Centers for Youth and Families, Inc.

Deficiency cited, complaint survey : N 127 PROTECTION OF RESIDENTS N 127

Based on record review and interviews the facility failed to ensure that antipsychotic medications were not ordered on an PRN (as-needed) basis for 1 client (Client #1) of two case mix clients reviewed for receiving antipsychotic medications. The findings are: Review of Client #1's facesheet dated 06/17/2025 included diagnoses of disruptive mood dysregulation disorder, impulse control disorder and attention deficit disorder with hyperactivity. Review of a physician order dated 06/19/2025 by APRN(Advanced Practice Registered Nurse) #3 revealed a PRN (as-needed) order for an antipsychotic medication to be given every 12 hours as needed for anxiety/agitation. Review of a report titled "Client Doctor Orders" for Client #1 that included physician orders with a date range between 06/02/25 and 09/032025, included an order per APRN #3 dated 06/19/2025 for olanzapine (an antipsychotic medication) 5mg (milligrams) tablet disintegrating oral, to be given as needed every 12 hours for anxiety/agitation. Review of Medical Progress notes for Client #1 revealed client #1 had received chemical restraints after the provider had been notified of aggressive behaviors and then provided the authorization to administer the following medication on the following dates: - 06/18/25 at 3:45 AM; olanzapine (antipsychotic) 5 mg (milligrams) ODT(oral dissolving tablet) and diphenhydramine (antihistamine with sedative effect) 50 mg PO (by mouth) for physical aggression; -06/22/2025 at 2:24 PM; olanzapine ...

Deficiency cited, complaint survey : N 140 ORDERS FOR USE OF RESTRAINT OR N 140

Based on interviews and record review the facility failed to ensure a physician's order for a physical restraint was obtained for 1 Client (Client #1) of two clients in the sample mix reviewed for receiving physical restraints. The findings are: Review of Client #1's facesheet dated 06/17/2025 included diagnoses of disruptive mood dysregulation disorder, impulse control disorder and attention deficit disorder with hyperactivity. Review of an ESI (Emergency safety intervention) dated 06/19/2025 for Client #1 indicated Client #1 had been placed in a physical restraint for aggression toward staff, attempted property destruction, and fighting with peers. Client #1 was placed in a physical hold at 5:58 AM by QBHP (Qualified Behavioral Health Professional) #8 and released at 6:24 AM due to "no nurse present." Under the section titled, "ESI Monitoring from Onset of Restraint" documentation reflected "No nurse was present for the hold" from the onset though the release of the restraint. Review of a report titled "Client Doctor Orders" for Client #1 that included physician orders with a date range between 06/02/25 and 09/032025, revealed there was no physician order for a physical restraint for 06/19/2025 for Client #1. On 08/28/2025 during a phone interview that began at 9:42 PM, QBHP# 8 verified that Client #1 had a behavior on 06/19/2025 before 6:00 AM which included yelling, agitation, and trying to wake up the other clients on the dorm. QBHP #8 called a code over the ...

Deficiency cited, complaint survey : N 145 ORDERS FOR USE OF RESTRAINT OR N 145

Based on interviews, record review and facility policy review, the facility failed to ensure that a face-to-face assessment was completed within one hour of a restraint being initiated for one client (Client #1) of four case mix clients reviewed for emergency safety interventions. The findings are: Review of Client #1's facesheet dated 06/17/2025 included diagnoses of disruptive mood dysregulation disorder, impulse control disorder and attention deficit disorder with hyperactivity. Review of an ESI (Emergency safety intervention) dated 06/19/2025 for Client #1 indicated Client #1 had been placed in a physical restraint for aggression toward staff, attempted property destruction, and fighting with peers. Client #1 was placed in a physical hold at 5:58 AM by QBHP (Qualified Behavioral Health Professional) #8 and released at 6:24 AM due to "no nurse present." Under the section titled, "ESI Monitoring from Onset of Restraint" documentation reflected "No nurse was present for the hold" from the onset though the release of the restraint. Under the section titled, "ESI Face to Face Evaluation" documentation indicated the evaluation which included pulse, oxygen saturation, and blood pressure was not completed due to no nurse being present for the hold. On 08/28/2025 during a phone interview that began at 9:42 PM, QBHP# 8 verified that Client #1 had a behavior on 06/19/2025 before 6:00 AM which included yelling, agitation, and trying to wake up the other clients on the dorm. QBHP #8 ...

Deficiency cited, complaint survey : N 149 ORDERS FOR USE OF RESTRAINT OR N 149

Based on interviews and record review the facility failed to ensure that an Emergency safety intervention assessment with required information regarding chemical restraints were documented in clients' charts for 1 client (Clients #1) of 2 clients reviewed for receiving chemical restraints: The findings are: Review of Client #1's facesheet dated 06/17/2025 included diagnoses of disruptive mood dysregulation disorder, impulse control disorder and attention deficit disorder with hyperactivity. Review of a physician order dated 06/19/2025 by APRN #3 revealed a PRN (as-needed) order for an antipsychotic medication to be given every 12 hours as needed for anxiety/agitation, Review of a report titled "Client Doctor Orders" for Client #1 that included physician orders with a date range between 06/02/25 and 09/032025, that included diphenhydramine 50 mg to be given orally on the following dates. 06/18/2025, 07/15/2025, 07/29/2025, 08/20/2025, and Review of Medical Progress notes for Client #1 revealed client #1 had received chemical restraints after the provider had been notified of aggressive behaviors and then provided the authorization to administer the following medication on the following dates: - 06/18/25 at 3:45 AM; olanzapine (antipsychotic) 5 mg (milligrams) ODT(oral dissolving tablet) and diphenhydramine (antihistamine with sedative effect) 50 mg PO (by mouth) for physical aggression; -06/22/2025 at 2:24 PM; olanzapine 10 mg ODT and diphenhydramine 50 mg PO for physical ...

Deficiency cited, complaint survey : N 165 MONITORING DURING AND AFTER N 165

Based on record review and interviews, the facility failed to ensure that a nurse was present during a physical restraint to assess and monitor the physical and psychological safety and well-being of one client (Client #1) out of two clients in the case mix reviewed for receiving physical restraints. The findings are: Review of Client #1's facesheet dated 06/17/2025 included diagnoses of disruptive mood dysregulation disorder, impulse control disorder and attention deficit disorder with hyperactivity. Review of an ESI (Emergency safety intervention) dated 06/19/2025 for Client #1 indicated Client #1 had been placed in a physical restraint for aggression toward staff, attempted property destruction, and fighting with peers. Client #1 was placed in a physical hold at 5:58 AM by QBHP (Qualified Behavioral Health Professional) #8 and released at 6:24 AM due to "no nurse present." Under the section titled, "ESI Monitoring from Onset of Restraint" documentation reflected "No nurse was present for the hold" from the onset though the release of the restraint. Under the section titled, "ESI Face to Face Evaluation" documentation indicated the evaluation which included pulse, oxygen saturation, and blood pressure was not completed due to no nurse being present for the hold. On 08/28/2025 during a phone interview that began at 9:42 PM, QBHP# 8 verified that Client #1 had a behavior on 06/19/2025 before 6:00 AM which included yelling, agitation, and trying to wake up the other clients ...

Deficiency cited, complaint survey : N 178 NOTIFICATION OF PARENT(S) OR LEGAL N 178

Based on record review, interview, and facility policy reviews, the facility failed to ensure documentation for guardian notification was in the client's clinical record after the implementation of an emergency safety intervention for one (Client #1) of two case mix clients who had restraints documented in their record. The findings are: Review of Client #1's facesheet dated 06/17/2025 included diagnoses of disruptive mood dysregulation disorder, impulse control disorder and attention deficit disorder with hyperactivity. Review of an ESI (Emergency safety intervention) dated 06/19/2025 for Client #1 indicated Client #1 had been placed in a physical restraint for aggression toward staff, attempted property destruction, and fighting with peers. Client #1 was placed in a physical hold at 5:58 AM by QBHP (Qualified Behavioral Health Professional) #8 and released at 6:24 AM due to "no nurse present." Under the section titled, "ESI Monitoring from Onset of Restraint" documentation reflected "No nurse was present for the hold" from the onset though the release of the restraint. In response to the printed question of who notified the guardian the documentation reflected, "No nurse was present for the hold." In response to the question "Was a letter mailed to parent" in this section the response was "N/A. (not applicable)" On 08/28/2025 during a phone interview that began at 9:42 PM, QBHP# 8 verified that Client #1 had a behavior on 06/19/2025 before 6:00 AM which included yelling ...

Deficiency cited, complaint survey : N 188 POST INTERVENTION DEBRIEFINGS N 188

Based on record review and interviews the facility failed to ensure that a post intervention debriefing was completed with 24 hours of 1 client (Client #1) of 2 casemix clients who were reviewed for being placed in a physical restraint. The findings are: Review of Client #1's facesheet dated 06/17/2025 included diagnoses of disruptive mood dysregulation disorder, impulse control disorder and attention deficit disorder with hyperactivity. Review of an ESI (Emergency safety intervention) dated 06/19/2025 for Client #1 indicated Client #1 had been placed in a physical restraint for aggression toward staff, attempted property destruction, and fighting with peers. Client #1 was placed in a physical hold at 5:58 AM by QBHP (Qualified Behavioral Health Professional) #8 and released at 6:24 AM due to "no nurse present." Under the section titled, "Client Debriefing" documentation reflected client debrief was incomplete and last attempt to debrief with client was on 06/19/2025 at 7:02 AM. The section containing questions to ask the client were left unanswered. On 08/28/2025 during a phone interview that began at 9:42 PM, QBHP# 8 verified that Client #1 had a behavior on 06/19/2025 before 6:00 AM which included yelling, agitation, and trying to wake up the other clients on the dorm. QBHP #8 called a code over the walkie-talkie system and QBHP#6 responded. When QBHP#6 arrived Client #1 started hitting staff member QBHP #6 who instructed QBHP#8 to physically restrain the client and ...