HospitalInspections.org

Based on document review, video review, policy review, record review and interview, the hospital failed to ensure Patients Rights were promoted and patients received care in a safe setting for one of two (Patient #1) patients who was found in Patient #2's room in a sexually compromising position.

The findings included:

1. Review of Hospital Policies included the following:
The Occurrence Reporting of Critical Incidents/Sentinel Events Policy with a revised date of 6/2021 and an effective date of 6/2021 detailed the assurance of immediate documentation and reporting to proper supervisors when a critical and/or sentinel event occurs.
The Patient Safety Policy with a revised date of 01/2018 and last approved date of 01/2018 detailed the hospital's guidance for ensuring the safety and protection of all patients.
The Abuse Prohibition Plan with a revised date of 5/2022 and an effective date of 05/2022 detailed the framework for screening employees, training employees in prevention, identification, reporting, protection of patients at risk and investigating allegations.
The Mandatory Incident Reporting to the State Certification Office Policy with a revised date of 12/2016 and an effective date of 5/2005 which detailed times of reporting.
The Patient Rights and Responsibilities Policy with a revised date of 5/2021 and an effective date of 5/2021 detailed observation of patient rights.
The Seclusion and Restraint Policy with a revised date of 10/2021 and an effective date of 10/2019 detailed definitions and procedures for seclusion and restraints.
The Medication Administration Policy with a revised date of 8/2021 and an effective date of 8/2021 detailed procedure for medication administration.
The Wandering Behavior Policy with a revised date of 11/2021 and an effective date of 11/2019 detailed wandering behavior assessments and management of wandering.
The Observation Levels Policy with a revised date of 9/2021 and an effective date of 9/2021 detailed procedure for patient observations and documentation.

Patient #1 was admitted with 15 minute observation which is the standard minimum observation time per policy.

2. Medical Record Review revealed Patient #1 was voluntarily admitted to the hospital on 3/7/22. Patient #1 was referred from an Assisted Living facility and resided in the Memory Care Unit. Patient #1 presented with a history of dementia and anxiety. Patient #1 yelled/screamed, was high risk for wandering, hypersexual and displayed aggressive, assaultive behavior in the Nursing Home. Patient #1 attempted to open entrance doors at the Memory Care unit on multiple occasions. She was difficult to redirect, and would wander into other patient's rooms, yell at them, refused to take medication and touch other male residents in their personal space. She was admitted to this facility for behavior and medication management.

The hospital was aware of Patient #1's behaviors of wandering and hypersexual tendencies, touching men in their personal space and aggressive behavior upon admission on 3/7/22.

3. Review of a video dated 3/28/22 of the long hallway beginning at 6:57 PM, revealed Patient #1 wandering in and out of patient rooms. The video also revealed multiple staff members were on the hallway thorough out patient #1 and Patient #2 in the hallway. The video revealed Patient #1 walked into Patient #2's room and stayed there for 10 minutes while staff was walking in the hallway. By not monitoring Patient #1's wandering in and out of rooms, Patient #1 was in an unsafe environment and was in danger of sexual abuse.

There were no problems or interventions documented on the Treatment Plan for wandering, aggressive behavior, and hypersexuality (touching men in their personal space).

There was no documentation the staff followed the Hospital's policy and procedure when Patient #1 was wandering in and out of patient rooms and ultimately wandered into Room 406 where she was sexually abused.
Refer to A-144.

Based on document review, video review, policy review, record review and interview, the hospital failed to ensure patients received care in a safe setting when one of one (Patient #1) patients was found in a sexually compromising position and potentially sexually abused by another patient (Patient #2) while being cared for by hospital staff, failed to ensure the safety of all patients who had diagnoses of dementia by not properly monitoring the patients who would wander throughout the hospital and failed to ensure the medication cart was locked when unattended to prevent patients from access to medications.

The findings included:

1. Review of the hospital's policy titled, Abuse Prohibition Plan with a revised date of 5/2022 and an effective date of 05/2022 revealed "...has a zero-tolerance policy for abuse....sexual abuse is prohibited...Definitions..."Sexual Abuse" includes but not limited to sexual harassment, sexual coercion, or sexual assault...Involuntary Seclusion" refers to the separation of a patient from other patients or...confinement to their room against the patient's will...Training...All employees will receive training during initial orientation, annually and with ongoing sessions...Training will include...Activities that constitute abuse, neglect...How to identify patients who are at risk for abuse, neglect...Understanding behavioral symptoms of patients that may increase the risk of abuse and neglect and how to respond...The symptoms include...Wandering...Difficulty in adjusting to new routines or staff...Dementia management and patient abuse prevention...Protection... It is the policy of the facility that patients will be protected from the alleged offender...If the alleged offender is a facility patient, the staff member will immediately remove the perpetrator from the situation and another staff member will stay with the alleged offender and wait further instructions from the Administration...The patient's physician will be notified...Notification of law enforcement and/or State Agency, Crisis Response...APS [Adult Protective Services], or other agencies will be made as indicated and within the appropriate time frames...A medical, evidentiary, or sexual assault exam will be completed as soon as possible as appropriate...Education will be provided as needed to all of those identified in need of education by the Administrator...Reporting and Response...It is the policy of the facility that abuse allegations...are reported per Federal and State Regulations and Law...Internal Reporting...Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the patient...Note: If sexual abuse is suspected, the patient WILL NOT be bathed, and clothing or linen will not be washed. No items will be removed from the area in which the incident occurred. The police will be immediately called...The patient's family/responsible party will be notified by the Administrator or designee of the report of an incident of an abuse and that an investigation is being conducted. The patient/patient's responsible party will be informed of the results of the investigation as well..."

2. Review of the hospital's policy titled, Patient Rights and Responsibilities with a revised date of 5/2021 and an effective date of 05/2021 revealed, "...To ensure all facility staff and contract staff shall observe these patient's rights to respect and foster the patient's dignity, autonomy...civil rights and involvement in his/her care...All facility staff, medical staff, and contracted agency staff performing patient care activities shall observe these patient rights...The Statement of Patient Rights shall include...the patient's right to...Considerate, dignified and respectful care, provided in a safe environment, free from all forms of abuse, neglect...exploitation...Remain free from restraint and seclusion of any form that are not medically necessary or are used as a...convenience by staff..."

3. Review of the hospital's policy titled Seclusion and Restraint Policy with a revised date of 10/2021 and an effective date of 10/2019 revealed "...Policy...Seclusion/Restraint is not to be used as...convenience of staff, or in a manner that causes undue/physical discomfort, harm or pain to the patient...Definitions: Seclusion/Isolation - Involuntary confinement of a patient alone in a room or area where the person is physically prevented from leaving..."

4. Review of the hospital's policy titled Medication Administration Policy with a revised date of 8/2021 and an effective date of 8/2021 revealed, "...Procedure...Medication carts shall be locked when left unattended..."

5. Review of the hospital's policy titled Wandering Behavior Policy with a revised date of 11/2021 and an effective date of 11/2019 revealed, "...Wandering Behavior Assessment will be completed on each patient at the time of admission..."

6. Review of the hospital's policy titled Observation Levels Policy with a revised date of 9/2021 and an effective date of 9/2021 revealed, "...Routine Observation (Q-15) [every 15 minutes] - Standard/Low Risk. The patient will be checked every 15 minutes by a staff member and document, as appropriate, in the medical record. The staff member designated to perform every 15 minute observations must be in the patient's physical presence and can identify the patient's location, activity and behavior. When a patient is in her/her room at any time, the designated staff member must enter the room and assess for breathing. The observer must be within a distance that respirations can be observed...1:1 Observation - High Risk...1:1 Observation is the third level of observation. It includes all the components of routine observation (Q-15). Additionally a staff member is assigned by the nurse to be physically present (within arm's reach) of the patient at all times. The RN [Registered Nurse] assigned to this patient is responsible to ensure that 1:1 observation is in progress at all times. The RN documents each shift the continuation of 1:1 observation...Upon admission observation levels will be discussed with the attending LIP [Licensed Independent Provider] who will decide if in addition to routine observation...there is a need for...1:1 observation...A RN may independently initiate line of sight (LOS) or 1:1 observation if it is assessed that the patient is at risk to act on...harm self or others, a desire to elope...increased agitation..."

7. Medical Record Review revealed Patient #1 was voluntarily admitted to the hospital on 3/7/22. Patient #1 was referred from an Assisted Living facility and resided in the Memory Care Unit. Patient #1 presented with a history of dementia and anxiety. Patient #1 yelled/screamed, was high risk for wandering, hypersexual behavior and displayed aggressive, assaultive behavior in the Nursing Home.

Review of the Call Intake Referral dated 3/7/22 revealed, "...Describe Precipitating Events: Patient is...referring from [Named Memory Care Unit] Patient presents with a history of dementia and anxiety. Patient is attempting to open entrance door [to the Memory Care Unit prior to transfer] on multiple occasions, when redirected...becomes agitated...anxious, going in and out of other residents room trying to wake them, yelling at other residents...touching other residents food on their plates, not wanting to take medication, going up to men residents touch them in their personal space..." This was a Nurse to Nurse call report and summarized Patient #1's behavior in the Memory Care Unit prior to admission to this hospital.

Review of the Nursing Assessment dated 3/7/22 revealed, "...Pt is at risk of elopement due to her exit seeking behavior. Safety precaution by frequent checks and monitoring...Recent High Risk Behaviors: Assaultive/Combative Behaviors, Elopement..."

Review of the History and Physical dated 3/8/22 revealed, "...She is here for behavior and medication management. Alert, standing up in hallway. Disoriented. Patient would not answer any questions. Patient was talking illogically..."

Review of the Psychosocial Assessment dated 3/8/22 revealed, "...Clinical Summary/Impression: Patient presents with Patient is attempting to open entrance door on multiple occasions, when redirected she becomes agitated, threatens to break staff arm after redirection, anxious, going in and out of other residents room trying to wake them, yelling at other residents, rasing [raising] her hands like she is going to hit staff, not wanting to take medication, going up to male residents and touching them in their personal space, and defecting [defecating-having a bowel movement] on the floor...Discharge Plan...Patient will be discharged when stable to a lower level of care to a safe environment where continuous care will continue..."

Problem #2 revealed Potential High Risk for exposure to COVID-19 with interventions to include Maintain contact isolation to minimize exposure to or from patients regarding COVID 19 when necessary and Covid testing 48 hours after admission and when displaying respiratory symptoms.

There were no problems or interventions documented on the Treatment Plan for wandering, aggressive behavior, and hypersexuality (touching men in their personal space).

Review of the hospital's video recordings for 3/28/22 revealed the following:
From 7:05 PM until 7:41 PM, Patient #2 (Male) was sitting at the end of the hall in a chair outside Room 401 talking to Random Patient #3 (Female) also sitting in a chair she put in the doorway of her room 401. The video had no sound but it appeared the 2 patients were talking for the entire time. (36 minutes). Multiple staff members walked up and down the hall during this time. Patient #1 (Female) was not seen during this time in the hallway.
At 7:23 PM, a staff member who was taking vital signs of the patients using a rolling Dinamap machine (A machine to take Blood Pressure and Pulse) entered Room 407 (Patient #1's room) to take Patient #1's vital signs.
At 7:25 PM the staff member walked out of Patient #1's room (Rm 407). Patient #1 has still not come out of the room.
At 7:41 PM, Patient #2 and Random Patient #3 got up and walked to Room 406 (Patient #2's room) doorway and looked in the room. Neither Patient entered Room 406.
At 7:43 PM, Patient #2 and Random Patient #3 walked back to the chairs at the end of the hall by Room 401 and sat down. Staff continued to be seen walking up and down the hallway taking vital signs with a rolling Dinamap machine.
At 7:59 PM a staff member walking down the hall stopped and glanced in to Room 407 (Patient #1's room) and kept walking.
At 8:04 PM a staff member walking up the hall (toward the camera) stopped and completely closed the door of Room 407 (Patient #1's) room.
At 8:21 PM a staff member walked down the hall to Rm 407 (Patient #1's room) opened the door and went in.
At 8:24 PM the staff member exited Room 407 and went into Room 408.
At 8:42 PM Patient #2 got up from the chair at the end of the hall and walked into his room (Room 406).
At 9:25 PM Patient #1 came out of her room (Rm 407) and walked over to Rm 410 and looked in. She then walked into Room 409.
At 9:26 PM Patient #1 walked out of Room 409 and walked down the hallway. Patient #1 then looked into Room 405.
At 9:27 PM Patient #1 walked down the hall to Room 401 and looked in. Patient #1 then walked up the hallway (toward the camera) and looked in Room 404, She walked past Room 406, then walked in to Room 410.
At 9:28 PM Patient #1 walked out of Room 410, walked across the hallway and went in Room 409. She walked back out of Room 409 almost immediately. Patient #1 continued to walk in the hallway.
At 9:29 PM Patient #1 walked into Room 404. The patient in Room 404 immediately ushered Patient #1 out of her room with her hands on Patient #1's shoulders. She walked her to the middle of the hallway and left Patient #1 there and went back into her room. Patient #1 turned around and walked back to Room 404, but stopped in the doorway and did not go in.
At 9:30 PM Patient #1 walked to the end of the hallway and looked through the window of the locked doors. Patient #1 then turned and looked into Room 401, then entered the room.
At 9:30 PM Patient #2 peeked out of his room (Room 406) as he stood just inside the doorway.
At 9:31 PM Patient #1 came out of Room 401 and looked into Room 402 across the hall.
At 9:31 PM Patient #1 continued to walk up the hall (toward the camera) and walked to Room 406 (Patient #2's Room). She stopped at the door and then walked into the room.
At 9:36 PM A staff member walks down the hallway with linens in her arm. She walked past Room 406, did not look in as she went to Room 402.
At 9:40 PM, LPN #1 came down the hall with the medication cart and parked it outside of Room 410. The staff member with the linens walked back up the hallway (toward the camera) with no linens in her arms. She walked slowly by Room 406 (Patient #1 and #2 are in the room) The staff member did not look into the room but went to Room 410 and went in.
At 9:40 PM another staff member walks down the hall and looks into Room 407 (Patient #1's room), stops and goes into the room. She comes out of the room and walks up the hall (toward the camera) and off the hallway out of camera view.
At 9:41 PM, 2 staff members walk down the hallway together looking in the rooms. When they get to Room 406 (Patient #1 and #2 are in this room together) they enter the room.
At 9:42 PM the LPN leaves the Medication Cart in the hallway unlocked and walks briskly to Room 406.
At 9:46 PM 2 staff members and the LPN come out of Room 406 and escort Patient #1 to her room 407. Patient #1 was fully dressed.
At 9:48 PM A staff member comes out of room 406 and shuts the door as she leaves. Patient #1 is left alone in Room 407.
Patient #2 has been left alone in Room 406.
At 9:50 PM the LPN #1 comes back to the medication cart and begins to pass medications again. Each time LPN #1 goes into a patient's room, the medication cart is left unattended and unlocked in the hallway.
At 9:50 PM A staff member enters Patient #1's room 407 and comes right back out.
At 9:51 PM Patient #2 peeks out of his room 406 but does not come out of the room.
At 9:52 PM, a staff member walks down the hall to Patient #1's room 407, opened the door, looked in and then closed the door again.
At 9:57 PM, Patient #1 came out of Room 407, LPN #1 guided her back into her room and closed the door.
At 9:57 PM, A staff member went into Patient #1's room and brought a large chair out and placed it just outside Room 407. Another staff member came and sat in the chair blocking the doorway to Room 407. Patient #1 was inside the room.
At 10:39 PM A staff member is sitting in the chair in Patient #1's doorway with her legs crossing the doorway and her feet are on the door facing. Patient #1 appears to try and get out of her room by trying to move the staff member's foot. The staff member does not move her foot and Patient #1 is unable to come out of her room.

Patient #1 wanders in and out of several patient's rooms with no staff interventions or redirection. Patient #1 was in Patient #2's room from 9:31 PM until found at 9:41 PM (10 minutes). Patient #1 was found on the bed. Patient #2 was on top of Patient #1. Both patients were undressed from the waist down. Patient #2 was found with a full erection. The facility failed to keep Patient #1 safe from sexual abuse.

Review of the Hospital's investigation report dated 3/28/22 revealed the family of Patient #1 was notified 3/28/22 at 11:22 PM (1 hour and 41 minutes later). The Nurse Practitioner was notified on 3/28/22 at 11:54 PM (2 hours and 13 minutes later). No orders were received. The investigation report revealed the Nurse Practitioner stated, "Keep me posted."
During a telephone interview on 6/22/22 at 10:07 AM, Patient #1's family member revealed he was not called or notified of the incident until the next morning when the Rape Crisis Center called him to ask permission to do a rape kit on Patient #1.

Review of the Rape Crisis Center Forensic Nursing Evaluation dated 3/29/22 revealed, "...THIS NP [Nurse Practitioner] SPOKE TO [Named Husband] @ [at] 0737 [7:37 AM] AND RECEIVED CONSENT FOR EXAM, EVIDENCE COLLECTION, STI [Sexually Transmitted Infection] TESTING AND ABX [Antibiotics] PROPHYLAXIS..."

Review of the Ambulance Run Report dated 3/29/22 revealed the hospital called for an ambulance on 3/29/22 at 3:24 AM (5 hours and 43 minutes after the incident occurred). The report revealed, "...The patient's nurse notified me that this was not medical clearance, this was a potential sexual assault...The nurse laughed about the situation and said nothing could have happened in 9 minutes but they are required to have the patient medically cleared...The incident occurred at 9pm, we were dispatched at 3:30am with arrival at 3:45am...Due to the severity of the incident, supervisors were called and informed about the current situation and directive about the next step whether police should be notified or patient should just be transported to hospital given...Upon arrival at [Hospital #2], patient was checked into Triage. Report and recent set of vitals were given, nurse called [Hospital #1 where incident occurred] for more information about the incident. Another different story was given, they informed the nurse that the patient was found in the male patient's room with male on top and the female patients legs spread in the air both naked and male had an erection. The nurse was notified police were at the scene at 12:00 am, 3 hours and 45 minutes prior to EMS arrival. Police interviewed the male patient and departed the scene. Nurse called police to escort us to [Named Rape Crisis Center] for a rape kit to be done for our patient. A MPD [Memphis Police Department] office arrived and did not know how to handle the situation, he deemed the situation as not rape and didn't believe patient needed to [Named Rape Crisis Center] even though nurse and ems [EMS] crew suggested patient needs to. The officer stated that the patient could give consent even though the patient was only responsive to pain. The officer tried to get in contact with Sex Crimes expert for awhile before he received a response back. Sex crimes expert notified the officer he was En Route. Once he arrived, the officers compared the situation to children. The officers were uncooperative and were brushing off the situation. The officers ended up deciding to escort us to [Named Rape Crisis Center]. Upon arrival to [Named Rape Crisis Center] we were posted until a forensic expert arrived for the rape kit. Once they arrived we were notified they need to gain consent from patient's spouse for the rape kit to be performed...Once they got ahold of the spouse at 8am [3/29/22] it was found out the spouse had not been notified about the incident since it happened at 9pm. He gave consent, we transferred the patient to the facility...Report and papers was given to the forensic expert...patient care was transferred. EMS crew cleared the room..."

During an interview on 6/20/22 at 4:10 PM, the Administrator stated training for care of patients with dementia is on the computer learning and it is a standard. He further stated that behaviors are treated individually and in groups, there are two group rooms and the patients are separated based on their needs. The Administrator further stated that they have a lot of wanderers and checks are done every 15 minutes. He stated they keep staff in the halls if a patient is hard to be redirected. He stated they meet as a treatment team and they look at the underlying conditions.

During a telephone interview on 6/22/22 at 10:07 AM, Patient #1's family member and Power of Attorney (POA) stated Patient #1 was supposed to be transferred back to the Memory Care Unit the next day 3/29/22. The POA stated Patient #1 passed away on May 5, 2022. The POA stated Patient #1 was really traumatized and stated the District Attorney was not going to prosecute the other patient because Patient #2 also had dementia. The POA was crying during the telephone interview and stated he just wants someone to be held accountable. The POA stated he felt no one was taking him seriously.

During an interview on 6/22/22 at 10:55 AM, the Regional Director of Operations confirmed this incident was a tragic situation and the facility was committed to ensuring patients would be safe and there were multiple implementations being done to ensure this would not happen again. The Regional Director of Operations stated they are committed to doing everything that can be done including they are already doing staff education.

During an interview on 6/23/22 at beginning at 11:48 AM, the Director of Nursing (DON) stated she expected the nurses to lock the medication cart when it was unattended.

Based on document review, policy review, and record review, the hospital failed to ensure nursing services used admission assessments that identified patient care needs to develop treatment plans and implement nursing interventions to assess, monitor and protect from wandering, dementia, sexual abuse, and aggressive behavior for two of three (Patient #1 and 2) sampled patients.

The findings included:

1. Review of Hospital Policies included the following:
The Master Treatment Plan Review Policy with a revised date of 5/2021 and an effective date of 5/2021 detailed when to initiate the treatment plan and when to update it.
The Treatment Plan Policy with a revised date of 12/2021 and an effective date of 12/2021 detailed what the treatment plan included, planning, when to initiate the plan.
The Observation Levels Policy with a revised date of 9/2021 and an effective date of 9/2021.

2. The Observation Levels Policy dated 9/2021 revealed, "...An RN [Registered Nurse] may independently initiate line of sight (LOS) or 1:1 observaton if it is assessed that the patient is at risk to act on...harm self or others, a desire to elope...or increasing agitation..."

3. Medical Record Review revealed Patient #1 was voluntarily admitted to the hospital on 3/7/22. Patient #1 was referred from an Assisted Living facility and resided in the Memory Care Unit. Patient #1 presented with a history of dementia and anxiety. Patient #1 yelled/screamed, was high risk for wandering, hypersexual and displayed aggressive, assaultive behavior in the Nursing Home. Patient #1 attempted to open entrance doors at the Memory Care unit on multiple occasions. She was difficult to redirect, and would wander into other patient's rooms, yell at them, refused to take medication and touch other male residents in their personal space. She was admitted to this facility for behavior and medication management.
Based on Patient #1's previous documented history of wandering, hypersexuality, aggressive assaultive behavior while in the Memory Care Unit, Patient #1 should have been put on the highest level of observation which was 1:1 per hospital policy.

The hospital was aware of Patient #1's behaviors of wandering and hypersexual tendencies, touching men in their personal space and aggressive behavior upon admission on 3/7/22 but failed to initiate a treatment plan that identified and addressed dementia, wandering, hypersexuality, and aggressive behavior.


3 Medical Record Review revealed Patient #2 was admitted on 3/22/22 with diagnoses of major depressive disorder, recurrent severe without psychotic features and Alzheimer's Dementia.

The hospital was aware of Patient #2's diagnosis of dementia but failed to initiate a treatment plan with interventions to address dementia.
Refer to A-396

Based on document review, policy review, record review and interview, the hospital failed to ensure nursing staff created a treatment plan that addressed dementia for two of three patients (Patient #1, and #2) and failed to address wandering, and hypersexuality for Patient #1.

The findings included:

1. Review of the hospital's policy titled Preliminary/Initial Treatment Plan Policy with a revised date of 6/2021 and an effective date of 6/2021 revealed, "...A preliminary/initial treatment plan shall be developed when care, treatment, or services are initiated prior to completion of the screening and assessment process...The preliminary/initial treatment plan shall focus on the patient's safety...The preliminary/initial treatment plan shall be completed by a RN within 24-hours of admission..."

2. Review of the hospital's policy titled Master Treatment Plan Review Policy with a revised date of 5/2021 and an effective date of 5/2021 revealed, "...Procedure...At least once every seven (7) days the treatment team shall meet and review the patient's goals, progress, interventions, and discharge criteria...Newly identified problems shall be considered for additions to the MTP [Master Treatment Plan]..."

3. Medical Record Review revealed Patient #1 was voluntarily admitted to the hospital on 3/7/22. Patient #1 was referred from an Assisted Living facility and resided in the Memory Care Unit. Patient #1 presented with a history of dementia and anxiety. Patient #1 yelled/screamed, was high risk for wandering, hypersexual and displayed aggressive, assaultive behavior in the Nursing Home. Patient #1 attempted to open entrance doors at the Memory Care unit on multiple occasions. She was difficult to redirect, and would wander into other patient's rooms, yell at them, refused to take medication and touch other male residents in their personal space. She was admitted to this facility for behavior and medication management.

Review of the Treatment Plan dated 3/8/22 did not reflect or address Patient #1's diagnosis of dementia, wandering, hypersexual tendencies, or touching men in their personal space.

Review of the Treatment Plan for Patient #1 dated 3/8/22 revealed a problem: At risk of harming others, with interventions to include every 15 minute checks for safety and listed medications.

The hospital was aware of Patient #1's behaviors of wandering and hypersexual tendencies, touching men in their personal space upon admission on 3/7/22 but the treatment plan did not address wandering, hypersexual behavior, or dementia.

4. Medical Record Review revealed Patient #2 was voluntarily admitted on 3/22/22

Review of the Treatment Plan dated 3/24/22 did not address interventions for Patient #2's diagnosis of dementia.

Review of the Treatment Plan for Patient #2 dated 3/24/22 revealed a problem: Patient has a history of dementia, anxiety, and depression. Patient presents with suicidal ideation (SI) with plan by cutting his wrist. Patient is crying and stating he wants to die. The interventions include safety checks every 15 minutes, groups daily, Reassessment of SI daily and listed medications.

During an interview on 6/28/22 at beginning at 10:34 AM, the DON confirmed the treatment plans for Patient #1 did not address dementia, wandering, hypersexuality, and the treatment plan for Patient #2 did not address interventions specifically for dementia.

During an interview on 6/28/22 at beginning at 10:34 AM, the DON stated the agency nurses are not trained to do treatment plans.