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A. Based on record review, document review and staff interviews it was revealed the facility failed to ensure patient rights information is given to each patient/designated person in a manner they understand before services began in twelve (12) of thirty (30) records reviewed (patients #3, 5, 8, 14, 16, 17, 18, 21, 22, 24, 26 and 27). This failure to inform patients of their rights before they receive services at the facility has the potential to negatively impact all patient care if patient rights are not explained to patients/designated person in a manner they understand before services are rendered.

Findings include:

1. A review of the medical record for patient #3 on the identifier list revealed an admission date of 1/27/19. The consent and patient rights acknowledgement form was dated 5/15/19. There was no documentation of patient rights/consent given before services were started.

2. A review of the medical record for patient #5 on the identifier list revealed an admission date of 3/7/19. There was no documentation of patient rights/consent given before services were started.

3. A review of the medical record for patient #8 on the identifier list revealed an admission date of 2/7/19. There was no documentation of patient rights/consent given before services were started.

4. A review of the medical record for patient #14 on the identifier list revealed an admission date of 2/7/19. There was no documentation of patient rights/consent given before services were started.

5. A review of the medical record for patient #16 on the identifier list revealed an admission date of 2/6/19. The consent and patient rights acknowledgement form was dated 2/12/19. There was no documentation of patient rights/consent given before services were started.

6. A review of the medical record for patient #17 on the identifier list revealed an admission date of 5/11/19. The consent and patient rights acknowledgement form was dated 5/15/19. There was no documentation of patient rights/consent given before services were started.

7. A review of the medical record for patient #18 on the identifier list revealed an admission date of 2/14/19. There was no documentation of patient rights/consent given before services were started.

8. A review of the medical record for patient #21 on the identifier list revealed an admission date of 11/17/17. The consent and patient rights acknowledgement form was dated 11/20/17. There was no documentation of patient rights/consent given before services were started.

9. A review of the medical record for patient #22 on the identifier list revealed an admission date of 11/17/17. There was no documentation of patient rights/consent given before services were started.

10. A review of the medical record for patient #24 on the identifier list revealed an admission date of 1/31/19. The consent and patient rights acknowledgement form was dated 3/4/19. There was no documentation of patient rights/consent given before services were started.

11. A review of the medical record for patient #26 on the identifier list revealed an admission date of 2/5/19. There was no documentation of patient rights/consent given before services were started.

12. A review of the medical record for patient #27 on the identifier list revealed an admission date of 1/31/19. The consent and patient rights acknowledgement form was dated 2/5/19. There was no documentation of patient rights/consent given before services were started.

13. A review of the facility policy titled Admissions, last reviewed 2/21/17, stated in part: "Patients will receive appropriate patient rights and financial information prior to admission and the admission personnel will ensure that appropriate consent and admission forms are completed prior to admission."

14. An interview was conducted with the Chief Quality Officer (CQO) on 5/15/19 at approximately 3:10 p.m. The above record reviews and policy were discussed. She agreed the facility did not follow their own policy for admissions/patient rights as they had not documented patient nor designated person had received patient rights or documented consent before service was started.


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B. Based on document review and staff interviews it was determined the staff failed to follow their own policies regarding the completion of an incident report following a suspected sexual encounter. This failure has the potential to negatively impact any patient receiving services of the facility.

Findings include:

1. An interview was conducted with the CQO on 5/14/19 at approximately 1:20 p.m. She stated after viewing the Supervisor's report from 5/2/19 on 5/3/19 and watching the video of the incident, she realized that an incident report had not been completed after a suspected sexual encounter between patient #1 and patient #2. She stated the incident report was completed, the physician was notified, an APS report was completed and the guardians of patient #1 and patient #2 were notified on 5/3/19.

2. A review of the facility policy titled Abuse and Neglect Procedure, last revised on 1/28/16, states: "All suspected and reported cases of abuse and neglect of patients will be immediately reported to both the Quality Assurance (QA) or designee and the Director of Therapy and Social Services or designee in order for the necessary steps of investigation and determination of the need for external reporting to occur within the required timeframes."

3. A review of the facility policy titled Incident Reporting, last revised 6/21/18, states: "Any staff member who witnesses, discovers or has direct knowledge of an incident shall fill out an Incident Report." The document further states: "The Incident Report should be completed as soon as practical after the incident is witnessed but must be completed before the end of shift/work day."

4. A review of the facility document titled Nursing Shift Assessment, assessment date 5/02/2019, revealed the Charge Nurse stated, "While she was eating her snack she was sitting closely to another male patient. Staff was very observant of the two and security noticed her attempt to go underneath the table in front of the male. Staff immediately responded and she was sitting back in her chair when we arrived asking what was wrong and stated she wasn't doing anything."

5. An interview was conducted with the Charge Nurse on 5/15/19 at approximately 7:25 a.m. She stated the security guard was watching patient #1 and patient #2 on the monitor at the nurse's station and he noticed patient #1 was bent towards the lap of patient #2. She stated, "When I looked up and didn't see patient #1 I immediately took off running. When I got there she was standing by the table asking what was wrong and that she wasn't doing anything." She stated she notified the Nursing Supervisor and she didn't think anything had happened so an incident report was not completed.

6. An interview was conducted with the House Supervisor on 5/15/19 at approximately 9:05 a.m. She stated the Charge Nurse of 5 North had called and notified her of an incident between patient #1 and patient #2. She said the Charge Nurse told her she had already taken care of the incident but asked what else she needed to do. She stated, "I told her to make sure she kept them separated and to watch the patient and to let me know if she came back out of her room. I called main security and asked them to keep an extra eye on them. I put it on my shift report." When questioned why an incident report was not completed she stated, "I didn't think any contact had occurred between the patients."

7. In an interview with the CQO on 5/15/19 at approximately 1:15 p.m. she concurred the staff did not follow facility policy and procedure.