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Based on interview and document review, the hospital failed to protect patients' rights when patients were not adequately supervised and the hospital was found not in substantial compliance with the Condition of Participation of Patient Rights at 42 CFR 482.13.

The hospital failed to protect and promote each patient's right to care in a safe setting for 2 of 20 patients (P-1 and P-2) reviewed when staff failed to provide adequate supervision and safety checks and P-1 and P-2 engaged in sexual activity. Refer to the deficiency issued at A144.

The deficient practice had the potential to impact all patients receiving services at the hospital.

Based on interview and document review the hospital failed to provide patients care in a safe setting for 2 of 20 patients (P-1 and P-2) reviewed when staff failed to provide adequate supervision and safety checks and P-1 and P-2 engaged in sexual activity.

Findings include:

Medical record review revealed P-1 was admitted to the hospital in August 2015 with diagnoses that included Moderate Intellectual Disability, Mood Disorder, Post Traumatic Stress Disorder, history of sexual assault and suicidal ideation, after accessing a knife at her group home and threatening to hurt herself. Emergency Department notes dated 8/31/2015 revealed P-1 was a vulnerable adult due to lower intellectual functioning and P-1's history of being sexually assaulted and sexually abused. P-1's multidisciplinary team meeting notes dated 9/1/2015 revealed P-1 had a history of being sexually abused since the age of 4. P-1 was known to solicit sex from others in the hospital and community. Hospital staff initiated visitor/phone restrictions as part of her care plan related to her behavior of calling people outside the hospital for sex. P-1's Care Plan dated 8/31/2015 revealed P-1's physician orders included basic safety checks (every 15 minutes) upon admission. No other supervision interventions were implemented related to the patient's high risk. Medical record review revealed P-2 was admitted to the hospital on 10/5/2015 with diagnoses including Schizophrenia and substance use disorder. C-2's admission occurred after C-2 began eating dirt and licking shoes, the floor and electrical outlets in his group home. C-2's Progress Notes revealed C-2 was on a court commitment since 10/8/2015. C-2's clinical assessment dated 10/7/2015 revealed C-2 was assessed at minimal risk for harm to self or others. C-2's Care Plan dated 10/5/2015 revealed C-2's physician orders included basic safety checks upon admission.

An Incident Report dated 10/10/2015 revealed that on 10/9/2015 at approximately 11:39 p.m. a registered nurse phoned security and stated staff found P-1 and P-2 in the laundry room of the Mental Health unit and it was suspected the two patients engaged in sexual activity.
During an interview on 11/4/2015 at 8:00 a.m., P-2 stated P-1 wrote a note to him requesting sex with him in his room. P-2 stated he and P-1 made arrangements to meet in the laundry room. P-2 stated a staff member let him in the laundry room and he put a piece of paper over the latch on the door so it would remain unlocked. Staff did not stay with P-2 while he was in the laundry room P-2 left the laundry room and went back to his room. P-2 stated he put pillows in his bed to make it look like he was asleep in bed when staff did safety rounds. P-2 went back to the laundry room minutes and P-1 joined him. P-2 stated he and P-1 had oral sex and were in the laundry room for about 30 minutes. P-2 denied that he forced P-1 to have sex. P-2 stated staff have changed how they are letting people in the laundry room now, and staff stay by the door when patients are in there now.

During an interview on 11/3/2015 at 11:25 a.m. P-1 stated P-2 told her to leave her shower on and to come into the laundry room to have sex with him, so she did. P-1 stated P-2 forced her to have oral, vaginal and anal sex. P-1 stated she hid in the laundry cart because P-2 told her to.During an interview on 11/3/2015 at 3:25 p.m., Mental Health Associate E (MHA-E), stated he was working on 10/9/2015. MHA-E stated the laundry room was locked and P-2 requested to go in the laundry room to do laundry around 10:45 p.m. (MHA-E stated that the laundry room is opened for patients to do laundry or get supplies, but staff do not stay with patients once the door is opened.) MHA-E stated that during the 11:00 p.m. safety rounds P-1's shower was on and she had told him earlier that she was getting in the shower, so he assumed she was in the shower. MHA-E stated he did not call out verbally to ensure P-1 was in the shower, as that was not the procedure at that time, but that policy/procedure has since changed to verbally or visibly confirm with a patient during the safety check. MHA-E stated at 11:15 p.m. he and MHA-F were doing rounds when heard a conflict/noises by the laundry room. MHA-E stated he responded to the sounds and found the laundry room door closed and blocked from the inside. When staff were able to get the door open, P-1 was hiding in a side loading laundry cart under some blankets with her clothes on, and P-2 was in the room naked.During an interview on 11/10/2015 at 3:10 p.m. MHA-F stated during safety checks on 10/9/2015 at 11:15 p.m. he checked the laundry room door as part of his normal safety check procedure. He found that it was unlocked, but a patient was in the room and was blocking the door and would not open the door to him. The patient pushed the door back at him and said he was changing. The patient did not want to let MHA-F in to the laundry room. MHA-F stated he was concerned about the attention P-1 and P-2 had been displaying toward one another that evening, so he went to check on P-1 in her room. When he went into her room, her shower was running, and MHA-F checked the shower and P-1 was not in the shower. When staff were able to open the laundry room door, P-2 was in the room with no shirt on and P-1 was hiding in the laundry cart. P-1 and P-2 denied they had engaged in any sexual behavior.

During an interview on 11/4/2015 at 7:40 a.m. Registered Nurse G (RN-G) stated she worked nights on 10/9/2015 through 10/10/2015. RN-G stated that the policy prior to this event between P-1 and P-2 was to keep the laundry rooms open during the day, but they are to be locked at night. RN-G stated there are no cameras in the laundry room,and no windows on the door, so when patients are in there, there is no way to supervise what goes on in that room. RN-G stated the laundry room is around the corner from the nursing station, so it cannot be visualized from the nursing desk. RN-G stated initially P-1 and P-2 denied anything happened in the laundry room, then both patients, during subsequent interviews, admitted they had sex. RN-G stated she immediately had P-2 moved to another unit. RN-G stated she also increased P-1's level of supervision. RN-G stated law enforcement was alerted to the incident and initiated an investigation, and a sexual assault examination was completed on P-1. A document titled 10/13 Reviewed Video, (a surveillance video recording of the hallways and some common areas of the hospital that is used by staff to review incidents and was reviewed by staff after the incident), provided by hospital security staff revealed on 10/9/2015 at 10:43 p.m. P-2 was in the laundry room. At 10:45 p.m. P-2 leaves the laundry room. At 10:52 p.m. P-2 goes back into the laundry room. At 10:53 p.m. P-1 goes into the laundry room. At 11:02 p.m. MHA-E starts safety checks, but does not check the laundry room door (not following the practice to check all locked doors). At 11:14 p.m. MHA-F starts the next round of safety checks and finds P-1 and P-2 in the laundry room. P-1 and P-2 were alone in the laundry room for 21 minutes from 10:53 p.m.-11:14 p.m. The document titled Mental Health Observation Checks and dated 10/9/2015 was reviewed. The documentation revealed that P-1 was documented as being in the shower at 11:00 p.m. and P-2 was documented as being asleep in bed at 11:00 p.m., by MHA-E, during the time they were in the laundry room together.
The Policy titled Mental Health Patient Observation Checks (basic safety checks) dated, reviewed 11/1/2014 revealed under section III. Procedures: The whereabouts of each patient will be ascertained and documented every fifteen minutes on the Observation Log Sheet by nursing staff 24 hours a day. All locked doors will be checked and documented every 15 minutes.

The policy titled Safety Assistant and Alternative Observation Levels used in Mental Health and dated, reviewed 9/3/2014 revealed under section iii. Procedures:2) Observation levels: a) Close observation (when a patient is in his/her room, the door must remain open and staff increases frequency of safety checks, b) Line of sight, (the patient remains within line of sight of a staff person at all times) c) 1:1 safety assistant, (a staff person must be in the immediate proximity of the patient at all times.)