HospitalInspections.org

Based on hospital policy and procedure reviews, medical record reviews, police report reviews, internal incident investigations, video monitoring review, intensive analyses review, visitor log reviews,direct care staffing lists, and interviews, facility's leadership failed to provide oversight and have systems in place to ensure the protection and promotion of patient's rights to provide a safe environment for behavioral health patients; failed to maintain an organized and effective quality assessment and improvement program; failed to have an organized Nursing Service to meet patient care and safety needs; failed to ensure an effective infection control and prevention program that reduced the risk of exposure to COVID-19; and failed to provide oversight of active treatment for behavioral health patients. The cumulative effect of these systemic problems resulted in the hospital's inability to ensure behavioral health patients received care in a therapeutic environment and remained safe from potential harm.

Findings included:

Interview on 12/22/2022 at 1155 with MD #7 revealed the clinicians drive the treatment plan. MD #7 stated, "No real group therapy." Interview revealed the patients should attend programming as part of their treatment. Interview revealed the provider/facility does not track group attendance. Interview revealed that most of the patient's treatment in an inpatient psychiatric hospital was medication therapy. Interview revealed the facility would "try medication" and "one-to-one (1:1)" to decrease escalating behaviors. Interview revealed the milieu on the units was considered when deciding where to admit the patients. MD #7 revealed "The corporate office does not want to restrain and seclude patients." MD #7 stated "The staff do not know how to decrease the escalating behaviors. Ineffective de-escalation." Interview revealed the therapeutic intervention coordinators were hired to assist with de-escalation. MD #7 stated, "People afraid to go on the unit" and "other patients afraid." Interview revealed the facility did not typically accept patients with a history of aggressive and assaultive behaviors, however the facility does not always receive information to determine if we should accept the patient(s) at this facility. Interview revealed the facility had "lost lots of staff" and "no acute clinicians." Interview revealed the treatment team met three (3) times a week. Interview revealed MD #7 cared for around 40 in-house patients on the 2-East and 2-West units. Interview revealed the patients had previously been divided with a Physician Assistant (PA), however the PA left in the Spring of 2022 and MD #7 currently had no midlevel assistance. MD #7 stated she was called for her patients and when she was on-call for other patients. Interview revealed MD #7 stated "I don't write orders to separate patients. One-to-one (1:1) patients should be kept separate. Try to keep separated but sometimes difficult. Worse with turnover." Interview revealed if "afraid some going to be assault target, we'll move to 2-East if able." Interview revealed "staff don't attempt to de-escalate patients because they are afraid." Interview revealed the facility needs to get "staff out from the behind nurses' station to milieu to intervene with patients." Interview revealed "Patients learn and believe the staff are afraid. Need additional training."

1. The hospital staff failed to provide care in a safe setting for adult and adolescent behavioral health patients by failing to supervise an adult coed unit to prevent a male patient from entering a female patient's room during hours of rest for 2 of 2 sampled patients (Patient #18 and #41); failing to supervise four adolescent female patients with threatening behavior toward other patients (Patient #29, #42, #43,and #45), who subsequently attacked an adolescent female patient resulting in harm for 1 of 1 sampled patients (Patient #2); and failing to supervise adolescent male patients with a known history of physical aggression toward each other for 2 of 2 sampled patients (Patient #28 and #1) to prevent a repeated physical assault resulting in harm for 1 of 2 sampled patients (Patient #1) .
~cross refer to 482.13(c)(2) Patients' Rights Standard: Care in a Safe Setting, Tag A0144

2. The facility staff failed to maintain investigative summaries of patient-to-patient sexual abuse in 7 of 9 patients with sexual abuse allegations reviewed. (Patients #16, #26, #31, #32, #33, #34, #35).

~cross refer to 482.13(c)(3) Patients' Rights Standard: Free from Abuse, Tag A0145

3. The facility failed to monitor and track the completion of sexual abuse allegation investigations and failed to provide the numeric classification level for 2 of 2 incidents of physical aggression toward other patients involving the same patient. (Patient #49)

~cross refer to 482.21(a), (b)(1), (b)(2)(i), (b)(3) QAPI Standard: Data Collection & Analysis, Tag A0273

4. Hospital leadership failed to ensure adequate follow-up of adverse incidents for patient safety in 3 of 4 Level #3 intensive analyses reviewed and failed to track causes of Level 1 and 2 patient aggression/ sexual events in order to implement preventive actions and identify success of actions taken.

~cross refer to 482.21(a), (c)(2), (e)(3) QAPI Standard: Patient Safety, Tag A0286

5. The hospital staff failed to supervise an adult coed unit to prevent a male patient from entering a female patient's room during hours of rest for 2 of 2 sampled patients (Patient #18 and #41); failed to supervise four adolescent female patients with threatening behavior toward other patients (Patient #29, #42, #43,and #45), who subsequently attacked an adolescent female patient resulting in harm for 1 of 1 sampled patients (Patient #2); and failed to supervise adolescent male patients with a known history of physical aggression toward each other for 2 of 2 sampled patients (Patient #28 and #1) to prevent a repeated physical assault resulting in harm for 1 of 2 sampled patients (Patient #1) .

~cross refer to 482.23(b)(3) Nursing Services Standard: RN Supervision of Nursing Care, Tag A0395

6. The hospital's infection control program staff failed to ensure implementation of established measures to prevent and control infections and communicable diseases, such as COVID-19 by failing to implement and monitor COVID-19 screening practices resulting in symptomatic employees reporting to work increasing potential COVID-19 positive exposure.

~cross refer to 482.42(a)(3) Infection Control Surveillance, Prevention Standard: Infection Control Surveillance, Prevention, Tag A0750

7. The facility staff failed to develop a comprehensive plan of care by not ensuring the psychiatric component of the treatment plan was established for 2 of 60 patients (Patients #49, #46), failed to ensure the treatment plan was presented to and reviewed with parent/guardian as evidence by lack of signature and date/time for 3 of 60 patients (Patients #21, #7, and #47), and failed to ensure all members of the treatment team members were identified as evidence by lack of signatures on the treatment plan for 3 of 60 patients (Patients #46, #7, and #47).

~cross refer to 482.61(c)(1) Special Medical Record Requirements for Psychiatric Hospitals Standard: Treatment Plan, Tag A1640

Based on hospital policy and procedure reviews, medical record reviews, police report reviews, internal incident investigations, video monitoring review, personnel record review, and interviews the facility failed to promote and protect patients' rights by failing to ensure a safe environment for the delivery of care to behavioral health patients.

Findings included:

1. The hospital staff failed to provide care in a safe setting for adult behavioral health patients by failing to supervise an adult coed unit to prevent a male patient from entering a female patient's room during hours of rest for 2 of 2 sampled patients (Patient #18 and #41).

~cross refer to 482.13(c)(2) Patients' Rights Standard: Care in a Safe Setting, Tag A0144

2. The hospital staff failed to provide care in a safe setting for adolescent behavioral health patients by failing to failing to supervise four adolescent female patients with threatening behavior toward other patients (Patient #29, #42, #43,and #45), who subsequently attacked an adolescent female patient resulting in harm for 1 of 1 sampled patients (Patient #2).

~cross refer to 482.13(c)(2) Patients' Rights Standard: Care in a Safe Setting, Tag A0144

3. The hospital staff failed to provide care in a safe setting for adolescent behavioral health patients by failing to supervise adolescent male patients with a known history of physical aggression toward each other for 2 of 2 sampled patients (Patient #28 and #1) to prevent a repeated physical assault resulting in harm for 1 of 2 sampled patients (Patient #1) .

~cross refer to 482.13(c)(2) Patients' Rights Standard: Care in a Safe Setting, Tag A0144

4. The facility staff failed to maintain investigative summaries of patient-to-patient sexual abuse in 7 of 9 patients with sexual abuse allegations reviewed. (Patients #16, #26, #31, #32, #33, #34, #35).

~cross refer to 482.13(c)(3) Patients' Rights Standard: Free from Abuse, Tag A0145

5. The facility staff failed to ensure a physician order for 1 of 3 restraint/ seclusion patient records reviewed (Patient # 13) and failed to ensure the order was time limited for 1 of 2 restraint/ seclusion patient orders reviewed (Patient # 14).

~cross refer to 482.13(e)(5) Patients' Rights Standard: Restraint or Seclusion, Tag A0168

6. The facility failed to ensure the clinical staff had current CPI (Psychological Capital Intervention) training in two (2) of fourteen (14) clinical staff's personnel records reviewed (RN #3 and MHT #4).

~cross refer to 482.13(f)(1) Patients' Rights Standard: Restraint or Seclusion, Tag A0196

Based on hospital policy and procedure reviews, medical record reviews, police report reviews, internal incident investigations, video monitoring review, and interviews, the hospital staff failed to provide care in a safe setting for adult and adolescent behavioral health patients by failing to supervise an adult coed unit to prevent a male patient from entering a female patient's room during hours of rest for 2 of 2 sampled patients (Patient #18 and #41); failing to supervise four adolescent female patients with threatening behavior toward other patients (Patient #29, #42, #43,and #45), who subsequently attacked an adolescent female patient resulting in harm for 1 of 1 sampled patients (Patient #2); and failing to supervise adolescent male patients with a known history of physical aggression toward each other for 2 of 2 sampled patients (Patient #28 and #1) to prevent a repeated physical assault resulting in harm for 1 of 2 sampled patients (Patient #1) .

Findings included:

Review of the hospital policy titled "Patient Observation Policy PC-1-002" last approved 08/12/2021 revealed " ... Unit Nurse: a. Assigns responsibility for completion of patient observation rounds at the beginning of each shift. ... Mental Health Technician (MHT): ... c. Observe and document each patient a minimum of every 15 minutes and/or according to precaution level. ... d. Perform rounds at staggered intervals and in a varying pattern or sequence throughout the unit to minimize planned acting out opportunities. ... g. While monitoring hallways and patient care areas, ensure patients are: not entering rooms not assigned to them. ... h. Observe patients on bed rest/laying down by: looking for rise and fall of the chest, counting at least three respirations, and making sure the patient has moved from his/her previous sleeping position. Using flashlight at night to observe patients in bed i. Visually observe patients when behind closed doors or curtains by: knocking on bedroom door, announcing you are stepping into the room for rounds, opening the door or bathroom curtain and visually observing the safety of the patient ... k. Hand off assigned patient-observation rounds to another staff member before leaving the patient treatment area (meals, breaks, emergencies). l. Identify and report any findings while conducting observation rounds: ... Ensure doors that are to be locked are, in fact, locked. ..."

A. Review of the hospital policy titled "Room Assignments/Mattress Type" last approved 08/12/2021 revealed " ... Procedure: ... D. Adult patients will have room assignments made based on gender, admitting diagnosis, level of observation and current mental status."

Review of the hospital policy titled "Sexual Assault Examination" last approved 08/12/2021 revealed " ... Procedure: 1. Upon being made aware of an incident of sexual assault, the unit nurse shall immediately report the incident to the Nurse Supervisor. ... 2. Staff will not interview the patient(s) involved. Staff who received the report of sexual assault will document what was reported by the patient. 3. ... After hours, the Nurse Supervisor will notify Jacksonville Police Department of the allegation of sexual assault. ... 5. The staff shall discourage the patient from changing clothes, showering, or using the bathroom. ... 10. The nurse shall document in the patient's medical record concerning the event, treatment, and any medical follow up or medical care to be provided."

Review of the medical record for Patient #18 revealed a 45-year-old male admitted via involuntary commitment on 05/14/2022 with a diagnosis of "Schizophrenia." Patient #18 was assigned to room 618 on the 3-East Adult unit. Review of the "High Risk Notification Alert" form dated 05/14/2022 at 1700 revealed documentation of sexually aggressive, elopement risk and assaultive/aggression risk factors with no documentation of whether the sexually aggressive risk factor was history of or current. Documentation revealed the elopement risk factor was current with documentation of Patient #18 "checking all doors in admissions to get out." Documentation revealed the assaultive/aggression risk factor was current with documentation of Patient #18 being "increasingly aggressive with wife." Admission intake assessment dated 05/14/2022 revealed documentation that Patient #18 had a medical issues/risk of renal calculi. Patient #18 presented to the hospital with delusions, paranoid thoughts, increasingly aggressive with wife, racing thoughts and visual hallucinations. Review of the admission intake assessment revealed the staff checked "Sexually Aggressive Behavior Unable to assess due to: pt in psychosis" and "Potential for Sexual Victimization Behavior Unable to assess due to: pt in psychosis." Review of the Nursing Admission Assessment dated 05/14/2022 at 1255 revealed documentation of no potential sexual victimization in the last 6 months and "unknown" history of sexual victimization over lifetime. The Nursing Admission Assessment revealed documentation of no sexually aggressive behavior in the last 6 months and no history of sexual aggression over lifetime. Nursing documentation revealed no history of sexual and/or physical abuse. Review of the Psychosocial Assessment revealed documentation that Patient #18 denied history of sexual aggression. Review of the admission physician orders dated 05/14/2022 at 1700 revealed Patient #18 was placed on every 15-minute checks, elopement risk precautions, and assault/homicide precautions. Review of a Nursing Assessment/Reassessment 7p-7a shift note dated 06/06/2022 at 0734 revealed "Pt presented with blunted affect - exhibited attention-seeking, somatic behaviors. Cooperative with staff - compliant with HS (bedtime) meds. Denied any AVH (audio-visual hallucinations). Constantly asking MHT or RN for items multiple times. Paced halls, restless throughout shift, + (positive) minimal peer interactions. Hyper-focused on D/C (discharge). C/o (complaining of) right shoulder pain, nicotine cravings, and requested prn (as needed) for sleep. Rested on/off. Scheduled meds given. Motrin given po (by mouth) prn (as needed) right shoulder pain, nicotine gum given po prn cravings, and Ambien (medication for sleep) given po prn insomnia. Encouraged to continue developing and using + coping skills, increase + interactions, and ongoing tx (treatment), med-compliance. Voice concerns, c/o to staff. Pt med-compliant, + effects with prn Motrin, nicotine gum. Minimal effect with prn Ambien (sleep med). Agreed to seek staff with needs. Rested on/off. Continue to monitor pt progress, behaviors, and med-effectiveness. Monitor for mood changes/pt safety." Updated note documented on 06/06/2022 revealed "Select female peer woke and found (Name Patient #18) standing by her bed in what appeared to be ejaculate on her linens and clothes - supervisor notified - will continue to follow up and notify Risk Management, MD - pt denies doing anything, but peer also had roommate witness." Review of nursing progress notes revealed every two (2) hours documentation of one-to-one (1:1) observations beginning on 06/06/2022. Review of physician orders dated 06/06/2022 at 0700 revealed Patient #18 was placed on Sexual Aggression Risk precautions and orders continued through discharge on 07/13/2022. Physician orders revealed Patient #18 was placed on one-to-one (1:1) observation level on 06/06/2022 at 1400. Review of a treatment team meeting note dated 06/06/2022 at 0915 revealed Patient #18 was on every 15 minutes observation level, cheeking, assaultive/aggression, sexual aggression, and elopement precautions with documentation in comment field that "Patient ejaculated on one of his peers at 5:00 a.m. and is now on sexual aggression precautions." Review of a clinical progress note documented on 06/06/2022 at 1305 revealed "Session: Clinician spoke to patient's mom who stated that said he would d/c tomorrow and that mom needs to pick him up. Patient is still reporting to mom that someone is trying to break into his home. Collateral reported that patient call his wife and screams at her so much that the wife hangs up the phone on him. Clinician plan: Clinician will attend Treatment Team Tuesday (06/07/2022) to discuss Patient's progress, and discharge planning. Patient progress toward treatment plan: Patient is compliant with medication management and attends some groups. Discharge plan update: Patient's discharge date is unknown at this time. Discharge will continue to be assessed during Treatment Team. Next session: Acute Clinician will check in with Patient to assess progress. Acute Clinician will attend Treatment Team Tuesday (06/07/2022) to discuss Patient's progress, and discharge planning." Review of a provider progress note completed on 06/06/2022 at 1350 revealed " ... Assessment (address significant risks): Staff report patient stays up at night then sleeps during the day. Staff report inappropriate behavior by patient this AM towards a female peer. Patient is irritable and focused on being discharged home. Patient easily agitated today. Medication Change: yes, Ongoing mood lability-Increase Depakote ER to 2000mg (milligrams) po QHS (every night at bedtime [2100]); add Doxepin 150mg po QHS for sleep. ... Refer to State hospital; 6/6/2022: 1:1 observations started for safety of others. ... Vital Signs: BP sitting 128/65, Pulse sitting 85, Temp 98.1, RR 18, SaO2 (oxygen saturation) 98. ..." Review of the 15-minutes observation record for 06/06/2022 revealed documentation by MHT #20 that Patient #18 was in his room lying down from 0400 through 0700. Review of the observation record revealed precaution levels documented included assault/aggression, sexually aggressive, elopement with one-to-one (1:1) observation level started on 06/06/2022 at 0830. Patient #18 was discharged from the facility to home on 07/13/2022.

Review of the medical record for Patient #41 revealed a 19-year-old female admitted via involuntary commitment on 06/01/2022 with a diagnosis of "Xanax Overdose" and "Major Depressive Disorder." Patient #41 was assigned to room 620 on the 3-East Adult unit. Review of the "High Risk Notification Alert" form dated 06/01/2022 at 1754 revealed documentation of "Suicidal Moderate" with history and current risk factor related to depression and recent suicide attempt via overdose. Admission intake assessment dated 06/01/2022 at 1741 revealed documentation that Patient #41 had a medical issues/risk of anemia and diabetes per patient. Patient #41 presented to the hospital with recent suicide attempt via overdose and has exhibited risk for suicide (ideations, plans, behaviors) in the past 6 months due to ongoing depression. Review of the admission intake assessment revealed the staff checked "No" for Sexually Aggressive Behavior in the past 6 months and over lifetime. Review of assessment revealed the staff checked "Yes" for Potential for Sexual Victimization Behavior over lifetime as a child with no report made and the staff checked "No" to sexual victimization in the last 6 months. Nursing documentation revealed the intake unit filed a report with DSS (dept. of social services) reference suicide attempt. Continued review of the intake assessment revealed documentation of substance withdrawal risk for drugs - marijuana used one (1) week ago. Documentation of Patient #41's risk summary on the intake assessment revealed "Pt admitted due to suicide attempt via overdose. Pt is though-blocking during assessment and minimizing behaviors. Pt is agitated during assessment and denies everything. ..." Review of the Nursing Admission Assessment dated 06/01/2022 at 2000 revealed surgical history documentation of an abortion performed on 03/18/2022. Continued review of the Nursing Admission Assessment revealed documentation of no potential sexual victimization in the last 6 months and no history of sexual victimization over lifetime. The Nursing Admission Assessment revealed documentation of no sexually aggressive behavior in the last 6 months and no history of sexual aggression over lifetime. Nursing documentation revealed no history of sexual and/or physical abuse but did admit to emotional abuse by an ex-boyfriend. Review of the Psychosocial Assessment revealed documentation that Patient #41 denied history of sexual aggression. Review of the History and Physical note revealed vital signs were temperature 98.1, blood pressure 105/88, pulse 82, respirations 16 and no complaints of pain. Review of the Psychiatric Evaluation dated 06/02/2022 at 1212 revealed Patient #41 was admitted with a "history of anxiety, depression, and trauma with significant benzodiazepine, cannabinoid addiction. ... patient reported abusing Xanax for the past two years, noting she usually snorts 2mg pills every night. ... patient was admitted with a near lethal overdose on Xanax. ..." Review of a treatment team meeting note dated 06/06/2022 at 0915 revealed Patient #41 was on every 15 minutes observation level, and suicidal precautions with documentation in comment field that "Patient was ejaculated on by another peer from 3E and was moved to 3W today." Review of the provider progress notes for 06/06/2022 revealed no documentation of the incident with Patient #18. Review of a Nursing Assessment/Reassessment 7p-7a shift note dated 06/06/2022 at 0216 revealed "Pt presented with blunted to bright affect, + interactions with staff, select peers. Appropriate, cooperative, polite with staff - compliant with HS meds, hygiene. Stated she had a 'good day.' No SI (suicidal ideations) verbalized. Resting well, no C/o (complaints). ..." Review of Nursing Assessment/Reassessment 7a-7p shift note dated 06/06/2022 at 0750 revealed "Patient on phone with mom this am. Patient spoke with supervisor this am r/t (related to) incident in early am prior to shift. Pt also per supervisor spoke to police. Patient transferred to 3-West adult unit." Review of the 15-minutes observation record for 06/06/2022 revealed documentation by MHT #20 that Patient #41 was in her room lying down from 0400 to 0500. Continued review revealed the Patient was standing in her room at 0515, sitting in her room from 0530-0600, lying down in her room at 0615 and standing in the hallway from 0630-0700. Review of the observation record revealed precaution levels documented included suicidal - moderate risk. Patient #41 was discharged from the facility to home on 06/13/2022.

Review of the Police Incident/Investigation Report revealed the police department was notified on 06/06/2022 at 0635. Police investigation report revealed "NARRATIVE On Monday, June 6th, 2022, at 0635, I, Officer (Name), in Unit 354, responded to 192 Village Drive in reference to a sexual assault. Review of the Police Department Report revealed "... 3. ... (Name) Patient #41 said she would like to make a report and she would like to press charges. (Name) Patient #41 said she was asleep in her bedroom when she heard someone enter the room. (Name) Patient #41 said the hospital staff is required to check on the patients every 15 minutes so it was normal to hear someone walking in her bedroom. In addition, (Name) patient #41 informed me that patients are required to keep their bedroom doors open by hospital policy. (Name) Patient #41 said she was sleeping on her stomach when she felt something warm and wet on her legs and back. (Name) Patient #41 looked up to see (Name) Patient #18 holding his penis ejaculating onto her. (Name) Patient #41 recalled (Name) Patient #18's eyelids fluttering, and he appeared to be in a trance. (Name) Patient #41 said at first, she believed (Name) Patient #18 was urinating on her because she was confused about what was going on. (Name) Patient #41 said she jumped out of bed and ran towards her roommate's bed, (Roommate Name). (Name) Patient #41 exclaimed, 'What the (expletive) man!' (Name) Patient #41 said her yelling woke up (Name of roommate). (Name) Patient #41 said (Name) Patient #18 shuddered the words, 'I'm sorry.' He (Patient #18) began re-dressing and quickly left the room. (Name) Patient #41 said (Name) Patient #18 exited her room, Room 620, and ran into his room, Room 621. (Name) Patient #41 said her roommate chased after (Name) Patient #18 and notified the nurses about the incident. 4. I (police officer) asked (Name) Patient #41 if she still had her clothes or her bedding. Patient #41 said she changed after the incident and turned her clothes and bedding over to the laundry staff. Patient #41 said she immediately showered because she believed Patient #18 had urinated on her. Patient #41 said while in the shower she realized the substance on her skin was not urine. Patient #41 thought about Patient #18's body posture, mannerisms, and how he finished ejaculating on her after she had woken up. Patient #41 was certain Patient #18 had masturbated over her sleeping body. Patient #41 said she had no previous relationship with Patient #18. ..." The house supervisor (HS #23) asked Patient #18 if he would like to speak with the officer. Patient #18 refused to speak with the police officer stating he did nothing wrong and closed his room door. The police officer then interviewed Patient #41's roommate.

Review of the facility incident report documented on Patient #41 revealed the event occurred on 06/06/2022 at 0415 in the female patient's (#41) room. DSM diagnosis included: Cannabis Abuse, uncomplicated; Adjustment Disorders; and Attention Deficit/Hyperactivity Disorders. No injuries were reported. Patient #41 was cooperative and angry after the incident. Review of the incident report revealed the House Supervisor (HS) was notified on 06/06/2022 at 0525, the Police Department (PD) was notified at 0600 by the HS, the Risk Manager (RM) was notified at 0612, and the Physician (MD) was notified at 0623. Incident report comments revealed "Pt reported waking up to a male patient either urinating or masturbating on her while she was sleeping. No physical injuries reported." Documentation revealed the incident report was reviewed by a supervisor on 06/06/2022 at 0941 and reviewed by the Risk Manager on 06/08/2022 at 1530.

Review of the facility incident report documented on Patient #18 revealed the event occurred on 06/06/2022 at 0415 in the female patient's (Patient #41's) room. No injuries were reported. Patient #18's treatments revealed his observations were increased. Patient #18 was angry after the incident. Review of the incident report revealed the House Supervisor (HS) was notified on 06/06/2022 at 0525, the Police Department (PD) was notified at 0600 by the HS, the Risk Manager (RM) was notified at 0612, and the Physician (MD) was notified at 0623. Incident comments revealed "A peer (Patient #41) reported pt (#18) came into her room and urinated or masturbated on her bed while she was in it, peer (Pt #41) was removed from the unit and this patient (#18) was made an unofficial 1:1 until an official 1:1 order could be obtained." Documentation revealed the incident report was reviewed by a supervisor on 06/06/2022 at 1346 and reviewed by the Risk Manager on 06/08/2022 at 0919.

Review of the incident investigation report for Patient #18 and #41 revealed the incident occurred and was disclosed on 06/06/2022 and the incident type was labeled as Pt/Pt (Patient to Patient) Sexual Assault. The incident investigation report revealed the female patient (Patient #41) was a 19-year-old admitted involuntarily to the adult unit 3 East on 06/01/2022 with a presenting problem of suicidal attempt via overdose on Xanax. Patient #41 was placed on suicide precautions and fifteen (15) minute patient observations level upon admission. Patient #41 had an admitting diagnosis of Major Depressive Disorder. The incident investigation report revealed Patient #18 was a 45-year-old male patient that was admitted involuntarily to the adult unit 3 East on 05/14/2022 with a presenting problem of acute psychosis. Patient #18 was placed on elopement and assault/aggression precautions and fifteen (15) minute patient observations level upon admission. Patient #18 had an admitting diagnosis of Schizophrenia unspecified. Review of the incident investigation report revealed "Brief Description of the incident: FRM (Facility Risk Manager) received call from House Supervisor (Name) 6/6/22 at 6:10am to report allegations of male patient (Name) #18 entering the bedroom of (Name) Patient #41 and another female patient at approximately 0500 today. (Name) Patient #41 was asleep and woke to a warm sensation on her lower body and legs and saw (Name) [Patient #18] standing by her bed with his penis out of his pants. The roommate also saw (Name) [Patient #18] in the room but did not observe any exposure. (Name) Patient #41 reports (Name) [Patient #18] ran from the room when she started shouting at him. Per House Supervisor, (Name) [Patient #18] slammed his bedroom door. (Name's) Patient #41's roommate came to the Nurses Station to report the incident. (Name) Patient #41 reported the incident to MHT #20 (Mental Health Technician) [Name] at that time. (Name) Patient #41 initially felt it was urine then later reported it might have been semen after the patient had already showered and bedding had been laundered." Continued review of the incident investigation report revealed "Investigation findings: (staffing, as applicable, video review-brief): Per initial camera review, MHT #20 (Name) completed a check on (Name) [Patient #18's] room at 0412. The door to the patient bedroom was closed, and the MHT completed the check through the window without opening the door or entering the patient bedroom. (Name) [Patient #18] is observed leaving his assigned bedroom (room 618) fully clothed with his hands on his waistband at 04:15:40, then enters the bedroom to the left of his room, assigned to patient (Name) [female patient] (room 620) at 04:15:58, then exits (Name's) Patient #41's room fully clothed at 04:16:13, and returns to his room at 04:16:24 and shuts the door. (Name) [Patient #18] stays in (Name) Patient #41's room for 15 seconds. MHT #20 (Name) completed 15 minute checks timely, with the last check on (Name) Patient #18's room at 0412 but failed to open the door to visualize 3 respirations during checks. MHT #20 reported (Name) Patient #18 was sleeping at the time of this check and there were no indications prior to the incident that (Name) Patient #18 was targeting other patients, females, or (Name) Patient #41 in particular. MHT #20 first learned of the allegations once (Name) Patient #41's roommate came to the Nurses station where he was filing paperwork to report (Name) Patient #18 'peeing' on (Name) Patient #41. The allegations later changed to (Name) Patient #18 'masturbating' on her because the liquid did not smell like urine, according to (Name) Patient #41's roommate, as reported to the MHT. Chart review conducted by FRM revealed (Name) Patient #18 was not on sexual assault precautions prior to the incident and had no previous incident reports during his admission. Interviews with both (Name) Patient #41 and her roommate corroborate (Name) Patient #18 being inside their bedroom. (Name) Patient #41 reported waking to a warm sensation on her back and legs and hearing liquid hit the floor. MHT #20 (Name) reported not much liquid on the sheets or clothing and the pattern being 'a straight line.' (Name) Patient #41 showered immediately after the incident and MHT #20 (Name) washed the bedding and her clothing. (Name) Patient #18 denies the allegations to MHT #20 and Unit Nurse RN #21 and refused to speak with police. Additional interviews were attempted throughout the day, and patient was sleeping each time, so (Name) Patient #18 has not been interviewed by FRM as of this report. Police interviewed the victim (Patient #41) but collected no physical evidence and requested to view camera footage. Unit was staffed to ratio (1 MHT, 1 RN, 1 RN in training and Physician Assistant on unit during this time) with census of 9."

Review of the June 6, 2022 Facility's Camera Review of the 3-East Unit Timeline revealed the following:
04:00 No staff visible in hallway.
04:03 MHT #20 exits Nurses Station and enters laundry room
04:05 MHT #20 exits laundry room and back into Nurses Station
04:08 MHT #20 opens Nurses Station door, steps into hallway briefly, then goes back inside Nurses Station
04:10 Physician Assistant (Name) [PA # 25] walks onto unit
04:11 MHT #20 exits Nurses Station
04:12 MHT #20 completes check on Patient #18's room (#618) through window in door
04:13 MHT #20 enters the Nurses Station
04:14 RN #21 (Name) and RN #22 (RN trainee) return to the unit and walk past Patient #41 and Patient #18 rooms, enter the Nurses Station
04:15:28 PA #25 walks by Patient #18 and Patient #41 rooms and exits the unit
04:15:40 Patient #18 walks out of his bedroom fully clothed with both hands on waistband
04:15:58 Patient #18 enters Patient #41's bedroom (#620) for a period of 15 seconds
04:16:13 Patient #18 exits Patient #41's bedroom
04:16:24 Patient #18 enters his bedroom and closes the door
04:16:34 Patient #41's roommate runs out of bedroom to the Nurses Station, knocks on window, MHT #20 exits and walks with Patient #41's roommate to her bedroom
04:21 MHT #20 takes clean linen to Patient #41's room
04:26 RN #21 unlocks Patient #18's closed room door, MHT #20 and RN #21 enter Patient #18's room
04:31 MHT #20 enters Patient #41's room with gloves and cleaning supplies
04:32 MHT #20 exits patient #41's room bedding and clothing, take to the laundry room
04:54 MHT #20 completes check on Patient #18's room through window in door
05:05 MHT #20 sits in hallway to monitor, and HS #23 enters the unit
05:07 MHT #20 completes a check on Patient #18's room
05:13 MHT #20 returns to chair in hallway to monitor
05:21 MHT #20 moves chair to sit directly across from Patient #18's bedroom for increased hallway monitoring

Review of the Nursing Staff Meeting minutes for 06/20/2022 and 06/22/2022 revealed the CEO discussed during leadership rounding audits via camera reviews, the following was noted: At times, there were no hallway presence (days and nights) -If MHT is doing laundry, filing, unstructured transition, hygiene times, etc. the RN needs to observe the hallway.

Interview with RM #1 on 12/20/2022 revealed the video for Pt #18 and #41 was available to review however the facility was unable to access the video prior to survey exit on 12/22/2022.

Telephone interview on 12/20/2022 at 1035 with MHT #20 revealed he had worked at the facility for 1 ½ years. Interview revealed MHT #20 was the MHT assigned to the 3-East unit on 06/05-06/2022 for the 7p-7a shift. Interview revealed Patient #18 was assigned to room 618 bed A (blocked room-no roommate) and Patient #41 was assigned to room 620 bed A. Interview revealed MHT #20 was responsible for the 15-minutes observation checks. MHT #20 stated he completed the 15-minute observation for Patient #18 about 0412. Interview revealed the MHT opened the room door but did not cross the door threshold, used the flashlight to see the patient, checked for breathing and to see if the patient was awake. Interview revealed the MHT was quiet and tried not wake Patient #18 as the patient did not sleep often at night and was in psychosis. Interview revealed Patient #18 had psychosis and was doing "weird things - talking to things that were not there and taking his clothes off." MHT #20 stated Patient #18 would go into the bathroom and tear up papers and toilet paper and throw the paper on the floor. Interview revealed that when MHT #20 conducted his 15-minute checks, he would go up the hallway on the even numbered side and come back down the hallway on the odd numbered side. Interview revealed MHT #20 left the hallway and went into the file room to file paperwork. Interview revealed the unit did not have a unit secretary/unit coordinator on night shift. MHT #20 stated he was not sure if the nurse assigned to the unit was on the unit or in the medication room when he left the hallway. Interview revealed there was no staff on the hallway watching the patients when he went into the file room. Interviewed revealed he became aware of the incident when Patient #41's roommate came to the nurses' station and informed him that Patient #18 had come into their room and "peed". The roommate informed him that Patient #41 had jumped up after she saw Patient #18 standing over her at the edge of the bed. Interview revealed Patient #41 stated that Patient #18 said "I'm sorry" and ran back to his room. MHT #20 revealed he went to Patient #18's room and the door had been closed shut and was locked. Interview revealed that when the MHT went into Patient #41's room, he noted a liquid substance across the bed linens with "drops every 4-5 inches to other side of bed where there was a small puddle of liquid." Interview revealed MHT #20 took Patient #41's linen to the laundry room and gave her towels to wash off in the shower. Interview revealed MHT #20 stated "I didn't think about that (dirty linens & clothes as evidence) prior to washing the linen and clothes." Interview revealed the RN and the MHT went to Patient #18's room and the RN unlocked the room door. MHT stated Patient #18 continued to state "I did not do anything" after the incident. Interview revealed Patient #18 was placed on a one-to-one (1:1) precaution after the incident. Interview revealed the MHT recalled receiving verbal re-education from the house supervisor (HS #23) and the nurse manager (NM #31).

Telephone interview on 12/22/2022 at 1730 with RN #21 revealed the nurse did not recall if she was on the unit when the incident occurred with Patient #41 and Patient #28. Interview revealed the nurse was required to count the Pyxis every Sunday night with another nurse. Interview revealed RN #21 and the nurse from the 3-West unit were in the medication room counting medications. Interview revealed the medication room was on the opposite end of the hallway from Patient #18's room and she would not have been able to see the Patient if he left his room. Interview revealed the MHT was in the hallway when she left the unit to go to the 3-West unit to count medications. Interview revealed the facility staff were expected to have hallway presence at all times when patient were on the unit. Interview revealed RN #21 did not recall a Physician Assistant on the unit during this time. Interview revealed RN #21 did not recall if the MHT was on the hallway when she and the 3-West nurse returned to 3-East to count the medications on 3-East.

Interview on 12/22/2022 at 1800 with CNO #6 revealed the house supervisors are usually available to assist with counting the Pyxis medications. Interview revealed the expectation was for the unit nurse to contact the house supervisor so that the other nurses could remain on their units as the night shifts on 3-East and 3-West were typically only staffed with 1 RN and 1 MHT.

Interview on 12/05/2022 at 1315 with NM #31 revealed the staff were expected to monitor the hallway at all times when patients are on the unit or in the rooms.

Telephone interview on 12/22/2022 at 1105 with Physician Assistant #25 (PA #25) revealed she did not recall the incident with Patient #18 and Patient #41. Interview revealed PA #25 was not typically in the facility at 4 or 5 a.m. Interview revealed PA #25 usually arrived at the facility around 8 a.m. Interview revealed PA #25 stated "I don't believe it was me."

B. A closed medical record review on 11/29/2022 revealed patient #2 a 17-year-old involuntarily admitted on 08/04/2022 for suicide ideation with plan to overdose and anger outburst. Review of the psychiatric evaluation performed on 08/05/2022 revealed a history of post-traumatic stress disorder and depression. The patient received a chief diagnosis of disruptive mood dysregulation disorder with a treatment plan to include individual, family and group therapy sessions and medication management. Review of the dayshift (registered nurse) RN #36 note revealed on 08/05/2022 Patient #2 was in the lounge during nursing group and was confronted and attacked by three peers who grabbed her hair, hit her in the face multiples times and she was kicked. Further review of the note revealed the peers were separated by staff and Patient #2 was placed in seclusion for her own safety, physician notified, order placed to move the patient's (#2) room to 2E and as needed (PRN) Tylenol given. Review of the nightshift RN #3 note revealed Patient #2 and peers were in a verbal altercation, Patient #2 sat up and yelled "can you not just shut (expletive) up, I'm trying to sleep here. This now made Patient

Based on facility policy review, medical record review, incident report review, and staff interview, the facility staff failed to maintain investigative summaries of patient-to-patient sexual abuse in 12 of 16 patients with sexual abuse allegations reviewed. (Patients #16, #26, #31, #32, #33, #34, #35, #37, #57, #58, #59, #60).

Findings included:

Review of the facility policy Patient Abuse, Neglect and Exploitation - Reporting & Investigating approved 07/25/2019, revealed, "...A timely, thorough and objective investigation of all allegations of abuse, neglect or exploitation will be completed... d. The investigation must include an interview of the complainant and request for statements form all employees, patients and others having knowledge of or involved in the incident... 5. Investigative Report Completion. The Report must be completed within seven (7) working days from the date of the allegation. The following elements shall be included: A brief, clear description of the allegation with identification of the victim, alleged perpetrator(s) and complainants, when the incident occurred and where. It should state the time of reporting. b. Investigation Summary: A detailed description of the investigation from initiation to completion. The narrative should state all elements of evidence such as: 1. Date, time and location of alleged incident 2. Location of victim, witnesses and the alleged perpetrator 3. Description of any injuries by victim (with photographs, if applicable) 4. How the incident was discovered and by whom 5. Description of any other evidence 6. Analysis of evidence: explain how the investigator reached his/her decision 7. Determination: A brief statement supported by analysis as to whether abuse, neglect or exploitation occurred and by whom 8. All witness statements and supporting documentation. c. This information shall be maintained by Risk Management, or designee..."

1. Closed medical record review of Patient #16 revealed a 12-year-old female who was involuntarily admitted to the facility on 07/29/2021. Medical record review revealed admitting diagnoses included Disruptive mood Dysregulation disorder (DMD), Post-traumatic stress disorder (PTSD), Suicidal ideations (SI), Attention-deficit hyperactivity disorder (ADHD), Personal history of physical and sexual abuse in childhood. Record review revealed Patient #16 was placed on Q 15 m (every 15-minute) observations and Suicidal (S), Self Harm (SH), Victim of Sexual Aggression (VSA), and Elopement (E) risk precautions. Review of nursing note dated 09/18/2021 at 1842 revealed, "... Reported to a staff member today that a male peer touched her inappropriately and on purpose, in her private area/groped pt(patient). Pt reports it occurred two days ago. Pt reports to this RN that she did inform several staff members on day incident occurred. This RN informed House Supervisor of pt allegations. RN called Pt's DSS (Department of Social Services) guardian and left voicemail to call back about allegations. House Supervisor reported to this RN that report had been made with (named police department) about pt. Peer she made allegations against had already discharged this morning before pt had informed staff member of their allegations..." Review of Patient Observation Record failed to reveal documentation of inappropriate touching. Medical record review revealed Patient #16 was discharged to a residential facility on 10/05/2021.

Review of the Incident Report dated 09/18/2021 revealed, "... Pt reports that 2 days ago male peer purposely touched her in her private area, supervisor notified and (named police department) called and came at 2030 on 09/18/2021 and took report, case # (number) assigned..." Incident report review failed to reveal the investigative summary for the allegation. Incident report failed to reveal if the facility determined that the allegation was substantiated or unsubstantiated.

Interview on 12/01/2022 at 1530 with RN #3 revealed the facility staff put safeguards in place when patient's reported allegations of abuse. Interview revealed that when a patient made an allegation of abuse, the information was relayed to the nurse supervisor/manager, physician, and guardian. Interview revealed the patients were separated and monitoring/risk precautions were modified as needed. Interview revealed that nursing leadership was supposed to investigate the allegations.

Interview on 12/02/2022 at 0940 with RN #5 revealed that when the nurse supervisor was notified, patient safety was the first priority. Interview revealed that the nurse supervisors ensured that the patients had been separated, then tried to determine what happened. Interview revealed that RN #5 notified the patient's guardians, physician, administrator on call (AOC), and police department (if appropriate). Interview revealed that RN #5 did not document the investigation of the allegations, nor performed video review. Interview revealed that RN #5 deferred the investigation and completion of the investigative summary to Risk Management and the Nurse Managers.

Interview on 11/30/2022 at 1430 with MD #7 revealed that the facility staff notified the provider whenever allegations of abuse were made. Interview revealed that MD #7 gave orders depending on the situation and allegations made. Interview revealed that MD #7 commonly ordered alternative sleep, increased monitoring, or additional risk precautions in response to abuse allegations.

Interview on 12/06/2022 at 1135 with CNO #6 revealed that the investigative summary for the abuse allegation was not available. Interview revealed that CNO #6 was unable to verify what steps of the investigation were completed for each allegation of abuse. Interview revealed that CNO #6 expected staff and patients to relay abuse allegations to the nurse and nurse supervisor. Interview revealed CNO #6 expected nursing staff to ensure patient safety and to document details in the medical record for each patient involved. Interview revealed a report was to be completed on every incident. Interview revealed the nurse manager and risk manager reviewed each incident report for completeness prior to signing off on it. Interview revealed the facility was working on creating a process to ensure that allegations of abuse were thoroughly investigated and documented.

Interview on 12/07/2022 at 0900 with RM #1 revealed that the investigative summary for the sexual abuse allegation was unavailable. Interview revealed that the facility was ensuring patient safety, but did not complete the investigation of all of the Level 1 and Level 2 allegations (Sexual boundary violations and Sexual misconduct). Interview revealed that the investigation process and resulting documentation was outlined in the abuse policy, but RM #1 was unable to speak to which steps of the investigation that were actually completed. Interview revealed the expectation that nursing staff and the patient advocate investigated the allegations. Interview revealed that the patient advocate role that investigated allegations was only part time and their priority was on grievances, complaints, and court. Interview revealed that the facility was working on creating a process to ensure that all allegations of abuse were thoroughly investigated and documented. Interview revealed RM #1 was unsure of the timing of implementation of the new investigation process.

2. Closed medical record review of Patient #26 revealed an 11-year-old male who was voluntarily admitted to the facility on 06/30/2022. Medical record review revealed admitting diagnoses included DMD, ADHD, Bipolar Disorder, Autism Spectrum Disorder (ASD), Generalized Anxiety Disorder, and SI. Record review revealed Patient #26 was placed on Q15m observations and S, VSA, E, and Assaultive/Aggression (A) risk precautions. Review of physician note dated 08/09/2022 at 1244, "...Patient shows gradual improvement in mood lability but still seems to easily get stuck mentally and can't process information. Was upset that peer asked to kiss him last night..." Review of Nursing Notes and Patient Observation Record failed to reveal documentation of sexual boundary violation. Medical record review revealed Patient #26 was discharged home on 10/06/2022.

Review of the Incident Report dated 08/15/2022 revealed, "... Pt had reported to staff on 8/8/22 that his room mate tried to kiss him good night. Room mate was alt (alternative) slept." Incident report review failed to reveal the investigative summary for the allegation. Incident report failed to reveal if the facility determined that the allegation was substantiated or unsubstantiated.

Interview on 12/06/2022 at 1135 with CNO #6 revealed that the investigative summary for the abuse allegation was not available. Interview revealed that CNO #6 was unable to verify what steps of the investigation were completed for each allegation of abuse. Interview revealed that CNO #6 expected staff and patients to relay abuse allegations to the nurse and nurse supervisor. Interview revealed CNO #6 expected nursing staff to ensure patient safety and to document details in the medical record for each patient involved. Interview revealed a report was to be completed on every incident. Interview revealed the nurse manager and risk manager reviewed each incident report for completeness prior to signing off on it. Interview revealed the facility was working on creating a process to ensure that allegations of abuse were thoroughly investigated and documented.

Interview on 12/07/2022 at 0900 with RM #1 revealed that the investigative summary for the sexual abuse allegation was unavailable. Interview revealed that the facility was ensuring patient safety, but did not complete the investigation of all of the Level 1 and Level 2 allegations (Sexual boundary violations and Sexual misconduct). Interview revealed that the investigation process and resulting documentation was outlined in the abuse policy, but RM #1 was unable to speak to which steps of the investigation that were actually completed. Interview revealed the expectation that nursing staff and the patient advocate investigated the allegations. Interview revealed that the patient advocate role that investigated allegations was only part time and their priority was on grievances, complaints, and court. Interview revealed that the facility was working on creating a process to ensure that all allegations of abuse were thoroughly investigated and documented. Interview revealed RM #1 was unsure of the timing of implementation of the new investigation process.

3. Closed medical record review of Patient #31 revealed a 15-year-old female who was involuntarily admitted to the facility on 10/26/2021. Medical record review revealed admitting diagnoses included Major Depressive Disorder, ADHD, and SI. Record review revealed Patient #31 was placed on Q15m observations and S, SH risk precautions. Review of Nursing Notes dated 11/05/2021 at 1630 revealed, "...Pt let social worker know she was inappropriately kissed on the lips by another peer today. Pt felt violated and moved to another unit (named) for safety..." Review of Patient Observation Record failed to reveal documentation of sexual misconduct. Medical record review revealed Patient #31 was discharged to a residential facility on 12/02/2021.

Review of the Incident Report dated 11/05/2021 at 1600 for Patient #31 revealed, "...Pt stated to Acute Clinician that another patient had came up behind her in the hallway and kissed her on the lips. Following this the Patient felt violated and told acute clinician who reported it to Nursing Staff who in turn move patient to alternative unit for Safety and comfort in continued milieu management. Mother did give permission for patient to speak with police..." Incident report review failed to reveal the investigative summary for the allegation. Incident report failed to reveal if the facility determined that the allegation was substantiated or unsubstantiated.

Interview on 12/06/2022 at 1135 with CNO #6 revealed that the investigative summary for the abuse allegation was not available. Interview revealed that CNO #6 was unable to verify what steps of the investigation were completed for each allegation of abuse. Interview revealed that CNO #6 expected staff and patients to relay abuse allegations to the nurse and nurse supervisor. Interview revealed CNO #6 expected nursing staff to ensure patient safety and to document details in the medical record for each patient involved. Interview revealed a report was to be completed on every incident. Interview revealed the nurse manager and risk manager reviewed each incident report for completeness prior to signing off on it. Interview revealed the facility was working on creating a process to ensure that allegations of abuse were thoroughly investigated and documented.

Interview on 12/07/2022 at 0900 with RM #1 revealed that the investigative summary for the sexual abuse allegation was unavailable. Interview revealed that the facility was ensuring patient safety, but did not complete the investigation of all of the Level 1 and Level 2 allegations (Sexual boundary violations and Sexual misconduct). Interview revealed that the investigation process and resulting documentation was outlined in the abuse policy, but RM #1 was unable to speak to which steps of the investigation that were actually completed. Interview revealed the expectation that nursing staff and the patient advocate investigated the allegations. Interview revealed that the patient advocate role that investigated allegations was only part time and their priority was on grievances, complaints, and court. Interview revealed that the facility was working on creating a process to ensure that all allegations of abuse were thoroughly investigated and documented. Interview revealed RM #1 was unsure of the timing of implementation of the new investigation process.

4. Closed medical record review of Patient #32 revealed a 12-year-old male who was involuntarily admitted to the facility on 11/01/2021. Medical record review revealed admitting diagnoses included DMD, ADHD, ASD, and Homicidal Ideations (HI). Record review revealed Patient #32 was placed on Q15m observations and S, SH risk precautions. Review of Physician Notes dated 11/09/2021 at 1325 revealed, "...Pt and certain peer have accused one another of inappropriate things...please see nurses notes for details/full reports made..." Review of Nursing Notes dated 11/09/2021 at 0030 revealed, "...kissed peer on forehead at bedtime. states he didn't know it was not ok..." Review of Nursing Notes dated 11/09/2021 at 1053 revealed, "...accused of grabbing roommate in the crotch last night. Roommate claims that pt. said, 'I want to suck it.' Pt denies and seems confused as to what roommate is talking about..." Review of Patient Observation Record failed to reveal documentation of sexual boundary violation or misconduct. Medical record review revealed Patient #32 was discharged home on 11/23/2021.

Review of the Incident Report dated 11/08/2021 revealed, "...MHT (mental health technician) walked into rom (sic), saw (named Patient #32) run from roommates's side of room to his own bed, when asked what they were doing they stated (named Patient #32) kissed roommate on the forehead. Both state that they didn't know this behavior was not allowed or ok. Both apologized and roommate feels he was at fault for letting (named Patient #32) kiss him. Roommate willingly agrees to sleep in comfort room. Alt sleep ordered by (named physician). Mom notified and satisfied with intervention of them not sleeping in same room tonight..." Incident report review failed to reveal the investigative summary for the allegation. Incident report failed to reveal if the facility determined that the allegation was substantiated or unsubstantiated.

Review of the Incident Report dated 11/09/2021 revealed, "...Last night pt and roommate reported that pt kissed roommate on the forehead. Today, roommate changed story and said pt grabbed roommate in the private area and told him he wanted to suck it..." Incident report review failed to reveal the investigative summary for the allegation. Incident report failed to reveal if the facility determined that the allegation was substantiated or unsubstantiated.

Interview on 12/06/2022 at 1135 with CNO #6 revealed that the investigative summary for the abuse allegation was not available. Interview revealed that CNO #6 was unable to verify what steps of the investigation were completed for each allegation of abuse. Interview revealed that CNO #6 expected staff and patients to relay abuse allegations to the nurse and nurse supervisor. Interview revealed CNO #6 expected nursing staff to ensure patient safety and to document details in the medical record for each patient involved. Interview revealed a report was to be completed on every incident. Interview revealed the nurse manager and risk manager reviewed each incident report for completeness prior to signing off on it. Interview revealed the facility was working on creating a process to ensure that allegations of abuse were thoroughly investigated and documented.

Interview on 12/07/2022 at 0900 with RM #1 revealed that the investigative summary for the sexual abuse allegation was unavailable. Interview revealed that the facility was ensuring patient safety, but did not complete the investigation of all of the Level 1 and Level 2 allegations (Sexual boundary violations and Sexual misconduct). Interview revealed that the investigation process and resulting documentation was outlined in the abuse policy, but RM #1 was unable to speak to which steps of the investigation that were actually completed. Interview revealed the expectation that nursing staff and the patient advocate investigated the allegations. Interview revealed that the patient advocate role that investigated allegations was only part time and their priority was on grievances, complaints, and court. Interview revealed that the facility was working on creating a process to ensure that all allegations of abuse were thoroughly investigated and documented. Interview revealed RM #1 was unsure of the timing of implementation of the new investigation process.

5. Closed medical record review of Patient #33 revealed a 15-year-old female who was involuntarily admitted to the facility on 10/25/2021. Medical record review revealed admitting diagnoses included Bipolar Disorder, Oppositional Defiant Disorder (ODD), ADHD, and SI. Record review revealed Patient #33 was placed on Q15m observations and S, SH, A risk precautions. Review of Nursing Notes dated 11/05/2021 at 1442 revealed, "... Pt alleges select peer touched her lower extremity while in lounge this am (morning). Not witnessed by staff. pt stated felt uncomfortable/unwanted by pt. no injuries..." Review of Patient Observation Record failed to reveal documentation of sexual boundary violation or misconduct. Medical record review revealed Patient #33 was discharged home on 11/11/2021.

Review of the Incident Report dated 11/05/2021 revealed, "...Pt alleges select peer touched her lower extremity while in lunge this am. Not witnessed by staff. Stated she felt uncomfortable/unwanted by pt. No injuries..." Incident report review failed to reveal the investigative summary for the allegation. Incident report failed to reveal if the facility determined that the allegation was substantiated or unsubstantiated.

Interview on 12/06/2022 at 1135 with CNO #6 revealed that the investigative summary for the abuse allegation was not available. Interview revealed that CNO #6 was unable to verify what steps of the investigation were completed for each allegation of abuse. Interview revealed that CNO #6 expected staff and patients to relay abuse allegations to the nurse and nurse supervisor. Interview revealed CNO #6 expected nursing staff to ensure patient safety and to document details in the medical record for each patient involved. Interview revealed a report was to be completed on every incident. Interview revealed the nurse manager and risk manager reviewed each incident report for completeness prior to signing off on it. Interview revealed the facility was working on creating a process to ensure that allegations of abuse were thoroughly investigated and documented.

Interview on 12/07/2022 at 0900 with RM #1 revealed that the investigative summary for the sexual abuse allegation was unavailable. Interview revealed that the facility was ensuring patient safety, but did not complete the investigation of all of the Level 1 and Level 2 allegations (Sexual boundary violations and Sexual misconduct). Interview revealed that the investigation process and resulting documentation was outlined in the abuse policy, but RM #1 was unable to speak to which steps of the investigation that were actually completed. Interview revealed the expectation that nursing staff and the patient advocate investigated the allegations. Interview revealed that the patient advocate role that investigated allegations was only part time and their priority was on grievances, complaints, and court. Interview revealed that the facility was working on creating a process to ensure that all allegations of abuse were thoroughly investigated and documented. Interview revealed RM #1 was unsure of the timing of implementation of the new investigation process.

6. Closed medical record review of Patient #34 revealed an 11-year-old female who was involuntarily admitted to the facility on 10/26/2021. Medical record review revealed admitting diagnoses included Bipolar Disorder, ODD, ADHD, SI, and aggressive behaviors. Record review revealed Patient #34 was placed on Q15m observations and S, SH risk precautions. Review of Physician Notes dated 11/01/2021 at 1533 revealed, "...She was caught kissing a female peer and her mom was notified..." Review of Nursing Notes dated 10/31/2021 at 1718 revealed, "...Pt and roommate both confessed to kissing one another consensually last night in their room. Now both are claiming to be uncomfortable with being in the room with the other. pt admitted to initiating the kiss but roommate agreed..." Review of Patient Observation Record failed to reveal documentation of sexual boundary violation or misconduct. Medical record review revealed Patient #34 was discharged home on 11/05/2021.

Review of the Incident Report dated 10/29/2021 revealed, "...Patient accused of inappropriate boundaries with roommate, roommate claimed pt was attempting to touch her breast and roommate had to deflect her hand away. pt denied doing it..." Incident report review failed to reveal the investigative summary for the allegation. Incident report failed to reveal if the facility determined that the allegation was substantiated or unsubstantiated.

Interview on 12/06/2022 at 1135 with CNO #6 revealed that the investigative summary for the abuse allegation was not available. Interview revealed that CNO #6 was unable to verify what steps of the investigation were completed for each allegation of abuse. Interview revealed that CNO #6 expected staff and patients to relay abuse allegations to the nurse and nurse supervisor. Interview revealed CNO #6 expected nursing staff to ensure patient safety and to document details in the medical record for each patient involved. Interview revealed a report was to be completed on every incident. Interview revealed the nurse manager and risk manager reviewed each incident report for completeness prior to signing off on it. Interview revealed the facility was working on creating a process to ensure that allegations of abuse were thoroughly investigated and documented.

Interview on 12/07/2022 at 0900 with RM #1 revealed that the investigative summary for the sexual abuse allegation was unavailable. Interview revealed that the facility was ensuring patient safety, but did not complete the investigation of all of the Level 1 and Level 2 allegations (Sexual boundary violations and Sexual misconduct). Interview revealed that the investigation process and resulting documentation was outlined in the abuse policy, but RM #1 was unable to speak to which steps of the investigation that were actually completed. Interview revealed the expectation that nursing staff and the patient advocate investigated the allegations. Interview revealed that the patient advocate role that investigated allegations was only part time and their priority was on grievances, complaints, and court. Interview revealed that the facility was working on creating a process to ensure that all allegations of abuse were thoroughly investigated and documented. Interview revealed RM #1 was unsure of the timing of implementation of the new investigation process.

7. Closed medical record review of Patient #35 revealed a 10-year-old male who was involuntarily admitted to the facility on 10/26/2021. Medical record review revealed admitting diagnoses included Bipolar Disorder, ADHD, Conduct Disorder, and SI. Record review revealed Patient #35 was placed on Q15m observations and H, S, SH, VSA risk precautions. Review of Physician Notes dated 11/09/2021 revealed, "...Later he did accuse a peer of grabbing his privates and saying something sexual..." Review of Nursing Notes dated 11/09/2021 at 0130 revealed, "... kissed by peer on forehead. states he let peer do it and is not uncomfortable by it..." Review of Nursing Notes dated 11/09/2021 at 1650 revealed, "...also pt accused male peer of grabbing his crotch last night. stated the initial incident of roommate kissing his forehead actually didn't happen as he reported last night..." Review of Patient Observation Record failed to reveal documentation of sexual boundary violation or misconduct. Medical record review revealed Patient #35 was discharged home on 11/16/2021.

Review of the Incident Report dated 11/08/2021 revealed, "... MHT walked into rom (sic), saw (named patient) run from (named Patient #35) side of room to his own bed, when asked what they were doing they stated (named patient) kissed (named Patient #35) on the forehead. Both state that they didn't know this behavior was not allowed or ok. Both apologized and (named Patient #35) feels he was at fault for letting (named patient ) kiss him. (named Patient #35) willingly agrees to sleep in comfort room to show his cooperation in hope he will still discharge on schedule. Parents notified, dad states 'that's highly inappropriate' parents cooperative and satisfied with intervention of them not sleeping in same room tonight. Alt sleep ordered by (named physician)..." Incident report review failed to reveal the investigative summary for the allegation. Incident report failed to reveal if the facility determined that the allegation was substantiated or unsubstantiated.

Review of the Incident Report dated 11/09/2021 revealed, "... Last night, pt reported that peer kissed him on the forehead. Today, pt changed the allegation to peer grabbing pt in the private area. Pt reports that peer said 'I want to suck it' ..." Incident report review failed to reveal the investigative summary for the allegation. Incident report failed to reveal if the facility determined that the allegation was substantiated or unsubstantiated.

Interview on 12/06/2022 at 1135 with CNO #6 revealed that the investigative summary for the abuse allegation was not available. Interview revealed that CNO #6 was unable to verify what steps of the investigation were completed for each allegation of abuse. Interview revealed that CNO #6 expected staff and patients to relay abuse allegations to the nurse and nurse supervisor. Interview revealed CNO #6 expected nursing staff to ensure patient safety and to document details in the medical record for each patient involved. Interview revealed a report was to be completed on every incident. Interview revealed the nurse manager and risk manager reviewed each incident report for completeness prior to signing off on it. Interview revealed the facility was working on creating a process to ensure that allegations of abuse were thoroughly investigated and documented.

Interview on 12/07/2022 at 0900 with RM #1 revealed that the investigative summary for the sexual abuse allegation was unavailable. Interview revealed that the facility was ensuring patient safety, but did not complete the investigation of all of the Level 1 and Level 2 allegations (Sexual boundary violations and Sexual misconduct). Interview revealed that the investigation process and resulting documentation was outlined in the abuse policy, but RM #1 was unable to speak to which steps of the investigation that were actually completed. Interview revealed the expectation that nursing staff and the patient advocate investigated the allegations. Interview revealed that the patient advocate role that investigated allegations was only part time and their priority was on grievances, complaints, and court. Interview revealed that the facility was working on creating a process to ensure that all allegations of abuse were thoroughly investigated and documented. Interview revealed RM #1 was unsure of the timing of implementation of the new investigation process.



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8. Closed medical record review on 12/22/2022 revealed a 16-year-old female Patient #37 involuntarily admitted on 10/05/2021 for being a danger to herself. The patient`s history included bipolar disorder, oppositional defiant disorder and attention-deficit disorder. Review revealed the patient was placed on every 15-minute monitoring and was on suicidal and sexual aggression precautions, and elopement risk. Review revealed the patient was placed in a blocked room (no roommate) on 10/13/2021 for sexual advances towards other patients. Review of a nursing note dated 11/05/2021 at 0320 revealed "Discussed boundaries issues and inappropriate sexual gestures with peers." Review of the Patient Observation Record for 11/05/2021 failed to reveal documentation of inappropriate sexual advances or behaviors to other patients. Review revealed the patient was discharged to a long-term care facility on 03/25/2022.

Review of the incident report dated 11/05/2021 at 1600 for Patient #37 revealed "Pt [patient] was reported by 2 other peers for sexual contact of various kinds including this patient walking up and kissing a patient on the lips that was unwanted ..." Review revealed the investigative summary was unavailable. Incident report failed to reveal if the facility determined that the allegation was substantiated or unsubstantiated.

Interview on 12/20/2021 with the RN #43 who cared for the patient on 11/05/2021 during the allegation revealed she did remember patient. She recalled the patient was in a blocked room for sexual aggression and required frequent redirection for being uncooperative.

Request for interview for the staff performing every 15-minute documentation on 11/05/2021 during the allegation revealed the employee no longer worked at the facility.

Interview on 12/22/2022 at 0953 with a MHT #45, revealed he worked the night shift after the incident and recalled there were allegations of invasion of space, and the staff increased awareness by watching the patients closer and allowed them the opportunity to talk about it. Interview revealed he recalled the staff "did a good job keeping them separated."

Interview on 12/20/2022 at 1100 with MD #7 who cared for the above patients during the allegation revealed she did not recall the incident. Interview revealed that many similar incidences take place at the facility due to the age group, psychiatric diagnosis, and manipulative nature of some patients. Interview revealed boundary issues were ongoing with this type of population. Interview revealed in a case as this one, nursing management would have been notified, and or a patient may have been moved to a single room with no roommate, increased observations, patient moved to another unit and or placed on special precautions.

Request for interview with the Social Worker (Acute Clinician) present on 11/05/2021 during the allegation revealed the employee was not available.

9. Closed medical record review on 12/22/2022 revealed a 14-year-old male Patient #57 voluntarily admitted for being a danger to himself. Review revealed the patient`s history included bi-polar disorder, attention-deficit disorder, Autism and identifies as a female. Review revealed the patient was placed on every 15-minute monitoring and was on suicidal precautions and self-harm risks. Review of a nursing note dated 11/06/21 at 1100 revealed "Pts father came to hospital upset about what happened to his child Frida

Based on policy review, medical record review and staff interview, facility staff failed to ensure a physician order for 1 of 3 restraint/ seclusion patient records reviewed (Patient # 13) and failed to ensure the order was time limited for 1 of 2 restraint/ seclusion patient orders reviewed (Patient # 14)

Findings included:

Review of policy PC-1-009-A "Proper Use and Monitoring of Physical/Chemical Restraint and Seclusion Acute", last revised 03/31/2022, revealed "...Physician Orders....Restraint or seclusion shall be used in emergency situations only and requires an order from a physician....The physician/LIP (licensed independent practitioner)....must be contacted for an order either during the emergency initiation of the restraint/seclusion or immediately....after the restraint/seclusion has been initiated....Time limits not to exceed 2 hours for children and adolescents ages 9 to 17... ."

1. Medical record review for Patient #13, from 11/30-12/1/2022, revealed Patient # 13 was a 15 year old male admitted 04/30/2022 with a diagnosis of Disruptive Mood Dysregulation Disorder (DMDD - childhood condition of extreme irritability, anger and intense outbursts) and Generalized Anxiety Disorder. Review revealed on 05/14/2022 at 1515 "...threatening, instigating, aggressive, kicking and hitting doors. 1341 hit peer, placed in seclusion room....Remains agitated hitting and kicking doors, will not cooperate with redirection. ..." Record review of the "RESTRICTIVE INTERVENTION - RN NOTE" revealed seclusion was initiated at 1341 and discontinued at 1412. Record review failed to reveal a physician order for the seclusion.

Staff interview on 12/02/2022 at 1130 with RN #8 revealed policy required an order for restraint or seclusion. Interview revealed no seclusion order was located for Patient #13's 5/14/2022 seclusion. Interview revealed the facility transitioned from paper to computerized restraint/seclusion orders recently but neither a computer order nor paper order were located.

2. Medical record review, on 12/01/2022, revealed Patient #14 was a 12 year old male who was admitted 08/10/2022 with diagnoses of Attention Deficit Disorder (condition with persistent difficulty maintaining attention and concentration sometimes with impulsive or hyperactive behavior) and DMDD. Record review revealed that on 10/16/2022 at 1709, Nursing documentation indicated "...Pt (patient) took off and hit peer in right side of face. 1710 Back in restraint and walked toward seclusion. 1711 Door shut to seclusion. ..." Review of physician orders revealed a computerized order for the seclusion. Review revealed the order was for "Seclusion Aggression toward staff and peers....Start Time: 10/16/22 17:11." Review revealed the stop time or time limit for the seclusion was not ordered. Review failed to reveal a time limited order for seclusion.

Staff interview with RN #8 on 12/02/2022 at 1130, revealed the computerized order for seclusion on Patient #14 was not time limited. Interview revealed the facility previously used to a paper order which included the time limit but with the transition to a computerized order the time limit was no longer there. Interview revealed there was no time limited order for Patient #14 but there should have been a 2 hour time limit.

Based on policy review, personnel record review, and staff interviews, the facility failed to ensure the clinical staff had current CPI (Psychological Capital Intervention) training in two (2) of fourteen (14) clinical staff's personnel records reviewed (RN #3 and MHT #4).

Findings included:

Review of the facility policy titled "Staff Competency and Training" approved 08/05/2022 revealed, "...Clinical/Nursing Staff will receive additional training, appropriate to their positions, in the following areas: ...Proper use and monitoring of physical and chemical restraint and seclusion (semi- annually) ..."

1. A review on 12/02/2022 of personnel record for Registered Nurse (RN) #3 revealed a CPI certification card with an expired date of 09/30/2022. The review revealed no current CPI certification available.

Review on 12/02/2022 of the CPI refresher course log revealed RN #3 attended a CPI course on 03/10/2022. The review revealed the certification issued from the class expired on 09/30/2022.

An interview on 12/02/2022 at 1320 with Risk Management (RM) #1 confirmed that the staff CPI certification had expired on 09/30/2022 due to a data entry error. The interview revealed that Human Resources (HR) was unaware that the CPI recertification was overdue because the expiration date was entered incorrectly into the system. The interview revealed the expiration date was entered for 09/30/2023, therefore the computer did not flag the expired CPI certification.

Interview on 12/05/2022 at 1220 with the HR Director revealed the staff received a copy of their CPI recertification cards with an expiration date. The interview revealed that the staff was expected to take ownership of their training and recertification, but ultimately HR was responsible for all recertifications. The interview revealed that HR was unaware of the expired CPI because the HR staff entered the expected expiration date incorrectly. The interview revealed the staff was working on the units while the CPI certification was overdue. The interview revealed the policy was not followed.

2. A review on 12/02/2022 of personnel record for Mental Health Technician (MHT) #4 revealed a CPI certification card with an expired date of 09/30/2022. The review revealed no current CPI certification available.

Review on 12/02/2022 of the CPI refresher course log revealed (MHT) #4 attended a CPI course on 03/01/2022. The review revealed the certification issued from the class expired on 09/30/2022.

An interview on 12/02/2022 at 1320 with (RM) #1 confirmed that the staff CPI certification had expired on 09/30/2022 due to a data entry error. The interview revealed that Human Resources (HR) was unaware that the CPI recertification was overdue because the expiration date was entered incorrectly into the system. The interview revealed the expiration date was entered for 09/30/2023, therefore the computer did not flag the expired CPI certification.

Interview on 12/05/2022 at 1220 with the HR Director revealed the staff received a copy of their CPI recertification cards with an expiration date. The interview revealed that the staff was expected to take ownership of their training and recertification, but ultimately HR was responsible for all recertifications. The interview revealed that HR was unaware of the expired CPI because the HR staff entered the expected expiration date incorrectly. The interview revealed the staff was working on the units while the CPI certification was overdue. The interview revealed the policy was not followed.

Based on policy review, incident report review, intensive analysis review and staff interviews, hospital leadership failed to maintain an effective quality assessment and performance improvement program for patient safety.

Findings included:

1. The facility failed to monitor and track the completion of sexual abuse allegation investigations and failed to provide the numeric classification level for 2 of 2 incidents of physical aggression toward other patients involving the same patient.

~cross refer to 482.21(a), (b)(1), (b)(2)(i), (b)(3) -QAPI Standard: Data Collection & Analysis, Tag A0273

2. Hospital leadership failed to ensure adequate follow-up of adverse incidents for patient safety in 3 of 4 intensive analyses reviewed and failed to track causes of Level 1 and 2 patient aggression/ sexual events in order to implement preventive actions and identify success of actions taken.

~cross refer to 482.21 (a), (c)(2), (e)(3) -QAPI Standard: Patient Safety, Tag A0286

Based on facility policy reviews, incident report reviews, medical record reviews, police report review, and staff interviews, the facility failed to monitor and track the completion of sexual abuse allegation investigations for 12 of 16 patients with sexual abuse allegations reviewed (Patients #16, #26, #31, #32, #33, #34, #35, #37, #57, #58, #59, #60); and failed to provide the numeric classification level for 2 of 2 incidents of physical aggression toward other patients involving the same patient. (Patient #49)

Findings included:

A. Review of the facility policy Patient Abuse, Neglect and Exploitation - Reporting & Investigating approved 07/25/2019, revealed, "...A timely, thorough and objective investigation of all allegations of abuse, neglect or exploitation will be completed... 7. Determination: A brief statement supported by analysis as to whether abuse, neglect or exploitation occurred and by whom... c. This information shall be maintained by Risk Management, or designee..."

Review of Sexual Incidents for 2021 revealed a total of 358 events. Review revealed 227 incidents were Level 1 (Sexual Boundary Violation), 124 incidents were Level 2 (Sexual Misconduct), and 7 incidents were Level 3.

Review of Sexual Incidents for 2022 revealed a total of 477 events. Review revealed 299 incidents were Level 1, 172 events were Level 2, and 6 incidents were Level 3.

1. Review on 12/06/2022 of the Incident Report for Patient #16 dated 09/18/2021 revealed, "... Pt reports that 2 days ago male peer purposely touched her in her private area, supervisor notified and (named police department) called and came at 2030 on 09/18/2021 and took report, case # (number) assigned..." Incident report failed to reveal the completion of an investigation and determination of substantiation.

2. Review on 12/06/2022 of the Incident Report for Patient #26 dated 08/15/2022 revealed, "... Pt had reported to staff on 8/8/22 that his room mate tried to kiss him good night. Room mate was alt (alternative) slept." Incident report failed to reveal the completion of an investigation and determination of substantiation.

3. Review on 12/06/2022 of the Incident Report for Patient #31 dated 11/05/2021 revealed, "...Pt stated to Acute Clinician that another patient had came up behind her in the hallway and kissed her on the lips. Following this the Patient felt violated and told acute clinician who reported it to Nursing Staff who in turn move patient to alternative unit for Safety and comfort in continued milieu management. Mother did give permission for patient to speak with police..." Incident report failed to reveal the completion of an investigation and determination of substantiation.

4. Review on 12/06/2022 of the Incident Report for Patient #32 dated 11/08/2021 revealed, "...MHT (mental health technician) walked into rom (sic), saw (named Patient #32) run from roommate's side of room to his own bed, when asked what they were doing they stated (named Patient #32) kissed roommate on the forehead. Both state that they didn't know this behavior was not allowed or ok. Both apologized and roommate feels he was at fault for letting (named Patient #32) kiss him. Roommate willingly agrees to sleep in comfort room. Alt sleep ordered by (named physician). Mom notified and satisfied with intervention of them not sleeping in same room tonight..." Incident report failed to reveal the completion of an investigation and determination of substantiation.

Review on 12/06/2022 of the Incident Report for Patient #32 dated 11/09/2021 revealed, "...Last night pt and roommate reported that pt kissed roommate on the forehead. Today, roommate changed story and said pt grabbed roommate in the private area and told him he wanted to suck it..." Incident report failed to reveal the completion of an investigation and determination of substantiation.

5. Review on 12/06/2022 of the Incident Report for Patient #33 dated 11/05/2021 revealed, "...Pt alleges select peer touched her lower extremity while in lunge this am. Not witnessed by staff. Stated she felt uncomfortable/unwanted by pt. No injuries..." Incident report failed to reveal the completion of an investigation and determination of substantiation.

6. Review on 12/06/2022 of the Incident Report for Patient #34 dated 10/29/2021 revealed, "...Patient accused of inappropriate boundaries with roommate, roommate claimed pt was attempting to touch her breast and roommate had to deflect her hand away. pt denied doing it..." Incident report failed to reveal the completion of an investigation and determination of substantiation.

7. Review on 12/06/2022 of the Incident Report for Patient #35 dated 11/08/2021 revealed, "... MHT walked into rom (sic), saw (named patient) run from (named Patient #35) side of room to his own bed, when asked what they were doing they stated (named patient) kissed (named Patient #35) on the forehead. Both state that they didn't know this behavior was not allowed or ok. Both apologized and (named Patient #35) feels he was at fault for letting (named patient) kiss him. (named Patient #35) willingly agrees to sleep in comfort room to show his cooperation in hope he will still discharge on schedule. Parents notified, dad states 'that's highly inappropriate' parents cooperative and satisfied with intervention of them not sleeping in same room tonight. Alt sleep ordered by (named physician)..." Incident report failed to reveal the completion of an investigation and determination of substantiation.

Review on 12/06/2022 of the Incident Report for Patient #35 dated 11/09/2021 revealed, "... Last night, pt reported that peer kissed him on the forehead. Today, pt changed the allegation to peer grabbing pt in the private area. Pt reports that peer said 'I want to suck it' ..." Incident report failed to reveal the completion of an investigation and determination of substantiation.



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8. Review on 12/22/2022 of the incident report dated 11/05/2021 at 1600 for Patient #37 revealed "Pt [patient] was reported by 2 other peers for sexual contact of various kinds including this patient walking up and kissing a patient on the lips that was unwanted ..." Incident report failed to reveal the completion of an investigation and determination of substantiation.

9. Review on 12/22/2022 of the incident report dated 11/05/2021 at 1500 for Patient #57 revealed "This pts dad came to [named facility] and told staff that his child was slapped on butt and back of head on Friday." Incident report failed to reveal the completion of an investigation and determination of substantiation.

10. Review on 12/22/2022 of the incident report dated 11/05/2021 at 1600 for patient #58 revealed "Per patient, info [information] obtained today ...Incident happened 1 month ago per patient, inappropriate touching. Police were contacted today and have a case number. Patient provided a handwritten statement to police stating another patient touched her vagina, buttocks, and breasts." Incident report failed to reveal the completion of an investigation and determination of substantiation.

11. Review on 12/22/2022 of the incident report dated 11/05/2021 at 1500 for Patient #59 revealed "It was brought to staff attention by another pt [patient] dad that this pt slapped his child on the butt and back of head. The dad stated this took place on Friday." Incident report failed to reveal the completion of an investigation and determination of substantiation.

12. Review on 12/22/2022 of the incident report dated 11/05/2021 at 1600 for Patient #60 revealed "This patient reported that another patient had touched her inappropriately several times by "slapping her on the butt," and "putting her chest in my face ..." Incident report failed to reveal the completion of an investigation and determination of substantiation.

Interview on 12/06/2022 at 1135 with CNO #6 revealed that the investigative summaries for the abuse allegations were not available. Interview revealed an incident report and investigation was to be completed on every allegation of abuse. Interview revealed the nurse manager and risk manager reviewed each incident for completeness prior to signing off on it. Interview revealed that CNO #6 was unable to verify what steps of the investigation were completed for each allegation of abuse. Interview revealed that the facility acknowledged that there were gaps in the investigation of the allegation, but was working on creating a process to ensure that all allegations of abuse were thoroughly investigated and documented completely.

Interview on 12/07/2022 at 0900 with RM #1 revealed that the investigative summaries for the Level 1 and Level 2 abuse allegations were unavailable. Interview revealed that the facility was ensuring patient safety, but did not complete the investigation of all of the Level 1 and Level 2 allegations (Sexual boundary violations and Sexual misconduct). Interview revealed that the investigation process and resulting documentation was outlined in the abuse policy, but RM #1 was unable to speak to which steps of the investigation that were actually completed for each allegation. Interview revealed that the facility was working on creating a process to ensure that all allegations of abuse were thoroughly investigated and documented. Interview revealed RM #1 was unsure of the timing of implementation of the new investigation process.



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B. Review 12/20/2022, of a document titled "INCIDENT REPORT - FACILITY RISK MANAGER TIPS FOR SUCCESS CLASSIFYING SIGNIFICANCE LEVELS ....", last released 01/01/2022, revealed, four levels of incidents from Level I (least severe) to Level IV (most severe). Review revealed " ...LEVEL I - Occurrence: Incidents where the impact to the patient or parties involved is thought to be none to slight .... LEVEL II - Non-Serious: Incidents where impact to the patient or parties involved is thought to be minimal.... LEVEL III - Serious: Any major injury or impairment.... or any violation of law or regulatory authority shall be classified no less than a Level III regardless of evidence of patient injury. ..."

Review 12/20/2022 of the incident log revealed, from September 2021 through December 2021, Patient #49 had 2 of 2 incidents of aggression towards other patients.

1. Review 12/20/2022 of an incident report revealed, on 11/2/2021 at 1640, Patient #49 unprovokedly punched Patient #30 in the face during recreational time while in the courtyard. Patient #30 sustained a busted lip. Interventions for Patient #49 were medication, unit restriction, voluntary time out, and guardian notification. Intervention for Patient #30 was first aid. Review failed to reveal, the numeric classification level of the incident.

Closed medical record review 12/20/2022 revealed on 10/25/2021, Patient #49, a 17-year-old was involuntarily admitted to the male adolescent unit of the facility for self-injurious behaviors and suicidal ideations for one week. The patient was a high risk for aggression. On 10/26/2021, a psychiatric evaluation was performed, and the patient received a primary diagnosis of Unspecified Bipolar and Related disorder (abnormal mood without meeting criteria for Bipolar I and or II). Admission orders included monitoring every 15-minutes. On 11/2/2021, the patient had ongoing changes in mood, and was easily agitated by peers, impulsive, instigative, verbally aggressive and threatening. At 1530, the Adolescent male unit was in the courtyard for recreational therapy. Patient #30 was on the swing. As Patient #49 approached the swings, Patient #30 told another patient to get on the swings so that Patient #49 would not be able to because Patient #49 had been picking on him and threatening him. Patient #49 went to and unprovokedly punched Patient #30 in the face, resulting in a busted lip. Facility staff stopped the fight, and the patients were separated. Patient #49 was taken inside. While inside, Patient #49 started throwing chairs, attempted to punch the television, and started self-injurious behavior by cutting himself with parts of the gutter that he pulled down prior to entering the building. The facility staff continued de-escalation techniques with Patient #49, by administering as needed medication and placing him on unit restrictions for 24-hours. On 11/3/2021, a code was called because Patient #49 made verbal threats after finding out Patient #30 pressed charges against him for the November 2, 2021 patient-to-patient incident. Further review revealed, the psychiatric component of the treatment plan was not established nor was Patient #49 placed on aggression precautions after the incident. Telephone communication attempts with the parent/guardian was unsuccessful on November 2nd, 3rd, 4th, 9th, 12, 13th, 14th, 2021. Review revealed, the patient was identified as the aggressor in an unprovoked patient-to-patient incident.

Closed medical record review 12/20/2022 revealed on 10/26/2021, Patient #30, a 14-year-old was involuntarily admitted to the male adolescent unit of the facility for suicidal thoughts and after turning himself in to the police department, with knife in hand, for being a "bad kid". The patient was not a high risk for aggression. On October 27, 2021, a psychiatric evaluation was performed, and the patient received a primary diagnosis of Disruptive mood dysregulation disorder (childhood condition of irritability, anger, with frequent and intense outbursts). Admission orders included monitoring every 15-minutes. On 11/2/2021, the patient had an outburst because Patient #49 made fun of the patient's appearance. The situation was de-escalated with 1:1 intervention. At 1640, the patient was identified as the victim in an unprovoked patient-to-patient incident wherein, Patient # 49, the aggressor, punched Patient #30 in the face during recreational time in the courtyard. As a result, Patient #30 sustained a busted lip. Staff provided first aid treatment to Patient #30. Further review revealed, the psychiatric component of the treatment plan was established and included aggression on the problem list. On 11/3/2021 at 1329, the facility staff telephoned and spoke with the parent/guardian. Consent was obtained for the patient to speak with law enforcement and law enforcement could take photos of the patient's injuries, if needed for evidence. Review revealed, the patient was identified as the victim in an unprovoked patient-to-patient incident.

Review 12/20/2022 of a police report revealed, on 11/3/2021 at 1030, the facility staff notified law enforcement regarding an assault. At 1049, the officer arrived at the facility to gather information regarding the 11/2/2021 incident involving Patient #49 and Patient #30, wherein Patient #30 sustained a busted lip caused by a fist punch to face from Patient #49. NM #29 and another staff member provided the officer information about the incident. The officer was informed no video was available because there was no video surveillance over the recreational area. Additionally, the officer inquired about collecting photographs of Patient #30. The two staff members were unsure if photographs of Patient #30 could be obtained without supervisor notification. The two staff member planned to contact law enforcement once a response was received. The officer obtained Patient #49 information, including his parents, provided a [case number] to the two staff members, and left the facility. At 1507, facility staff contacted and informed law enforcement photographs of Patient #30 could be obtained. An officer arrived at the facility, photo log was completed, and the officer left the facility. Further review of the report revealed, an officer obtained additional information from the facility's website about the type of services the facility provided. The officer spoke with [county] District Attorney Office and was advised that no criminal charges would be pursued because most patients at the facility had behavioral issues and were in crisis. As a result, the plan was to forward each report received from the facility to North Carolina Department of Health and Human Services for review. On 11/10/2021 at 1615, an officer spoke with RM #1 regarding the 11/2/2021 incident between Patient #49 and Patient #30 as well as, the other reports received from the facility dated from 10/7/2021 through 11/9/, 2021. RM #1 informed the officer that parental/guardian notification occurred, and the two patients were separated per facility policy. On 11/15/2021 at 1431, an officer attempted telephone contact with the parent/guardian of Patient #30. The purpose of the telephone call was to inform the parent/guardian that incident involving Patient #30 would be forward to the North Carolina Department of Health and Human Services. The parent/guardian was unavailable and a voice message for a return telephone call was requested. Law enforcement closed the case and prosecution was declined. Review revealed, the facility staff reported a patient injury, sustained from a patient-to-patient incident to law enforcement.

Information request on 12/22/2022 at 1053 made with CNO#6, for the numeric classification level of the 11/2/2021 incident involving Patient #49 and Patient #30 along with any investigation, was not provided prior to survey exit.

2. Review 12/20/2022 of an incident report revealed, on 11/21/2021 at 1212, two patient-to-patient incidents occurred simultaneously involving the same two patients. The first incident occurred wherein, Patient #55 attacked Patient #49 on the side of the neck after Patient #49 threw cards at him and hit him on the shoulder. The second incident occurred wherein; Patient #49 attacked Patient #55 because he "had it coming" from the first attack on Patient #49. Neither patient sustained any injuries from either incident. Interventions included the notification of the facility administrator and the guardians for both patients. Review failed to reveal, the numeric classification level of the incident.

Closed medical record review 12/22/2022 revealed on 9/27/2021, Patient #55, a 17-year-old was involuntarily admitted to the male adolescent unit of the facility for aggression towards group home staff member(s) after group staff member(s) harassed the patient. Patient stated as to being attacked at every behavioral health facility. The patient was a high risk for aggression. On 9/28/2021, a psychiatric evaluation was performed, and the patient received a primary diagnosis of Unspecified Bipolar and Related disorder (abnormal mood without meeting criteria for Bipolar I and or II). Admission orders included monitoring every 15-minutes. On 11/21/2021 at 12:00 noon, a code was called because the two patients began to fight on the unit wherein, Patient #49 became frustrated, yelled at, and threw the card deck at, and physically hit Patient #55 on the shoulder. Patient #55 had a flashback of verbal abuse from a stepparent which led him to chase after and scratch Patient #49 on the left side of his neck leaving welt marks. As a result, multiple patients were triggered and attempted to fight. Group therapy could not occur because of the distressing environment on the unit. Patient #55 expressed remorse for his actions, received 1:1 intervention with staff, and was administered a medication for anxiety. Further review revealed, guardian notification was not indicated. Review revealed, the patient was involved in a patient-to-patient incident.

Closed medical record review 12/20/2022 revealed on 10/25/2021, Patient #49, a 17-year-old was involuntarily admitted to the male adolescent unit of the facility for self-injurious behaviors and suicidal ideations for one week. The patient was a high risk for aggression. On 10/26/2021, a psychiatric evaluation was performed, and the patient received a primary diagnosis of Unspecified Bipolar and Related disorder (abnormal mood without meeting criteria for Bipolar I and or II). Admission orders included monitoring every 15-minutes. On 11/21/2021 at 12:00, a code was called because Patient #49, who was not originally involved, but inserted himself into the conflict with and hit Patient #55. At 12:12, Patient #49 became agitated when the unit environment deteriorated and hit Patient #55 in the center of the forehead with his fist for yelling at staff. As a result, multiple patients were triggered and attempted to fight. Group therapy could not occur because of the distressing environment on the unit. Patient #49 expressed no remorse for his actions. Staff de-escalated and redirected Patient #49, offered him 1:1 support, administered medication to him, and encouraged him to actively participate in treatment plan. Further review revealed, the psychiatric component of the treatment plan was not established nor was Patient #49 placed on aggression precautions after the incident, and guardian notification was not indicated. Review revealed, the patient was involved in a second patient-to-patient incident.

Information request on 12/22/2022 at 1053 made with CNO#6, for the numeric classification level of the 11/2/2021 incident involving Patient #49 and Patient #30 along with any investigation, was not provided prior to survey exit.

Based on policy review, incident report review, intensive analyses review and staff interviews, hospital leadership failed to ensure adequate follow-up of adverse incidents for patient safety in 3 of 4 Level #3 intensive analyses reviewed and failed to track causes of Level 1 and 2 patient aggression/ sexual events in order to implement preventive actions and identify success of actions taken.

Findings included:

Review of the hospital's "Performance Improvement Plan 2022", revealed " ...4. PURPOSE The QAPI program is designed to provide a coordinated, objective and systematic approach to organization-wide performance improvement activities ....To promote safety and prevent untoward occurrences through systematic monitoring of the treatment environment....At a minimum, the organization collects data on quality assurance measures outlined by The Joint Commission, CMS and State regulations including ...Risk management ....adverse events. ..."

Review of the "Incident Report (IR) Incident Reporting Process" policy, dated 12/15/2021, revealed "PURPOSE: ....C. Investigate incidents in a timely manner to identify and implement patient safety improvement and prevention strategies .... D. Conduct follow up and investigation to ensure that appropriate actions are taken to prevent further incident/ injury or reoccurrence.

Review of a document titled "INCIDENT REPORT - FACILITY RISK MANAGER TIPS FOR SUCCESS CLASSIFYING SIGNIFICANCE LEVELS ....", last released 01/01/2022, revealed four levels of incidents from Level I (least severe) to Level IV (most severe). Review revealed " ...LEVEL I - Occurrence: Incidents where the impact to the patient or parties involved is thought to be none to slight .... LEVEL II - Non-Serious: Incidents where impact to the patient or parties involved is thought to be minimal....LEVEL III - Serious: Any major injury or impairment....or any violation of law or regulatory authority shall be classified no less than a Level III regardless of evidence of patient injury. ..."

1.a. Review of the "Patient Observation Policy", approved 08/12/2021, revealed "POLICY STATEMENT: To ensure patient safety, as well as to provide a process for observing and documenting patient location and behavior....while monitoring hallways and patient care areas, ensure patients are....not entering rooms not assigned to them....not in rooms or areas that are not designated areas for patients. ..." Review did not reveal a statement that specifically indicated if hallways should be continuously monitored.

Review of a Level III incident investigation related to a "Pt/Pt (Patient to Patient) Sexual Assault" involving Pt #41 and Pt #18 on 06/06/2022, updated and received 12/20/2022, revealed "...BRIEF FACTUAL DESCRIPTION OF THE INCIDENT ...received call from House Supervisor....6/6/22 at 6:10am to report allegations of male patient.... entering the bedroom of (Pt #41) at approximately 0500 today. (Pt #41) was asleep and woke to a warm sensation on her lower body and legs and saw (Pt #18) standing by her bed with his penis out of his pants. The roommate also saw (Pt #18) in the room but did not observe any exposure. (Pt #41) reports (Pt #18) ran from the room when she started shouting....Per House Supervisor (Pt #18) slammed his bedroom door. (Pt #41)'s roommate came to the Nurses Station to report the incident. ..."

Review of the "Cameral Review" revealed the camera documentation began at 0400 with the first note stating "04:00 No staff visible in hallway". Camera review noted at 0403 the MHT exited the Nurses Station and entered the laundry room, then exited the laundry room and went back in the Nurses Station at 0405. At 0412 the MHT was noted to complete a check on Patient #18's room through the window in the door. At 04:15:40 Patient #18 was noted on video to exit his room and at 04:15:58 he entered Pt #41's room for a period of 15 seconds, exiting at 04:16:13. Pt #18 was noted to return to his room at 04:16:24 and close the door. Review of the Summary of Findings from the Camera Review indicated "MHT...completed timely checks on patient (#18), but failed to open the door to visualize 3 respirations. Patient (#18) did leave his assigned room and entered the bedroom of (Pt #41 and roommate) for a period of 15 seconds. (Pt #18) was fully clothed and was seen with his hands on his waistband prior to entering (Pt #41's) bedroom. Multiple staff were present in the hallways around the time of the reported incident to include a check by MHT...at 04:12, RN.... and RN trainee walking down the hallway at 04:14 and PA....walks down the hallway at 04:15, 12 seconds prior to (Pt #18) exiting his room. Review of the document failed to reveal anyone was stationed in the hallway at the precise time Pt #18 exited his room and entered Pt #41's room.

Review of the incident investigation failed to reveal a documented cause and action related to lack of continuous hallway presence. Further, documented actions included a statement that "Findings of the case discussed with CEO and Regional Risk Manager. Due to (Pt #18)'s continued display of acutely psychotic behavior to include urinating in public areas and not his bathroom during nighttime hours, allegations were not substantiated as a sexual assault." Review of the investigation document did not reveal if this history was considered as a cause of the event or whether any actions were taken prior to the incident to mitigate the risk of Pt #18 continuing to exit his room at night and urinate in public spaces.

Review of "Nursing Staff Meeting June 20 & 22, 2022" notes revealed "...Patient Observation.....Upon camera reviews, the following were noted....At times, there were no hallway presence ....If the MHT is doing laundry, filing, unstructured transition, filing, unstructured transition, hygiene times, etc. the RN needs observe the hallway. ..."

Review of data labeled "Hall Monitoring Compliance" revealed a document with compliance percentage for hall monitoring and a target compliance of 88 %. Compliance data showed percentages ranging from 88% to 100% per month from July through November 2022. Review of the document revealed only one compliance percentage per month. Document review did not reveal the methodology used, the number of observations per month, which units were monitored and did not reveal if any trend in monitoring were identified, specifically in relation to the unit where the event happened.

Interview with CNO #6, on 12/21/2022 at 1345, revealed that Pt #18 was able to enter Pt #41'w room because there was no one in the hallway. Interview revealed the lack of hallway presence was noted on camera review. Interview revealed staff were educated to ensure there was a hall monitor all the time. If the MHT needed to go file or do other tasks, interview revealed, the nurse should come out and be the hall monitor. Interview further revealed that whoever is the administrator-on-call for the week should make a day, evening, night and weekend round. CNO #6 indicated the rounds were sometimes in person and sometimes on camera. Interview revealed CNO #6 was not aware of any specific monitoring of the action plan from this event.

Telephone interview with RM #1, on 12/22/2022 at 1025, revealed there was not a policy on hallway monitoring. Interview revealed the Observation Policy indicated hallway presence should be maintained between rounds, that the policy indicated what staff should observe when monitoring the hallway. Interview revealed that in relation to the patient leaving his room and urinating in public spaces at night, "I don't know that we fully addressed that." Interview revealed RM #1 agreed the event " ...was a hallway presence issue". RM#1 stated there was discussion about the nurse coming out to cover when the tech had to leave the hallway for other duties, but that was not sustainable. Interview revealed the facility did monitor for hallway presence using an audit tool for camera observation - monitored one room for one hour, during which time hallway presence and rounding was observed. As far as trends of non-compliance, interview revealed it was typically the two adult units, which included the unit where this occurred.

1.b. Review of a Level III investigation, Incident Type "Aggression by Another Patient" revealed an incident with injury occurred on 08/05/2022. Review revealed " ...(Pt #2) got into a verbal confrontation with peers. Peer then began grabbing her hair, standing over her on chairs and kicking her in the face. Patient was scratched all over her body with cuts inside her mouth from her braces and a cut in her hair line. Her glasses were also broken during the incident. ..." Review revealed Pt #2 was sent to the Emergency Department for further evaluation with X-rays and CT scans (imaging), which per the document were within normal limits. Pt #2 was prescribed an oral antibiotic, topical antibiotic cream and pain medication. Document review noted that Pt #2 was observed "laying in chairs in one of the group rooms prior to the incident" and the four peers who attacked Pt #2 were observed "walking and speaking together in the hallway and entering a patient bedroom for several minutes" and noted that bedroom doors were open and unlocked during programming hours. Review of the "Summary of Findings" from the "Camera Review" revealed the Code AIMZ (emergency code to bring additional staff assistance) was not called soon enough, unit nurses did not have radios, a Unit Coordinator was positioned in the doorway of the room the 4 patients went into but left to respond to a Code AIMZ on another unit, and a nurse allowed the aggressive patients with knowledge of their behaviors and targeting of Pt #2 into the group room. Review of the actions taken on the investigation document revealed Pt #2 was moved to another unit. Other actions were taken including educating on calling Code AIMZ and carrying the walkie-talkies. Additionally an patient bedroom doors were to be closed during programming hours, monitored by continuing " ...Monthly leadership patient observation audits"

Review of auditing revealed the following data: In September 2022, per the documentation, 88% compliance with doors closed and locked during program hours (29 yes, 4 no). In October 2022, documentation of data indicated only 6 observations were made and 67% compliance. A note of action taken was recorded indicated there would be education, including a standing agenda item, for staff to ensure that doors were closed immediately after a patient was allowed to use his/her bathroom. Overall compliance was noted at the bottom of that sheet as August 33%, September 88%, October 67%, November 96%. Document review did not reveal the number of observations for August and November, did not reveal if all units were monitored and/or review for trends by unit or shift, specifically in the relation to the unit where the event happened.

The incident investigation document review did not reveal analysis of why the 4 patients involved in the attack were not in programming, were able to congregate in a patient's room and come together and target another patient without intervention. The document also did not reveal documentation of discussion/analysis related to when a staff member responded to a code and left the unit when that staff member had been a hallway presence during a potentially escalating situation. The incident investigation document failed to show evidence of a thorough investigation, actions and follow-up to mitigate risk of a future similar event for patient safety.

Telephone interview with RM #1 on 12/22/2022 at 1025 revealed the only issue discussed was trying to separate the patients into different groups. Interview revealed as far as programming, if a patient refused to program that would be discussed with treatment team and forwarded to the clinicians. Interview revealed RN #1 did not recall as much about the 4 patients involved in the attack, the focus was mostly on Pt #2 who was sleeping. Interview revealed if there was extensive unit disruption a supervisor should be notified which would trigger additional support.

1.c.Review of Incident Reports for Pt #1 and Pt #28 revealed that on 08/15/2022 at 1410 the two patients got into a physical altercation in the cafeteria, with no injury to either patient. Per review, Patient #28 went into a voluntary time out, was separated from Pt #1 and returned to the unit. Pt #1, per incident report review, was separated from Pt #28 and returned to the unit.

Review of a Level III incident investigation, "...Incident Type: Aggression by Another Patient" revealed an incident occurred on 08/17/2022. Review revealed "BRIEF FACTUAL DESCRIPTION OF THE INCIDENT: (Pt #1 and Pt #28) were eating dinner side by side in the cafeteria on 8/17/2022. (Pt #28) got up to throw his tray away, and returned to the table when he began punching (Pt #1) in the head, knocking him to the floor, then proceeded to kick (Pt #1) in the head. Incident occurred over a span of 5 seconds. (Pt #1) was sent to the emergency room for further evaluation due to altered mental status and returned with diagnosis of head trauma. ..." Review of the document revealed Pt #1 was on one-to-one monitoring at the time of the incident and noted the camera review showed the one-to-one staff member present at the time of the incident. Review did not reveal the proximity of the one-to-one and the patient. Review of actions taken revealed a recommendation was made after the 08/17/2022 event for Pt #1 and Pt #28 " ...to be separated during meal times since they had a previous altercation with each other 2 days prior to the event, also in the cafeteria.

Review of the 08/15/2022 incident reports for Pts #1 and #28 did not reveal that the 08/15/2022 altercation resulted in actions to decrease future risk of an subsequent altercation and an altercation happened again on 08/17/2022 while the patients were in the cafeteria and had been seated side by side, causing a head injury to Pt #1 that required transfer to a hospital. Review of the 08/17/2022 investigation document revealed that these two patients should be separated in the cafeteria in the future and indicated actions were taken for one-to-one for both patients. The investigation document review did not reveal any specific actions and monitoring the organization would take to decrease the likelihood of future similar situations for patient supervision and safety.

Telephone interview with RM #1, on 12/22/2022 at 1025, revealed there was nothing documented related to keeping Pt #1 and Pt #28 apart, but the two patients should not have been seated together in the cafeteria because of the incident two days prior.

Interview, on 12/21/2022 at 1345 with CNO #6 revealed the two patients should have been separated in the cafeteria.

2. Review of Incident Report Categories and Trends received 12/06/2022 revealed the following data on Level I and II events for all reported events including RTC, the majority of which were either aggression or boundary reports, were:
January 2022 LEVEL I = 68 LEVEL II = 61
February 2022 LEVEL I = 106 LEVEL II = 43
March 2022 LEVEL I = 57 LEVEL II = 47
April 2022 LEVEL I = 82 LEVEL II = 50
May 2022 LEVEL I = 128 LEVEL II = 92
June 2022 LEVEL I = 150 LEVEL II = 69
July 2022 LEVEL I = 198 LEVEL II = 101
August 2022 LEVEL I = 164 LEVEL II = 88
September 2022 LEVEL I = 187 LEVEL II = 79
October 2022 LEVEL I = 240 LEVEL II = 56

Review of selected incident reports of Level I and II incidents for aggression and sexual boundary events revealed data was collected including a brief description of the event, injuries, immediate actions such as voluntary time out or separated for safety, but did not include further analyses of causes to determine potential relevant trends and preventive actions.

Interview with RM #1 on 12/01/2022 at 1510 revealed the hospital investigates adverse events, including aggressive/sexual misconduct events. Interview revealed the hospital had a stated goal to reduce aggressive incidents by 10% in 6 months but as of now, even though actions had been taken, Level I and II events were still rising. Interview further revealed the hospital recently implemented "Get Smart" training to decrease sexual related events. The Director stated that any higher lever (Level III or IV) patient events received an intensive review or root cause analysis. For Level I and II events, interview revealed, analyses were in incident reports, "The incident report is the investigation." Follow-up interview with RM #1 on 12/05/2022 at 0940 revealed staff completed incident reports and supervisors reviewed and implemented immediate actions for patient safety. RM #1 stated she reviewed all incident reports and took copies to the daily "Flash" meetings each morning. Interview revealed the clinical leaders first reported on any incidents that had occurred since the previous meeting. All incidents were reviewed and if there was not an incident report it was assigned for completion. Further, if more information was needed about the event, assignments were made for follow-up which would go into the incident report. Patient specific information, RM #1 stated, was placed in the patient's medical record. Interview revealed there was no trending of causes of Level I and II patient incidents for potential future preventive actions outside the incident reports.

Based on hospital policy and procedure reviews, medical record reviews, police report reviews, internal incident investigations, video monitoring review, and interviews, the hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations by failing to ensure systems were in place to supervise and provide safe delivery of care to behavioral health patients.

Findings included:

1. The hospital staff failed to supervise an adult coed unit to prevent a male patient from entering a female patient's room during hours of rest for 2 of 2 sampled patients (Patient #18 and #41).

~cross refer to 482.23(b)(3) Nursing Services Standard: RN Supervision of Nursing Care Tag A0395

2. . The hospital staff failed supervise four adolescent female patients with threatening behavior toward other patients (Patient #29, #42, #43,and #45), who subsequently attacked an adolescent female patient resulting in harm for 1 of 1 sampled patients (Patient #2).

~cross refer to 482.23(b)(3) Nursing Services Standard: RN Supervision of Nursing Care Tag A0395

3. . The hospital staff failed to supervise adolescent male patients with a known history of physical aggression toward each other for 2 of 2 sampled patients (Patient #28 and #1) to prevent a repeated physical assault resulting in harm for 1 of 2 sampled patients (Patient #1) .

~cross refer to 482.23(b)(3) Nursing Services Standard: RN Supervision of Nursing Care Tag A0395

Based on hospital policy and procedure reviews, medical record reviews, police report reviews, internal incident investigations, video monitoring review, and interviews, the hospital staff failed to supervise an adult coed unit to prevent a male patient from entering a female patient's room during hours of rest for 2 of 2 sampled patients (Patient #18 and #41); failed to supervise four adolescent female patients with threatening behavior toward other patients (Patient #29, #42, #43,and #45), who subsequently attacked an adolescent female patient resulting in harm for 1 of 1 sampled patients (Patient #2); and failed to supervise adolescent male patients with a known history of physical aggression toward each other for 2 of 2 sampled patients (Patient #28 and #1) to prevent a repeated physical assault resulting in harm for 1 of 2 sampled patients (Patient #1) .

Findings include:

Review of the hospital policy titled "Patient Observation Policy PC-1-002" last approved 08/12/2021 revealed " ... Unit Nurse: a. Assigns responsibility for completion of patient observation rounds at the beginning of each shift. ... Mental Health Technician (MHT): ... c. Observe and document each patient a minimum of every 15 minutes and/or according to precaution level. ... d. Perform rounds at staggered interval and in a varying pattern or sequence throughout the unit to minimize planned acting out opportunities. ... g. While monitoring hallways and patient care areas, ensure patient are: not entering rooms not assigned to them. ... h. Observe patients on bed rest/laying down by: looking for rise and fall of the chest, counting at least three respirations, and making sure the patient has moved from his/her previous sleeping position. using flashlight at night to observe patients in bed i. Visually observe patients when behind closed doors or curtains by: knocking on bedroom door, announcing you are stepping into the room for rounds, opening the door or bathroom curtain and visually observing the safety of the patient ... k. Hand off assigned patient-observation rounds to another staff member before leaving the patient treatment area (meals, breaks, emergencies). l. Identify and report any findings while conducting observation rounds: ... Ensure door that are to be locked are, in fact, locked. ..."

A. Review of the hospital policy titled "Room Assignments/Mattress Type" last approved 08/12/2021 revealed " ... Procedure: ... D. Adult patients will have room assignments made based on gender, admitting diagnosis, level of observation and current mental status."

Review of the hospital policy titled "Sexual Assault Examination" last approved 08/12/2021 revealed " ... Procedure: 1. Upon being made aware of an incident of sexual assault, the unit nurse shall immediately report the incident to the Nurse Supervisor. ... 2. Staff will not interview the patient(s) involved. Staff who received the report of sexual assault will document what was reported by the patient. 3. ... After hours, the Nurse Supervisor will notify Jacksonville Police Department of the allegation of sexual assault. ... 5. The staff shall discourage the patient from changing clothes, showering, or using the bathroom. ... 10. The nurse shall document in the patient's medical record concerning the event, treatment, and any medical follow up or medical care to be provided."

Review of the medical record for Patient #18 revealed a 45-year-old male admitted via involuntary commitment on 05/14/2022 with a diagnosis of "Schizophrenia." Patient #18 was assigned to room 618 on the 3-East Adult unit. Review of the "High Risk Notification Alert" form dated 05/14/2022 at 1700 revealed documentation of sexually aggressive, elopement risk and assaultive/aggression risk factors with no documentation of whether the sexually aggressive risk factor was history of or current. Documentation revealed the elopement risk factor was current with documentation of Patient #18 "checking all doors in admissions to get out." Documentation revealed the assaultive/aggression risk factor was current with documentation of Patient #18 being "increasingly aggressive with wife." Vital signs documented on admission were temperature 98, blood pressure 174/99, pulse 94, respirations 18 and no complaints of pain. Admission intake assessment dated 05/14/2022 revealed documentation that Patient #18 had a medical issues/risk of renal calculi. Patient #18 presented to the hospital with delusions, paranoid thoughts, increasingly aggressive with wife, racing thoughts and visual hallucinations. Review of the admission intake assessment revealed the staff checked "Sexually Aggressive Behavior Unable to assess due to: pt in psychosis" and "Potential for Sexual Victimization Behavior Unable to assess due to: pt in psychosis." Review of the Nursing Admission Assessment dated 05/14/2022 at 1255 revealed documentation of no potential sexual victimization in the last 6 months and "unknown" history of sexual victimization over lifetime. The Nursing Admission Assessment revealed documentation of no sexually aggressive behavior in the last 6 months and no history of sexual aggression over lifetime. Nursing documentation revealed no history of sexual and/or physical abuse. Review of the Psychosocial Assessment revealed documentation that Patient #18 denied history of sexual aggression. Review of the admission physician orders dated 05/14/2022 at 1700 revealed Patient #18 was placed on every 15-minute checks, elopement risk precautions, and assault/homicide precautions. Physician orders for mouth check with medication and cheeking precautions placed on 05/16/2022 at 0700. Review of a Nursing Assessment/Reassessment 7p-7a shift note dated 06/06/2022 at 0734 revealed "Pt presented with blunted affect - exhibited attention-seeking, somatic behaviors. Cooperative with staff - compliant with HS (bedtime) meds. Denied any AVH (audio-visual hallucinations). Constantly asking MHT or RN for items multiple times. Paced halls, restless throughout shift, + (positive) minimal peer interactions. Hyper-focused on D/C (discharge). C/o (complaining of) right shoulder pain, nicotine cravings, and requested prn (as needed) for sleep. Rested on/off. Scheduled meds given. Motrin given po (by mouth) prn right shoulder pain, nicotine gum given po prn cravings, and Ambien given po prn (as needed) insomnia. Encouraged to continue developing and using + coping skills, increase + interactions, and ongoing tx (treatment), med-compliance. Voice concerns, c/o to staff. Pt med-compliant, + effects with prn Motrin, nicotine gum. Minimal effect with prn Ambien (sleep med). Agreed to seek staff with needs. Rested on/off. Continue to monitor pt progress, behaviors, and med-effectiveness. Monitor for mood changes/pt safety." Updated note documented on 06/06/2022 revealed "Select female peer woke and found (Name Patient #18) standing by her bed in what appeared to be ejaculate on her linens and clothes - supervisor notified - will continue to follow up and notify Risk Management, MD - pt denies doing anything, but peer also had roommate witness." Review of nursing progress notes revealed every two (2) hours documentation of one-to-one (1:1) observations beginning on 06/06/2022. Review of physician orders dated 06/06/2022 at 0700 revealed Patient #18 was placed on Sexual Aggression Risk precautions and orders continued through discharge on 07/13/2022. Physician orders revealed Patient #18 was placed on one-to-one (1:1) observation level on 06/06/2022 at 1400. Review of a treatment team meeting note dated 06/06/2022 at 0915 revealed Patient #18 was on every 15 minutes observation level, cheeking, assaultive/aggression, sexual aggression, and elopement precautions with documentation in comment field that "Patient ejaculated on one of his peers at 5:00 a.m. and is now on sexual aggression precautions." Review of a clinical progress note documented on 06/06/2022 at 1305 revealed "Session: Clinician spoke to patient's mom who stated that said he would d/c tomorrow and that mom needs to pick him up. Patient is still reporting to mom that someone is trying to break into his home. Collateral reported that patient call his wife and screams at her so much that the wife hangs up the phone on him. Clinician plan: Clinician will attend Treatment Team Tuesday (06/07/2022) to discuss Patient's progress, and discharge planning. Patient progress toward treatment plan: Patient is compliant with medication management and attends some groups. Discharge plan update: Patient's discharge date is unknown at this time. Discharge will continue to be assessed during Treatment Team. Next session: Acute Clinician will check in with Patient to assess progress. Acute Clinician will attend Treatment Team Tuesday (06/07/2022) to discuss Patient's progress, and discharge planning." Review of a provider progress note completed on 06/06/2022 at 1350 revealed " ... Assessment (address significant risks): Staff report patient stays up at night then sleeps during the day. Staff report inappropriate behavior by patient this AM towards a female peer. Patient is irritable and focused on being discharged home. Patient easily agitated today. Medication Change: yes, Ongoing mood lability-Increase Depakote ER to 2000mg (milligrams) po QHS (every night at bedtime [2100]); add Doxepin 150mg po QHS for sleep. ... Refer to State hospital; 6/6/2022: 1:1 observations started for safety of others. ... Vital Signs: BP sitting 128/65, Pulse sitting 85, Temp 98.1, RR 18, SaO2 (oxygen saturation) 98. ..." Review of the 15-minutes observation record for 06/06/2022 revealed documentation by MHT #20 that Patient #18 was in his room lying down from 0400 through 0700. Review of the observation record revealed precaution levels documented included assault/aggression, sexually aggressive, elopement with one-to-one (1:1) observation level started on 06/06/2022 at 0830. Patient #18 was discharged from the facility to home on 07/13/2022.

Review of the medical record for Patient #41 revealed a 19-year-old female admitted via involuntary commitment on 06/01/2022 with a diagnosis of "Xanax Overdose" and "Major Depressive Disorder." Patient #41 was assigned to room 620 on the 3-East Adult unit. Review of the "High Risk Notification Alert" form dated 06/01/2022 at 1754 revealed documentation of "Suicidal Moderate" with history and current risk factor related to depression and recent suicide attempt via overdose. Admission intake assessment dated 06/01/2022 at 1741 revealed documentation that Patient #41 had a medical issues/risk of anemia and diabetes per patient. Patient #41 presented to the hospital with recent suicide attempt via overdose and has exhibited risk for suicide (ideations, plans, behaviors) in the past 6 months due to ongoing depression. Review of the admission intake assessment revealed the staff checked "No" for Sexually Aggressive Behavior in the past 6 months and over lifetime. Review of assessment revealed the staff checked "Yes" for Potential for Sexual Victimization Behavior over lifetime as a child with no report made and the staff checked "No" to sexual victimization in the last 6 months. Nursing documentation revealed the intake unit filed a report with DSS (dept. of social services) reference suicide attempt. Continued review of the intake assessment revealed documentation of substance withdrawal risk for drugs - marijuana used one (1) week ago. Documentation of Patient #41's risk summary on the intake assessment revealed "Pt admitted due to suicide attempt via overdose. Pt is though-blocking during assessment and minimizing behaviors. Pt is agitated during assessment and denies everything. ..." Review of the Nursing Admission Assessment dated 06/01/2022 at 2000 revealed surgical history documentation of an abortion performed on 03/18/2022. Continued review of the Nursing Admission Assessment revealed documentation of no potential sexual victimization in the last 6 months and no history of sexual victimization over lifetime. The Nursing Admission Assessment revealed documentation of no sexually aggressive behavior in the last 6 months and no history of sexual aggression over lifetime. Nursing documentation revealed no history of sexual and/or physical abuse but did admit to emotional abuse by an ex-boyfriend. Review of the Psychosocial Assessment revealed documentation that Patient #41 denied history of sexual aggression. Review of the History and Physical note revealed vital signs were temperature 98.1, blood pressure 105/88, pulse 82, respirations 16 and no complaints of pain. Review of the Psychiatric Evaluation dated 06/02/2022 at 1212 revealed Patient #41 was admitted with a "history of anxiety, depression, and trauma with significant benzodiazepine, cannabinoid addiction. ... patient reported abusing Xanax for the past two years, noting she usually snorts 2mg pills every night. ... patient was admitted with a near lethal overdose on Xanax. ..." Review of a treatment team meeting note dated 06/06/2022 at 0915 revealed Patient #41 was on every 15 minutes observation level, and suicidal precautions with documentation in comment field that "Patient was ejaculated on by another peer from 3E and was moved to 3W today." Review of the provider progress notes for 06/06/2022 revealed no documentation of the incident with Patient #18. Review of a Nursing Assessment/Reassessment 7p-7a shift note dated 06/06/2022 at 0216 revealed "Pt presented with blunted to bright affect, + interactions with staff, select peers. Appropriate, cooperative, polite with staff - compliant with HS meds, hygiene. Stated she had a 'good day.' No SI (suicidal ideations) verbalized. Resting well, no C/o (complaints). ..." Review of Nursing Assessment/Reassessment 7a-7p shift note dated 06/06/2022 at 0750 revealed "Patient on phone with mom this am. Patient spoke with supervisor this am r/t (related to) incident in early am prior to shift. Pt also per supervisor spoke to police. Patient transferred to 3-West adult unit." Review of the 15-minutes observation record for 06/06/2022 revealed documentation by MHT #20 that Patient #41 was in her room lying down from 0400 to 0500. Continued review revealed the Patient was standing in her room at 0515, sitting in her room from 0530-0600, lying down in her room at 0615 and standing in the hallway from 0630-0700. Review of the observation record revealed precaution levels documented included suicidal - moderate risk. Patient #41 was discharged from the facility to home on 06/13/2022.

Review of the Police Incident/Investigation Report revealed the police department was notified on 06/06/2022 at 0635. Police investigation report revealed "NARRATIVE On Monday, June 6th, 2022, at 0635, I, Officer (Name), in Unit 354, responded to 192 Village Drive in reference to a sexual assault. Review of the Police Department Report revealed "... 3. ... (Name) Patient #41 said she would like to make a report and she would like to press charges. (Name) Patient #41 said she was asleep in her bedroom when she heard someone enter the room. (Name) Patient #41 said the hospital staff is required to check on the patients every 15 minutes so it was normal to hear someone walking in her bedroom. In addition, (Name) patient #41 informed me that patients are required to keep their bedroom doors open by hospital policy. (Name) Patient #41 said she was sleeping on her stomach when she felt something warm and wet on her legs and back. (Name) Patient #41 looked up to see (Name) Patient #18 holding his penis ejaculating onto her. (Name) Patient #41 recalled (Name) Patient #18's eyelids fluttering, and he appeared to be in a trance. (Name) Patient #41 said at first, she believed (Name) Patient #18 was urinating on her because she was confused about what was going on. (Name) Patient #41 said she jumped out of bed and ran towards her roommate's bed, (Roommate Name). (Name) Patient #41 exclaimed, 'What the (expletive)man!' (Name) Patient #41 said her yelling woke up (Name of roommate). (Name) Patient #41 said (Name) Patient #18 shuddered the words, 'I'm sorry.' He (Patient #18) began re-dressing and quickly left the room. (Name) Patient #41 said (Name) Patient #18 exited her room, Room 620, and ran into his room, Room 621. (Name) Patient #41 said her roommate chased after (Name) Patient #18 and notified the nurses about the incident. 4. I (police officer) asked (Name) Patient #41 if she still had her clothes or her bedding. Patient #41 said she changed after the incident and turned her clothes and bedding over to the laundry staff. Patient #41 said she immediately showered because she believed Patient #18 had urinated on her. Patient #41 said while in the shower she realized the substance on her skin was not urine. Patient #41 thought about Patient #18's body posture, mannerisms, and how he finished ejaculating on her after she had woken up. Patient #41 was certain Patient #18 had masturbated over her sleeping body. Patient #41 said she had no previous relationship with Patient #18. ..." The house supervisor (HS #23) asked Patient #18 if he would like to speak with the officer. Patient #18 refused to speak with the police officer stating he did nothing wrong and closed his room door. The police officer then interview Patient #41's roommate.

Review of the facility incident report documented on Patient #41 revealed the event occurred on 06/06/2022 at 0415 in the female patient's (#41) room. DSM diagnosis included: Cannabis Abuse, uncomplicated; Adjustment Disorders; and Attention Deficit/Hyperactivity Disorders. No injuries were reported. Patient #41 was cooperative and angry after the incident. Review of the incident report revealed the House Supervisor (HS) was notified on 06/06/2022 at 0525, the Police Department (PD) was notified at 0600 by the HS, the Risk Manager (RM) was notified at 0612, and the Physician (MD) was notified at 0623. Incident report comments revealed "Pt reported waking up to a male patient either urinating or masturbating on her while she was sleeping. No physical injuries reported." Documentation revealed the incident report was reviewed by a supervisor on 06/06/2022 at 0941 and reviewed by the Risk Manager on 06/08/2022 at 1530.

Review of the facility incident report documented on Patient #18 revealed the event occurred on 06/06/2022 at 0415 in the female patient's (Patient #41's) room. No injuries were reported. Patient #18's treatments revealed his observations were increased. Patient #18 was angry after the incident. Review of the incident report revealed the House Supervisor (HS) was notified on 06/06/2022 at 0525, the Police Department (PD) was notified at 0600 by the HS, the Risk Manager (RM) was notified at 0612, and the Physician (MD) was notified at 0623. Incident comments revealed "A peer (Patient #41) reported pt (#18) came into her room and urinated or masturbated on her bed while she was in it, peer (Pt #41) was removed from the unit and this patient (#18) was made an unofficial 1:1 until an official 1:1 order could be obtained." Documentation revealed the incident report was reviewed by a supervisor on 06/06/2022 at 1346 and reviewed by the Risk Manager on 06/08/2022 at 0919.

Review of the incident investigation report for Patient #18 and #41 revealed the incident occurred and was disclosed on 06/06/2022 and the incident type was labeled as Pt/Pt (Patient to Patient) Sexual Assault. The incident investigation report revealed the female patient (Patient #41) was a 19-year-old admitted involuntarily to the adult unit 3 East on 06/01/2022 with a presenting problem of suicidal attempt via overdose on Xanax. Patient #41 was placed on suicide precautions and fifteen (15) minute patient observations level upon admission. Patient #41 had an admitting diagnosis of Major Depressive Disorder. The incident investigation report revealed Patient #18 was a 45-year-old male patient that was admitted involuntarily to the adult unit 3 East on 05/14/2022 with a presenting problem of acute psychosis. Patient #18 was placed on elopement and assault/aggression precautions and fifteen (15) minute patient observations level upon admission. Patient #18 had an admitting diagnosis of Schizophrenia unspecified. Review of the incident investigation report revealed "Brief Description of the incident: FRM (Facility Risk Manager) received call from House Supervisor (Name) 6/6/22 at 6:10am to report allegations of male patient (Name) #18 entering the bedroom of (Name) Patient #41 and another female patient at approximately 0500 today. (Name) Patient #41 was asleep and woke to a warm sensation on her lower body and legs and saw (Name) [Patient #18] standing by her bed with his penis out of his pants. The roommate also saw (Name) [Patient #18] in the room but did not observe any exposure. (Name) Patient #41 reports (Name) [Patient #18] ran from the room when she started shouting at him. Per House Supervisor, (Name) [Patient #18] slammed his bedroom door. (Name's) Patient #41's roommate came to the Nurses Station to report the incident. (Name) Patient #41 reported the incident to MHT #20 (Mental Health Technician) [Name] at that time. (Name) Patient #41 initially felt it was urine then later reported it might have been semen after the patient had already showered and bedding had been laundered." Continued review of the incident investigation report revealed "Investigation findings: (staffing, as applicable, video review-brief): Per initial camera review, MHT #20 (Name) completed a check on (Name) [Patient #18's] room at 0412. The door to the patient bedroom was closed, and the MHT completed the check through the window without opening the door or entering the patient bedroom. (Name) [Patient #18] is observed leaving his assigned bedroom (room 618) fully clothed with his hands on his waistband at 04:15:40, then enters the bedroom to the left of his room, assigned to patient (Name) [female patient] (room 620) at 04:15:58, then exits (Name's) Patient #41's room fully clothed at 04:16:13, and returns to his room at 04:16:24 and shuts the door. (Name) [Patient #18] stays in (Name) Patient #41's room for 15 seconds. MHT #20 (Name) completed 15 minute checks timely, with the last check on (Name) Patient #18's room at 0412 but failed to open the door to visualize 3 respirations during checks. MHT #20 reported (Name) Patient #18 was sleeping at the time of this check and there were no indications prior to the incident that (Name) Patient #18 was targeting other patients, females, or (Name) Patient #41 in particular. MHT #20 first learned of the allegations once (Name) Patient #41's roommate came to the Nurses station where he was filing paperwork to report (Name) Patient #18 'peeing' on (Name) Patient #41. The allegations later changed to (Name) Patient #18 'masturbating' on her because the liquid did not smell like urine, according to (Name) Patient #41's roommate, as reported to the MHT. Chart review conducted by FRM revealed (Name) Patient #18 was not on sexual assault precautions prior to the incident and had no previous incident reports during his admission. Interviews with both (Name) Patient #41 and her roommate corroborate (Name) Patient #18 being inside their bedroom. (Name) Patient #41 reported waking to a warm sensation on her back and legs and hearing liquid hit the floor. MHT #20 (Name) reported not much liquid on the sheets or clothing and the pattern being 'a straight line.' (Name) Patient #41 showered immediately after the incident and MHT #20 (Name) washed the bedding and her clothing. (Name) Patient #18 denies the allegations to MHT #20 and Unit Nurse RN #21 and refused to speak with police. Additional interviews were attempted throughout the day, and patient was sleeping each time, so (Name) Patient #18 has not been interviewed by FRM as of this report. Police interviewed the victim (Patient #41) but collected no physical evidence and requested to view camera footage. Unit was staffed to ration (1 MHT, 1 RN, 1 RN in training and Physician Assistant on unit during this time) with census of 9."

Review of the June 6, 2022 Facility's Camera Review of the 3-East Unit Timeline revealed the following:
04:00 No staff visible in hallway.
04:03 MHT #20 exits Nurses Station and enters laundry room
04:05 MHT #20 exits laundry room and back into Nurses Station
04:08 MHT #20 opens Nurses Station door, steps into hallway briefly, then goes back inside Nurses Station
04:10 Physician Assistant (Name) [PA # 25] walks onto unit
04:11 MHT #20 exits Nurses Station
04:12 MHT #20 completes check on Patient #18's room (#618) through window in door
04:13 MHT #20 enters the Nurses Station
04:14 RN #21 (Name) and RN #22 (RN trainee) return to the unit and walk past Patient #41 and Patient #18 rooms, enter the Nurses Station
04:15:28 PA #25 walks by Patient #18 and Patient #41 rooms and exits the unit
04:15:40 Patient #18 walks out of his bedroom fully clothed with both hands on waistband
04:15:58 Patient #18 enters Patient #41's bedroom (#620) for a period of 15 seconds
04:16:13 Patient #18 exits Patient #41's bedroom
04:16:24 Patient #18 enters his bedroom and closes the door
04:16:34 Patient #41's roommate runs out of bedroom to the Nurses Station, knocks on window, MHT #20 exits and walks with Patient #41's roommate to her bedroom
04:21 MHT #20 takes clean linen to Patient #41's room
04:26 RN #21 unlocks Patient #18's closed room door, MHT #20 and RN #21 enter Patient #18's room
04:31 MHT #20 enters Patient #41's room with gloves and cleaning supplies
04:32 MHT #20 exits patient #41's room bedding and clothing, take to the laundry room
04:54 MHT #20 completes check on Patient #18's room through window in door
05:05 MHT #20 sits in hallway to monitor, and HS #23 enters the unit
05:07 MHT #20 completes a check on Patient #18's room
05:13 MHT #20 returns to chair in hallway to monitor
05:21 MHT #20 moves chair to sit directly across from Patient #18's bedroom for increased hallway monitoring

Review of the Nursing Staff Meeting minutes for 06/20/2022 and 06/22/2022 revealed the CEO discussed during leadership rounding audits via camera reviews, the following was noted: At times, there were no hallway presence (days and nights) -If MHT is doing laundry, filing, unstructured transition, hygiene times, etc. the RN needs to observe the hallway.

Interview with RM #1 on 12/20/2022 revealed the video for Pt #18 and #41 was available to review however the facility was unable to access the video prior to survey exit on 12/22/2022.

Telephone interview on 12/20/2022 at 1035 with MHT #20 revealed he had worked at the facility for 1 ½ years. Interview revealed MHT #20 was the MHT assigned to the 3-East unit on 06/05-06/2022 for the 7p-7a shift. Interview revealed Patient #18 was assigned to room 618 bed A (blocked room-no roommate) and Patient #41 was assigned to room 620 bed A. Interview revealed MHT #20 was responsible for the 15-minutes observation checks. MHT #20 stated he completed the 15-minute observation for Patient #18 about 0412. Interview revealed the MHT opened the room door but did not cross the door threshold, used the flashlight to see the patient, checked for breathing and to see if the patient was awake. Interview revealed the MHT was quiet and tried not wake Patient #18 as the patient did not sleep often at night and was in psychosis. Interview revealed Patient #18 had psychosis and was doing "weird things - talking to things that were not there and taking his clothes off." MHT #20 stated Patient #18 would go into the bathroom and tear up papers and toilet paper and throw the paper on the floor. Interview revealed that when MHT #20 conducted his 15-minute checks, he would go up the hallway on the even numbered side and come back down the hallway on the odd numbered side. Interview revealed MHT #20 left the hallway and went into the file room to file paperwork. Interview revealed the unit did not have a unit secretary/unit coordinator on night shift. MHT #20 stated he was not sure if the nurse assigned to the unit was on the unit or in the medication room when he left the hallway. Interview revealed there was no staff on the hallway watching the patients when he went into the file room. Interviewed revealed he became aware of the incident when Patient #41's roommate came to the nurses' station and informed him that Patient #18 had come into their room and "peed". The roommate informed him that Patient #41 had jumped up after she saw Patient #18 standing over her at the edge of the bed. Interview revealed Patient #41 stated that Patient #18 said "I'm sorry" and ran back to his room. MHT #20 revealed he went to Patient #18's room and the door had been closed shut and was locked. Interview revealed that when the MHT went into Patient #41's room, he noted a liquid substance across the bed linens with "drops every 4-5 inches to other side of bed where there was a small puddle of liquid." Interview revealed MHT #20 took Patient #41's linen to the laundry room and gave her towels to wash off in the shower. Interview revealed MHT #20 stated "I didn't think about that (dirty linens & clothes as evidence) prior to washing the linen and clothes." Interview revealed the RN and the MHT went to Patient #18's room and the RN unlocked the room door. MHT stated Patient #18 continued to state "I did not do anything" after the incident. Interview revealed Patient #18 was placed on a one-to-one (1:1) precaution after the incident. Interview revealed the MHT recalled receiving verbal re-education from the house supervisor (HS #23) and the nurse manager (NM #31).

Telephone interview on 12/22/2022 at 1730 with RN #21 revealed the nurse did not recall if she was on the unit when the incident occurred with Patient #41 and Patient #28. Interview revealed the nurse was required to count the Pyxis every Sunday night with another nurse. Interview revealed RN #21 and the nurse from the 3-West unit were in the medication room counting medications. Interview revealed the medication room was on the opposite end of the hallway from Patient #18's room and she would not have been able to see the Patient if he left his room. Interview revealed the MHT was in the hallway when she left the unit to go to the 3-West unit to count medications. Interview revealed the facility staff were expected to have hallway presence at all times when patient were on the unit. Interview revealed RN #21 did not recall a Physician Assistant on the unit during this time. Interview revealed RN #21 did not recall if the MHT was on the hallway when she and the 3-West nurse returned to 3-East to count the medications on 3-East.

Interview on 12/22/2022 at 1800 with CNO #6 revealed the house supervisors are usually available to assist with counting the Pyxis medications. Interview revealed the expectation was for the unit nurse to contact the house supervisor so that the other nurses could remain on their units as the night shifts on 3-East and 3-West were typically only staffed with 1 RN and 1 MHT.

Interview on 12/05/2022 at 1315 with NM #31 revealed the staff were expected to monitor the hallway at all times when patients are on the unit or in the rooms.

Telephone interview on 12/22/2022 at 1105 with Physician Assistant #25 (PA #25) revealed she did not recall the incident with Patient #18 and Patient #41. Interview revealed PA #25 was not typically in the facility at 4 or 5 a.m. Interview revealed PA #25 usually arrived at the facility around 8 a.m. Interview revealed PA #25 stated "I don't believe it was me."

B. A closed medical record review on 11/29/2022 revealed patient #2 a 17-year-old involuntarily admitted on 08/04/2022 for suicide ideation with plan to overdose and anger outburst. Review of the psychiatric evaluation performed on 08/05/2022 revealed a history of post-traumatic stress disorder and depression. The patient received a chief diagnosis of disruptive mood dysregulation disorder with a treatment plan to include individual, family and group therapy sessions and medication management. Review of the dayshift (registered nurse) RN #36 note revealed on 08/05/2022 Patient #2 was in the lounge during nursing group and was confronted and attacked by three peers who grabbed her hair, hit her in the face multiples times and she was kicked. Further review of the note revealed the peers were separated by staff and Patient #2 was placed in seclusion for her own safety, physician notified, order placed to move the patient's (#2) room to 2E and as needed (PRN) Tylenol given. Review of the nightshift RN #3 note revealed Patient #2 and peers were in a verbal altercation, Patient

Based on policy reviews, visitor log reviews, direct care staffing lists, and staff interviews, the hospital failed to provide an effective infection prevention and control program for surveillance and prevention of hospital acquired infections.

Findings included:

1. The hospital's infection control program staff failed to ensure implementation of established measures to prevent and control infections and communicable diseases, such as COVID-19 by failing to implement and monitor COVID-19 screening practices resulting in symptomatic employees reporting to work increasing potential COVID-19 positive exposure.

~cross refer to 482.42 IC Standard: Tag 0750

Based on policy reviews, visitor log reviews, direct care staffing lists, and staff interviews, the hospital's infection control program staff failed to ensure implementation of established measures to prevent and control infections and communicable diseases, such as COVID-19 by failing to to implement and monitor COVID-19 screening practices resulting in symptomatic employees reporting to work increasing potential COVID-19 positive exposure.

Findings included:

1. Review of a policy titled "Novel Coronavirus Precautions" with revision date of 07/12/2021, revealed "PURPOSE: The purpose of this policy is to provide specific guidelines to reduce the risk of transmission of emerging Coronavirus COVID-19....Symptomatic employees will stay at home until at least 3 days (72 hours) have passed since recovery (defines as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and, at least 7 days have passed since symptoms first appeared. If the employee has a positive screen with symptoms, they need to leave the hospital, contact their physician and notify the Department of Health...."

Review of the "COVID Screening--Daily Employee and Visitor Sign In Log Screening Questions:" revealed "In the last 7 days have you tested positive for COVID or do you currently have a pending COVID test? Have you traveled internationally within the last 14 days? Have you had contact within 6 feet of an infected person for a cumulative total of 15 minutes over a 24 hours period starting 2 days prior to symptom onset or positive specimen collection 'until the time the person was isolated?' Do you have any of the following symptoms: Fever >/= 100.0 F within the last 48 hours; Cough or flu like symptoms, difficulty breathing, including sore throat, headache, muscle aches, nausea, diarrhea, or abdominal pain in the last 24 hours?; Recent loss of smell or taste?"

Review of visitor logs dated July 4, 2022 through July 18, 2022 revealed only a handwritten date on the visitor log. Review revealed no information on the logs. Review revealed no more current logs were available.

Interview on 12/21/2022 at 1200 with AS #34 (Administrative staff--Admissions Director) revealed the most recent completed visitor log was dated July 18, 2022. Interview revealed the Admissions Director was not aware of the incomplete log. Interview revealed the process had been reviewed with CNO as recent as September 2022, indicating the visitor screening should have been continued. Interview revealed the forms are supposed to be kept for 3 years. Interview revealed the visitor screening process was not being followed.

2. Review of facility's attestation titled "Attestation for Facility Staff/Medical Staff Providers" with no date, revealed "All who enter the facility will attest to the following: I am not experiencing any flu-like symptoms. I am free from fever (>100 F) or chills within the last 48 hours. I am not experiencing any of the following COVID-19 symptoms within the last 24 hours: cough, sore throat, headache, muscle or body aches, abnormal fatigue, congestion or runny nose, shortness of breath, nausea, vomiting, diarrhea, new loss of taste or smell. I will sanitize my hands upon hands upon entry into the facility, re-sanitizing as appropriate and necessary. Per CDC guidelines, I will mask appropriately and in accordance to facility policy. For those who are not fully vaccinated, they must additionally attest to the following: I have not been in close contact with any person who is COVID-19 positive over the past 14 days when not wearing appropriate PPE. I will maintain social distancing practices. If you are unable to attest or have questions regarding the information above, please contact the House Supervisor or other clinical manager. Thank you for helping to keep all who enter this facility safe."

Review of facility's list of direct care staff provided on 12/20/2022 at 1335 revealed a total of 5 employees listed as symptomatic. Review revealed a Medical Record employee was listed as "Most recent day employee was present in the workplace--12/20/2022. Date of COVID-19 diagnosis or positive COVID test: 12/20/2022. Date of onset of symptoms: 12/17/2022." Review of an additional column revealed "Unit scheduled...1 East. (Worked) on 12/19, 12/20."

Interview on 12/20/2022 at 1245 with NM #31 revealed the facility Christmas party was five days ago, on December 15, 2022 which included a catered meal with 70 staff members in attendance. Interview revealed currently 15 staff were symptomatic and 5 of the 15 were direct care staff who were currently experiencing symptoms. Interview revealed positive COVID patients requiring isolation. Interview revealed four adolescent patients were isolated after COVID positive diagnosis.

Interview on 12/21/2022 at 1130 with CNO #6 revealed there was one symptomatic direct care staff member who worked on 12/20/2022 was COVID positive on 12/20/2022 and exhibited symptoms on 12/17/2022, 3 days earlier. Interview revealed the staff member worked on the patient care floor filing medical records during her shift. Interview revealed the employee should not have worked with symptoms.

Interview on 12/22/2022 at 1050 with RM #1 revealed she arrived to work on Wednesday, December 21, 2022 with symptoms and notified her CNO #6 of her symptoms. Interview revealed RM #1 was symptomatic with vomiting episodes; however arrived to work. Interview revealed RM #1 felt obligated to come to work on that day. Interview revealed the employee did not perform the employee attestation prior to arriving to work.

Interview on 12/21/2022 at 1130 with CNO #6 revealed there was one administrative employee who came to work with symptoms. Interview revealed the employee should not have worked with symptoms.

Based on policy review, incident log review, medical record review, and staff interviews, the facility staff failed to develop a comprehensive plan of care by not ensuring the psychiatric component of the treatment plan was established for 2 of 60 patients (Patients #49, #46), failed to ensure the treatment plan was presented to and reviewed with parent/guardian as evidence by lack of signatures, dates and times for 3 of 60 patients (Patients #21, #7, and #47), and failed to ensure all members of the treatment team members were identified as evidence by lack of signatures on the treatment plan for 3 of 60 patients (Patients #46, #7, and #47).

Findings included:

Review on 12/20/2022 of the facility's policy, "Treatment Plan" reviewed 07/21/2021 revealed, "POLICY STATEMENT: Therapeutic interventions by the staff are made to assist the patient manage unsafe behaviors ... DEFINITIONS: [space] Policy: ...Procedure: Treatment Planning [space] Treatment Teams [space] There is an established treatment team that consists of the physician, a nurse, and a Therapist/Acute Clinician. ... Treatment Planning [space] .... The Master Treatment Plan is initiated, completed by the Therapist/Acute Clinicians, and communicated to the staff and the patient within 72 hours of admission on the acute units ...."

Review 12/20/2022 of the incident log revealed, Patient #49 had twelve incidents, from September 2021 through December 2021 wherein, two of the incidents were aggression towards other patients.

1. Closed medical record review 12/20/2022 revealed on 10/25/2021, Patient #49, a 17-year-old was involuntarily admitted to the male adolescent unit of the facility for self-injurious behaviors and suicidal ideations for one week. The patient had a history and was a high risk for aggression. On 10/26/2021, a psychiatric evaluation was performed, and the patient received a primary diagnosis of Unspecified Bipolar and Related disorder (abnormal mood without meeting criteria for Bipolar I and or II). Admission orders included monitoring every 15-minutes. On 11/2/2021 the patient was identified as the aggressor in a patient-to-patient incidents involving Patient #30 wherein, Patient #30 sustained an injury. As a result, a police report was filed after consent was received from the parent/guardian of Patient #30. On 11/21/2021, the patient was identified as the aggressor in a patient-to-patient incident involving Patient #55. Neither patient sustained any injuries nor was a police report filed. For each incident, the Patient #49 lacked remorse for his actions. Further review revealed, the treatment plan only consisted of the medical component. Review revealed, the facility staff failed to establish the psychiatric component of the treatment plan for a patient with incidents of aggression towards other patients.

Interview 12/20/2022 at 1255 with NM#29 revealed, Patient #49 had a history of aggression and was not on aggression precautions nor was the psychiatric component of the treatment plan implemented. Interview revealed, the facility staff failed to establish the psychiatric component of the treatment plan of care for a patient with acute on chronic aggression.

Review 12/20/2022 of the facility's policy, "Interdisciplinary Patient-Centered Care Planning-Acute" reviewed 03/31/2022 revealed, "Scope: ...Purpose: ...Policy: ...Procedure: Developing the Treatment Plan [space] 1. ...5. The patient/family and/or representative is to sign the treatment plan indicate their agreement with and participation in the development of the plan. ..."

2. Open medical record review 12/1/2022 revealed on 9/5/2022, Patient #21, a 20-year-old was involuntarily admitted to adult unit of the facility for assaulting and threatening to kill parent(s) and responding to internal stimuli. The patient was high risk for psychosis, assault, and homicide. A psychiatric evaluation was performed, and the patient received a primary diagnosis of Schizophrenia, unspecified (schizophrenia not classified into a subtype). Orders included monitoring every 15-minutes and a blocked room. Further review revealed, the treatment plan consisted of psychiatric and medical components, but failed to indicate it was presented to and reviewed with the family and/or representative due to lack of signature with date and time. Review revealed, the facility staff failed to present and review the treatment plan with the family or representative.

Interview 12/21/2022 at 1024 with CNO #6 revealed, the treatment plan was not signed, but should have been signed by the family or representative.



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3. Medical record review on 12/20/2022 revealed Patient #46, a 12-year-old, was admitted 10/15/2021 for ODD (Oppositional Defiant Disorder - disorder involving frequent and ongoing pattern of anger and defiance toward parents/ authority figures) and ADHD (Attention Deficit/Hyperactivity Disorder - chronic condition with issues of attention difficulty, impulsiveness, hyperactivity). Review of the MTP, signed/ dated by the Therapist 10/20/2021 at 1000 (5 days after admission), by the physician 10/21/2021 at 0831, the nurse 10/21/2021 at 0833, revealed the Interdisciplinary Master Treatment Plan listed one medical problem, Asthma. MTP review did not reveal any problems, goals or actions related to the diagnoses of ODD or ADHD. Record review revealed Patient #46 was discharged 11/05/2021. Record review failed to reveal a complete Interdisciplinary Master Treatment Plan.

Interview with RN #8, on 12/21/2022 at 0930, revealed there was no Master Treatment Plan related to psychiatric issues found for Patient #46.

Telephone interview, on 12/21/2022 at 0958, with MD #40, revealed he did not recall the patient/ situation. Interview revealed issues were discussed and agreed upon in Treatment Team. MD #40 revealed he signed the MTP to prevent delay expecting "in good faith" that the clinician would ensure documentation of the problems and goals. Interview revealed the Treatment Team met 3 days per week and if anything changed there would usually be a treatment plan update every 7 days.

Interview with LCSW #39, on 12/22/2022 at 0935, revealed she was new to the facility. Interview revealed LCSW #39 was not sure what had been historically done related to treatment planning and updates. Interview revealed they were trying to get policy updates done and a treatment team note should now be used. Interview revealed that historically treatment team notes were not documented. Follow-up interview at 1230 revealed LCSW #39 reviewed Pt #46's medical record and found a good initial assessment but nothing in follow-up for treatment planning.

Review of the "Treatment Plan" policy, last reviewed 07/21/2021, revealed " ...Policy: It is the policy and practice of (Hospital Name) to provide treatment planning, intervention and review of services, ensuring that the patient's goals are individualized, measurable and based on assessment findings, from the multi-disciplinary team members ....Treatment Teams There is an established treatment team that consists of the physician, nurse, and a Therapist/Acute Clinician. The team is responsible for prioritizing of care interventions, case management and the treatment process. ..." Review of the policy did not reveal if the treatment team needed to sign the Master Treatment Plan.

Review of the policy "Interdisciplinary Patient-Centered Care Planning - Acute", last reviewed 03/31/2022, revealed " ...Within 72 hours of admission, the multidisciplinary team shall meet and develop the treatment plan ....The treatment team will complete the MTP ....The treatment team, including the patient/family/representative will complete a review of the treatment plan as clinically indicated, or at a minimum every seven (7) days ....Reviews of the treatment plan are documented on the appropriate treatment plan forms in the medical record. ..."

4. Closed medical record review on 11/28/2022 revealed Patient #7, a 15-year-old, was admitted 05/05/2022 on an involuntary basis due to suicidal and homicidal ideations. Review of the MTP revealed the signature page of the MTP was signed by a Social Worker, date unclear. Review of the MTP did not reveal it was signed by the Physician, the Nurse, or the Nurse Practitioner until 05/26/2022 (two days after Patient #7 was discharged on 05/24/2022). Review revealed Patient #7 signed the MTP but did not reveal any discussion/ signature on the MTP from the responsible person/ parent. Record review failed to reveal a complete signed MTP during Patient #7's hospitalization.

Interview with RM #1 on 12/01/2022, revealed MTPs should be signed by treatment team members and updated.

Interview with Chief Clinical Officer (CCO) #38, on 12/01/2022 at 1435, revealed the CCO did not work at the hospital during Pt #7's hospitalization and could not speak to what was happening at that time. Interview revealed CCO #38 was not certain if the MTP should be signed by all treatment team members and acknowledged it needed to be clarified. Interview revealed the Social Worker involved with Patient #7 no longer worked at the facility. Interview revealed treatment plans should be updated.

5. Closed medical record review for Patient #47, on 12/20/2022, revealed the 13-year-old patient was admitted voluntarily as a walk-in on 11/01/2021. Review of the Discharge Summary, discharge date 11/12/2021, noted the patient had a history of Bipolar Disorder (chronic mental health disorder characterized by extreme mood swings from depression to mania), ADHD, and Autistic Disorder (developmental disability that can affect social skills, repetitive behaviors and communication). Review of the Interdisciplinary Master Treatment Plan revealed the typed name and date/time of the Care Coordinator/Therapist and revealed two typed problems, "Impulsivity" and "Aggression". Review revealed two preprinted problem sheets in the medical record, one for "Impulsivity" and one for "Aggression", each of which had pre-printed short term goals and interventions, with an initial date of 11/02/2021 and a target date of 11/09/2021 typed on each. No other information was noted, no updates or added problems or actions were found. Further review of the MTP failed to reveal the names of any other treatment team members, neither printed nor signed and did not reveal the Care Coordinator/Therapist signed the form. Review revealed Patient #47 signed the MTP but did not reveal any discussion/ signature from the responsible party/parent. Patient #47 was discharged 11/12/2021. Review failed to reveal a thorough Interdisciplinary Master Treatment Plan.

Interview with RN #8, on 12/21/2022 at 0930, revealed there was not a completed Master Treatment Plan found for Patient #47.

Telephone interview, on 12/21/2022 at 0958, with MD #40, revealed issues were discussed and agreed upon in Treatment Team. Interview revealed the physician depended on the Clinician/Therapist to give the physician the treatment plan to sign. Interview revealed MD #40 expected he would have received it and then would have signed it.

Interview with LCSW #39, on 12/22/2022 at 1230, revealed LCSW #39 reviewed Pt #47's medical record and found a good initial assessment but nothing in follow-up for treatment planning. Interview revealed no additional treatment planning documentation was located.