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Based on observation, record review and interview, the hospital failed to provide care in a safe setting for 5 of 5 sampled patients. This is evidenced by 1) failing to ensure that Patients #1 and #2 did not engage in sexual activity without the staff awareness and 2) failing to ensure Patients #1, #2, #3, #4 and #5 were observed per ordered observation levels.
Findings:

1) Failing to ensure that Patients #1 and #2 did not engage in sexual activity without the staff awareness

Review of an LDH self-report (dated 10/05/24) revealed in part that during the morning report on 10/05/2024, it was reported that Patient #1 had stuffed her bed the night before and was not in her bed when the night shift tech was performing rounds. The tech was unaware that the patient was not in her bed. Upon the 10/05/2024 day shift tech arriving, she noticed a "hickey" on Patient #2's neck and the other patients reported that Patient #1 and Patient #2 had engaged in sexual behaviors the night before. This allegedly took place in the bathroom of Patient #2.

Review of psychiatric evaluation, dated 10/01/2024, for Patient #1 revealed the patient had a history of sexual abuse. Further review revealed physician orders for routine every 15 minute observation level.

Review of the medical record for Patient #2 revealed an admission date of 10/02/2024. The patient was placed on routine every 15 minute observation level.

Review of the observation logs for Patient #1 and Patient #2 revealed they were to be monitored with documentation of location, activity and behavior every 15 minutes. The logs during the time period 10/04/2024 at 9:15 p.m. until 10/05/2024 at 6:15 a.m. revealed the tech documented the patients were in their rooms asleep in bed with eyes closed (during the alleged incident).

On 10/23/2024 at 9:45 a.m., interview with S1Compliance revealed that Patient #1 admitted to stuffing her bed and going to Patient #2's room during the night to perform sexual activities. S1Compliance confirmed that Patient #1 and #2 were not observed and monitored every 15 minutes as required, when the above alleged incident occurred. When asked if there was any documented education for the staff after this incident occurred regarding the observation of patients to ensure they are alive and breathing on rounds, he stated no.

2) Failing to ensure Patients #1, #2, #3, #4 and #5 were observed per ordered observation levels

Review of the hospital policy titled, Admission Assessment Management-Safety Precautions (December 2023), revealed in part that patients on routine every 15 minute observation level should be observed every 15 minutes and the observation is logged by the observer on the Close Observation form.

Review of the medical record for Patient #1 revealed routine every 15 minute observation level was ordered. Review of the observation log dated 10/03/2024 revealed the log stopped at 5:45 a.m. and did not pick up until 7:00 a.m. (no observations for one hour, 15 minutes). The RN signed off on the observation log during this time frame as being completed, but it was blank.

Review of the medical record for Patient #2 revealed routine every 15 minute observation level was ordered. Review of the observation sheet dated 10/16/2024 revealed the log stopped at 4:00 p.m. and did not pick up until three hours later, at 7:00 p.m.

Review of the medical record for Patient #3 revealed an admission date of 10/11/2024 with orders for every 15 minute routine observations. Review of the patient's observation logs from admit until discharge on 10/16/2024 revealed there was no observation log for the night shift (7PM-7AM) on 10/12/2024.

Review of the medical record for Patient #4 revealed an admission date of 10/02/2024 with orders for routine every 15 minute observation level. Review of the patient's observation logs from admit to present revealed the following missing observation logs for the night shift (7PM-7AM):
10/19/2024, 10/12/2024, 10/08/2024, 10/06/2024, 10/05/2024.

Review of the medical record for Patient #5 revealed and admission date of 10/02/2024 with orders for routine every 15 minute observation level. Review of the patient's observation logs from admit to present revealed the following missing observation logs:
10/21/2024 - day shift (7AM-7PM)
10/19/2024 - night shift (7PM-7AM)
10/16/2024 - day shift
10/13/2024 - day shift
10/07/2024 - no observation sheets for this day
10/03/2024 - day shift

On 10/23/2024 at 1:45 p.m., S2RN reviewed Patient #5's record and confirmed she was unable to locate the missing observation logs. She further stated that the hospital has been using a lot of agency staff and they may have misplaced the logs.

On 10/23/2024 at 3:00 p.m., interview with S1Compliance confirmed that the above missing observation logs for Patients #3, #4 and #5 were unable to be located. S1Compliance further confirmed that the patients were not being monitored/observed as ordered.

Based on record review and interview, the hospital failed to ensure the QAPI program took actions aimed at performance improvement as evidenced by failing to implement a performance improvement plan after two patients (Patient #1 and #2) were not observed per ordered observation level and engaged in sexual behaviors.
Findings:

Review of an LDH self-report (dated 10/05/24) revealed in part that during the morning report on 10/05/2024, it was reported that Patient #1 had stuffed her bed the night before and was not in her bed when the night shift tech was performing rounds. The tech was unaware that the patient was not in her bed. Upon the 10/05/2024 day shift tech arriving, she noticed a "hickey" on Patient #2's neck and the other patients reported that Patient #1 and Patient #2 had engaged in sexual behaviors the night before. This allegedly took place in the bathroom of Patient #2.

Review of the observation logs for Patient #1 and Patient #2 revealed they were to be monitored with documentation of location, activity and behavior every 15 minutes. The logs during the time period 10/04/2024 at 9:15 a.m. until 10/05/2024 at 6:15 a.m. revealed the tech documented the patients were in their rooms asleep in bed with eyes closed.

On 10/23/2024 at 9:45 a.m., interview with S1Compliance confirmed that Patient #1 and #2 were not observed and monitored every 15 minutes as required, when the above alleged incident occurred. S1Compliance confirmed Patient #1 had stuffed her bed with sheets, making it look like she was in bed. When asked if there was any performance improvement plan implemented after this incident to ensure that observations were being accurately performed, he stated no. When asked if there was any education provided to the staff after this incident regarding the observation of patients on rounds to make sure they are alive and breathing, he stated no.

Further review of the medical records for Patients #1, #2, #3, #4 and #5 revealed their observation logs had gaps in documentation of observations and/or multiple missing observation logs. On 10/23/2024 at 2:30 p.m., interview with S1Complaince revealed that the hospital currently had a performance improvement plan in place for monitoring for completeness of the observation logs and had been doing this for several months. S1Compliance stated that S3BHT Lead had been completing the monitoring of the logs and turns the information into him weekly. The surveyor requested the most current data, and at that time S1Compliance reviewed his computer and stated the last time data had been turned in was on 09/16/2024. At that time, S1Compliance called S3BHT Lead on the phone and she stated she had not been performing any monitoring of the observation logs. S1Compliance stated he did not realize that monitoring was not being performed, although he had not received any data in over a month. S1Compliance then confirmed that there was no current monitoring of observation logs.

Based on record review and interview, the hospital failed to ensure that the registered nurse supervised and evaluated the nursing care of each patient as evidenced by failing to have a policy in place to follow for safety precautions (suicide, elopement, homicidal/assault, hypersexual) as ordered by the physician for 3 of 3 patients reviewed for precautions (Patient #1, #2, #3).
Findings:

1. Review of the medical record for Patient #1 revealed an admission date of 09/30/2024 with diagnoses including major depressive disorder and suicidal ideations. Review of the physician orders revealed the physician ordered the patient to be placed on suicidal precautions on 10/01/2024 and hypersexual precautions on 10/05/2024.

2. Review of the medical record for Patient #2 revealed an admission date of 10/02/2024 with a diagnosis of suicidal ideations. Review of the nurses notes dated 10/03/2024 revealed the patient was on suicidal precautions. Review of the physician orders dated 10/05/2024 revealed the physician ordered the patient to be placed on hypersexual precautions.

3. Review of the medical record for Patient #3 revealed an admission date of 10/11/2024 with a diagnosis of disruptive mood dysregulation disorder. The patient was under OJJ custody. Review of the physician orders dated 10/11/2024 revealed the physician ordered the patient to be placed on elopement precautions and assault/violence precautions.

Review of the hospital policy titled, Admission Assessment Management-Safety Precautions (December 2023), revealed in part that prior to admission and upon admission, patients are assessed for high risk indicators which require safety precaution interventions. Recognized precaution interventions are as follows: suicide precautions, homicide/violence/aggression precautions, elopement precautions.
The policy did not indicate interventions that would be utilized for patients on these precautions.

On 10/23/2024 at 11:20 a.m., interview with S1Compliance confirmed there was no policy developed that instructed the nursing staff and techs on what interventions to implement for patients on specific precautions. S1Compliance further also confirmed that "hypersexual" precautions was not even addressed in the policy, although Patients #1 and #2 are currently on hypersexual precautions. When asked what the specific interventions would be for these specific precautions, S1Compliance stated he was unsure.

On 10/23/2024 at 1:00 p.m., interview with S4BHT revealed that patients on specific precautions (such as suicidal, homicidal, hypersexual) would be placed on 1:1 monitoring and that they would be watched a little closer.

On 10/23/2024 at 1:22 p.m., interview with S5BHT revealed that patients on specific precautions (such as suicidal, homicidal, hypersexual) would be watched a little more and stated she would keep a "close eye on them". When asked if anything extra is done with these patients on special precautions than patients who don't have them, she stated no.

Based on observation, record review and interview, the hospital failed to maintain an accurate medical record for 2 (Patient #1, #2) of 5 sampled patients (Patients #1-5) who had orders for observation levels every 15 minutes.
Findings:

Review of an LDH self-report (dated 10/05/24) revealed in part that during the morning report on 10/05/2024, it was reported that Patient #1 had stuffed her bed the night before and was not in her bed when the night shift tech was performing rounds. The tech was unaware that the patient was not in her bed. Upon the 10/05/2024 day shift tech arriving, she noticed a "hickey" on Patient #2's neck and the other patients reported that Patient #1 and Patient #2 had engaged in sexual behaviors the night before. This allegedly took place in the bathroom of Patient #2.

Review of the observation logs for Patient #1 and Patient #2 revealed they were to be monitored with documentation of location, activity and behavior every 15 minutes. The logs during the time period 10/04/2024 at 9:15 p.m. until 10/05/2024 at 6:15 a.m. revealed the tech documented the patients were in their rooms asleep in bed with eyes closed (during the alleged incident).

On 10/23/2024 at 9:45 a.m., interview with S1Compliance revealed that Patient #1 admitted to stuffing her bed and going to Patient #2's room during the night to perform sexual activities. S1Compliance confirmed that Patient #1 and #2 were not observed and monitored every 15 minutes as required, when the above alleged incident occurred. S1Compliance confirmed the tech inaccurately documented the monitoring of Patients #1 and #2 in their medical records.