HospitalInspections.org

AMENDED

Based on a review of facility policies and procedures, medical records, observations, and staff interviews, it was determined that the facility failed to ensure that nursing staff adhered to policies and procedures related to patient observation/monitoring for two (Patient (P) #1 and P#4) of six (P#1, P#2, P#3, P#4, P#5, and P#6) patients reviewed. Specifically, staff failed to provide adequate supervision of P#1 and P#4, both under observation for SI when on 10/12/25, they both went into a single-occupancy patient restroom and occupied the restroom for over two minutes until staff intervened. This failure led to possible inappropriate activity between P#1 and P#4.

This failure had the potential to result in the patient self-harming.
Findings Included:

A review of the facility's policy titled "Care of Behavioral Health Patients Policy," policy #18576722, last revised 8/4/25, revealed that the purpose of the policy was to provide guidance for safe, appropriate, and effective care for patients who demonstrate behaviors suggestive of risk for suicide, risk of harm to others, substance abuse/addiction, or other behaviors that pose a serious and significant safety risk.

2. Constant Observation
Contact observation is performed by a Constant Observer (sitter) who is provided by the facility and who remains within close proximity to the patient at all times.
o The constant observer should maintain the ability to constantly visualize the patient at all times.

A review of the facility's document titled "Patient Care Tech/Sitter Orientation", dated 10/13/2025, revealed the following:
General guidelines:
1. Patients must be observed at all times and never left alone.
Responsibilities:
1. Keep the patient safe by observing the patient at all times.
Continued review revealed, Care of Behavioral Health Patients, continuous observation is required for patients who are at risk of harming themselves or others. Follow the guidelines below to provide a safe environment for them:
o Never leave the patient alone. You must have visual contact with them at all times and should be within four to six feet of the patient.
High risk behavioral health required documentation, you will be required to complete the Behavioral Observation Flowsheet in Epic for each patient you are assigned. You will document your observations every 15 minutes. Required documentation should be completed every hour on patients who are not deemed high risk. You will be making the following observations:
o Awake vs asleep
o Change in the patient's condition
o Change in the patient's mental status
o Safety of the patient
o Comfort level of the patient
o Physical needs of the patient
o Sitter must remain in the pod and not behind the nurse's station


1. A review of P#1's medical record revealed a Form 1013 (a form to certify that an individual appears to be mentally ill requiring involuntary treatment) dated 10/9/25 at 9:44 p.m. by a Medical Doctor (MD) in the ED.

A review of the "Emergency Dept (ED) Notes" dated 10/9/25 at 10:30 p.m., by a Registered Nurse (RN) revealed a psychosocial assessment. P#1 was placed on safety precautions, elopement risk, and suicide risk due to self-destructive ideas. The RN noted safety interventions for a sitter, visual checks, and continuous 1:1 observation for P#1.

A review of "ED Notes" dated 10/10/25 at 9:00 a.m. by an RN revealed that P#1 remained on 2:1 continuous observation and was awaiting a psychiatric assessment.


A review of "ED Notes" dated 10/10/25 at 11:35 a.m. by an RN revealed that P#1 denied SI or homicidal ideations (HI). The RN noted that P#1 was on a 2:1 continuous observation.


A review of P#1's medical record failed to reveal observation documentation from 10/11/25 at 10:00 p.m. to 10/12/25 at 7:00 a.m.


Continued review of P#1's medical record revealed Form 1013 was rescinded on 10/12/25 at 11:19 a.m.


2. A medical record review of P#4 revealed that P#4 presented to the facility's ED on 10/12/25 at 4:30 a.m. with a complaint of suicidal ideation (SI) with use of alcohol and substances.

Continued review of P#4's medical record revealed that on 10/12/25 at 7:27 a.m., a medical doctor (MD) ordered a 1013.

A review of an "ED Note" dated 10/12/25 at 12:15 p.m. by RN AA revealed that upon RN AA returning to the unit after retrieving a patient's valuables from a safe, she was made aware that an incident of inappropriate sexual behavior may have occurred between P#4 and P#1.


A review of an "ED Note" dated 10/12/25 at 12:33 p.m., by RN AA revealed that RN AA contacted the nursing supervisor and local law enforcement.

Continued review of P#4's medical record revealed that P#4 was escorted out of the facility with local law enforcement on 10/12/25 at 5:37 p.m.

A camera surveillance footage review was conducted on 11/13/25 with the Director of Quality, the Risk Manager, and the Major of Public Safety. Camera surveillance footage dated 10/12/25 from 11:45 a.m. to 1:04 a.m. in the facility's emergency department (ED) E Pod was viewed and revealed the following:

12:58 PM: P#4 exited the restroom into the hallway to an area off camera.
12:59 PM - 1:02 PM: P#4 went back in the restroom. P#1 went to nurses' station and interacted with staff. Then P#1 went into the restroom.
1:02 PM: Staff came out into the hallway. P#1 exited the restroom. Staff go toward the restroom to interact with P#1 and P#4. P#4 stuck his head out of restroom door.


During a telephone interview on 11/12/25 at 3:35 p.m. in the conference room, Patient Care Technician (PCT) FF. PCT FF said that a part of her responsibility was to function as a safety sitter when requested.

PCT FF recalled that on 10/12/25, the 1013 for P#1 was rescinded because he was getting discharged. PCT FF recalled that Registered Nurse (RN) AA left the unit to retrieve P#1's paperwork and clothes. PCT FF recalled that when P#1 got his clothes, he went to get dressed and wait for his family to come and get him. PCT FF recalled that P#1 reported to have four dollars and then RN AA left to retrieve it. PCT FF recalled that at one-point PCT FF noticed that P#4 went to the restroom, and when she looked around and did not see P#1, she went to go and check on them. PCT FF recalled that she discovered P#1 was in the restroom with P#4 and told them this was not allowed. PCT FF recalled that she told P#1 he was not supposed to be in the restroom with another patient and then P#1 said that he liked men and ignored PCT FF. PCT FF recalled notifying security, who was at the nurses' station where P#1 reported the allegation of sexual assault. PCT FF recalled that RN AA also came back and reported the incident to the Charge Nurse (CN) and Nursing Supervisor. PCT FF recalled that the Public Safety Officer (PSO) reported the incident to her supervisor as well. PCT FF said that P#1 did not look distress and was in fact happy and still moving around the unit. PCT FF said that after the allegation was made, P#1 and P#4 were separated, and eventually local law enforcement was contacted, and they came to perform an investigation.

PCT FF said that when patients are under a 1013 observation, staff should document on the patient at least every hour unless they are on a one-to-one watch, then documentation is done every 15 minutes. PCT FF said that staff usually document every 15 minutes regardless because it is hard to remember sometimes and it is just easier.


During an interview on 11/13/25 at 9:53 a.m. in a conference room, Public Safety Officer (PSO) GG recalled the event on 10/12/25, when PCT FF reported to PSO GG that she saw P#1 follow P4 into a restroom and P#1 would not listen to PCT FF's directions. PSO GG recalled that she explained to P#1 that he was not allowed to go into the restroom while other patients were occupying it. PSO GG recalled that she argued with P4 while he stuck his head out of the restroom door, and P#1 was already in the waiting room/area. PSO GG recalled that P#1 reported to PSO GG about the allegation of sexual assault by P4. PSO GG recalled that she then reported it to her supervisor and the hospital house supervisor.

PSO GG recalled that no officer was assigned to the unit, E Pod, because there was no patient with a 1013 status as P#1's was rescinded. PSO GG said that she ended up at the unit because she was just conducting rounds of the area and another officer requested help in looking for P#1's belongings, so PSO GG went to check the unit. PSO GG recalled that she arrived at the unit, RN AA was off the unit and PCT FF was the only one present. PSO GG said that she later learned RN AA was off the unit because she went to get a stretcher for another patient and went to go retrieve some money from the hospital vault that belonged to P#1.
PSO GG recalled that local law enforcement (LEO) arrived at the unit around 5:15 p.m. PSO GG recalled that LEO conducted their own investigation, could not obtain a video without a warrant, and took P4 into custody for other warrants not related to this situation.
PSO GG recalled that when P#1's family member came to pick up P#1, he did not seem upset or in distress about the situation. PSO GG recalled informing P#1's family member about what occurred, and he said that he thought that P#1 was lying because P#1 had a history of it including running away. PSO GG said that it was her understanding that once P#1 left the facility, they were followed by LEO to another facility to obtain a rape kit and examination.


A telephone interview was conducted with Emergency Department (ED) Nurse Practitioner (NP) BB on 11/13/25, at 10:30 a.m. NP BB explained that P#1 had already been taken off the 1013 monitoring, and P#1's family had been notified about his pending discharge before the alleged incident was reported to her. NP BB stated that she was notified of the alleged sexual assault and subsequently NP BB returned to reassess P#1.

NP BB reported that during this reassessment, P#1 appeared upset and was no longer smiling, which NP BB interpreted as a possible sign that he had been assaulted. NP BB stated that she did not assess P#1's skin for bruising and did not write orders for a complete head-to-toe assessment because she was focused on evaluating his mental state.
NP BB explained that orders for a full physical assessment would come from the attending physician if deemed necessary and would be completed by a nurse. NP BB stated that she cleared P#1 for discharge, as P#1 denied suicidal ideation, or any intent to harm himself, and did not appear to be in any distress.


During a telephone interview on 11/13/25 at 10:32 a.m. in the conference room, Registered Nurse (RN) AA. RN AA recalled that when she cared for P#1, he was the only patient in the E Pod along with a dementia patient. RN AA recalled that later P#4 was brought to the unit. RN AA recalled that P#1 interacted with #P4 welcoming him to the unit and made random conversation. RN AA recalled that P#1 and P#4 went in and out of their rooms into the waiting area throughout the shift.

RN AA recalled that she was in the process of getting P#1's Form 1013 rescinded which required her to leave the unit to obtain the physician's signature, print the discharge paperwork, and then contact P#1's family member. RN AA recalled that security was bringing P#1's belonging to him and then P#1 mentioned that he had money in the hospital vault. RN AA recalled that she left to go retrieve the money and to obtain a stretcher for another patient that was being admitted to her care. RN AA recalled that when she returned, she saw PSO GG and PCT FF and learned about the allegation of sexual assault reported by P#1. RN AA recalled that she contacted her Charge Nurse and the Nursing Supervisor. RN AA recalled that she ensured that P#1 and P#4 were separated. RN AA said that she did not look at the restroom but did assess P#1 and did not notice any visible marks. RN AA recalled that P#1 did not report any sodomy or oral sex in the allegation but that P4 touched him inappropriately.

RN AA recalled that local law enforcement (LEO) came to the unit and conducted their investigation. RN AA recalled that P4 was put in handcuffs and taken into custody. RN AA said that while he was also taken for the sexual assault allegation, LEO said that he was ultimately taken for other warrants. RN AA recalled that when P#1's uncle came, he did not seem liked he was upset or cared about the allegation of sexual assault. RN AA recalled that P#1 was acting normal, requesting food, and jumping around the unit. RN AA recalled that Medical Doctor (MD) DD and Nurse Practitioner (NP) BB were contacted and saw P#1 prior to his discharge. RN AA recalled that a sexual assault nurse examiner (SANE) was contacted over the telephone, and a referral was made for P#1 to follow up, and she believed that P#1's family member was supposed to take P#1 to this outside facility.

RN AA said that documentation on a patient with a 1013 status depends on if they are required to be on a one-to-one observation or not. RN AA said that if the patient is on a one-to-one observation, then the sitter is supposed to document every 15 minutes, but if they are not then it should be done at least every hour.


During an interview on 11/13/25 at 2:30 p.m. in the conference room, the Director of Quality said that when a patient is put on 1013 status, the physician can further order the observation status for a patient. The Director of Quality said that not at all 1013 status patients are required to be on a 1:1 constant observation and it would depend on their suicide risk assessment. The Director of Quality said that most patients are on a 2:1 constant observation. The Director of Quality said that if a patient is on a 1:1 observation then staff should document every 15 minutes. The Director of Quality said that if the patient is not on a 1:1 observation, then organization protocol is to document every hour.