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Based on a review of medical records, policy and procedures, observations, and staff interviews, it was determined that the facility failed to promote and protect patient rights for two patients (P) (P#1 and P#2) out of four sampled patients. On 3/26/23, P#1 and P#2 engaged in sexual boundary violations when the facility staff failed to provide watchful oversight to prevent sexually inappropriate behavior.

Cross Reference to A 0145 as it relates to the facility's failure to protect the rights of P#1 and P#2 from all forms of abuse or harassment.

Based on a review of medical records, policy and procedures, observations, and staff interviews, it was determined that the facility failed to protect the patient's right to be from abuse for two patients (P) (P#1 and P#2) of four sampled patients.


Findings included:

A medical record (MR) review revealed that Patient (P) #1 was a 15-year-old male admitted to the facility involuntarily on 3/22/23 at 4:55 a.m. due to cutting himself with glass. A review of the 'High-Risk Assessment' form by Registered Nurse (RN) LL revealed that P#1 was at high risk for suicide and required every 5-minute observation. Suicide precautions and every 5-minute observations were ordered by the provider on 3/22/23 at 5:00 a.m. Documentation on the Observation Sheets revealed that P#1 was in his room on 3/26/23 from 2:05 p.m. to 4:00 p.m. Behavioral Health Associate (BHA) EE initialed the observation forms every five minutes.

A review of an order signed by the Nurse Practitioner (NP) on 3/26/23 at 8:23 p.m. revealed that P#1 was sent out for medical clearance and a check-up due to inappropriate sexual behavior.
A review of a nursing reassessment on 3/27/23 at 1:05 p.m. by RN BB revealed that P#1 was sexually inappropriate with one of his peers. As a result, P#1 was sent to the hospital for a medical evaluation.

A review of P#2's medical record revealed that he was an 11-year-old boy admitted to the facility involuntarily on 3/25/23 at 8:03 p.m. with diagnoses of Major Depressive Disorder (depression) and attention deficit hyperactivity disorder (ADHD). A review of the 'Intake Assessment' on 3/25/23 at 8:52 p.m. by Social Worker (SW) JJ revealed that P#2 presented to the emergency department (ED) with active homicidal behaviors toward family members. A 'High-Risk Assessment' completed on 3/25/23 at 9:54 p.m. revealed that P#2 had a low risk for suicide and a history of aggressive behavior. P#2 was placed on every 5-minute observation with suicide and assault precautions. Documentation on the Observation Sheets revealed that P#2 was in his room on 3/26/23 from 2:05 p.m. to 4:00 p.m. Behavioral Health Associate (BHA) EE initialed the observation forms every five minutes.

A review of a telephone order signed by RN CC on 3/26/23 at 7:00 p.m. and NP HH revealed that P#2's room would be blocked (no roommates allowed), and P#2 was placed on sexual-acting-out (SAO) precautions, every 5-minute observations for inappropriate sexual behavior, and P#2 would sleep in the dayroom. A review of a telephone order taken by RN CC on 3/26/23 at 8:23 p.m. revealed that P#2 would be sent out for a medical check-up and clearance due to inappropriate sexual behavior.

A review of a nurse progress note on 3/26/23 at 11:05 p.m. revealed the nurse contacted P#2's parent to notify the parent that both boys said they had sex with each other. The parents gave permission for the hospital to follow protocol regarding the incident.



A review of the facility's policy titled "Patient Rights" policy #RI-001, reviewed 1/2022, revealed that it was the facility's policy to ensure that all patients received a copy of the Patient Rights form prior to admission, as well as an oral explanation of those rights in the patient's primary language in simple non-technical terms.

A review of the facility's policy titled "Levels of Observation" policy #CTS-113, reviewed 1/2022, revealed that a level of observation was defined as an intensified level of staff awareness and attention to patient safety/security needs requiring the initiation of specific protocols and supplemental documentation. The nurse or physician would determine the level of risk associated with each new admission and throughout their hospitalization on the basis of past behavior, present situation, and current mental status. A Rounds Sheet, which reflected the level of observation, precautions, date, time, location, and observed behaviors, would be maintained by the assigned nursing staff. The staff would maintain visual and verbal contact sufficient to monitor the patient's condition at a frequency level as ordered by the physician (every 15 minutes, for example). One-to-one (1:1) observation required a staff member to be within close proximity to safely intervene as needed.

A review of the facility's policy titled "Alleged Patient Abuse, Neglect, and Exploitation" policy #R1-009, reviewed 1/2023, revealed that it was the facility's policy that all allegations of patient abuse, neglect, and exploitation be reported immediately and investigated within 24 hours of the time the incident occurred. The purpose of the policy was to ensure that patients were treated with dignity and respect in accordance with the Patient's Bill of Rights and other applicable laws and to ensure that incidents or allegations were handled fairly, thoroughly, and expeditiously. Abuse was defined as a serious physical bodily, or mental injury that was not accidental. Neglect was any circumstance which resulted from leaving unfinished or unattended one's duties and responsibilities for patient care which endangered a patient's life or development or impaired the patient's functioning. Child abuse was an act or failure to act which caused non-accidental and serious physical or mental injury to a child or sexual abuse.

A review of the facility's policy titled "Abuse and/or Neglect of Patients," policy #R1-010 revealed that no employee would mistreat and/or neglect a patient. Examples of actions/inactions which could be mistreatment/abuse included failing to attend to the necessary care and treatment of a patient or failure to intervene to protect a patient from abuse and/or mistreatment by another patient or employee.

An interview took place with the Director of Risk Management (RM) AA on 4/11/23 at 3:49 p.m. in the conference room. RM AA stated she was on the unit when NP DD and charge nurse RN BB spoke to P#2 because P#2 had allegations of abuse. P#2 said P#1 pulled him down the hallway to his room, and he put his penis on his side and buttocks. RM AA stated she reviewed the video and saw P#2 enter P#1's room during reflection time (personal time). P#1 would motion for P#2 to come, and the patients went back and forth down the hallway to each other's rooms. RM AA said that BHA FF was supposed to walk the hallway during reflection time, but RM AA did not see BHA FF get up to enter the rooms. The time of the incident was during reflection from 2:00 p.m. to 3:30 p.m. on 3/26/23. RM AA further said that corporate Risk Management chose severity Level I after the incident was reported to them. The incident investigation was due to be completed on 4/11/23.

An interview took place with the BHA EE on 7/11/23 at 5:33 p.m. BHA EE stated that on the date of the incident, she was on the unit at the beginning of reflection time, settled the kids down for reflection, and went to lunch. BHA EE said BHA FF was sitting on one side of the unit when she left the unit. BHA EE said she was gone longer than usual because of car problems and returned to the unit after 4:00 p.m. when reflection time was over. When BHA EE got ready to leave for the day, another patient told BHA EE that P#2 tried to lure P#1 to his room to have sex with him. BHA EE spoke to P#1 and P#2, who said nothing happened. The other patient was pressuring P#1 to tell BHA EE what happened and brought P#1 to talk to BHA EE again. P#1 said P#2 kept coming into his room wanting to have sex with him, and P#1 admitted that he and P#2 had sex. BHA EE explained that the facility policy was to visualize patients every five minutes. The BHAs would walk the floor, and there was usually a BHA on each unit hallway. BHA EE said BHA FF could not observe patients on both hallways every five minutes, and it was impossible to see both hallways simultaneously.

A telephone interview took place with the RN CC on 4/12/23 at 9:55 a.m. RN CC stated that on 3/26/23, P#2 told RN CC that he had sex with P#1 during reflection. RN CC said she was on the unit during reflection, and they did not have the other BHA who was supposed to be there. One BHA (FF) was on the unit, and RN CC was the only nurse with 20 patients. RN CC said she would frequently have to leave the unit to go to other units to use their fax machine for medication orders.

An interview took place with the NP DD on 4/12/23 at 10:28 a.m. in the conference room. NP DD stated that according to P#2, P#1 came to his room, dragged P#2 to his room, and put his penis on P#1's buttocks.

An interview took place with the BHA FF on 4/12/23 at 10:50 a.m. BHA FF said he was assigned to watch one side of the hallway of the adolescent unit while another team member watched the other side. The other team member stepped off the unit. BHA FF said the unit was at capacity, and he was on the other hallway (girls' side) trying to de-escalate the girls who were going into each other's rooms. The boys' side was not being watched. BHA FF said he had all the rounds sheets but could not complete the observation rounds. BHA FF explained that typically, the observation rounds involved putting eyes on the patients and checking for breathing for patients who were sleeping. BHA FF confirmed that visualizing the boys every five minutes did not occur. BHA FF said the rounds sheets had already been pre-filled out by BHA EE before she left the unit. BHA FF explained that BHA EE was gone from the unit for more than 30 minutes. BHA FF said that the nurses would have been at the nurses' station and had to peek over the counter or stand up to see the hallways.

An interview took place with the Director of Nursing (DON) GG on 4/12/23 at 1:27 p.m. DON GG stated that anytime someone was making sexual advances at a child, it was considered sexual abuse. DON GG explained that two nurses were scheduled on the date of the incident, and one nurse called out. DON GG said two BHAs were on the unit on the day of the incident. DON GG said if a staff member left the unit, the staff member was required to get relief from a different unit. DON GG further said BHA EE falsified the observation sheets when BHA EE initialed the sheets at a time when she was not on the unit. DON GG said BHA EE was terminated for leaving her post for an extended period and falsifying documentation. BHA FF was terminated for not doing observation rounds, which was patient neglect. RN CC was also terminated due to not requesting assistance when there was insufficient staff to monitor the unit. All three staff were terminated on 4/12/23 after the facility investigation was completed.

A review of video footage from 3/26/23 took place in the RM office with RM AA on 4/13/23 at 12:30 p.m.

The following was observed:

3:20:57 p.m.- P#1 was standing in his bedroom doorway.
3:21:10 p.m. P#1 motioned with his hands to P#2, who was standing in his bedroom doorway, to come to P#1's room.
3:21:22 p.m. P#2 came to P#1's room where he and P#1 stood in the corner of P#2's bedroom near the hallway.
3:21:59 p.m. P#1 and P#2 observed kissing.
3:22:07 p.m. P#2 went back to his room.
3:22:55 p.m. P#2 went back to P#1's room. P#1 was standing by the doorway in the corner of his room.
3:23:20 p.m. P#1 wrapped his arms around P#2, guided him into the bathroom, and closed the door.
3:24:54 p.m. The bathroom door opened.
3:25:20 p.m. P#2 left P#1's room and returned to his room.
3:28:00 p.m. P#2 returned to P#1's room. P#1 was observed bending over. P#2 pulled P#1's pants down and held P#1 in front of him in the corner of P#1's room.
3:29:08 p.m. P#1 walked P#2 into his bathroom.
3:31:02 p.m. P#2 was observed on his hands on the bathroom floor.
3:31:11 p.m. P#1 was lying on the bathroom floor with P#2 on top of him.
3:32:04 p.m. P#2 ran to his room. P#1 was still in the bathroom.


It was observed on the video surveillance review that BHA FF left the unit at 3:10:56 p.m. and returned at 3:46:37 p.m. No other staff was observed present on the unit during the times reviewed.

A tour of the adolescent unit took place on 4/12/23 at 3:30 p.m. with the Chief Executive Officer (CEO). It was observed that two hallways split from a nurse's station in two different directions. The nurses' station was in the center of the hallways with countertops that were high enough that the hallways would not be visible to an individual seated behind the nurses' station. One hallway was not visible from the other hallway.

Based on review of medical records, policy and procedures, observations, and staff interviews, it was determined that the facility failed to ensure that nursing services provided watchful oversight of patients. Facility staff failed to conduct every five-minute observation as ordered. As a result of this failure, P#1 and P#2 engaged in sexually inappropriate behavior on 3/26/23.


Cross Reference to A-0382 as it relates to the facility's failure to ensure adequate personnel to provide care and nursing services.

Based on review of medical records, policy and procedures, observations, and staff interviews, it was determined that the facility failed to ensure that adequate numbers of staff were available to monitor patients for safety as ordered. Video recording confirmed that the facility staff failed to conduct every five-minute observation as ordered. However, documentation in the medical record indicated that every five-minute observation had been conducted. As a result of this failure, P#1 and P#2 engaged in sexually inappropriate behavior on 3/26/23.

Finding included:

A review of medical record documentation on the Observation Sheets revealed that P#1 and P#2 was in his respective room on 3/26/23 from 2:05 p.m. to 4:00 p.m. Behavioral Health Associate (BHA) EE initialed the observation forms every five minutes.

A review of the facility's policy titled "Levels of Observation" policy #CTS-113, reviewed 1/2022, revealed that a level of observation was defined as an intensified level of staff awareness and attention to patient safety/security needs requiring the initiation of specific protocols and supplemental documentation. The nurse or physician would determine the level of risk associated with each new admission and throughout their hospitalization on the basis of past behavior, present situation, and current mental status. A Rounds Sheet, which reflected the level of observation, precautions, date, time, location, and observed behaviors would be maintained by the assigned nursing staff. The staff would maintain visual and verbal contact sufficient to monitor the patient's condition at a frequency level as ordered by the physician (every 15 minutes, for example). One to one (1:1) observation required a staff member to be within close proximity to safely intervene as needed.

A review of the facility's policy titled "Alleged Patient Abuse, Neglect, and Exploitation" policy #R1-009, reviewed 1/2023, revealed that it was the purpose of the policy to ensure that patients were treated with dignity and respect in accordance with the Patient's Bill of Rights and other applicable laws, and to ensure that incidents or allegations were handled fairly, thoroughly, and expeditiously. Neglect was any circumstance which resulted from leaving unfinished or unattended one's duties and responsibilities for patient care which endangered a patient's life or development or impaired the patient's functioning.


A review of the facility's policy titled "Abuse and/or Neglect of Patients" policy #R1-010, revealed that no employee would mistreat and/or neglect a patient. Examples of actions/inactions which could be mistreatment/abuse included failing to attend to the necessary care and treatment of a patient or failure to intervene to protect a patient from abuse and/or mistreatment by another patient or employee.

An interview took place with the Director of Risk Management (RM) AA on 4/11/23 at 3:49 p.m. in the conference room. RM AA stated the BHA FF was supposed to walk the hallway during reflection time, but RM AA did not see BHA FF get up to go into the rooms.

An interview took place with the BHA EE on 4/11/23 at 5:33 p.m. BHA EE stated that on the date of the incident, she was on the unit at the beginning of reflection time, settled the kids down for reflection, and went to lunch. BHA EE said BHA FF was sitting on one side of the unit when she left the unit. BHA EE said she was gone longer than usual because of car problems and returned to the unit after 4:00 p.m. when reflection time was over. BHA EE explained that facility policy was to visualize patients every five minutes. The BHAs would walk the floor, and there was usually a BHA on each hallway of the unit. BHA EE said BHA FF could not observe patients on both hallways every five minutes, and it was impossible to see both hallways at the same time.

A telephone interview took place with the RN CC on 4/12/23 at 9:55 a.m. RN CC stated that she was on the unit during reflection on 3/26/23, and they did not have the other BHA who was supposed to be there. There was one BHA (FF) on the unit, and RN CC was the only nurse with 20 patients. RN CC said she would frequently have to leave the unit to go to other units to use their fax machine for medication orders.


An interview took place with the BHA FF on 4/12/23 at 10:50 a.m. BHA FF said he was assigned to watch one side of the hallway of the adolescent unit while another team member watched the other side. The other team member stepped off the unit. BHA FF said the unit was at capacity, and he was on the other hallway (girls' side) trying to de-escalate the girls who were going into each other's rooms. The boys' side was not being watched. BHA FF said he had all the rounds sheets but was not able complete the observation rounds. BHA FF explained that typically, the observation rounds involved putting eyes on the patients and checking for breathing for patients who were sleeping. BHA FF confirmed that visualizing the boys every five minutes did not occur. BHA FF said the rounds sheets had already been pre-filled out by BHA EE before she left the unit. BHA FF explained that BHA EE was gone from the unit for more than 30 minutes. BHA FF said that the nurses would have been at the nurses' station and would have had to peak over the counter or stand up to see the hallways.


An interview took place with the Director of Nursing (DON) GG on 4/12/23 at 1:27 p.m. DON GG stated that anytime someone was making sexual advances at a child, it was considered sexual abuse. DON GG explained that two nurses were scheduled on the date of the incident, and one nurse called out. DON GG said that two BHAs were on the unit the day of the incident. DON GG said if a staff member left the unit, the staff member was required to get relief from a different unit. DON GG further said BHA EE falsified the observation sheets when BHA EE initialed the sheets at a time that she was not on the unit. DON GG said BHA EE was terminated for leaving her post for an extended period of time and falsification of documentation. BHA FF was terminated for not doing observation rounds, which was patient neglect. RN CC was also terminated due to not requesting assistance when there were not enough staff to monitor the unit. All three staff were terminated on 4/12/23, after the investigation was completed.


A review of video footage from 3/26/23 took place in the RM office with RM AA on 4/13/23 at 12:30 p.m. The video footage revealed that BHA FF left the unit at 3:10:56 p.m. and returned at 3:46:37 p.m. No other staff were observed present on the unit during the times reviewed.

A tour of the adolescent unit took place on 4/12/23 at 3:30 p.m. with the Chief Executive Officer (CEO). It was observed that there were two hallways that split from a nurse's station in two different directions. The nurses' station was in the center of the hallways with countertops that were high enough that the hallways would not be visible to an individual seated behind the nurses' station. One hallway was not visible from the other hallway.