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Based on policy and procedure review, clinical record review, and interviews, it was determined the facility failed to protect Patient #1 from the likelihood of potential sexual abuse in that continuous observation of Patient #2 did not occur on Unit 2 on the 7 PM to 7AM shift on 07/13/19. Failure to ensure Patient #2 was continuously observed allowed Patient #2 to enter Patient #1's room unnoticed for six minutes on 07/13/19 from 8:34 PM to 8:40 PM. The failed practice affected Patient #3 on 07/13/19 and had the potential to affect any patient on Unit 2. Findings follow:

A. Review of the policy titled "Observation Rounds Policy," received from the Director of Nursing (DON) at 12:15 PM on 08/07/19, showed observation of all patients would occur continuously.

B. Review of the policy and procedure titled "Special Precautions," received from the DON at 10:30 AM on 08/05/19 showed LOS meant the patient must remain in the line of sight of a staff member at all times ... even when showering and toileting. LOS is automatically discontinued while asleep unless a physician order indicates otherwise; and SAO (Sexually Acting Out) precautions consisted of every 15 minute checks for any verbal or non-verbal behavior that was sexually inappropriate and related to a history of sexual abuse, sexual perpetration, or promiscuity.

C. Review of Patient #2's clinical record showed after the report of sexual abuse was made, Patient #2 was moved to a room closer to the nursing station, the other bed was blocked, and LOS precautions were instituted by physician's order.

D. Review of Patient #2's clinical record showed he was admitted to the facility on 07/07/19. Review of the History and Physical/Psychiatric Evaluation, performed by Physician #1 at 5:20 AM on 07/08/19 showed Patient #2's admission diagnoses were DMDD (Disruptive Mood Dysregulation Disorder), Conduct Disorder, Unspecified Schizophrenia, Personal History of childhood neglect, and Epilepsy. The history and physical stated Patient #2 was in a current legal involvement due to sexual assault charges while in a treatment facility. Review of the history and physical showed Patient #2 spent one year (6/2018 - 6/2019) in a residential treatment program for problematic sexual behaviors. Review of the chart showed physician's orders dated 07/08/19 at 7:49 AM for Patient #2 to be placed on SAO (Sexually Acting Out) precautions only.

E. The Administrator stated during an interview at 2:40 PM on 08/05/19 a meeting with department heads was held on 07/16/19 and a global was scheduled for 08/14/19 for all staff at which point training related to the 07/13/19 incident would be conducted.

F. Interviews were conducted on Units 1 and 2 at 10:30 AM on 08/06/19. Registered Nurses (RNs) #3 and #4 stated they did not have any additional training relating to the incident, precautions, or monitoring of the patients. RN #1 was asked what the norm was for patients with SAO precautions: blocked bed? LOS? RN #1 stated if a history of SAO the patient would be placed on SAO precautions which included every 15 minute checks, monitor to make sure the patient did not go into another room with another patient, blocked beds were not standard for SAO, and if intake is aware of an open investigation for a sexual assault charge the bed would be automatically blocked. Interviews were conducted on Units 3 and 4 at 10:50 AM on 08/06/19 and RNs #3 and #4 stated they did have verbal training by the DON and the Nursing Supervisor the Monday following the incident.

G. A training roster and subject matter (hand hygiene) dated 07/23/19 and timed 13:00, and a monthly meeting dated 07/23/19 and timed 14:00 received from the Nursing Supervisor at 10:50 AM on 08/06/19, showed "Follow your Physician Precaution Orders, No excepts, no excuses ..." There was no mention of the 07/13/19 incident and any special training, instruction, or reminders.

H. The DON stated during an interview at 11:10 AM on 08/06/19 that a patient with SAO history does not automatically mandate a blocked bed. The DON stated if the patient was not exhibiting any SAO behaviors, the bed will not be blocked, and they will be on every 15 minute checks.

I. The Administrator was asked during an interview at 8:28 AM on 08/07/19, what steps the facility took to protect all patients from the likelihood of the incident reoccurring. The Administrator reiterated the steps listed in C. The Administrator stated the Nursing Supervisor on the 07/14/19 shift went to staff and informed them of the incident and to ensure they monitored the patients per their precautions status. The Administrator was asked why, given Patient #2's history, that LOS, blocked bed and a room closer to the nursing station was not initiated on admission. The Administrator stated Patient #2 had spent a year in a SAO program and was considered treated/low risk for SAO behavior.

Based on policy and procedure review, clinical record review, and interviews, it was determined the facility failed to protect Patient #1 from the likelihood of potential sexual abuse in that continuous observation of Patient #2 did not occur on Unit 2 on the 7 PM to 7AM shift on 07/13/19. Failure to ensure Patient #2 was continuously observed allowed Patient #2 to enter Patient #1's room unnoticed for six minutes on 07/13/19 from 8:34 PM to 8:40 PM. The failed practice affected Patient #3 on 07/13/19 and had the potential to affect any patient on Unit 2. Findings follow:

A. Review of the policy titled "Observation Rounds Policy," received from the Director of Nursing (DON) at 12:15 PM on 08/07/19, showed observation of all patients would occur continuously.

B. Review of the policy and procedure titled "Special Precautions," received from the DON at 10:30 AM on 08/05/19 showed LOS meant the patient must remain in the line of sight of a staff member at all times ... even when showering and toileting. LOS is automatically discontinued while asleep unless a physician order indicates otherwise; and SAO (Sexually Acting Out) precautions consisted of every 15 minute checks for any verbal or non-verbal behavior that was sexually inappropriate and related to a history of sexual abuse, sexual perpetration, or promiscuity.

C. Review of Patient #2's clinical record showed after the report of sexual abuse was made, Patient #2 was moved to a room closer to the nursing station, the other bed was blocked, and LOS precautions were instituted by physician's order.

D. Review of Patient #2's clinical record showed he was admitted to the facility on 07/07/19. Review of the History and Physical/Psychiatric Evaluation, performed by Physician #1 at 5:20 AM on 07/08/19 showed Patient #2's admission diagnoses were DMDD (Disruptive Mood Dysregulation Disorder), Conduct Disorder, Unspecified Schizophrenia, Personal History of childhood neglect, and Epilepsy. The history and physical stated Patient #2 was in a current legal involvement due to sexual assault charges while in a treatment facility. Review of the history and physical showed Patient #2 spent one year (6/2018 - 6/2019) in a residential treatment program for problematic sexual behaviors. Review of the chart showed physician's orders dated 07/08/19 at 7:49 AM for Patient #2 to be placed on SAO (Sexually Acting Out) precautions only.

E. The Administrator stated during an interview at 2:40 PM on 08/05/19 a meeting with department heads was held on 07/16/19 and a global was scheduled for 08/14/19 for all staff at which point training related to the 07/13/19 incident would be conducted.

F. Interviews were conducted on Units 1 and 2 at 10:30 AM on 08/06/19. Registered Nurses (RNs) #3 and #4 stated they did not have any additional training relating to the incident, precautions, or monitoring of the patients. RN #1 was asked what the norm was for patients with SAO precautions: blocked bed? LOS? RN #1 stated if a history of SAO the patient would be placed on SAO precautions which included every 15 minute checks, monitor to make sure the patient did not go into another room with another patient, blocked beds were not standard for SAO, and if intake is aware of an open investigation for a sexual assault charge the bed would be automatically blocked. Interviews were conducted on Units 3 and 4 at 10:50 AM on 08/06/19 and RNs #3 and #4 stated they did have verbal training by the DON and the Nursing Supervisor the Monday following the incident.

G. A training roster and subject matter (hand hygiene) dated 07/23/19 and timed 13:00, and a monthly meeting dated 07/23/19 and timed 14:00 received from the Nursing Supervisor at 10:50 AM on 08/06/19, showed "Follow your Physician Precaution Orders, No excepts, no excuses ..." There was no mention of the 07/13/19 incident and any special training, instruction, or reminders.

H. The DON stated during an interview at 11:10 AM on 08/06/19 that a patient with SAO history does not automatically mandate a blocked bed. The DON stated if the patient was not exhibiting any SAO behaviors, the bed will not be blocked, and they will be on every 15 minute checks.

I. The Administrator was asked during an interview at 8:28 AM on 08/07/19, what steps the facility took to protect all patients from the likelihood of the incident reoccurring. The Administrator reiterated the steps listed in C. The Administrator stated the Nursing Supervisor on the 07/14/19 shift went to staff and informed them of the incident and to ensure they monitored the patients per their precautions status. The Administrator was asked why, given Patient #2's history, that LOS, blocked bed and a room closer to the nursing station was not initiated on admission. The Administrator stated Patient #2 had spent a year in a SAO program and was considered treated/low risk for SAO behavior.

Based on policy and procedure review, staffing assignment sheets, and interview, it was determined the facility failed to assure a Registered Nurse (RN) was assigned to each unit to ensure the immediate availability of a RN at the bedside of any patient for two (Units 3 and 4) of four (#1-4) units. Failure to ensure one RN was assigned to each unit did not assure the availability of a professional nurse for immediate assessment, evaluation, and response to treatment. The failed practice had the potential to affect all patients on Units 3 and 4. Findings follow:

A. Review of the policy and procedure titled "Staffing," received from the Director of Nursing (DON) at 12:15 PM on 08/07/19, showed the staffing pattern would be one RN assigned to each unit.

B. The following is examples of ten days in which there was not one RN assigned to each shift:
1) 07/04/19 RN #8 assigned as the Nursing Supervisor for Units 1, 3 and 4, (Unit 2 is marked N/A, not applicable), and the primary RN for Unit 4 on the 3 PM -11PM shift. RN #7 assigned as the Nursing Supervisor for Units 1-4, and the primary RN for Unit 3 on the 11PM - 7AM shift.
2) 07/05/19 RN #8 assigned as the Nursing Supervisor for Units 1-4, and the primary RN for Unit 4 on the 3PM -11PM shift. RN #7 assigned as the Nursing Supervisor for Units 1-4, and the primary RN for Units 3 and 4 on the 11PM - 7 AM shift.
3) 07/08/19 RN #8 assigned as the Nursing Supervisor for Units 1-4, and the primary RN for Unit 4 on the 3 PM - 11PM shift. RN #7 assigned as the Nursing Supervisor for Units 1-4, and the primary RN for Units 3 and 4 on the 11PM - 7AM shift.
4) 07/09/19 RN #8 assigned as the Nursing Supervisor for Units 1-4, and the primary RN for Unit 4 on the 3 PM - 11 PM shift. RN #7 assigned as the Nursing Supervisor for Units 1-4, and the primary RN for Unit 3 on the 11PM - 7AM shift.
5) 07/10/19 RN #7 assigned as the Nursing Supervisor for Units 1-4, and the primary RN for Unit 3 on the 11PM - 7AM shift.
6) 07/17/17 RN #7 assigned as the Nursing Supervisor for Units 1-4, and the primary RN for Unit 3 on the 11PM - 7 AM shift.
7) 07/20/19 RN #9 assigned as the Nursing Supervisor for Units 1-4, and the primary RN for Units 1 and 2 on the 11 PM - 7 AM shift...
8) 07/21/19 RN #9 assigned as the Nursing Supervisor for Units 1-4, and the primary RN for Units 1 and 2 on the 11 PM - 7 AM shift.
9) 08/01/19 RN #8 assigned as the Nursing Supervisor for Units 1-4, and the primary RN for Unit 4 on the 3 PM - 11PM shift. RN #7 assigned as the Nursing Supervisor for Units 1-4, and the primary RN for Units 3 and 4.
10) 08/05/19 RN #7 assigned as the Nursing Supervisor for Units 1-4, and the primary RN for Units 3 and 4 on the 11 PM - 7 AM shift.

C. During an interview with the Administrator and the DON at 2:00 PM on 08/09/19 the findings in A and B were verified.

Based on policy and procedure review, clinical record review, and interview, it was determined a registered nurse failed to supervise and evaluate the nursing care for three (##3, #4, and #6) of fifteen (#1-15) patients in that the facility failed to ensure every 15 minute observations were made and recorded for two (#4 and #6) of fifteen (#1-15) patients; and Sexual Acting Out (SAO) precautions were transcribed to the 24 hour Observation Records for two (#2 and #6) of 15 (#1-15) patients. Failure to ensure every 15 minute observations were made and recorded did not allow staff to be knowledgeable of each patients' location, activities, and psychological state; and failure to ensure SAO precautions were listed on the 24 hour Observation Records did not ensure each staff member assigned, or handed off to, was aware of what precautions each patient was on and the level of observation each required. The failed practices had the likelihood to affect Patient #2, #4, and #6. Findings follow:

A. Review of the policy and procedure titled "Observation Rounds Policy," received from the Director of Nursing (DON) AT 12:15 pm ON 08/07/19, showed observation of all patients would occur continuously with location and behavior of all patients documented on the Observation Rounds Sheet at regular intervals depending on the status. The policy state the sheets would be carried by staff at all times and if leaving the patient care area for any reason, staff were to physically hand off the Observation Rounds Sheets to the staff member replacing/relieving them.

B. Review of Patient #2's clinical record showed orders for SAO precautions beginning 07/08/19. Review of the clinical record showed 3 (07/08/19, 07/14/19 and 07/15/19) of 14 (07/07/19 - 07/20/19) Observation Records did not have SAO precautions marked.

C. Review of Patient #4's clinical record showed orders dated 07/26/19 for every 15 minute observation checks. Review of the clinical record showed 4 days (07/30/19, 07/31/19, 08/05/19 and 08/07/19) of 11 (07/30/19 - 08/07/19) days where every 15 minute observations were not documented. Examples included: 07/30/19: none from 12:00 to 12:30 PM, none from 1330 to 1430 PM, 08/05/19 none from 1315 to 1445.

D. Review of Patient #6's clinical record showed orders dated 07/30/19 for every 15 minute observation checks and SAO precautions. Review of the clinical record showed two (08/03/19 and 08/05/19) of seven (07/31/19 - 08/05/19) Observation Records did not have SAO precautions marked. Review of the clinical record showed two (07/31/19 and 08/03/19) of six (07/31/19 - 08/05/19) days where every 15 minute observations were not documented. Example included 08/03/19: none from 0000 (12:00 AM) to 06:45 AM.

E. The Administrator verified the findings in A, B, C, and D during an interview at 2:20 PM on 08/09/19.

Based on policy and procedure review, clinical record review, and interview, it was determined the facility failed to ensure sexual acting out (SAO) behavior was identified, interventions and goals identified and implemented on the Master Treatment Plan for three of three (#2, #6 and #7) Patients identified with SAO precautions ordered. Failure to ensure SAO behavior, interventions, and goals were placed on the Master Treatment Plan did not assure communication among disciplines as to what behaviors were problematic, the treatment and interventions, and the goals for any patient with SAO behavior. The failed practice affected Patients #2, #6 and #7. Findings follow:

A. Review of the policy and procedure titled "Master Treatment Planning," received at 9:51 AM on 08/08/19 from the Director of Nursing (DON) showed care, treatment, and service issues that are integral to meeting goals and objectives are reflected in the plan of care, treatment and services; specific interventions should address the patient's physical, psychological and social symptoms and behaviors; the overall goal of treatment planning and interventions is to promote and reinforce behaviors and responses that will heighten or improve the patient's adjustment and adaptability to his/her life and environment.

B. Review of Patient #2's clinical record showed the history and physical/psychiatric evaluation showed a history and treatment for SAO, a criminal charge pending for sexual assault, and physician's orders for SAO precautions. Review of the Master Treatment Plan did not show any problems, interventions, or goals related to SAO behavior.

C. Review of Patient #6's clinical record showed the history and physical/psychiatric evaluation showed a history of engagement in sexual activities, and physician's orders for SAO precautions. Review of the Master Treatment Plan did not show any problems, interventions, or goals related to SAO behavior.

D. Review of Patient #7's clinical record showed the history and physical/psychiatric evaluation showed a history of exposing self to others, and physician's orders for SAO precautions and line of sight orders four days after admission. Review of the Master Treatment Plan did not show any problems, interventions, or goals related to SAO behavior.

E. During an interview with the DON at 1:55 PM on 08/09/19 the findings in A, B, C, and D were verified.