national origin, disability (mental or physical), socioeconomic status or diagnosis, that is humane treatment environment that ensures protection from harm, provides privacy to as great degree as possible with regards to personal needs...."

Policy titled," Standards of Conduct", revealed: "...A. Work Rules: Violation of the following standards shall be deemed good cause for which an employee may be subject to disciplinary corrective action...6. Fighting or threatening violence in the workplace...7. Boisterous or disruptive activity in the workplace...9. Insubordination or other disrespectful conduct...11. Unprofessional conduct...18. Comments construed as disloyal or damaging to client relations or contracts...."

Policy titled, "Written Plan of Service and Staff Composition: Leadership", revealed: "...The first priority in staffing the facility is to provide a safe environment while maintaining a therapeutically sound program...The nursing staff is responsible for the delivery of quality care to all patients; maintains confidentiality of patient information and respect for the patient's dignity and maintains professional competency...."


Policy titled, "Restraint and Seclusion," revealed: "...All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion...Restraint-(42CFR 482.13 (c)(1)) Any manual method, physical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a (patient to move his or her arms, legs, body, or head freely)- Personal Restraint: Defined as the application of a physical force without the use of any device, for the purpose of restricting the free movement of a patient's body...."

1.

While on survey at facility on 04/24/2024 the SA reviewed hospital documentation of a camera review on 04/24/2024, of a seclusion episode involving Patient #5, on 04/20/2024, revealed: " ...(Employee #9) puts [his] hands on pt first, grabs by arm. Pt exculated {sic}...Techs holding (Employee #9) back...(Employee #9) assaults patient.... "

Hospital documentation revealed Employee #9 was seen on video showing "aggression" towards Patient #5. The documentation also revealed the DON would be performing employee interviews, and HR, along with Employee #1, were "handling the suspension of (Employee #9)."

Further hospital documentation revealed Employee #9 was placed on administrative leave pending an investigation, and then terminated, when the investigation was completed, due to the interaction with Patient #5 seen during the camera review.

Patient #5's medical record was reviewed and revealed no documentation of assault or abuse, nor documentation of notification to the Department of Child Services (DCS), or to Patient #5's guardian.

Documentation of notification of Patient #5's guardian and DCS, of the abuse and assault incident was requested during state survey on 04/24/2024 from Employee #1, and was not provided.

Employee #2 confirmed in an interview on 06/04/2024, while reviewing a video on 04/24/2024, of a seclusion episode on 04/20/2024, for Patient #5, Employee #9 was seen assaulting Patient #5. Employee #2 also confirmed the abuse was not reported to Patient #5's guardian or to DCS.

2.
A video review of the hallway camera from Lotus unit, an adolescent unit, on May 25, 2024, at 2020 to 2220 identified:

At 2020-2030, Patient #8 is seen walking animated up and down the hallway and into the day room on multiple occasions. During this time Patient #8 is observed to be talking to other patients in the hallway and staff members in the day room and at the nurse's station.

At 2030, Patient #8 is seen going to the nurse's station and throws papers and a clipboard that were on the counter of the nurse's station desk onto the floor. Employee # 11 is observed redirecting Patient #8.

At 2031- 2153 Patient #8 is seen walking up and down the hallway, talking to other patients and staff members in the hallway.

At 2138 -2152 Employee #12 is observed at the nurse's station on the telephone. Employee #4 is observed entering the nurse's station from the Phoenix unit and entering the medication room.

At 2153 Employee #4, #11, #12, #13 and #14 are observed leaving the nurse's station and walking toward Patient #8 in the hallway. Patient #8 is observed walking toward the direction of the employees. Patient #8 sees the employees, stops and removes [her] socks and turns around walking hurriedly away from the employees. Patient #8 is met by [her] bedroom by another unidentified employee by the door to [her] bedroom and turns away toward the direction of the employees. Patient #8 attempts to walk past the employees but is blocked in the hallway by the employees and is directed toward the entrance to [her] room.

At 2154 Patient #8 enters [her] room followed by the five (5) employees #4,11,12,13, and 14.

At 2156 the five employees exit Patient #8 room and return to the nurse's station.

At 2156-2220 Patient #8 is observed walking up and down the hallway talking animatedly to other patients.

Patient #8 "Grievance Report Form" revealed: "...On 25 May nurse (Employee #4) being unprofessional s/he said "Why don't you do it your f***ing self....Because I wouldn't shut the hell up. Then s/he gave me shots like s/he was playing dots...."

Patient #8 Grievance Follow up Form revealed: "...Details of Grievance: A nurse (Employee #4) being unprofessional 'why? Do it your f****** self'', because I wouldn't shut the hell up. Then s/he was given the shots like s/he was playing dots...Interview with patient and staff: (patient) confirmed what was written. S/he mentioned the nurse was nurse(Employee #4). S/he felt that this was not okay and felt something should be done about [her] being treated this way...BHT (Employee #13) stated this was said and wrote an IR stating that nurse (Employee #4) was administering a B52 shot to patient (Patient #8), (Employee #4) stated "If you can take f****** needles you should have just taken the f****** shot"...This incident was also noted in the shift report from 05/25/2024 by the house supervisor (Employee #14)...CNO will be writing up RN...."

Document titled, "Incident Report" revealed: "...While nurse (Employee #4) was administering a B52 shot to patient (Patient #8), (Employee #4) stated "If you can take f***ing needles you should have just taken the f***ing shot... Additional Comments: Awaiting incident report from another witness to incident in order to verify and discipline nurse named in incident...."

Employee #3 confirmed on 06/04/2024 that Patient #8 threw the papers and clipboard at the nurse's station at 2038 and received a chemical restraint for aggressive behavior at 2155. Employee #3 could not confirm the reason for the delay in the administration of the chemical restraint. Employee #3 confirmed that Employee #4 did swear and spoke unprofessionally at Patient #8 during the administration of the chemical restraint.

Based on review of documents, videotape review and staff interviews, it was determined the Hospital failed to ensure staff did not utilize a chemical restraint as a means of coercion, discipline, convenience or retaliation for one (1) patient (Patient #8). This deficient practice poses the potential risk of injury to patients, being unnecessarily restrained with no danger of imminent harm, a nontherapeutic and unsafe environment, and is a violation of patient rights.

Repeat deficiency from event#SLZZ11 02/03/2023

Cross reference: Cross reference: A0043, A0057, A0115

Findings include:

Policy titled, "Restraint and Seclusion," revealed: "...All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion...Restraint-(42CFR 482.13 (c)(1)) Any manual method, physical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a (patient to move his or her arms, legs, body, or head freely)- Personal Restraint: Defined as the application of a physical force without the use of any device, for the purpose of restricting the free movement of a patient's body...."

A video review of the hallway camera from Lotus unit, an adolescent unit, on May 25, 2024, at 2020 to 2220 identified:

At 2020-2030, Patient #8 is seen walking animated up and down the hallway and into the day room on multiple occasions. During this time Patient #8 is observed to be talking to other patients in the hallway and staff members in the day room and at the nurse's station.

At 2030, Patient #8 is seen going to the nurse's station and throws papers and a clipboard that were on the counter of the nurse's station desk onto the floor. Employee # 10 is observed redirecting Patient #8.

At 2031- 2153 Patient #8 is seen walking up and down the hallway, talking to other patients and staff members in the hallway.

At 2138 -2152 Employee #12 is observed at the nurse's station on the telephone. Employee #4 is observed entering the nurse's station from the Phoenix unit and entering the medication room.

At 2153 Employee #4, #11, #12, #13 and #14 are observed leaving the nurse's station and walking toward Patient #8 in the hallway. Patient #8 is observed walking toward the direction of the employees. Patient #8 sees the employees, stops and removes [her] socks and turns around walking hurriedly away from the employees. Patient #8 is met by [her] bedroom by another unidentified employee by the door to [her] bedroom and turns away toward the direction of the employees. Patient #8 attempts to walk past the employees but is blocked in the hallway by the employees and is directed toward the entrance to [her] room.

At 2154 Patient #8 enters [her] room followed by the five (5) employees #4,11,12,13, and 14.

At 2156 the five employees exit Patient #8 room and return to the nurse's station.

At 2156-2220 Patient #8 is observed walking up and down the hallway talking animatedly to other patients.

Employee #3 confirmed on 06/04/2024 that Patient #8 threw the papers and clipboard at the nurse's station at 2038 and received a chemical restraint for aggressive behavior at 2155. Employee #3 could not confirm the reason for the delay in the administration of the chemical restraint.

Based on review of documents and staff interview, it was determined the Hospital failed to ensure medical staff authenticated a telephone order for a chemical restraint for one (1) patient (Patient #8) within the required 48 hour timeframe. This deficient practice poses a risk to the health and safety of patients if medical staff do not follow the hospital's rules and regulations when providing patient care.

Cross reference: Cross reference: A0043, A0057

Findings include:

Hospital document titled, "Medical Staff Rules and Regulations", revealed: "...All medical record documents shall be completed within the timeframes defined below: Telephone orders: Date, time, and authenticated within 48 hours...."

Review of Patient #8 medical record identified a telephone physician order which revealed: "...Seclusion and Restraint Order date and time 05/25/2024 2138...Seclusion/restraint start time: 2155 for 2 hr max (not to exceed 2 hours for adolescents, 3 hours for adults)...Medication ordered Benadryl 50 mg IM, Zyprexa 10mg IM...Indication for S&R/medications: Danger to others...Providers signature, credentials, date and time: (Provider signed) 05/28/2024 at 1106...."

Employee #3 confirmed on 06/04/2024 that the chemical restraint order for Patient #8 was not authenticated by the provider until 05/28/2024, 72 hours after the order was given to the RN.

Based on review of documents and staff interviews, it was determined the Hospital failed to ensure there were sufficient numbers of nursing personnel to assist patients to prevent four (4) patients from eloping from the hospital. This deficient practice is poses a risk to the health and safety of patients when there is not sufficient staff on units to prevent adverse events from occurring which can potentially cause patient harm.

Cross reference: Cross reference: A0043, A0057

Findings include:

A request was made for a policy on accompanying patients to the patio. None was provided.

Policy titled, "Written Plan of Service and Staff Composition", revealed: "...The first priority in staffing the facility is to provide a safe environment while maintaining a therapeutically sound program. Staffing patterns may be adjusted according to census and level of acuity and are adjusted to meet the needs of the patients at any particular time...."

Policy titled, "Staffing/Acuity Plan", revealed: "...Staffing Patterns: a. Number of Staff: Nursing units are staffed according to full-time equivalents (FTEs) derived from the average daily census of that unit. The hours of nursing care have been based on national averages of patient acuity levels adjusted to this institution and utilized through the patient acuity classification system...b. Staffing Mix: Consideration is given in the staffing plan to the utilization of registered nurses, behavioral health techs, and nursing assistants (if applicable) according to identified patient requirements for nursing care and the scope of nursing practice permitted by applicable law and regulation...Acuity Tool: The acuity tool is based on five categories: Utilization, Behaviors, Medical Complexity, Mobility, Toileting...A nursing average and a BHT average is determined to ensure the right skill mix for each unit...."

Review of Core Staffing Nursing Matrix for each inpatient unit was reviewed and revealed the following staff patterns for each unit (Monarch, Phoenix, Lotus, Cicada, Koi):
Monarch Days Afternoon Nights
Census RN/BHT RN/BHT RN/BHT
7-10 1/2 1/2 1/2
5-6 1/2 1/2 1/1
1-4 1/1 1/1 1/1

Phoenix Days Afternoons Nights
9-20 2/2 2/2 1/2
6-8 2/2 2/2 1/1
4-5 1/2 1/2 1/1
1-3 1/1 1/1 1/1

Lotus Days Afternoons Nights
9-20 2/2 2/2 1/2
6-8 2/2 2/2 1/1
4-5 1/2 1/2 1/1
1-3 1/1 1/1 1/1

Cicada Days Afternoons Nights
9-10 2/2 2/2 1/2
6-8 2/2 2/2 1/1
4-5 1/2 1/2 1/1
1-3 1/1 1/1 1/1

Koi Days Afternoons Nights
9-20 2/2 2/2 1/2
6-8 2/2 2/2 1/1
4-5 1/2 1/2 1/1
1-3 1/1 1/1 1/1

Review of the staffing assignments for 05/27/2024 2300-05/28/2024 0700 for Lotus and Phoenix units were as follows:
Phoenix Unit: Census 20 patients # of RNs: 1 # of BHTs: 1
Lotus Unit: Census 14 patients # of RNs: 1 # of BHTs: 1
Review of the staffing matrix revealed on Phoenix unit for 20 patients staffing should have been 1 RN and 2 BHT and Lotus unit for 14 patients staffing should have been 1RN and 2 BHT.

Document titled, "Incident report", revealed: "...Location: Lotus Unit (RN) called for assistance with four patients being unruly and belligerent with staff. Upon arrival to the unit noted 4 patients in the hallway upset and refusing to enter their rooms. (Patient #3) was so upset s/he stated s/he could not even talk about it. S/he was upset because s/he felt the staff on duty were being disrespectful to hem/her and the other kids. Pt was harming by banging fists into the wall. Pt was asked if s/he would calm down if we called the provider and got something to help him/her relax. Pt stated s/he would because it;s just too much here and they (staff on duty) make it harder. (RN) stated s/he had already given Patient #3 the "max" there was nothing else s/he could do. Call placed to DR. with the above and informed [him] that the pt had already received a Benadryl 50 mg and Vistaril 50 mg but still extremely agitated. [Dr. Carr] ordered Zyprexa 10 mg PO to be given. Pt took the medication but was still irate. Explained to the pt that it would take a little while to take effect. Pt was about to start banging the wall again, when it was suggested s/he try walking around the courtyard to get some fresh air. Pt agreeable. The other three patients also wanted to go so they included. All four patients did start to calm down and were expressing their concerns as they walked around, at 1305 (RN) on Phoenix unit came out and sat on a chair outside. The kids started saying they did not want her/him out there with them. They all started to escalate and start cursing and asking for her/him to leave, I informed them that s/he was just making sure all was safe. All four patients began to retaliate the decision was made to go back in side, when Patient #3 began kicking at the doors to the back wall across the glass doors of the hallway. The other kids also began kicking the doors because the two nurses and the BHT the patients were upset with were coming up the hallway towards them. They continued to kick in the doors until the doors busted open and all 4 patients escaped. A CODE support was called however the kids busted the door open before staff could arrive. [Dave] CEO was called with the above. Surprise PD was called. Pts [father] was called and informed...."

Hospital document titled, "Video Review", revealed: "...(Location Lotus unit) 00:24:55 pts down hall, in and out of rooms...00:28:29 Back to rooms...00:28:38 House supervisor shows up...00:29:30 patients in hall with RN and House supervisor escalating...00:33:57 2 patients at nurse station with house supervisor...00:39:09 House supervisor goes to take one patient our to courtyard, other patients in rooms, s/he allows for them to come first patient goes and gets 4th patient from room...00:40:03 RN from Phoenix unit goes outside...00:40:22 RN From Phoenix unit leaves courtyard with house supervisor and patients...00:44:41 RN enters hallway while supervisor and patients remain in corridor...00:46:07 patient starts to kick at exterior door...00:47:04 door starts to give way and all the patients begin kicking at door...00:48:31 Door gives way and all 4 elope...00:50 CODE called..."

Hospital document titled, "Follow up for Nursing Leadership", revealed: "...On 05/28/2024 at 00:40 am four adolescent patients were taken outside of lotus unit by acting House Supervisor (name). The patients walked around courtyard #2 for approximately five minutes. At 00:44:48 the adolescents were being escorted back to the unit from the courtyard and entered breezeway leading from courtyard #2 to Lotus unit exit door. Adolescent patients paused in breezeway. Adolescent patient #1 began hitting at fire exit door in breezeway which exits the west end and leads outside facility. Patient #2 walks over to the same door and begins pushing/kicking at door. Patient #3 starts hitting/pushing door approximately 30 seconds later. HS is seen standing next to the door and appears to be talking to patients. At 00:48 the exit door fails at the bottom corner end. A space is created in which the adolescents slide through one after the other and AWOL from facility...HS failed to ensure the safety of staff and patients. Error in judgement AEB by allowing patients outside without proper staffing to ensure safety. HS failed to call code during three minutes of patients attempting to elope...Monitoring and safety of patients inadequate...."

Hospital document titled, "Written Warning Form", revealed: "...Performance/Behaviors Observed: RN failed to ensure the safety of staff and patients. Error in judgement AEB by allowing patients outside without proper staffing to ensure safety...."

Employee #3 confirmed on 06/04/2024 that the staffing in all of the inpatient units at night is 1 RN and 1 BHT regardless of the patient census or patient acuity. Employee #3 confirmed that on 05/25/2024 at the time the four (4) patients eloped the RN from Phoenix unit was not on the Phoenix unit but was on the Lotus unit. Employee #3 confirmed that when the RN from Phoenix unit left to go to the Lotus unit there was no RN on the Lotus unit, only 1 BHT was on the Phoenix unit. Employee #3 confirmed that if a nurse or BHT is required on another unit to assist with a CODE situation then there is only 1 staff member remaining on the unit. Employee #3 confirmed that the House Supervisor is part of a CODE response team and would not be able to cover the unit that is short a staff member.