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Based on observation, interview, record review, and policy review, it was determined the facility failed to ensure care in a safe setting was provided to one (1) of ten (10) sampled patients (Patient #1). Patient #1, who had a history of sexual behaviors, and Patient #2, who displayed "lewd" behaviors just prior to admission, engaged in sexual relations while admitted to the facility. Subsequently, after discovery of the interaction between Patient #1 and Patient #2, the facility failed to protect other patients by supervising Patient #2, who tested positive for a communicable disease.

The findings include:

Review of the facility policy, "Sexual Behavior between Patients," dated June 2015, revealed "Intimate sexual behaviors between patients is not considered appropriate, and hospital staff would discourage such behavior."

Review of Patient #1's medical record revealed the facility admitted the patient to the psychiatric unit on 08/07/18 with diagnoses that included Schizoaffective Disorder Bipolar Type and a History of Sexually Acting Out. The patient was also identified to have a State Guardian.

Review of Patient #2's medical record revealed the facility admitted the patient on 08/15/18 with diagnoses that included Schizoaffective Disorder Bipolar Type and Substance Abuse Disorder. Review of the Behavior Health Psychiatric Evaluation for Patient #2 dated 08/16/18 revealed a family member reported the patient was hallucinating and displaying "lewd" behaviors.

Review of an incident reporting log revealed on 08/16/18, Patient #1 and Patient #2 were found having sexual intercourse in Patient #1's room. Per the Report of Unusual Incident, the interaction occurred at 10:37 AM on 08/16/18. Facility staff interviewed both patients and both stated the sexual intercourse was consensual. According to documentation on the incident reports and patient records, both patients' level of supervision was increased to every seven and one-half minutes.

Further review of Patient #1's record revealed a physician's order dated 08/16/18 for Patient #1 to be tested for Human Immunodeficiency Virus (HIV) "because of impulsive sexual exposure needs to repeat in 3-6 months" and an order for the patient to be placed on "7.5 checks for inappropriate behaviors."

Further review of Patient #2's medical record revealed the Advanced Practice Registered Nurse (APRN) ordered HIV testing, a Hepatitis Panel, a Rapid Plasma Reagin (RPR) panel, and screening for Syphilis, Gonorrhea, and Chlamydia. The orders also included placing the patient on seven and one-half minute checks due to sexually inappropriate behavior. Review of the lab reports for Patient #2 dated 08/17/18, revealed the Hepatitis C antibody was positive (greater than 11), which indicated no confirmation testing was required and should be reported as positive. However, review of a physician's order dated 08/20/18, revealed Patient #2's increased supervision for behaviors of sexually acting out was discontinued.

Interview with Patient Care Technician (PCT) #1 on 08/22/18 at 11:15 AM revealed she was working on 08/16/18 and was conducting supervision checks on patients. The PCT stated she had observed Patient #1 and Patient #2 approximately 4-5 minutes prior to opening the door to Patient #1's room and observing Patient #2 in Patient #1's bed. The PCT stated Patient #1 and Patient #2 were engaged in sexual intercourse, and she immediately informed the nurse. The PCT stated the nurse responded to the room and Patient #2 left. The PCT stated both patients were put on seven and one-half minute checks.

Interview with APRN #1 on 08/23/18 at 3:10 PM revealed she was notified on 08/16/18 that Patient #1 was observed engaging in sexual activity with Patient #2. The APRN stated she ordered lab testing for Patient #2 after the incident, because no protection was utilized to guard against sexually transmitted disease. The APRN stated there was no policy or protocol for testing patients if they had engaged in unprotected sexual activity, but due to both patients having "impaired judgement," she determined the testing should occur.

Interview with the Infection Control Coordinator (ICC) on 08/23/18 at 1:40 PM revealed he was unaware that Patient #2 had tested positive for Hepatitis C until 08/23/18. The Coordinator stated in light of the positive Hepatitis C results, both patients should have been tested for Hepatitis and HIV. In addition, the ICC stated that the Infectious Disease Physician should have been contacted related to the potential sexually transmitted diseases, and a report made to the regional epidemiologist.

Interview with the Nurse Manager on 08/23/18 at 3:50 PM revealed that she was aware of the incident between Patient #1 and Patient #2 but was not aware of Patient #2 being positive for Hepatitis C until 08/23/18. The Nurse Manager stated when lab results were received the nurse should ensure any significant results were added to the treatment plan so that the treatment team could discuss and plan any actions needed. However, the Nurse Manager stated that the positive Hepatitis results were not added to the treatment plan for Patient #2. In addition, the Nurse Manager stated the supervision level should have been increased for Patient #2.

Interview with RN #5 on 08/23/18 revealed the RN had cared for Patient #2 the night after the incident (08/16/18 into 08/17/18). RN #5 said she reviewed and signed off on the positive Hepatitis C results for Patient #2 and placed the lab results in the physician's box to be reviewed the next day. The RN stated she was trained to only call critical labs to the physician.

Interview with the Executive Director on 08/23/18 at 4:15 PM revealed he was informed of the incident between Patient #1 and Patient #2. The Executive Director stated he met with Patient #1's physician the day of the incident and learned that Patient #1 was being discharged that day. The Executive Director stated he asked the supervisor if additional testing was planned but did not follow up to obtain the results of the testing. The Executive Director stated that he was not aware of Patient #2 being Hepatitis C positive until 08/23/18, and that the facility did not have a policy addressing patients with communicable diseases who have sexually inappropriate behaviors. The Executive Director stated that Patient #2's supervision level should be increased to ensure the Hepatitis C was not transmitted.

Based on interview, record review, and policy review, the facility failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care for one (1) of ten (10) patients (Patient #4). Patient #4 who had recent hip surgery exhibited signs of agitation and confusion on 07/07/18 after the Physical Therapist assisted the patient to get up in a chair. Nursing staff identified the need for a sitter and called for a sitter to stay with and monitor Patient #4. However, nursing staff failed to stay with the patient until the sitter arrived at the patient's room. A few minutes later, the RN found Patient #4 on the floor. Patient #4 sustained a fracture to the right femur, which required an additional surgical repair.

The findings include:

Review of the facility policy, "Falls," revised May 2017, revealed all patients would be assessed upon admission, each shift, and whenever the patient's clinical condition warranted. In addition, the policy stated that based upon a patient's risk assessment, the patient's environment would be designed to reduce the risk of falls and injuries.

Review of Patient #4's medical record revealed the facility admitted the patient on 07/02/18 with a fractured right hip, underwent an Open Reduction and Internal Fixation, and was admitted to the Intensive Care Unit (ICU) after the surgery on 07/02/18.

Further review of Patient #4's medical record revealed on 07/05/18, staff documented that the patient was confused and pulling at his/her oxygen and lines. A physician's order dated 07/05/18 directed a sitter to be provided to prevent self-harm. Subsequently, on 07/06/18, the physician's order was renewed for a sitter to be provided to Patient #4 as needed.

Patient #4's medical record revealed on 07/06/18, the patient was transferred to the medical/surgical unit, and review of a Patient Assessment Flow Sheet dated 07/06/18 revealed the facility assessed the patient to be at an increased risk for falls with a score of 100 (greater than 45 being high risk). Patient #4's medical record also indicated that a bed alarm was to be utilized for Patient #4 when he/she was up in a chair.

Interview with Physical Therapist (PT) #1 on 08/21/18 at 2:30 PM revealed he had provided therapy for Patient #4 on 07/07/18 after checking with the patient's nurse. The PT stated the patient was alert and he assisted the patient up to a chair and the PT said he "thought the bed alarm was in place."

On 07/07/18, at 10:30 AM, the nurse's notes indicated the Physical Therapist informed Patient #4's nurse that the patient was up in a chair without distress. Continued review of Patient #4's nursing notes revealed at 11:40 AM, Patient #4 was attempting to "pull off" telemetry and pulse oxygenation monitoring. At 11:43 AM, the nurse called the House Supervisor to request a sitter to sit with Patient #4, but left the patient unattended while awaiting the sitter. Further review of Patient #4's medical record revealed seven (7) minutes later the nurse documented that Patient #4 was found sitting on the floor after sustaining a fall. Patient #4's medical record revealed the fall resulted in a spiral fracture of the right femur. On 07/08/18, Patient #4 had surgery to repair the right femur fracture.

Interview with RN #1 on 08/22/18 at 2:20 PM revealed she was caring for Patient #4 on 07/07/18. The RN stated the Physical Therapist had told her that morning around 10:00 or 11:00 AM, that Patient #4 was sitting up in a chair. The RN stated that Patient #4's monitoring equipment began alarming indicating the patient's oxygen level was decreasing and she went to check on the patient. Patient #4 was up in a chair across the room from the oxygen outlet and the tubing was not long enough, and the patient's oxygen saturation was dropping. The RN stated that Patient #4 was also pulling at her telemetry and heart monitor. RN #1 said she notified Respiratory Therapy staff to provide the patient with longer oxygen tubing and asked a nurse aide to stay with the patient until the tubing arrived. However, the RN stated she failed to ensure that the patient's chair alarm was in place or that a staff person was going to stay with the patient and left Patient #4 unattended. RN #1 stated she went to the nurses' station to call for a sitter to sit with the patient, and then transported a patient downstairs who was being discharged. The RN stated when she returned she found Patient #4 on the floor. The RN stated she believed the patient fell due to confusion, not having the chair alarm on, and not having a sitter in place.

Interview with Certified Nurse Aide (CNA) #1 on 08/22/18 at 11:20 AM revealed she had worked on 07/07/18 and knew Patient #4 was at an increased risk for falls. However, the CNA stated she did not know that PT had assisted the patient up to a chair, and denied that the nurse asked her to stay with Patient #4.

Interview with RN #1 at 2:20 PM and RN #2 on 08/22/18 at 2:37 PM, revealed after the incident with Patient #4 occurred, the facility provided training related to ensuring chair alarms were in place after PT gets a patient up to a chair. The staff interviewed stated the PT staff were to notify one of the floor nursing staff members that the patient was up in a chair and then both were to witness that the alarm is in place before leaving the patient up and unattended in a chair.

Interview with the Nurse Manager and with the Chief Regulatory Affairs Officer (CRAO) on 08/23/18 at 10:37 AM revealed the patient did have a sitter ordered on 07/05/18 to prevent self-harm while the patient was still in the Intensive Care Unit. However, they stated that the order was changed to "as needed" on 07/06/18, because the patient was calm on that date. The patient was transferred to the Medical/Surgical Unit on 07/07/18. The CRAO stated that once staff identified that the patient required a sitter for safety reasons, a staff person should have remained with the patient until the sitter arrived.