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Based on record reviews and interview, the hospital failed to ensure the registered nurse supervised the care of each patient. This deficient practice was evidenced by failure of the registered nurse to ensure correct documentation of level of observation for sexual acting out precautions for 1 (#1) of 4 (#1 - #4) sampled patients.
Findings:

Review of the Hospital policy titled Observations, Patient, dated 11/2023, revealed in part:
Policy: In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the nurse.
Procedure: The physician will order one of three levels of observation at time of admission and as the patient's condition warrants a change: 15 minute check; 5 minute check; one-to-one.
The physician may also order a precaution level of observation for: Sexual Acting Out.
Documentation of Observations: Staff documents all levels of observation in the medical record. Each entry is to include the following ...Level of observation, Precautions, Location, Behavior, and Activity.

Patient #1
Review of Patient #1's medical record revealed an admit date of 01/13/2024. On 01/19/2024, Patient #1's level of observation increased from Q (every) 15 minute check to Q 5 minute check and then one-to-one for sexual acting out behaviors. On 01/20/2024, Patient #1's level of observation changed to Q 5 minute check for sexual acting out behaviors and remained at that level until discharge 02/01/2024. Further review for Patient #1 revealed an incident dated 01/27/2023 at 19:00. Review of this incident revealed Patient #1 and Patient #2 reported to staff that they had engaged in consensual sexual intercourse on 01/24/2024.

Review of Patient #1's Observations Sheets dated 01/26/2024, 01/28/2024, 01/29/2024, 01/30/2024, and 02/01/2024 revealed level of observation check every 5 minutes. Further review of these Observations Sheets revealed the box for monitoring sexual acting out precautions was not checked.

In an interview on 02/27/2024 at 9:33 a.m., S2Director of Risk Management confirmed the registered nurse was responsible for ensuring the correct precautions were checked on patient Observation Sheets. S2Director of Risk Management confirmed Patient #1 had sexual acting out behaviors and sexual acting out precautions should be checked on the observation sheets. S2Director of Risk Management confirmed this was not done for Patient #1 on the above dates.

Based on record reviews and interviews, the hospital failed to ensure the nursing staff developed, and kept current, an individualized nursing care plan for each patient. This deficient practice was evidenced by failure of the nursing staff to address sexual acting out behaviors on the care plan for 2 (#1, #4) of 4 (#1 - #4) sampled patients.
Findings:

Review of the hospital policy titled Treatment Planning, dated 10/2023 revealed in part:
Policy: Each patient's treatment shall be guided by the interdisciplinary treatment plan. The treatment plan is the tool used by the physician and interdisciplinary treatment team to implement the physician ordered services and move the patient toward the expected outcomes and goals.
Procedure: 3.0 Guidelines of Treatment Plans: 3.1 The treatment plan shall be an accurate and functional representation of the patient's treatment experience.

Patient #1:
Review of Patient #1's medical record revealed an admit date of 01/13/2024. On 01/20/2024, Patient #1's level of observation changed to Q 5 minute check for sexual acting out behaviors and remained at that level until discharge 02/01/2024. Further review for Patient #1 revealed an incident dated 01/27/2023 at 19:00. Review of this incident revealed Patient #1 and Patient #2 reported to staff that they had engaged in consensual sexual intercourse on 01/24/2024.

Review of Patient #1's treatment plan revealed the plan did not address sexual acting out precautions and behaviors.

In an interview on 02/27/2024 at 9:48 a.m., S2Director of Risk Management confirmed Patient #1 had sexual acting out behaviors that started soon after admit. S2Director of Risk Management confirmed Patient #1's treatment plan did not address sexual acting out precautions and behaviors.

Patient #4
Review of Patient #4's medical record revealed an admit date of 02/21/2024. Patient #4 had precautions for sexual acting out behaviors.

Review of Patient #4's treatment plan revealed the plan did not address sexual acting out precautions and behaviors.

In an interview on 02/28/2024 at 12:49 p.m., S2Director of Risk Management confirmed Patient #4 had sexual acting out behaviors since admit. S2Director of Risk Management confirmed Patient #4's treatment plan did not address sexual acting out precautions and behaviors.