HospitalInspections.org

Based on interview and record review, the facility failed to meet the Condition of Participation (CoP) for the patients right to be free from harm, neglect, and harassment by failing to comply with the requirements as evidenced by the following:

A. The facility failed to ensure the patients' right to receive care in a safe setting, and to be free from harm and harassment, by not monitoring patients, by not assigning and completing 15 minute checks timely. Refer to 0144.

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Based on record review and interview the facility failed to:
1. Ensure patients are receiving care in a safe setting by not monitoring patients, by not assigning and completing 15 minute checks timely, not having legible signatures, missing signatures, not having prescribed precautions, and missing 15 minute checks for P (patients) 1-10 reviewed.
2. Ensure patients are protected from harm by not assessing high risk level patients, by not identifying multiple risk factors for 2 (P1, P2) patients.
This deficient practice is likely to continue to put patients at risk for sexual abuse, injury, harm, serious impairment, or death for all patients receiving care at this facility.

Findings are:

A. Record review of facility policy titled "Behavioral Health (BH) Risk Estimation & Behavioral Monitoring" effective date 09/16/2021, stated under "Areas of Responsibility, Mental Health Technician and Mental Health Associate (MHT/MHA) [bolded and capitalized in policy]- Monitors patients as ordered. Documents patient location and activity. Documents changes in patient's behaviors in the "Agitated behavior Scale Form" and verbally reports behaviors to the patient's RN (Registered Nurse)." Under "Guideline Steps, 4. Unit Core Risk Mitigation:
e. Day and evening environmental scan: sanitation and safety. i. Environmental scan [to assess the area/unit for any potential risk to the patient and/or staff] is assigned to MHT/MHA by the RN. 9. Monitoring defined, c. Every 15 Minute Monitoring, i. At a minimum, all patients will be monitored randomly within 15 minute blocks of time, including while the patient is asleep. These checks are documented on the Q-15.
iii. An assigned staff member will circulate throughout all patient care areas and patient rooms to visually ensure and document the patient's location and status.

Monitoring (not assigning 15 minute checks):

B. Interview with Staff (S)9, Unit Director on 10/04/2022 at 12:04 pm, when asked if there was a policy on making MHT assignments, answer was "No." When asked "How do the MHT's know what their duties are if the assignment sheet has not been done?" Response was, "They would communicate with each other. The ideal is the assignment sheet is supposed to be made and they know what they are supposed to be doing." When asked, "How do you ensure the patients on continuous observation or 1:1 observation are being monitored and the techs are doing what they need to be doing?" Response was, "There's no way to track it when the assignment sheet is not done."

C. Interview with S13, (Mental Health Tech) on 10/06/2022 at 2:35 pm, when asked "How do you know what to do if the assignment sheet isn't filled out?" Response was, "I'll ask the nurse, either one. I don't necessarily know who the charge nurse is because of seniority or things like that." When asked, "Does it ever cause confusion between the techs if there isn't an assignment sheet completed?" Response was, "Sometimes when were short staffed it does. If there's only 2 people, it's kind of rough to do everything."

D. Record review of Facility Name assignments from 09/01/2022 to 10/03/2022 show: 35 of 65 assignment sheets were not completed including 09/17/2022 night shift to 09/28/2022 night shift and of the 30 received from facility 9 of 30 assignments were missing dates. The facility failed to complete the assignment sheet and the sheets that were completed did not have a date.

E. Interview with S9, (Unit Director) on 10/03/2022 at 11:45 am when asked, "How are 15 minute rounds done?" Response was, "The assignment is created by the charge nurse and the Mental Health Techs are alternated from 15 minute rounds to 1:1 observations." When asked to see the assignment sheet for the unit, for the day, was told, "We just discovered we don't have an assignment sheet completed for today."

F. Interview with S10, Mental Health Tech on 10/05/2022 at 2:15 pm, when asked, "What training did you receive to complete 15 minute rounds?" Response was, "Oh, I'm sure there was an online course or on the job training and the seriousness of completing them was definitely underlined."

Monitoring (not completing 15 minute checks timely, not having legible signatures, missing signatures, not having prescribed precautions, and missing 15 minute checks):

G. Record review of 20 Adult Behavioral Monitoring Forms for P1 dated 09/13/2022 to 10/3/2022 shows 1 day of 15 minute rounds missing for 10/03/2022, 9 of 20 records show missing staffing initials on 15 minute checks, 20 of 20 records have illegible staff names signed on form, 20 of 20 records show illegible location/activity codes, 18 of 20 records have staff initials that do not match signature/initial box for staff, 19 of 20 records are missing precautions marked on form, 1 of 20 records show other marked in precautions box with no identifier noted, 1 of 20 records are missing 15 minute round checks.

H. Record review of 26 Adult Behavioral Monitoring Forms for P2 dated 09/7/2022 to 10/3/2022 shows 1 day of 15 minute rounds missing for 10/03/2022, 10 of 27 records show missing staffing initials on 15 minute checks, 26 of 26 records have illegible staff names signed on form, 20 of 20 records show illegible location/activity codes, 26 of 26 records have staff initials that do not match signature/initial box for staff, 26 of 26 records are missing precautions marked on form, and 1 of 20 records are missing 15 minute round checks.

I. Record review of 48 Adult Behavioral Monitoring Forms for P3 dated 08/15/2022 to 10/3/2022 shows 2 days of 15 minute rounds missing, 11 of 48 records show missing staffing initials on 15 minute checks, 48 of 48 records have illegible staff names signed on form, 45 of 48 records show illegible location/activity codes, 47 of 48 records have staff initials that do not match signature/initial box for staff, 48 of 48 records are missing precautions marked on form, and 1 of 20 records are missing 15 minute round checks.

J. Record review of 22 Adult Behavioral Monitoring Forms for P4 dated 08/27/2022 to 09/07/2022 shows 2 of 22 records missing staffing initials on 15 minute checks, 21 of 22 records have illegible staff names signed on form, 20 of 22 records show illegible location/activity codes, 21 of 22 records have staff initials that do not match signature/initial box for staff, 22 of 22 records are missing precautions marked on form, and 1 of 20 records are missing date on form.

K. Record review of 9 Adult Behavioral Monitoring Forms for P5 dated 08/31/2022 to 09/08/2022 show 7 of 9 records have illegible staff names signed on form, 7 of 9 records show illegible location/activity codes, 7 of 9 records have staff initials that do not match signature/initial box for staff, 9 of 9 records are missing precautions marked on form, and 1 of 9 records are missing location/activity codes.

L. Record review of 12 Adult Behavioral Monitoring Forms for P6 dated 09/20/2022 to 10/3/2022 shows 2 days of 15 minute rounds missing, 6 of 12 records show missing staffing initials on 15 minute checks, 12 of 12 records have illegible staff names signed on form, 11 of 12 records show illegible location/activity codes, 12 of 12 records have staff initials that do not match signature/initial box for staff, 12 of 12 records are missing precautions marked on form, and 1 of 12 records are missing 15 minute round checks.

M. Record review of 15 Adult Behavioral Monitoring Forms for P7 dated 09/13/2022 to 10/3/2022 shows 6 of 15 records missing staffing initials on 15 minute checks, 14 of 14 records have illegible staff names signed on form, 14 of 15 records show illegible location/activity codes, 14 of 15 records have staff initials that do not match signature/initial box for staff, 15 of 15 records are missing precautions marked on form, 1 of 15 records show other marked in precautions box with no identifier noted, 2 of 15 records are missing 15 minute round checks.

N. Record review of 24 Adult Behavioral Monitoring Forms for P8 dated 07/23/2022 to 08/15/2022 shows 2 of 24 records missing staffing initials on 15 minute checks, 24 of 24 records have illegible staff names signed on form, 24 of 24 records show illegible location/activity codes, 23 of 24 records have staff initials that do not match signature/initial box for staff, 24 of 24 records are missing precautions marked on form, and 1 of 24 records are missing 15 minute round checks.

O. Record review of 70 Adult Behavioral Monitoring Forms for P9 dated 07/27/2022 to 10/3/2022 shows 23 of 70 records missing staffing initials on 15 minute checks, 70 of 70 records have illegible staff names signed on form, 66 of 70 records show illegible location/activity codes, 66 of 70 records have staff initials that do not match signature/initial box for staff, 70 of 70 records are missing precautions marked on form, and 2 of 70 records are missing 15 minute round checks.

P. Record review of 9 Adult Behavioral Monitoring Forms for P10 dated 07/18/2022 to 07/26/2022 show 9 of 9 records have illegible staff names signed on form, 7 of 9 records show illegible location/activity codes, 8 of 9 records have staff initials that do not match signature/initial box for staff, and 9 of 9 records are missing precautions marked on form.

Assessing: (not assessing high risk level patients by not identifying multiple risk factors):

Q. Record review of policy labeled "Behavioral Health Risk Elimination & Behavioral Monitoring" effective date: 9/16/2021 states under High Risk Estimation: "This is an estimation of the patient's risk of harm to self or others based on clinical signs, symptoms, historical data and demographic protective factors and risk categories. Such risk estimation is based on but not limited to: ...impulsiveness, active attempts to elope, history of trauma, member of high risk demographic group ... Item 2: ...the Psychiatrist will estimate the patient's level of risk and order High Risk Precautions with Behavioral Monitoring as indicated. a. High Risk Precautions (HRP) i. Elopement ii. Danger to self or others. Item 7: The multidisciplinary treatment team will discuss a patient's current clinical presentation to further estimate risk of harmful actions and determine interventions and the level of care needed to maintain patient safety. Item 8.b.: Danger to self or others i. Patients may be placed on HRP for danger to self or others when a physician believes ... patient is unable to meet their basic psychological and/or physiological needs to such a degree that they are at risk for harm.


R. Record review of State of New Mexico Uniform Incident Report Incident No. 22-24042 shows that the facility and S10 did file a police report. Reporting Officer was not able to obtain statement from either party.

Findings for P1:

S. Record review of P1 BH Adult Inpt (Inpatient) Physician Note dated September 26, 2022 12:26 pm stated "pt (patient) had incident on unit where she was found having inappropriate sexual encounter with another pt. on 9/25 ... pt was found straddling the other patients lap in chair in day room ... neither patient involved is decisional"

T. Record review of P1 "All Orders" page 1 of 5 under Communication Orders stated on admission date 9/16/2022 17:13:00 (5:13 pm) Elopement Risk. Record review of P1 BH (Behavioral Health) History + Physical dated September 13, 2022, stated: "hx (history) including kidnapping by cult, sexual trafficking, and rape ... patient is reported to have poor insight and continued interaction with her abuser ... she is considered a danger to herself ... mother is plenary (full guardianship because the ward is determined to be completely incapacitated) guardian." Per the policy of High-Risk Estimation described above, all of these factors are considered high risk.

U. Record review of P1 "All Orders" page 1 of 5 under Patient Care Behavioral Monitoring states "9/27/2022 17:36 (5:36 pm) Line-of-sight while awake." High Risk Precaution Monitoring (within line of sight) was not implemented until after sexual abuse incident occurred (09/26/22), patient was deemed by facility to be High-Risk Estimation.

V. Record review of P1 Guardianship and Conservatorship proceedings states Item 3. [P1] is totally incapacitated. Item 6. The appointment of a guardian with plenary statutory powers is necessary and desirable as a means of providing continuing care and supervision of [P1].

W. In an interview on 10/05/2022 at 1 pm with S14, Medical Doctor, when asked if P1 has the capacity to consent to sexual intercourse responded "I would say no she doesn't. My reason would be she has been found incompetent to a court and she can't voice her appreciation of the act and what it entailed. She isn't able to articulate an understanding."

X. Record review of Event log for Regulations entry dated 09/25/22; shows "Event Type: Other miscellaneous, Event Category: Other miscellaneous, Description: [MHT reported] while sitting on a 1:1 after sure he had fallen asleep I got up to walk the unit to see if there was anything to be done. I came around the corner of the nurse's station and saw legs splayed awkwardly on a chair. After doing a double take, I noticed that it was in fact two patients, both in a seated position, with the female atop bouncing up and down. I said "Hey!" and they separated without incident, both pulling up their pants which were pulled down just enough to facilitate intercourse. At this point I informed the nurses and in turn the team."

Finding for P2:

Y. Record review of P2 BH Adult Inpt Nurse Note dated September 25, 2022, 19:56 (7:56 pm) stated "Around 1930 (7:30 pm) found this patient in the corner of the milieu (environment) with another patient. Both were seated in a chair together, with the other patient sitting on this patient; both had their pants pulled down and appeared to be engaged in sexual activity."

Z. During an interview on 10/05/2022 at 2:15 pm with S10, Mental Health technician, when asked about witnessing sexual assault on 9/25/2022 stated, "I was the tech that caught the patients on east unit having sex ... I was turning around and then out of the cornier of my eye I saw legs sprawled out awkwardly and they were going at it vigorously. I said "Hey" and they split up immediately. I went and told the nurse."

AA. Record review of P2 BH Adult Case Mgmt Note dated September 8, 2022, under Nursing stated "Behavior Observation: found naked in the hallway masturbating" Per the policy of High-Risk Estimation described above, this act is considered high risk and the patient should have been ordered High Risk Precautions.

BB. Record review of P2 BH Adult Case Mgmt Note dated September 9, 2022, under Nursing stated "Behavior Observation: ...found naked, took off clothing and sat in female room ..." Per the policy of High-Risk Estimation described above, this act is considered high risk.

CC. Record review of P2 BH Adult Case Mgmt Note dated September 13, 2022, under Nursing stated "Behavior Observation: Disruptive, masturbating, ejaculating all over seclusion room, hypersexual, taking clothes off in courtyard." Per the policy of High-Risk Estimation described above, this act is considered high risk .

DD. Record review of P2 BH Adult Case Mgmt Note dated September 15, 2022, under Nursing stated "Behavior Observation: broke a window in unit" Psychiatry states: "threatened to grope doctor ... attempted elopement". Per the policy of High-Risk Estimation described above, this act is considered high risk.

EE. Record review of P2 BH Adult Case Mgmt Note dated September 19, 2022, under Nursing stated "Behavior Observation: threatened staff, took pants off in lounge ... like showing his genitals to people". Per the policy of High-Risk Estimation described above, this act is considered high risk.

FF. Record review of P2 BH Adult Case Mgmt Note dated September 22, 2022, under Psychiatry stated "Hx of violence". Per the policy of High-Risk Estimation described above, this history is considered high risk.

GG. Record review of P2 BH Adult History + Physical dated September 07, 2022, stated "Patient has a treatment guardian. He previously had a plenary guardian but was recently dismissed from that agency." Per the policy of High-Risk Estimation described above, this status is considered high risk and the patient should have been ordered High Risk Precautions.

HH. Record review of P2 "All Orders" page 1 of 6 under Patient Care Behavioral Monitoring stated "9/27/2022 19:03:00 (5:03 pm) Line of Sight Continuous Observation due to aggression, hypersexuality ..." High Risk Precaution Monitoring (within line of sight) was not implemented until after sexual abuse incident occurred, Patient was deemed by facility to be High-Risk Estimation.

II. During an interview on 10/05/2022 at 1 pm with S14, Psychiatrist, when asked if P2 has the capacity to consent to sexual intercourse responded "No. He's also been found incompetent by courts in the past"

JJ. During an interview on 10/05/2022 at 11:35 am with S15, Psychiatrist, when asked: Upon admission of a hypersexual patient, what interventions are implemented? S15 stated "Well, we assess them and kind of what their presentation is ... They will be placed on a high level or restriction [which means] they can be line-of-sight or one to one or restraint."