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Based on interview and record review, the facility failed to keep two (P-1 and P-16) of two (2) patients reviewed for patient's rights, free from sexual abuse, resulting in the potential for further incidents to occur with all patients. Findings include:

A-0144 - Failure to provide care in a safe setting.

Based on interview and record review, the facility failed to provide care in a safe setting for two (P-1 and P-16) of two patients reviewed for one-on-one observation in restraints, resulting in patient-to-patient sexual abuse. Findings include:

On 06/04/2024 at 1115, interviews with staff in the Crisis Care Unit (CCU) revealed staff knowledge of an incident of "patient-to-patient" sexual abuse. The charge nurse, Staff R, when interviewed stated, "There was an incident a few months ago, one of the male patients tried to pull down the pants of a female patient in restraints. The female patient (P-1) had written orders to be watched at all times (one-to-one observation). The RN stepped away leaving the Mental Health Tech (MHT) to monitor, but she (Staff MM - the MHT) was not watching. Finally, a nurse came in and saw what was going on. The MHT (Staff MM) was fired."

On 06/04/2024 at 1120, the Director of the CCU Staff Q, was interviewed and confirmed the patient-to-patient abuse and added, "We have done training for all staff, and created new assignment sheets, partner care teams have been created...Where staff never leave the view of patients without letting your partner know." Staff Q further stated, "Staff must ensure their partner is monitoring before leaving the area. All staff on 04/09/2024 were taken off duty during the investigative period. After the video of the incident that occurred on 04/09/2024 was viewed, ultimately the MHT was terminated. We have done a lot of work and have a binder with a record of the action plan related to this incident. We are still tightening up the process."

On 06/05/2024 at 1130, the Chief Nursing Officer (CNO) Staff B, and Staff Q were interviewed, and the action plan related to the confirmed incident involving P-1 was discussed. Record review of the video was completed at the time of this interview. The video of 04/09/2024 revealed P-1 lying on a stretcher and initially no additional patients were observed in the video. P-1 was in 4 point restraints as ordered; A male patient was viewed entering the view on the video footage. The male patient was observed walking to the side of the stretcher where P-1 was located. He was then observed trying to remove P-1's slacks. The male patient was unable to remove the slacks and was then seen throwing a blanket off P-1. The male patient then tried to straddle the stretcher where P-1 was restrained but was unsuccessful. As the male patient continued to try multiple maneuvers to lower P-1's slacks, a staff member (identified by the CNO as MHT Staff MM) was observed in the nurse's station (also known as the fishbowl) with her head down, not facing the direction of P-1. Another staff member (identified by the CNO as a Registered Nurse) was viewed in the video footage. It appeared as though the RN was saying something to the male patient, at which point the staff member (Staff MM) looked up. Neither of the staff were observed leaving the fishbowl area. The male patient was seen walking away from P-1. The video footage ended prior to any staff member being observed to assist P-1.

On 06/05/24 at 1145, Staff B confirmed the above findings and stated staff did not go to assist P-1 due to feeling the area was unsafe until security had arrived. Staff B identified the person with her head down, "Not monitoring the patients as assigned," was MHT Staff MM. Staff B stated Staff MM was no longer employed by the facility.

On 06/05/2024 at 1430, while reviewing requested security records, it was revealed that a similar sexual abuse incident had been reported to a security officer on 06/03/2024. On 06/05/2024 at 1438, a request to review the video dated 06/02/2024 was made. This review confirmed a second case of "patient-to-patient" sexual abuse had occurred. The Director of CCU, Staff Q, and the CNO, Staff B, were aware of the incident and confirmed the incident had occurred two days prior on 06/02/2024 but had failed to include the incident on the incident report provided on 6/4/2024.

Record review of the video dated 06/02/2024 revealed a male patient (P-10) entered the quiet room where P-16 was seen on a stretcher in four point restraints. The male patient enters the room and hands a styrofoam cup with a straw in it to P-16. The male, P-10 proceeds to the side of the stretcher where he is seen touching P-16's breasts and her vaginal area. P-10 is then seen trying to get on top of P-16, he gets off the stretcher and P-10 puts his head between P-16's legs, then puts his hand between her legs and penetrates the vaginal area with his fingers. When queried regarding this second incident the CNO stated that the Director was doing her audits of reviewing video recordings, as part of the action plan secondary to the incident on 04/09/2024, and this second incident was identified. The CNO stated they were in the process of investigating and she confirmed she did not see the video until after 2100 on 06/02/2024. The facility failed to disclose the 06/02/2024 incident during the tour conducted on 06/04/2024 and during the extensive above interview conducted on 06/05/2024. After the interview of staff and record review of the video, an Immediate Jeopardy was identified.

A record review occurred of the facility's policy titled, "Constant Observer for patients under harm precautions," policy # CLN 02.07, last review date 6/10/22. According to the policy it revealed, under the subtitle "Definitions...Line of Sight Observation: One CCO in direct line of sight with one or more patients...One to One Observation: One CCO to one patient within line of sight, in proximity with no physical barriers in the same room/area unless there exists a risk to the CCO." This policy further revealed under subtitle, "Policy: Facilities will use Competent Constant Observers (CCOs) to provide continuous observation of a patient under suicide/self-harm and harm to other precautions to support safety." This policy further revealed, "Procedure: Implementation of CCO, The nurse assigned to the patient remains responsible for the nursing care throughout the shift regardless of the presence of a CCO....The nurse assigned to the patient will document the assessments and observations relative to the continued need for CCO use per unit assessment frequency protocols, and report findings to the Clinical Coordinator (or comparable role), who will relay the information to the House Supervisor (or comparable role). The Clinical Coordinator/Manager/Director/House Supervisor will round at the start of each shift with the nurse on all patients with a CCO to assess process and care. The nurse will provide a complete report to the CCO at the beginning of each shift.... The CCO will: Document patient observations every 15 minutes on the designated flow sheet. Review and sign the guidelines for the roles and responsibilities of the CCO provided by the nurse each shift. Provide a complete report to the on-coming CCO. Enforcement: All employees whose responsibilities are affected by this policy are expected to be familiar with the basic procedures and responsibilities created by this policy. Failure to comply with this policy will be subject to appropriate performance management pursuant to all applicable policies and procedures, up to and including termination. Such performance management may also include modification of compensation, including any merit or discretionary compensation awards, as allowed by applicable law."

Based on interview and record review, the facility failed to ensure ongoing assessment and care of a tracheostomy was performed according to facility policy and procedure for one (P-3) of one patient reviewed for tracheostomy care resulting in the potential for unidentified and unmet patient needs. Findings include:

A record review of P-3's medical record on 6/3/24 at 1400 revealed P-3 was a 67-year-old female with past medical history of ischemic stroke with residual right sided hemiplegia, chronic respiratory failure and ventilator dependent with tracheostomy. Review of assessment and care of tracheostomy documentation revealed no documentation between the dates of 10/8/23 through 10/11/23.

On 6/5/24 at 1000 an interview was conducted with Registered Nurse (RN) Staff II who stated that the tracheostomy inner cannula is to be cleaned or changed (depending on type) every twelve hours, along with an assessment of the tracheostomy site, including the dressing around the tracheostomy. The dressing ties are changed more often if needed. RN II stated that documentation of this assessment and interventions are done in the "Quick View" section of the medical record under artificial airways.

On 6/6/24 the facility's policy titled "Tracheostomy Care" dated 11/23/23 revealed "Tracheostomy care is performed every 12 hours at least and PRN...Tracheostomy care includes: Assessing skin and tissues under the tracheostomy dressing,...Cleaning outer cannula...Changing tracheostomy dressing...Changing soiled tracheostomy ties from twill to padded commercial tracheostomy holder. Commercial tracheostomy holder is changed every 72 hours and PRN soiling...Cleaning inner cannula or changing disposable inner cannula every 12 hours and PRN ... Documentation...EMR...Quick View, artificial airway subset, trach care...".

Based on interview and record review, the facility failed to provide adequate and appropriate care to prevent and/or treat bedsores by not following policy and physician orders for one (P-2) of one patient reviewed for treatment of bedsores, resulting in the potential for unidentified and unmet care needs. Findings include:

A review of P-2's medical record revealed the following: P-2 was admitted on 10/12/2023 for a burn to her left foot attributed to her foot touching a radiator at home. The initial skin assessment of P-2 dated 10/12/2023 at 1800 revealed P-2 had bedsores on the tail bone, right shoulder and left buttock prior to coming to the facility. The physician ordered interventions to manage and prevent additional bedsores from occurring. The interventions included repositioning the patient while in bed every two hours, providing patient education, applying a heel protector to the patient's feet, and performing a skin assessment to monitor for bed sores. Additional record review revealed by 10/26/2023 P-2 had two additional bed sores, one on the right hip and the other on the right foot. Also, this record review of P-2's medical record indicated staff did not always complete the physician ordered interventions to prevent or to heal bed sores.

A review of P-2's medical record revealed a physician order dated 10/12/2023 for daily skin assessments to be performed. The nurse failed to document a skin assessment in the plan of care between the hours of 2213 on 10/29/2023 to 0200 on 11/1/2023. Additionally, on 10/12/2023 at 1831, the physician ordered the use of heel protectors on the feet, however, from 10/22/23 at 2000 to 11/1/2023 at 0800, there was no documentation that this intervention was used.

On 6/6/2024 at 0910, during a review of the P-2's medical record with the Administrative Director of the Intensive Care Unit (ICU) Staff G, it revealed repositioning of the patient only occurred two times on 10/30/2023 at 2000 and 2200. When asked, Staff G acknowledged the missing documentation of skin breakdown interventions during this record review.

On 6/6/2024 at 1400, a record review occurred of the facility's policy titled "Skin and Wound Care," dated 7/21/2021. According to the policy "Any pressure injury that develops 24 hours after admission to the hospital and is not documented as present on admission within 24 hours is defined as a hospital-acquired pressure injury." The policy also states that "Patients are repositioned minimally every 2 hours."

On 6/6/2024 at 1415, a record review occurred of the policy titled "Patient Assessment and Documentation", dated 2/23/2022. According to the policy "An Ongoing Assessment is conducted minimally once every 12 hours and includes but is not limited to fall risk, self-harm risk, need for restraints and need for continuous observation. The Physical Assessment includes a core assessment of all systems with consideration to deviation from normal and special attention to new onset variance or change in degree of variance."

On 6/6/2024 at 1420, a record review occurred of the policy entitled "Nursing Plan of Care," dated 3/16/2022. According to the policy "The RN is responsible for reviewing, evaluating, and documenting the progress toward established plan of care goals and updates the plan of care accordingly, minimally every twelve hours. Documentation is reflective of findings from: On-going and focused assessments plus additional updates to be completed to address new findings or Change in the patient's condition (e.g., post-op, change in hemodynamic state, change in level of consciousness (LOC), invasive procedures)."

On 6/6/2024 at 1530, during an interview, CNO Staff B stated she expects nurses to follow all policies and procedures, including the ones noted above.