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Based on staff interviews, record review and facility policy review the facility failed to implement a physician ordered intervention (for patient #4) that resulted in sexual abuse for 1 of 5 sampled patients (#5).

The findings include:

Review of the patient #4's clinical record was conducted on 11/2/2012. The nurse's notes by the Intensive Care Unit Registered Nurse (ICU RN) dated 10/27/2012 7 AM - 11 PM stated patient #4 was seen giving oral sex to peer. The patient was transferred to the female unit to possibly decrease his acting out. The physician orders for patient #4 dated 10/24/2012 0100 stated constant observation 24/7-when patient is in his room he has to be observed by camera and no roommate. The physician orders dated 10/25/2012 at 1100 stated add sexual aggression to precautions. The orders were not discontinued and still current at the time of the incident on 10/27/2012.

The nurse's note by the ICU RN dated 10/27/2012 7 AM-11 PM stated patient #5 was found in peers room receiving oral sex from peer. Further notes by the RN on 10/27/2012 revealed patient #5 stated the incident was not consensual. The physician admission assessment dated 10/23/2012 revealed patient #5 had an admitting diagnosis of Alzheimer's Disease and was confused. The assessment also stated he was disoriented to time, place and situation. The RN nurse's note dated 10/27/2012 revealed he was oriented person only.

Review of the Risk Manager (RM) investigation documentation was conducted on 11/2/2012. The RM documentation revealed the date of the incident was 10/27/2012 at approximately 4:30 PM. The investigation revealed the ICU RN on duty phoned the RM on 10/27/2012 at approximately 4:30 PM and stated she had witnessed patient #4 having oral sex with patient #5. The physician and police were notified by the RN. The RM documentation on 10/30/2012 revealed she viewed the camera recording and documented as follows: 9:29 AM mental health technician takes male patients out to smoke leaving patient #4 and 5 on the unit together and RN is at the nurse's station. 9:50 AM Patient #5 walked into patient #4's room, his door was open. Patient #5 walks over to patient 4's bed and lies across the foot. Patient #4 was lying with his head towards the foot of the bed on his stomach. Patient #4 proceeds to rub patient #5's back. He puts his hand under his shirt and down his pants. Patient #4 appears to kiss patient #5's side twice. 9:56 AM The mental health technician walks in and finds the two together in bed. 12:43-12:47 mental health technician is seen rounding on ICU men's side. 12:51 PM Patient #5 walks into patient #4's room and kneels down at the foot of the far side of the bed. He then gets on the bed. The camera then skips forward until 1:07 PM and patient #5 is seen on his back with his shirt and pants open. 12:55 PM-1:13 PM mental health technician takes male patients out to smoke leaving patients #4 and 5 on the unit together. The RN is at the nurse's station and then helps out another nurse on the women's side with a patient needing assistance with moving from a wheelchair to a chair. 1:10 PM The mental health technician starts to round on the ICU men's side. 1:11 PM The mental health technician tried to go into patient #4's room but it is locked. He returns to the nurse's station, looks at the camera and apparently sees the two men in the bed together. The RN and the technician then went to the room and removed patient #5 from the room.

A telephone interview was conducted with the ICU RN on 11/4/2012 at approximately 12:35 PM. She stated she had observed resident #4 and 5 on 10/27/2012 as she told the RM. She stated when they looked at the camera monitor on 10/27/2012 patient #4 was observed with his head on the genital area of patient #5. She stated patient #4 was wearing a hospital gown and patient #5 had his pants down and was exposed. She stated patient #4 did not have an order for constant observation at the time of the incident. She stated all physician orders must be renewed every 24 hours. She stated patient #4 was only on every 15 minute checks.

An interview was conducted with the mental health technician on 11/2/2012 at approximately 3:21 PM. He stated he was working when the incident occurred. Staff were doing every 15 minute checks on patient #4 on 10/27/2012 and he was not sure if he was on constant observation on that day. He stated patient #4 was in his room and being monitored by camera when the incident occurred. He stated he took other patients out to smoke and left the ICU RN to watch the camera. When he came back in he did not see patient #5 who was in the day room when he left. he attempted to open patient #4's door and his key would not work. He returned to the nurse's station and saw patient #4 and 5 in patient #4's room on the camera screen. He and the RN went to the room, unlocked the door and separated the patients.

An interview was conducted with the Chief Executive Officer on 11/6/2012 at approximately 9:10 AM. He stated is was not the facility policy for physician orders to only be effective for 24 hours. he stated they are in effect until the physician changes or discontinues the order. He stated this was a breakdown in communication.

The facility policy for Special Precautions Guidelines (policy # PC.027) was reviewed on 11/6/2012. The policy stated a special precaution is defined as an intensified level of staff awareness and attention to patient safety/security needs requiring the initiation of specific protocols and supplemental documentation. An order for the appropriate level of precautions is documented in the physician's order section of the medical record, and the Precaution record is initiated by the Charge nurse or designee. A physician order is required to decrease or discontinue a special precaution level. Constant observation is included in the special precaution guidelines and stated the patient is within visual range of the assigned staff at all times, preferably not more than ten feet away. The staff education materials for sexual abuse were also reviewed. They defined sexual abuse as nonconsensual sexual contact of any kind or sexual contact with a person incapable of giving consent.

Based on staff interviews, record review and facility policy review the facility failed to implement a physician ordered intervention (for patient #4) that resulted in sexual abuse for 1 of 5 sampled patients (#5).

The findings include:

Review of the patient #4's clinical record was conducted on 11/2/2012. The nurse's notes by the Intensive Care Unit Registered Nurse (ICU RN) dated 10/27/2012 7 AM - 11 PM stated patient #4 was seen giving oral sex to peer. The patient was transferred to the female unit to possibly decrease his acting out. The physician orders for patient #4 dated 10/24/2012 0100 stated constant observation 24/7-when patient is in his room he has to be observed by camera and no roommate. The physician orders dated 10/25/2012 at 1100 stated add sexual aggression to precautions. The orders were not discontinued and still current at the time of the incident on 10/27/2012.

Review of patient #5's clinical record was conducted on 11/2/2012. The nurse's note by the ICU RN dated 10/27/2012 7 AM-11 PM stated patient was found in peers room received oral sex from peer. Further notes by the RN on 10/27/2012 revealed the patient stated the incident was not consensual. The physician admission assessment dated 10/23/2012 revealed the patient had an admitting diagnosis of Alzheimer's Disease and was confused. The assessment also stated he was disoriented to time, place and situation. The RN nurse's note dated 10/27/2012 revealed he was oriented person only.

Review of the Risk Manager (RM) investigation documentation was conducted on 11/2/2012. The RM documentation revealed the date of the incident was 10/27/2012 at approximately 4:30 PM. The investigation revealed the ICU RN on duty phoned the RM on 10/27/2012 at approximately 4:30 PM and stated she had witnessed patient #4 having oral sex with patient #5. The physician and police were notified by the RN. The RM documentation on 10/30/2012 revealed she viewed the camera recording and documented as follows: 9:29 AM mental health technician takes male patients out to smoke leaving patient #4 and 5 on the unit together and RN is at the nurse's station. 9:50 AM Patient #5 walked into patient #4's room, his door was open. Patient #5 walks over to patient 4's bed and lies across the foot. Patient #4 was lying with his head towards the foot of the bed on his stomach. Patient #4 proceeds to rub patient #5's back. He puts his hand under his shirt and down his pants. Patient #4 appears to kiss patient #5's side twice. 9:56 AM The mental health technician walks in and finds the two together in bed. 12:43-12:47 mental health technician is seen rounding on ICU men's side. 12:51 PM Patient #5 walks into patient #4's room and kneels down at the foot of the far side of the bed. He then gets on the bed. The camera then skips forward until 1:07 PM and patient #5 is seen on his back with his shirt and pants open. 12:55 PM-1:13 PM mental health technician takes male patients out to smoke leaving patients #4 and 5 on the unit together. The RN is at the nurse's station and then helps out another nurse on the women's side with a patient needing assistance with moving from a wheelchair to a chair. 1:10 PM The mental health technician starts to round on the ICU men's side. 1:11 PM The mental health technician tried to go into patient #4's room but it is locked. He returns to the nurse's station, looks at the camera and apparently sees the two men in the bed together. The RN and the technician then went to the room and removed patient #5 from the room.

A telephone interview was conducted with the ICU RN on 11/4/2012 at approximately 12:35 PM. She stated she had observed resident #4 and 5 on 10/27/2012 as she told the RM. She stated when they looked at the camera monitor on 10/27/2012 patient #4 was observed with his head on the genital area of patient #5. She stated patient #4 was wearing a hospital gown and patient #5 had his pants down and was exposed. She stated patient #4 did not have an order for constant observation at the time of the incident. She stated all physician orders must be renewed every 24 hours. She stated patient #4 was only on every 15 minute checks.

An interview was conducted with the mental health technician on 11/2/2012 at approximately 3:21 PM. He stated he was working when the incident occurred. Staff were doing every 15 minute checks on patient #4 on 10/27/2012 and he was not sure if he was on constant observation on that day. He stated patient #4 was in his room and being monitored by camera when the incident occurred. He stated he took other patients out to smoke and left the ICU RN to watch the camera. When he came back in he did not see patient #5 who was in the day room when he left. he attempted to open patient #4's door and his key would not work. He returned to the nurse's station and saw patient #4 and 5 in patient #4's room on the camera screen. He and the RN went to the room, unlocked the door and separated the patients.

An interview was conducted with the Chief Executive Officer on 11/6/2012 at approximately 9:10 AM. He stated is was not the facility policy for physician orders to only be effective for 24 hours. he stated they are in effect until the physician changes or discontinues the order. He stated this was a breakdown in communication.

The facility policy for Special Precautions Guidelines (policy # PC.027) was reviewed on 11/6/2012. The policy stated a special precaution is defined as an intensified level of staff awareness and attention to patient safety/security needs requiring the initiation of specific protocols and supplemental documentation. An order for the appropriate level of precautions is documented in the physician's order section of the medical record, and the Precaution record is initiated by the Charge nurse or designee. A physician order is required to decrease or discontinue a special precaution level. Constant observation is included in the special precaution guidelines and stated the patient is within visual range of the assigned staff at all times, preferably not more than ten feet away. The staff education materials for sexual abuse were also reviewed. They defined sexual abuse as nonconsensual sexual contact of any kind or sexual contact with a person incapable of giving consent.