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Based on observation, record review, and interview, the psychiatric hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by
1)failure of the staff to perform observations as ordered by the physician in 3(#1-#3) of 3 (#1-#3) reviewed patient records; and
2)failure of the staff to ensure precautions and increased observation levels post incident in 2 (#1, #2) of 3 (#1-#3) reviewed patient records
Findings:

Review of hospital policy number CS-23, titled "Level of Observations," last revised 03/01/2023, revealed in part: "PURPOSE: To provide staff with a framework for monitoring patients to ensure safety. POLICY: Observation Levels: Every 15 minutes- the staff member will visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities. PROCEDURE: 3. Staff members utilize the close observation checklist form (Q15 check sheet) to document the ongoing observation and location of the patient. The observing staff initials the 15-minute increments on the form to indicate the patient was observed. The staff member signs the signature line at the bottom of the form to validate their initials and credentials."

1)failure of the staff to perform observations as ordered by the physician in 3(#1-#3) of 3 (#1-#3) reviewed patient records

Patient #1
Review of Patient #1's medical record revealed Patient #1's observation level was every 15 minutes rounding by the Mental Health Technician (MHT). The Rounding Form dated 08/09/025 revealed the MHT rounding at 2:42 AM then again at 3:14 AM which is 32 minutes between patient rounding.

An interview on 09/09/2025 at 1:35 PM, S1QD verified the above information.

Patient #2
Review of Patient #2's medical record revealed Patient #2's observation level was every 15 minutes rounding by the Mental Health Technician (MHT). The Rounding Form dated 08/07/025 revealed the MHT did not round on Patient #2 from 4:00 AM to 7:45 AM which is 3 hours and 45 minutes between patient rounding.

An interview on 09/09/2025 at 1:35 PM, S1QD verified the above information.

Patient #3
Review of Patient #3's medical record revealed Patient #2's observation level was every 15 minutes rounding by the Mental Health Technician (MHT). The Rounding Form dated 09/07/025 revealed the MHT rounded on Patient #3 at 5:21 AM, 5:39 AM, and 6:18 AM which is 18 and 39 minutes between patient rounding.

An interview on 09/08/2025 at 2:55 PM, S1QD verified the above information.

2)failure of the staff to ensure precautions and increased observation levels post incident in 2 (#1, #2) of 3 (#1-#3) reviewed patient records

Review of hospital policy number CS-44, titled "Sexual Acting Out (SAO) Precautions," last revised on 09/01/2025, revealed in part: "PURPOSE: To provide staff with a framework for identifying patients who are at risk for exhibiting sexually inappropriate behavior and to provide guidance for the implementation of precautions to ensure the safety of all patients. To define actions to take in response to reports or allegations of sexual behavior or sexual acting out between patients. Criteria: 5. Patients found to be at risk for sexual behaviors will be placed on 1:1 observation or Line of Sight (LOS) until a face-to-face assessment is completed by the Physician to ensure appropriate level of precaution. PROCEDURE: Management of Sexual Incident (Inpatient Services) 1. Immediately separate patients involved in the alleged incident. Patients are either placed immediately on separate units if possible or on opposite sides of the same unit with increased observations for the alleged perpetrator until the investigation is completed and provider has completed evaluation. 4. Based on the incident, place the alleged perpetrator on 1:1 or LOS until the Provider completes a face-to-face evaluation of the patient to determine if the patient's activities or behaviors are appropriate for a lower level of observation. Patients with alleged and observed sexual acting out behaviors will be assessed daily by the Physician to ensure appropriate level of care.

Review of Patient #1's medical record revealed Patient #1 was admitted on 08/04/2025 with Major Depression Disorder. On 08/13/2025 at 7:26 PM, Patient #1 was found in bathroom with a female patient reporting consensual sex occurred. Hospital staff made notifications to provider and Patient #1's family, but did not place Patient #1 on SAO precautions until 08/14/2025 at 1:56 AM and did not increased observation level to LOS until 08/14/2025 at 10:00 AM.

In an interview on 09/09/2025 at 12:55 PM, S1QD verified above information did not follow hospital policies/procedures.

Review of Patient #2's medical record revealed Patient #2 was admitted on 08/06/2025 with Depression and Anxiety. On 08/13/2025 at 7:26 PM, Patient #2 was found in bathroom with male patient reporting consensual sex occurred. Hospital staff made notifications to provider and Patient #2's family, but did not place Patient #2 on SAO precautions until 08/14/2025 at 1:55 AM and did not increased observation level to LOS until 08/14/2025 at 10:00 AM.

In an interview on 09/09/2025 at 9:15 AM, S1QD verified above information did not follow hospital policies/procedures.

Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. The deficient practice is evidenced by:
1)failure of the Registered Nurse to follow provider orders in 3 (#1-#3) medical records reviewed; and
2)failure of the Registered Nurse to document patient observations every 2 hours per hospital policy in 2 (#1, #2) of 3 (#1-#3) medical records reviewed.
Findings:

1)Failure of the Registered Nurse to follow provider orders in 3 (#1-#3) of 3 (#1-#3) medical records reviewed.

Review of Patient #1's medical record revealed that Patient #1 was involved in sexual incident with a female patient on 08/13/2025 at 7:26 PM. Further review of Patient #1's medical record revealed the provider ordered the following labs Gonorrhea/Chlamydia on 08/13/2025, 08/14/2025, 08/16/2025, 08/19/2025, and 08/20/2025. The lab Gonorrhea/Chlamydia was never collected from Patient #1 before discharge on 08/21/2025 at 4:00 PM.

An interview on 09/09/2025 at 12:55 PM, S1QD verified the Gonorrhea/ Chlamydia labs were never collected while Patient #1 was hospitalized.

Review of Patient #2's medical record revealed that Patient #2 was involved in sexual incident with a male patient on 08/13/2025 at 7:26 PM. Further review of Patient #2's medical record revealed the provider ordered a repeat urinary pregnancy test (UPT) to be done on 08/19/2025 at 5:30 AM. Patient #2 was discharged from the hospital before repeat UPT was done.

An interview on 09/09/2025 at 9:20 AM, S1QD verified the UPT was never collected while Patient # 2was hospitalized.

2)Failure of the Registered Nurse to document patient observations every 2 hours per hospital policy in 2 (#1, #2) of 3 (#1-#3) medical records reviewed.

Review of hospital policy number CS-23, titled "Level of Observations," last revised 03/01/2023, revealed in part: "PURPOSE: To provide staff with a framework for monitoring patients to ensure safety. Observation should be both safe and therapeutic. PROCEDURE: 3. The Registered Nurse (RN) will conduct routine rounds to visually observe each patient for safety at least once every 2 hours (unless more often is warranted) and will validate rounds by initialing in the appropriate section(s) of the form."

Patient #1
Review of Patient #1's medical record revealed Patient #1's observation level was every 15 minutes rounding by the Mental Health Technician (MHT) and every 2 hours by the RN. The Rounding Forms dated with following times the RN missed rounding on the patient every 2 hours: 08/05/2025 at 7:00 AM; 08/07/2025 at 7:00 PM; 08/10/2025 at 7:00 AM; 08/11/2025 at 7:00 AM, 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM, 5:00 PM, AND 7:00 PM; 08/13/2025 at 7:00 PM, 08/15/2025 at 7:00 PM; AND 08/20/2025 at 7:00 AM.

In an interview on 09/09/2025 at 1:40 PM, S1QD verified the RN missed rounding every 2 hours on Patient #1 as mentioned above.

Patient #2
Review of Patient #2's medical record revealed Patient #1's observation level was every 15 minutes rounding by the Mental Health Technician (MHT) and every 2 hours by the RN. The Rounding Forms dated 08/13/2025 at 7:00 PM the RN missed every 2 hours rounding on Patient #2.

In an interview on 09/09/2025 at 10:06 AM, S1QD verified the RN missed rounding every 2 hours on Patient #2 as mentioned above.

Based on record review and interview, the nursing staff failed to develop and update an individualized plan of care for each patient. This deficient practice was evidenced by failing to update the care plan following an incident for 2 (#1, #2) of 3 (#1-#3) patient records reviewed.
Findings:

Review of hospital policy number CS-02 titled "Treatment Planning; Integrated/ Multidisciplinary", last revised 05/01/2025,revealed in part: "PURPOSE: To document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of patient's treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided. POLICY: The Treatment Plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient's involvement, throughout the course of treatment. PROCEDURE: 2. The admitting nurse is responsible for the following: Revising and developing nursing and medical components of the treatment plan based on additional findings from patient assessments, problems, needs, strengths, and limitations, and physician's orders.

Patient #1
Review of Patient #1's medical record revealed Patient #1 was admitted on 08/04/2025 with Major Depression Disorder. Patient #1 exhibited violent behaviors on 08/11/2025, 08/14/2025, and 08/17/2025 which required PRN medications to be administered. Further review of Patient #1's medical record revealed no update to Patient #1's treatment plan.

In an interview on 09/09/2025 at 1:50 PM, S1QD verified the above mentioned information.

Patient #2
Review of Patient #2's medical record revealed Patient #2 was admitted on 08/06/2025 with Depression and Anxiety. Patient #2 exhibited violent behaviors on 08/17/2025 requiring administration of PRN medication. Further review of Patient #2's medical record revealed no update to Patient #2's treatment plan.

In an interview on 09/09/2025 at 9:30 AM, S1QD verified the above mentioned information.

Based on record reviews and interview, the hospital failed to ensure that each patient's medical record contained all documentation. The deficient practice is evident by failing to ensure discharge instructions contained all pertinent information needed for post hospital care in 1 (#1) of the 3 (#1-#3) patients' medical records reviewed.
Findings:

Review of the hospital policy number PC-18 titled "Discharge Planning: Transition Record", last revised 10/01/2024, revealed in part: "PURPOSE: To establish guidelines for assisting patients to the appropriate level of psychosocial/physical care, treatment, and services for post-treatment placement, follow- up, and/or transfer. PROCEDURE: 5. The Nurse shall: Upon discharge, provide the patient recommendations for anticipated continuing care, treatment, and services and discharge medication interventions.

Review of Patient #1's medical record revealed Patient #1 was discharge on 08/21/2025 at 11:48 AM. Further review of Patient #1's medical record revealed the discharge instructions didn't contain the following information: who Patient #1 was released to upon discharge, who received the discharge instructions, and follow-up care after hospitalization resulting in an incomplete document.

In an interview on 09/09/2025 at 2:05 PM, S1QD verified Patient #1 did not have follow up care on the discharge instructions.

Based on record review and interview, the hospital failed to establish an appropriate discharge plan for each patient. This deficient practice was evidenced by failing to provide 2 (#1, #2) of 3 (#1-#3) patients' with a discharge plan that included discharge instructions/education for STI.
Findings:

Review of hospital policy PC-18, "Discharge Planning: Transition Record," revised 10/01/2024 revealed in part," PURPOSE: To establish for assisting patients to the appropriate level of psychosocial/physical care, treatment and services for post-treatment placement, follow-up, and/or transfer. PROCEDURE: 3. Discharge planning should encompass the following areas: Orders for continuing care to meet physical and psychosocial needs for discharge or transfer.

Review of Patient #1's medical record revealed that Patient #1 was involved in sexual incident with a female patient on 08/13/2025 at 7:26 PM. Further review of Patient #1's medical record revealed the provider ordered the following labs on 08/13/2025 a Sexually Transmitted Infection (STI) panel ordered which consisted of HIV, Hepatitis, RPR, and Gonorrhea/Chlamydia. Further review of the Patient #1's discharge plan did not reveal follow-up or education for STI.

In an interview on 09/09/2025 at 2:05 PM, SIQD verified the above information.

Review of Patient #2's medical record revealed that Patient #1 was involved in sexual incident with a male patient on 08/13/2025 at 7:26 PM. Further review of Patient #1's medical record revealed the provider ordered the following labs on 08/13/2025 a Sexually Transmitted Infection (STI) panel ordered which consisted of HIV, Hepatitis, RPR, UPT, and Gonorrhea/Chlamydia. Further review of the Patient #2's discharge plan did not reveal follow-up or education for STI.

In an interview on 09/09/2025 at 9:45 AM, SIQD verified the above information.