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The hospital failed 3 of 3 Patients (Patients #1, 2, 3) by failing to provide adequate care in a safe setting free of all forms of abuse and neglect. Patient's 1,2,3 were not under supervision for an hour and 17minutes. These patients engaged in appropriate sexual activity as result of no supervision. Patient #1 cheeked medications from the night before, crushed it on the countertop and snorted with Patient #3.

Findings Include:

During interview with Patient #1, it was confirmed in the interview that the activity started off with inappropriate touching escalating to kissings and fondling one another. It is described in one state as "eating peer out.'

During interivew with Patient #2 it was confirmed that Patient #1 and Patient #3 were engaged in sexual activity while observing and being the look out person for staff cming.

During Interview with Patietn #2 it was reported that Patient #1 and Patient #2 engaged in snorting a pill that was cheeked from the night before.

During Interivew with hospital Staff #4 it was reported that the hospital staff falsified the Patietn Observation Rounding Sheets for Patient #1, Patient #2, and Patietn #3 for an hour and 17 minutes.

During Record Review it was documented Patient #1 in the hospital Nursing Progress Note 05/03/2022 at 1000, "Another peer accused Patient #1 of inappropriate sexual behavior happening between pt #1. and another peer (Patient #3) on Saturday 04/30/2022 between the hours of 1900 and 21000 while other peers were off unit watching movie, apparently. Upon assessment, pt. #1 vehemently denies. However, 5 minutes later, pt.#1 admitted to asking two other peers (Patient 2 and Pateint #3) to play truth or dare. "So, the other peers came in her room, they shut the door, and everyone agreed to play which led to pt. performing oral sex on peer, pt. states. This allegedly happened 04/30/2022 evening time. PT. states, 'everyone was licking each other' and 'everyone was fingering each other.' Processed 1:1 with pt.#1 and reminded to seek staff if upset or has any further information."

During record review it was docmented in Patient #1's hospital Nursing Progress Note dated 05/03/2022 1730 MHT reported Patient is suspected of hoarding and snorting pills. Dr. was notified and order for room search obtained. Pt. denies snorting and hoarding pills.

During Record Review it was documented The hospital observation sheet reflected Patient Grumbrecht was in being observed during the 1900 hour on 04/30/2022.

During Record Review it was documented Patient #2 was in the hallway on 04/30/2022 in 1900 through 2000 on the Patient Observation Rounding sheet.

During Record Review of the Employee Corrective Action sheet 05/05/2022 reflected, "Staff #6 falsified observation rounds stated that eyes were on Patients that was left back on the unit. Camera observation shows that Pts were unattended for an hour and 17 minutes. Staff #6 documented that PTs. were in the gym and camera shows that they were on the unit and in the room. # Pt.'s were left on the unit unattended and engaged in inappropriate sexual activity."

Policy
The hospital Policy on Patient Rights dated 11/2024 reflected, "It is the policy of Millwood Hospital and Excel Centers to ensure that all patients receive a copy of their Patient Handbook which includes the Patient Bill of Rights as well as an oral explanation of those rights both in their primary language and in simple non-technical terms. We will strive to abide by and respect all patient rights without regard to race, religion, creed ethnicity gender, age, sexual orientation, or handicap. Millwood hospital and Excel Centers shall support and protect the fundamental human, civil constitutional and statutory rights of the individual patient and recognize and respect personal dignity of the patient at all times".

The hospital Policy on Patient Assessment dated 12/2021 reflected, All patients admitted to Millwood Hospital will receive a thorough assessment and evaluation."

The hospital Policy on Patient Reassessment dated 03/2021 reflected, "It is the policy of Millwood Hospital to assess patients at the time of admission, when transitioning to another level of care, and the time of discharge. Additional reassessment occurs on an ongoing basis via daily assessment by a Registered Nurse, Psychiatrist and Treatment Team reviews."

The hospital Policy on Appropriate Staffing levels dated 07/2021 reflected, "It is the policy of Millwood Hospital to ensure that the appropriate numbers and qualifications of nursing staff are available at all times for the care of patients. The Chief Nursing Officer (CNO) is responsible for the development and ongoing review of staffing requirements based on numbers of patients, population arrived, anxiety and measurements of patient outcomes that include patient falls, restraint/seclusion, medication errors, infection rates, patient complaints and grievances, as well as other types of incident occurrences. The staffing plan for Nursing Services to designed to comply with all applicable regulatory standards and is reviewed annually."

The hospital Policy on Reporting of Abuse, Neglect and Exploitation dated 03/2025 reflected, "It is the Policy of Millwood Hospital to report all incidents of patient abuse, neglect, and exploitation as soon as possible after the time the incident is identified."

The hospital Policy Incident Reporting Process dated 11/2021 reflected, "The Incident Reporting Process is the reporting methodology used to track incidents, outcomes or issues that potentially represent patient safety concerns or questionable clinical practices. The reporting process supports each family's patient safety efforts and multi-disciplinary peer review process."

The hospital Policy on Observation dated 12/2021 reflected, "To ensure patient safety, as well as to provide a process for observing and documenting patient location and behavior ...Review and update patient observation forms. Reflect changes in individual patient precautions levels room or bad changes ...Observe each patient, a minimum of every 15 minutes and/or according to precaution level and document observation on the patient observation form ...Perform staggered intervals and in a varying pattern or sequence throughout the unit to minimize planned acting out opportunities ...Hand off during the shift: a staff leaves the unit for break/emergencies, reassign patient observation rounds ...Handoff the Patient observation Rounds forms to person responsible for completing observation in your absence."

The hospital Policy on Medication Administration dated 01/2023 reflected, "Medications are administered by authorized licensed independent practitioners and clinical staff that are authorized to do so by the State and Federal law and hospital policy ...Medications and biologicals are administered upon the order of a practitioner responsible for the care of the patient or another practitioner responsible for the care of the patient or another practitioner acting in accordance with State law including scope of care of the patient or another practitioner acting in accordance with State law including scope of practice laws, hospital policy and procedures and medical staff by laws and rules and regulations ...Categories of licensed personnel and the types of medication they are authorized to administer are defined ...Training and staff education is provided for personnel authorized to administer medication and biologicals. Training and competency assessment are documented ...Timing of medication administration takes into account the complex nature and variability among medications, the indications for use, the clinical situation, and the needs of the patient ...Medications eligible for scheduled dosing times, medications not eligible for scheduled dosing times and time critical scheduled medications are defined ...Dose administration times are standardized for eligible scheduled medications ...Guidelines are established for initiating administration of first doses and missed or delayed dosed of scheduled medications ...Medications Procedures: "Properly position the patient if necessary ...Administer the medication, Offer additional liquid if appropriate...Observe the patient take the medication ...Stay with the patient until he/she has swallowed the medication."

The hospital Policy on Correction Action Process dated 08/2021 reflected, "The Facility expects all employees to comply with the organizations standards of behavior and performance and to know that any noncompliance with these standards must be remedied. The facility prefers to attempt to correct unacceptable behavior or unsatisfactory performance through a progressive corrective proves. However, the facility reserves the right to by-pass any progressive step(s) and impose the degree of discipline, including immediate employment termination, which it deems appropriate in the sole discretion of the Facility. It is also understood that there are certain rules of conduct that are so important that their violation usually should lead to the offender's immediate employment termination."

The hospital failed 2 of 2 Patients by failing to ensure medication was administered in accordance with Federal and State laws and regulations, and in accordance with the approved medical staff policies and procedures. Patient #1 was able to cheek medication from the night before, crush it and snort it with peer in assigned room.

Findings Included:

During interview with hospital patient #3 it was reported interview that Patient #1 was crushing her medication that cheeked the night before and snorting them on the counter with the roommate Patient #2.

During interview with hospital staff #2 it was reported in interview that they were informed that Patient #1 cheeked her medication from an unknown time and date and crushed the medications on the counter and snorted them along with Patient #2.

During record review the hospital physiican order on 05/03/2022 reflected a room search for contraband (pills).

During revord review the hospital nursing notes reflected, The hospital Nursing Progress Note dated 05/03/2022 1730 MHT reported Patient is suspected of hoarding and snorting pills. Dr. Notified and order for room search obtained. Pt. denies snorting and hoarding pills.

The hospital Policy on Medication Administration dated 01/2023 reflected, "Medications are administered by authorized licensed independent practitioners and clinical staff that are authorized to do so by the State and Federal law and hospital policy ...Medications and biologicals are administered upon the order of a practitioner responsible for the care of the patient or another practitioner responsible for the care of the patient or another practitioner acting in accordance with State law including scope of care of the patient or another practitioner acting in accordance with State law including scope of practice laws, hospital policy and procedures and medical staff by laws and rules and regulations ...Categories of licensed personnel and the types of medication they are authorized to administer are defined ...Training and staff education is provided for personnel authorized to administer medication and biologicals. Training and competency assessment are documented ...Timing of medication administration takes into account the complex nature and variability among medications, the indications for use, the clinical situation, and the needs of the patient ...Medications eligible for scheduled dosing times, medications not eligible for scheduled dosing times and time critical scheduled medications are defined ...Dose administration times are standardized for eligible scheduled medications ...Guidelines are established for initiating administration of first doses and missed or delayed dosed of scheduled medications ...Medications Procedures: "Properly position the patient if necessary ...Administer the medication, Offer additional liquid if appropriate...Observe the patient take the medication ...Stay with the patient until he/she has swallowed the medication."

The hospital Policy on Reporting of Abuse, Neglect and Exploitation dated 03/2025 reflected, "It is the Policy of Millwood Hospital to report all incidents of patient abuse, neglect, and exploitation as soon as possible after the time the incident is identified."

The hospital Policy Incident Reporting Process dated 11/2021 reflected, "The Incident Reporting Process is the reporting methodology used to track incidents, outcomes or issues that potentially represent patient safety concerns or questionable clinical practices. The reporting process supports each family's patient safety efforts and multi-disciplinary peer review process."

The hospital Policy on Observation dated 12/2021 reflected, "To ensure patient safety, as well as to provide a process for observing and documenting patient location and behavior ...Review and update patient observation forms. Reflect changes in individual patient precautions levels room or bad changes ...Observe each patient, a minimum of every 15 minutes and/or according to precaution level and document observation on the patient observation form ...Perform staggered intervals and in a varying pattern or sequence throughout the unit to minimize planned acting out opportunities ...Hand off during the shift: a staff leaves the unit for break/emergencies, reassign patient observation rounds ...Handoff the Patient observation Rounds forms to person responsible for completing observation in your absence."

The hospital Policy on Patient Rights dated 11/2024 reflected, "It is the policy of Millwood Hospital and Excel Centers to ensure that all patients receive a copy of their Patient Handbook which includes the Patient Bill of Rights as well as an oral explanation of those rights both in their primary language and in simple non-technical terms. We will strive to abide by and respect all patient rights without regard to race, religion, creed ethnicity gender, age, sexual orientation, or handicap. Millwood hospital and Excel Centers shall support and protect the fundamental human, civil constitutional and statutory rights of the individual patient and recognize and respect personal dignity of the patient at all times".