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Based on record review and interview, the hospital failed to ensure that patient Observation Sheets were complete as evidenced by having holes in documentation on Observation Sheets for 3 patient Observation Sheets reviewed (Patient #R1, R2, R3).
Findings:

Review of the policy titled Levels of Observation revealed in part that immediately after (or while) observing the patient, the staff member documents the patient's location and activity every 15 minutes on the Observation Sheet.

On 03/06/23 at 1:45 p.m., review of Patient #R1's Observation Sheet (dated 03/06/23) revealed no documentation of the patient's location or activity from 9:30 a.m. until 10:15 a.m.

On 03/06/23 at 1:50 p.m., review of Patient #R2's Observation Sheet (dated 03/06/23) revealed no documentation of the patient's location or activity from 9:30 a.m. until 10:45 a.m.

On 03/06/23 at 1:55 p.m., review of Patient #R3's Observation Sheet (dated 03/06/23) revealed no documentation of the patient's location or activity from 9:30 a.m. until 10:15 a.m.

On 03/06/23 at 2:00 p.m., S1Compliance confirmed the above patient's Observation Sheets were not completed and up to date.

Based on record review and interview, the hospital failed to ensure the QAPI program took actions aimed at performance improvement and after implementing those actions, measured and tracked performance to ensure success as evidenced by failing to monitor the corrective plan put into place after a patient (Patient #2) was sexually assaulted by another patient (Patient #1).
Findings:

Review of a Root Cause Analysis performed by the hospital regarding an incident on 02/10/23 when Patient #1 sexually assaulted Patient #2 revealed that an agency RN incorrectly documented on the daily assignment sheet an observation level of every 15 minutes instead of the ordered line of sight observations for Patient #1. As a result, Patient #1 was not observed at all times and sexually assaulted another patient.

Review of documentation of the corrective action steps that the hospital put into place after Patient #1 sexually assaulted Patient #2 on 02/10/23 revealed it included the following:
- Update nurse assignment sheet
- Update BHT observation log to include RN initialing every 4 hours
- Implement hand off communication policy
- Re-educate all staff on new/amended policies
- Audit compliance with amended assignment sheets and observation logs

Review of nursing inservice sign-in sheets, dated 02/14/23, revealed that all nurses were instructed on RN check offs every four hours on Observation Sheets, filling out Observation Sheets completely and documenting behaviors every 15 minutes on Observation Sheets.

Review of the Hospital Abuse Final Report (revised) dated 02/20/23 revealed that nurses will round on the BHTs every two hours to ensure that they are performing observation checks in accordance with orders and/or policy. The RNs will round and sign the observation sheets of each BHT every four hours. This monitoring will continue indefinitely to ensure RN supervision of care.

On 03/06/23 at 1:42 p.m., review of the Observation Sheets (dated 03/06/23) for Patient #2 and Patient #R4 revealed no documentation that the RN had signed off on the Observation Sheets every four hours.

On 03/06/23 at 1:45 p.m., review of the Observation Sheets (dated 03/06/23) for Patient #R1, R2, R5 and R6 revealed no documentation that the RN had signed off on the Observation Sheets every four hours. At this time, S1Complaince reviewed the Observation Sheets and confirmed there was no documented evidence that the RN had signed off on the logs every four hours.

On 03/06/23 at 2:00 p.m., interview with S2RN revealed that she went to sign off on the Observation Sheets earlier today for the above patients, but the BHT did not have the Observation Sheets current and up to date, so she didn't sign off on them.

On 03/06/23 at 2:10 p.m., interview with S3RN revealed that she signs off on the Observation Sheets at the end of her 12 hour shift. When asked if she signed off on the Observation Sheets every four hours, she asked the surveyor, "Am I supposed to?"

On 03/07/23 at 10:25 a.m., interview with S3Compliance and S4Corporate confirmed that the hospital does not have a monitoring system in place to ensure the corrective action plan was implemented after Patient #1 sexually assaulted Patient #2 on 02/10/23. They further stated that they were not aware that the nurses were not signing off on the Observation Sheets every four hours and that staff is in need of further education.