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Based on staff interview and review of patient rights information, grievance information, restraint documentation, medical records and hospital policies, it was determined the hospital failed to ensure patients' rights were protected and promoted. This resulted in the failure of the hospital to ensure written notice provided to complainants contained steps taken to investigate grievances and the resolution of grievances. Additionally, the hospital failed to ensure patients received care in a safe setting and were protected from abuse and harassment, and restraints were used safely, appropriately and only in accordance with a physician's order. Findings include:

1. Refer to A123 as it relates to the failure of the hospital to ensure written notice provided to patients or their legal representatives included the steps taken to investigate the grievance and the resolution of the grievance.

2. Refer to A144 as it relates to the failure of the hospital to ensure care was provided to patients in a safe manner.

3. Refer to A145 as it relates to the failure of the hospital to ensure all vulnerable patients were fully protected from abuse and harassment.

4. Refer to A167 as it relates to the failure of the hospital to provide evidence of the use of safe and appropriate restraint.

5. Refer to A168 as it relates to the failure of the hospital to ensure restraints were applied only with a physician's order.

6. Refer to A169 as it relates to the failure of the hospital to ensure restraint orders were clearly documented and were not written on an as needed basis (PRN.)

7. Refer to A187 as it relates to the failure of the hospital to ensure there was clear documentation of patients' conditions and symptoms that warranted the use of restraint.

The cumulative effects of these negative systemic practices seriously impeded the ability of the hospital to protect patient rights and provide services in a safe setting.

Based on review of hospital policy and grievance documentation, and staff interview, it was determined the hospital failed to ensure written notice provided to patients or their legal representatives included the steps taken to investigate the grievance and the resolution of the grievance. This resulted in an incomplete resolution to the grievance process. Findings include:

The hospital's policy, "Patient Grievance," revised 12/2014, stated "All patient grievances will be investigated in the specified time frame and the results of the investigation reported back to the complainant." The policy stated a written report of the investigation would be presented to the patient and would include "a review of the nature of the grievance, what was done in response to the grievance, the outcome of the grievance..."

The hospital's grievance log for 2016 was reviewed. Each entry included the grievance, the investigation, and the letter sent to the patient or legal representative following the investigation. The letters did not include the resolution of the grievance, or inform the complainant the grievance was resolved and no further actions would be taken. Examples include:

1. A grievance was received on 1/07/16. A letter to the complainant, dated 1/12/16, and signed by the Director of Performance Improvement/Risk Management stated "We value your feedback and the following actions have been taken in response to your complaint: We followed up with the physician and the Director of Social Services to address your concerns." The letter did not include additional information regarding the results of the investigation or the resolution, and did not state the grievance was resolved and no further actions would be taken.

2. A grievance was received on 3/04/16. A letter to the complainant, dated 3/10/16, and signed by the Director of Performance Improvement/Risk Management stated "We value your feedback and the following actions have been taken in response to your complaint: The Director of Nursing followed up with the nursing staff and the Risk Manager reviewed the actions taken." The letter did not include additional information regarding the results of the investigation or the resolution, and did not state the grievance was resolved and no further actions would be taken.

During an interview on 10/17/16 at 10:05 AM, the Director of Performance Improvement/Risk Management reviewed the 2016 grievances and the letters sent to the complainants. She stated the letters did not include the results of the investigation, or state the grievance was resolved.

The hospital failed to ensure complainants were provided with written notice of the investigation and resolution of grievances.

Based on staff interview and review of medical records, occurrence reports, hospital policies, and food allergy and dietary information, it was determined the hospital failed to ensure care was provided in a safe manner. This directly impacted the safety of 4 of 10 patients (#3, #4, #6 and #8,) whose records were reviewed, and had the potential to affect the safety of all patients. The failure to appropriately evaluate and monitor patients based on their individual needs had the potential to interfere with patient safety. Findings include:

1. The hospital's policy, "Level of Observation Orders," last revised on 7/08/16, stated "All patients will be closely observed in compliance with physician orders and prescribed protocols...Patients will be actively assessed and monitored for changes in their behavior and/or when medical conditions arise that may warrant a change in level of observation: 15 Minute Observations, Dedicated Observations, One-one (1:1) Observations...The RN, in consultation with the RN Manager/RN Supervisor may increase the level of observation...Employees will monitor hallways and be able to view the entire unit to eliminate problems with inappropriate patient activity..."

The hospital's practice guidelines, "Practice Guidelines for Levels of Observation," last revised on 7/08/16, was attached to the policy regarding levels of observation. It stated patients should have adequate impulse control and be able to express insight into their behavior if 15 minute checks are ordered.

The hospital did not adhere to the policy and guidelines as follows:

a. Patient #8 was a 13 year old female who was admitted voluntarily to the hospital on 9/26/16 and discharged home on 10/07/16. Her diagnoses included major depressive disorder, posttraumatic stress disorder, obsessive-compulsive disorder, conduct disorder, cannabis use disorder, alcohol use disorder and child victim of sexual abuse. She presented to the hospital as a transfer from a local ER, where she was assessed for suicidal ideations, self-harm behavior and significant substance use.

A "BH-HEALTHCARE PEER REVIEW REPORT," dated 9/30/16 at 8:00 PM and completed by an RN, was reviewed during the survey. The report was regarding Patient #8 and included a section "SEXUAL ALLEGATION." Contained within this section were descriptive terms with check boxes beside each item. The boxes beside Misconduct: Pt/Pt, and Intercourse: Pt/Pt were marked. The form also included documentation indicating the incident took place in a "Pt's bedroom," and her physician and parents were notified. The form also indicated a report was filed with local authorities, and the local office for sexual assault victims was notified.

Patient #8's admission orders, dated 9/26/16 at 2:20 PM and signed by a physician, included precaution orders for suicide and self harm. Also included on admission was an order for 15 minute checks. On 9/27/16, precaution orders for behavior, elopement, assault, sexual acting out, sexual victimization and sexual aggression were added. There was no corresponding order on 9/27/16 to elevate the level of observation for Patient #8. She remained on 15 minute checks.

An "ABUSE REPORT DOCUMENTATION" form, dated 9/30/16 at 7:45 PM and signed by an RN, stated Patient #8 reported to staff she had intercourse with a male adolescent peer (Patient #6) on 9/29/16. The form stated Patient #8 said she had "just gotten out of the shower and Patient #6 came into her bathroom." The form stated Patient #8's mother was notified and a report was submitted to CPS.

A "PHYSICIAN ORDERS" form, dated 9/30/16 at 7:15 PM and signed by a physician, ordered tests for HIV, chlamydia and gonorrhea. Also included were orders for the "morning after pill" and an order to transport patient for a "rape kit." Orders stated Patient #8's mother was notified and consented verbally to all orders.

An "EMERGENCY ROOM TRANSFER REPORT," dated 9/30/16 at 8:00 PM and signed by a physician and an RN, stated Patient #8 was transferred to a local ER for a "Rape Kit." The form included Patient #8 was on suicide precautions, self-injury precautions, assault/aggression precautions, elopement precautions and behavior precautions at the time of the transfer.

A "NURSING FLOW SHEET," dated 9/30/16 at 12:00 PM and unsigned, stated Patient
#8 returned from the local ER accompanied by law enforcement, who reported she made the statement "she wanted to kill herself." The note stated Patient #8 was placed in the "obs [observation] room with no sheets...Will continue to monitor Q15 min and more for her safety..." Though Patient #8 was placed in an observation room, her level of observation was not elevated to "Dedicated Observations or One-one (1:1) Observations." She remained on 15 minute checks.

The hospital failed to ensure policies and practices were followed by staff and were adequate to protect the safety of patient #8.

b. Patient #6 was a 17 year old male who was admitted voluntarily to the hospital on 9/19/16 and discharged home on 9/30/16. His diagnoses included generalized anxiety disorder, autism spectrum disorder and severe marijuana abuse. He presented to the hospital with multiple legal, educational, social and family difficulties related to abuse of marijuana. This was his second psychiatric hospitalization.

A "BH-HEALTHCARE PEER REVIEW REPORT," dated 9/30/16 at 8:00 PM and completed by an RN was reviewed during the survey. The report was regarding Patient #6 and included a section "SEXUAL ALLEGATION." Contained within this section were descriptive terms with check boxes beside each. The boxes beside Misconduct: Pt/Pt, and Intercourse: Pt/Pt were marked. The form also included documentation indicating the incident took place in a "Pt's bedroom," and his physician and parents were notified.

Patient #6's admission orders, dated 9/19/16 at 6:15 PM and signed by a physician, included precaution orders for self harm and behavior. Also included on admission was an order for 15 minute checks. On 9/30/16, precaution orders for sexual acting out and sexual aggression were added. There was no corresponding order on 9/30/16 to elevate the level of observation for Patient #6. He remained on 15 minute checks.

An "OVERFLOW CHARTING NOTES" form, dated 9/29/16 at 11:20 PM and signed by a PT, stated Patient #6 was found in the room of a female peer. The form stated Patient #6 was confronted and said he was helping the female peer with her assignments. The form stated he experienced a "level demotion" and "...will continue to monitor Q15." Patient #6's level of observation was not elevated as a result of the incident.

An "ADOLESCENT DAILY TRACKING SHEET," dated 9/30/16 and signed by a PT, stated at 3:00 PM, "found notes from female peer, Pt threatened staff, punched wall, sent to ER"

A "PHYSICIAN ORDERS" form, dated 9/30/16 and untimed, included an order to transfer Patient #6 to a local ER for evaluation of his right hand.

A "PHYSICIAN ORDERS" form, dated 9/30/16 at 7:15 PM and signed by a physician, ordered tests for HIV, chlamydia and gonorrhea. Orders stated Patient #6's mother was notified and consented verbally to all orders.

A "NURSING FLOW SHEET," dated 9/30/16 at 8:00 PM and signed by an RN, stated "Staff were informed about sexual misconduct on the unit. After reviewing video it did show pt went into another pt's room for about ten minutes. Before this was reported he did hit the wall and had to be sent to the ER. Pt did fracture right hand..."

The hospital failed to ensure policies and practices were followed by staff and were adequate to protect the safety of patient #6.

A male PT, who was assigned to the male patient hallway on the evening of 9/29/16, was interviewed on 10/13/16, beginning at 1:40 PM. He stated there were 3 PTs assigned to the adolescent unit on the evening of 9/29/16. He stated he was assigned to the male hallway, a female PT was assigned to the female hallway, and a second female PT was assigned to float between the hallways. He said Patient #8 was the only female patient assigned to the male hallway at that time. He stated the female PTs were responsible for performing 15 minute checks on Patient #8 and attending to her ADL needs, but he was responsible for observing the male hallway. He stated the incident of sexual misconduct must have occurred during the time he was passing out ADL supplies in preparation for showers. He stated the incident occurred as he was moving the "ADL cart" down the hallway, from male room to male room, while delivering ADL supplies. He stated there was a period of time when his back was turned to the rooms containing Patient #6 and Patient #8. He stated staff was allowed to review the 9/29/16 footage from the video camera that was on the male hallway. Based on review of the video footage, it was determined the male adolescent Patient #6 crossed the hallway and entered female Patient #8's room during the time the male PT was distributing ADL supplies and was unable to visualize the entire hallway. The male PT confirmed it was not possible for him to keep the entire hallway under observation "during ADL time." He also confirmed it was not possible to maintain constant observation of the entire hallway during the time he was responsible for performing 15 minute checks on the male patients.

A female PT, who performed 15 minute checks on female Patient #8 on the evening of 9/29/16, was interviewed on 10/12/16, beginning at 2:00 PM. She stated she was performing a 15 minute check on Patient #8 when she entered her room and heard the shower running. She stated she knocked on the bathroom door, called Patient #8's name and announced she was entering the bathroom for 15 minute checks. She stated Patient #8 wrapped part of the shower curtain around herself and displayed the upper part of her body outside the shower. The PT stated she was able to visualize only the upper part of Patient #8's body and a small area of the shower. She stated she did not ask Patient #8 to step aside and allow her to visualize the entire shower space. She stated after watching the video, she knew Patient #6 was in Patient #8's room during the time of the 15 minute shower check. She stated the only place he could have been was in the part of the shower she did not visualize.

A Program Manager was interviewed on 10/17/16, beginning at 10:30 PM. She recounted the incident on the evening of 9/29/16 involving Patient #8 and Patient #6. When asked why Patient #8 was assigned a room on the male hallway, she explained Patient #8 was being treated for head lice. She stated Patient #8 was placed in a room on the male hallway because there was not a private room available on the female hallway. She confirmed there were other options available to staff which may have prevented the incident. She confirmed a female patient(s) on a higher privilege level could have been moved to the male hallway, opening a private room on the female hallway for Patient #8. She confirmed a higher level of observation (direct line of sight or a one to one) was an option but did not occur.

2. The hospital's policy "Suicide Precautions," last revised 7/2016, stated "Patients at risk for suicide and/or self-destructive behavior require intensive support, close observation and indicated protective measure for their emotional and physical welfare at all times. 15 Minute checks are utilized as a minimum assessment protocol and patients may need to be monitored more frequently as patient acuity demands." Additionally, it stated "Nursing will implement a determination of risk in the initial treatment plan utilizing a level system." The policy described three levels of suicide precautions:

-Level I - Patients assessed to be a moderate potential risk of suicide who required a minimum of every 15 minute rounds.
-Level II - Patients who required dedicated observation by a staff member without being at arm's length.
-Level III - Patients who required a 1 to 1 intense observation within arm's length of a staff member at all times.

The hospital's treatment plan "SUICIDE IDEATION (RISK LEVELS)" had a section to designate the patient's risk level. It stated "Nursing/Social Services and MD will evaluate and utilize level system (I, II, III) related to suicide risk assessment and determination of risk on admission."
a. Patient #4 was a 16 year old female to male transgender admitted voluntarily on 6/14/16, for suicidal thoughts and concerns about safety. His diagnoses included major depressive disorder, severe, with psychosis and gender identity disorder. He was receiving regularly scheduled ECT treatments. Patient #4 presented directly to the hospital as recommended by his personal physician due to increasing suicidal ideation. He was discharged to his home on 6/23/16.

Patient # 4's record included admission orders dated 6/14/16. The orders included precautions of suicide and self-harm. Also included on admission was an order for 15 minute observation checks.

Patient #4's record included an admission assessment dated 6/14/16, and signed by an RN. It stated he was actively suicidal. It stated he gave up a razor blade that was in his mouth and a 6 inch blade was taken from him.

Patient #4's record included a "High Risk Notification Alert" dated 6/14/16, and signed by the RN. It listed high risk factors, as follows: suicidal and room assignment review.

Patient #4's record included a Psychiatric Evaluation completed on 6/15/16, and signed by his psychiatrist. It stated Patient #4 presented to the hospital "with worsening suicidal thoughts and concerns about safety." It stated he had a history of self-harming in May of 2016. It also stated he had suicidal ideation with a plan.

Patient #4's record included an H&P dated 6/15/16 and signed by an NP. It stated Patient #4 presented with increased anxiety and increased depression, and had a plan to carry out suicide on 6/30/16.

Patient #4's nursing flow sheets dated 6/16/16, 6/17/16, and 6/18/16 stated "Patient verbalizes suicide plan, intent, or ideation."

Patient #4's record included a treatment plan "SUICIDE IDEATION (RISK LEVELS)." The section titled "PRECIPITATING RISK FACTORS" was blank. The section designating his risk level was blank. It was unclear how it was determined every 15 minute observation checks were adequate to keep him safe.

During an interview on 10/17/16 at 12:30 PM, the Charge RN who was on duty the night Patient #4 was admitted stated "I was so worried that he would hurt himself, he has such a history."

During an interview on 10/14/16 beginning at 9:00, the DON reviewed Patient #4's treatment plan. She confirmed Patient #4's suicide risk level was not completed. She stated the risk level should be completed by the RN. She stated Patient #4 was placed on 15 minute checks at the time of his admission.

b. Patient #3 was a 57 year old female who was admitted involuntarily to the hospital on 3/11/16, and placed on a legal hold. She was transferred to another psychiatric hospital on 4/12/16. Her diagnoses included bipolar disorder, suicidal ideations, and history of physical and sexual abuse. She was admitted to the hospital from an ER where she was treated following an attempted suicide.

Patient #3's record included "ADMISSION ORDERS," received from her psychiatrist and signed by the RN on 3/11/16. The orders included precautions of suicide, elopement, assault, and fall risk. Also included on admission was an order for 15 minute observation checks.

Patient #3's record included a treatment plan "SUICIDE IDEATION (RISK LEVELS)," initiated on 3/11/16, and signed by an RN. The treatment plan listed "PRECIPITATING RISK FACTORS" of depression, hopelessness, panic/anxiety, previous/recent suicide attempts, and ongoing suicidal ideation.

The treatment plan stated Level II care, line of sight monitoring, was ordered for "patients who are felt to be at high enough risk for suicide attempt that they need to be watched and monitored continuously. This includes increased suicide risk because of...psychiatric symptoms such as hopelessness, severe anxiety, severe agitation..." Patient #3's risk factors included hopelessness and panic/anxiety. However, she was not placed on Level II care, line of sight monitoring. Her risk level was documented on the treatment plan as Level I, and she was placed on 15 minute observation.

The record did not contain an order to increase Patient #3's level of observation based on her individual needs as follows:

- Patient #3's record included an "APPLICATION FOR COMMITMENT OF THE MENTALLY ILL," dated 3/10/16 and signed by a physician. It stated "...patient is mentally ill and is likely to injure him/her self...the patient suffers from Bipolar Disorder and save up sedating medications with intent to kill herself - she took them and was not successful. She states she 'wants to die.' The patient also requires guardianship - she is not able to safely care for herself and plan for her future."

- Patient #3's record included a "CERTIFICATE OF DESIGNATED EXAMINER," dated 3/11/16, and signed by the state Designated Examiner. The document stated Patient #3 was likely to injure herself "as shown by: suicide attempt, plans of suicide, poor judgment, unstable mood, and lack of insight..." Additionally, the document stated "The patient expresses a desire to commit suicide...The patient's judgment is poor and her insight is limited."

- Patient #3's record included a "High Risk Notification Alert'" dated 3/11/16, and signed by an RN. It listed high risk factors, as follows: suicidal, fall risk, elopement risk and assaultive behavior.

- Patient #3's record included an admission assessment, dated 3/11/16, and signed by the RN. It included the question "How often are you thinking about suicide?" The answer stated "I think about it all the time." The assessment stated Patient #3 reported she felt hopeless, helpless, overwhelmed, worthless and felt her family would be better off without her.

- Patient #3's record included a "CERTIFICATE OF DESIGNATED EXAMINER," dated 3/15/16, and signed by the state Designated Examiner. The document stated Patient #3 was likely to injure herself "as shown by: Still wanting to die - overdosed." Additionally, the document stated "Continues to be suicidal."

- Patient #3's nursing flow sheets dated 3/12/16, 3/13/16, 3/15/16, 3/16/16, 3/17/16, and 3/18/16 stated "Patient verbalizes suicide plan, intent, or ideation."

During an interview on 10/14/16 at 8:05 AM, the DON reviewed Patient #3's record and confirmed she was placed on a 15 minute level of observation at the time of her admission. She stated patients on suicide precautions are sometimes put in observation rooms, or a staff member may be assigned to provide 1 to 1, or line of sight observation. The DON stated there was no documentation in Patient #3's record stating how it was determined 15 minute checks were adequate to ensure her safety, or stating her suicide risk was reviewed daily. She stated Patient #3's level of observation was not elevated based on her risk factors.

Patient #3's and Patient #4's records did not contain clear documentation stating suicide risk was fully evaluated in order to determine appropriate observation levels. As a result, Patient #3's and Patient #4's safety was placed at risk.

3. The hospital's policy "Ordering Routine and Special Diets," last revised 12/2015, stated "Nursing Staff will prepare and send to Food Services a Diet Order Form for specialized diets/allergies/needs..." Additionally, it stated nursing staff should use the Nutrition Consult Form to request the Registered Dietitian to consult with the patient.

The hospital did not adhere to the policy as follows:

Patient #3 was a 57 year old female who was admitted involuntarily to the hospital on 3/11/16, and placed on a legal hold. She was transferred to another psychiatric hospital on 4/12/16. Her diagnoses included bipolar disorder, suicidal ideations, and history of physical and sexual abuse. She was admitted to the hospital from an ER where she was treated following an attempted suicide.

Patient #3's record included admission orders received from her psychiatrist and signed by the RN on 3/11/16. The orders included a regular diet with food allergies to milk, nuts, beans, onions and shellfish. Her record included an admission assessment dated 3/11/16, and signed by the RN. The assessment stated she was allergic to milk, onions, nuts, shellfish and all peppers. Patient #3's record included an H&P completed on 3/12/16, and signed by an NP. The H&P stated she was allergic to milk, beans, onions, shellfish and peanuts.

Patient #3's record included a treatment plan titled "ALLERGIES TO FOODS," dated 3/11/16, and signed by the RN. The plan stated she was allergic to peppers, milk, beans, onions and shellfish. The treatment plan did not include her allergy to nuts or peanuts.

Patient #3's record included a "NUTRITION SERVICES REFERRAL REQUEST" dated 3/11/16, and signed by the RN. The request stated she was allergic to shellfish, beans, onions, peppers and milk. It did not include her allergy to nuts or peanuts. Additionally, it did not include a request for a dietician consultation related to her numerous food allergies.

Patient #3's record did not include documentation of a dietician consultation to verify her food allergies, and to ensure she was not served foods which may cause an allergic reaction.

During an interview on 10/14/16 at 8:05 AM, the DON reviewed Patient #3's record. She stated the dietary department was notified of patients' allergies or other dietary restrictions through the "NUTRITION SERVICES REFERRAL REQUEST" sent by the RN. The DON confirmed Patient #3's nutrition services request did not include all her food allergies, and stated the dietary department was not notified of her nut or peanut allergy. Additionally, she stated the RN who completed the referral request did not request a dietician consultation. She confirmed the dietician did not meet with Patient #3 during her hospitalization. The DON stated when the dietary department is notified of a patient with a peanut allergy the hospital stops serving peanut products to all patients during the allergic patient's hospital admission. She stated this did not occur during Patient #3's admission, as the dietary department was unaware of her allergy.

The hospital failed to ensure Patient #3 was not served foods which may cause an allergic reaction.

Based on staff interview and review of patient records, hospital policies and occurrence reports, the hospital failed to identify potential risk and prevent an incident of sexual abuse of 1 of 5 psychiatric adolescent patients (#8) whose closed records were reviewed. This interfered with the hospital's plan and policy to fully protect all vulnerable patients from any type of abuse, neglect and/or harassment. Findings include:

The hospital's policy, "Sexualized Behavior Precautions and Occurrence," last revised 12/2015, included the policy statement "To identify risk, prevent and safely resolve any incidences of sexualized behavior during hospitalization." The policy stated "A&R and admitting nurse on the unit will assess risk during the admission assessment and document results...Precipitating factors may include, but are not limited to...History of sexual abuse..." Also included in the policy was "...Once a patient has been identified as a potential risk for sexualized behavior, the physician or Registered Nurse will initiate sexual behavior precautions-SBP...Increase observations per the situation and review room assignments with every shift and with reassessments...Sexualized Behavior Precautions include, but may not be limited to...Staff is to monitor patient whereabouts and behavior every 15-minutes...Room assignment will be made based on the patient's clinical picture..."

The hospital did not adhere to this policy. Consequently, the hospital did not identify potential risk or prevent an incident of sexual abuse as follows:

Patient #8 was a 13 year old female who was admitted voluntarily to the hospital on 9/26/16 and discharged home on 10/07/16. Her diagnoses included major depressive disorder, posttraumatic stress disorder, obsessive-compulsive disorder, conduct disorder, cannabis use disorder, alcohol use disorder and child victim of sexual abuse. She presented to the hospital as a transfer from a local ER, where she was assessed for suicidal ideations, self-harm behavior and significant substance use.

A "BH-HEALTHCARE PEER REVIEW REPORT," dated 9/30/16 at 8:00 PM and completed by an RN was reviewed during the survey. The report was regarding Patient #8 and included a section "SEXUAL ALLEGATION." Contained within this section were descriptive terms with check boxes beside each item. The boxes beside "Misconduct: Pt/Pt and Intercourse: Pt/Pt" were marked. The form also included documentation indicating the incident took place in a "Pt's bedroom," and her physician and parents were notified. The form also indicated a report was filed with local authorities and the local office for sexual assault victims was notified.

Patient #8's admission orders, dated 9/26/16 at 2:20 PM and signed by a physician, included precaution orders for suicide and self harm. Also included on admission was an order for 15 minute checks. On 9/27/16, precaution orders for behavior, elopement, assault, sexual acting out, sexual victimization and sexual aggression were added. There was no corresponding order on 9/27/16 to elevate the level of observation for Patient #8. She remained on 15 minute checks.

A "Flash Report by Unit by Bed" for the adolescent unit, dated 9/29/16, was reviewed. The report indicated Patient #8 was the only female on a hallway with 7 adolescent male patients.

An "ABUSE REPORT DOCUMENTATION" form, dated 9/30/16 at 7:45 PM and signed by an RN, stated Patient #8 reported to staff that she had intercourse with an adolescent male peer (Patient #6) on 9/29/16. The form stated Patient #8 said she had "just gotten out of the shower and Patient #6 came into her bathroom." The form stated Patient #8's mother was notified and a report was submitted to CPS.

A "PHYSICIAN ORDERS" form, dated 9/30/16 at 7:15 PM and signed by a physician, ordered tests for HIV, chlamydia and gonorrhea. Also included were orders for the "morning after pill" and an order to transport patient for a "rape kit." Orders stated Patient #8's mother was notified and consented verbally to all orders.

An "EMERGENCY ROOM TRANSFER REPORT," dated 9/30/16 at 8:00 PM and signed by a physician and an RN, stated Patient #8 was transferred to a local ER for a "Rape Kit." The form stated Patient #8 was on suicide precautions, self-injury precautions, assault/aggression precautions, elopement precautions and behavior precautions at the time of the transfer.

A "NURSING FLOW SHEET," dated 9/30/16 at 12:00 PM and unsigned, stated Patient
#8 returned from the local ER accompanied by law enforcement, who reported she made the statement "she wanted to kill herself." The note stated Patient #8 was placed in the "obs room with no sheets...Will continue to monitor Q15 min and more for her safety..." Though Patient #8 was placed in an observation room, her level of observation was not elevated to "Dedicated Observations or One-one (1:1) Observations." She remained on 15 minute checks.

A male PT, who was assigned to the male patient hallway on the evening of 9/29/16, was interviewed on 10/13/16, beginning at 1:40 PM. He stated there were 3 PTs assigned to the adolescent unit on the evening of 9/29/16. He stated he was assigned to the male hallway, a female PT was assigned to the female hallway, and a second female PT was assigned to float between the hallways. He said Patient #8 was the only female patient assigned to the male hallway at that time. He stated the female PTs were responsible for performing 15 minute checks on Patient #8 and attending to her ADL needs, but he was responsible for observing the male hallway. He stated the incident of sexual misconduct must have occurred during the time he was passing out ADL supplies in preparation for showers. He stated the incident occurred as he was moving the "ADL cart" down the hallway, from male room to male room, while delivering ADL supplies. He stated there was a period of time when his back was turned to the rooms containing Patient #6 and Patient #8. He stated staff was allowed to review the 9/29/16 footage from the video camera that was on the male hallway. Based on review of the video footage, it was determined male adolescent Patient #6 crossed the hallway and entered the female adolescent Patient #8's room during the time he was distributing ADL supplies and was unable to visualize the entire hallway. The male PT confirmed it was not possible for him to keep the entire hallway under observation "during ADL time." He also confirmed it was not possible to maintain constant observation of the entire hallway during the time he was responsible for performing 15 minute checks on the male patients.

A female PT, who performed 15 minute checks on female Patient #8 on the evening of 9/29/16, was interviewed on 10/12/16, beginning at 2:00 PM. She stated she was performing a 15 minute check on female Patient #8 when she entered her room and heard the shower running. She stated she knocked on the bathroom door, called Patient #8's name and announced she was entering the bathroom for 15 minute checks. She stated Patient #8 wrapped part of the shower curtain around herself and displayed the upper part of her body outside the shower. The PT stated she was able to visualize only the upper part of Patient #8's body and a small area of the shower. She stated she did not ask Patient #8 to step aside and allow her to visualize the entire shower space. She stated after watching the video, she knew Patient #6 was in Patient #8's room during the time of the 15 minute shower check. She stated the only place he could have been was in the part of the shower she did not visualize.

A Program Manager was interviewed on 10/17/16, beginning at 10:30 PM. She recounted the incident on the evening of 9/29/16 between Patient #8 and Patient #6. When asked why Patient #8 was assigned a room on the male hallway, she explained Patient #8 was being treated for head lice. She stated Patient #8 was placed in a room on the male hallway because there was not a private room available on the female hallway. She confirmed there were other options available to staff which may have prevented the incident. She confirmed a female patient(s) on a higher privilege level could have been moved to the male hallway, opening a private room on the female hallway for Patient #8. She confirmed a higher level of observation (direct line of sight or a one to one) was an option but did not occur.

By failing to follow their policy to identify potential risk and prevent an incident of sexual misconduct, the hospital did not protect the rights of a vulnerable, 13 year old female, psychiatric patient, (#8).

Based on patient record review, policy review and staff interview, it was determined the hospital failed to provide evidence of the use of safe and appropriate restraint for 3 of 3 patients (#2, #4, and #5) who were restrained for violent or self-destructive behavior and whose records were reviewed. This resulted in an inability of the hospital to ensure restraints were implemented in a safe and effective manner. The findings include:

The Hospital's policy "Seclusion/Restraint/Physical Hold," revised 12/2015, stated:

" The physical restraint (hold) is applied to identified extremities ensuring that the staff member:
- If the patient is on a bed or stretcher- only placed on his or her back or side (no prone restraints are allowed)
- Protects the head from injury
- Ensures that weight is not placed directly on joints boney prominences (-knees, ankles, elbows, etc.)
- Ensures that joints are not hyperextended and that circulation is not impaired
- Ensures that weight is not placed directly on the chest cavity to inhibit adequate breathing"

The hospital did not adhere to this policy as follows:

1. Patient #4 was a 16 year old female to male transgender admitted voluntarily on 6/14/16, for suicidal thoughts and concerns about safety. His diagnoses included major depressive disorder, severe, with psychosis and gender identity disorder. He was receiving regularly scheduled ECT treatments. He presented directly to the hospital as recommended by his personal physician due to increasing suicidal ideation. He was discharged home on 6/23/16.

Patient #4's record included a "SECLUSION/PHYSICAL RESTRAINT/EMERGENCY USE OF MEDICATION NURSING DOCUMENTATION," dated 6/14/16, and signed by the RN in charge. The document stated a physical hold was initiated at 6:35 PM and lasted until 6:37 PM. It stated the purpose of the hold was to remove a knife from Patient #4's possession. There was no evidence of Patient #4's location or body position during the hold, or the number of staff who held him.

Patient #4's record included a "SECLUSION/PHYSICAL RESTRAINT/EMERGENCY USE OF MEDICATION NURSING DOCUMENTATION," dated 6/14/16, and signed by the RN in charge. The document stated a physical hold was initiated at 7:00 PM and lasted until 7:02 PM. It stated the purpose of the hold was to administer emergency medication to Patient #4. There was no evidence of Patient #4's location or body position during the hold, or the number of staff who held him.

2. Patient #2 was a 62 year old male who was admitted involuntarily on 4/18/16, in a paranoid, agitated and psychotic state. His diagnoses included bipolar disorder, depressed with manic psychotic symptomatology, a broken right hand, and ruling out history of PTSD. He was brought to the hospital by police, because he had been threatening his neighbors with harm. He was discharged to his home on 5/20/16.

Patient #2's record included a "SECLUSION/PHYSICAL RESTRAINT/EMERGENCY USE OF MEDICATION NURSING DOCUMENTATION," dated 4/21/16, and signed by the RN in charge. The document stated a physical hold was initiated at 4:04 PM and lasted until 4:06 PM. It stated the purpose of the hold was to administer emergency medication to Patient #2. There was no evidence of Patient #2's location or body position during the hold, or the number of staff who held him.

Patient #2's record included a "SECLUSION/PHYSICAL RESTRAINT/EMERGENCY USE OF MEDICATION NURSING DOCUMENTATION," dated 4/23/16, and signed by the RN in charge. The document stated a physical hold was initiated at 7:39 AM and lasted until 7:41 AM. It stated the purpose of the hold was to administer emergency medication to Patient #2. There was no evidence of Patient #2's location or body position during the hold, or the number of staff who held him.

Patient #2's record included a "SECLUSION/PHYSICAL RESTRAINT/EMERGENCY USE OF MEDICATION NURSING DOCUMENTATION," dated 4/25/16, and signed by the RN in charge. The document stated a physical hold was initiated at 11:37 AM. The end time of the hold was not documented. It stated the purpose of the hold was to administer emergency medication to Patient #2. There was no evidence of Patient #2's location or body position during the hold, or the number of staff who held him.

3. Patient #5 was a 16 year old male admitted voluntarily by his parents for manic behaviors, aggressive behaviors, violence and bestiality. His diagnoses included schizoaffective disorder, bipolar type, a history of physical and potential sexual abuse, and attention deficit hyperactivity disorder. Additionally, he had a medical history of seizure disorder. His parents brought him to the hospital because he had been running away and displaying aggressive behavior towards family. He was transferred to another psychiatric hospital on 10/02/16.

Patient #5's record included a "SECLUSION/PHYSICAL RESTRAINT/EMERGENCY USE OF MEDICATION NURSING DOCUMENTATION," dated 9/22/16, and signed by the RN in charge. The document stated a physical hold was initiated at 11:20 AM and lasted until 11:35 AM. It stated the purpose of the hold was to administer emergency medication to Patient #5. There was no evidence of Patient #5's location or body position during the hold, or the number of staff who held him.

Patient #5's record included a "SECLUSION/PHYSICAL RESTRAINT/EMERGENCY USE OF MEDICATION NURSING DOCUMENTATION," dated 9/22/16, and signed by the RN in charge. The document stated a physical hold was initiated at 11:47 AM and lasted until 11:52 AM. The purpose of the hold was not documented. There was no evidence of Patient #5's location or body position during the hold, or the number of staff who held him.

The DON was interviewed on 10/14/16 starting at 9:15 AM. She reviewed the Hospital documentation for SECLUSION/PHYSICAL RESTRAINT AND EMERGENCY USE OF MEDICATION on Patients #2, #4 and #5. She stated they did not document the patients' location or body position, or the number of staff involved in the holds.

The Hospital failed to provide evidence patients were restrained in a safe and appropriate manner.

Based on patient record review, policy review and staff interview, it was determined the hospital failed to ensure restraints were applied only with a physician's order for 1 of 3 patients (Patient #5) who were restrained for violent or self-destructive behavior and whose records were reviewed. This resulted in a patient being restrained without a physician order.

Patient #5 was a 16 year old male admitted voluntarily by his parents on 9/06/16, for manic behaviors, aggressive behaviors, violence and bestiality. His diagnoses included schizoaffective disorder, bipolar type, a history of physical and potential sexual abuse, and attention deficit hyperactivity disorder. Additionally, he had a medical history of seizure disorder. His parents brought him to the hospital because of a history of running away and aggression towards family. He was transferred to another psychiatric hospital on 10/02/16.

Patient #5's record included a "SECLUSION/PHYSICAL RESTRAINT/EMERGENCY USE OF MEDICATION NURSING DOCUMENTATION" form stating he was placed in physical restraint on 9/22/16 at 11:20 AM until 11:35 AM due to disruptive behavior and yelling at staff. It stated he received Benadryl and Ativan IM at 11:21 AM, and was placed in seclusion at 11:36 AM until 11:46 AM. At 11:47 AM, Patient #5 was physically restrained again until 11:52 AM and was again placed in seclusion from 11:52 AM to 12:06 AM.

Patient #5's record included a physician order for the initial physical restraint at 11:20 AM. However, his record did not include an order for the second physical restraint at 11:47 AM.

The DON was interviewed starting at 9:45 on 10/14/16. She reviewed Patient #5's restraint documentation. She confirmed there was no order for the second physical restraint.

Patient #5 was placed in restraint without a physician's order.

Based on patient record review, policy review and staff interview, it was determined the hospital failed to ensure orders for restraints were not written on an as needed basis for 1 of 3 patients (Patient #2) who were restrained for violent or self-destructive behavior, and whose records were reviewed. This put patients at risk to be placed in a physical restraint without the physicians' knowledge or approval, and placed patients at risk of unnecessary physical restraint. Findings include:

The Hospital's policy "Seclusion/Restraint/Physical Hold," last revised 12/2015, stated:

"The physician/RN assesses the need for restrictive intervention and a written or telephonic order is obtained from the physician...Ensures that seclusion/restraint orders are not written as standing or PRN orders."

Patient #4 was a 16 year old female to male transgender admitted voluntarily on 6/14/16, for suicidal thoughts and concerns about safety. His diagnoses included major depressive disorder severe with psychosis and gender identity disorder. He was receiving regularly scheduled ECT treatments. He presented directly to the hospital as recommended by his personal physician due to increasing suicidal ideation. He was discharged to his home on 6/23/16.

Patient #4's record included a physician order, taken as a telephone order by the RN in charge on 6/16/16, and dated 6/14/16 at 6:30 PM. It stated "Physical Restraint [Required, written with a line through it] if necessary pt withholding contraband danger to self & Staff."

The DON was interviewed on 10/14/16 beginning at 9:00 AM. She reviewed Patient #4's restraint orders and confirmed the written order was unclear and could be construed as a PRN restraint order.

The hospital failed to ensure there were no PRN orders written for restraints.

Based on medical record review, policy review, and staff interview, it was determined the hospital failed to ensure there was clear documentation of the condition or symptom(s) that warranted the use of restraints for 2 of 3 patients (#4 and #5) who required physical restraint and whose medical records were reviewed. This resulted in the potential for unnecessary use of restraints. Findings include:

The Hospital's policy "Seclusion/Restraint/Physical Hold," revised 12/2015, stated:

"Documentation of condition or symptoms that warranted the use of seclusion/restraint describes patient's specific behaviors that were observed. The documentation includes a detailed description of the patients' physical and mental status and an assessment of any environmental factors (e.g. physical milieu, activities) that may have contributed to the situation at the time of the intervention."

1. Patient #4 was a 16 year old female to male transgender admitted voluntarily on 6/14/16, for suicidal thoughts and concerns about safety. His diagnoses included major depressive disorder severe with psychosis and gender identity disorder. He was receiving regularly scheduled ECT treatments. He came to the hospital based on a recommendation from his personal physician due to increased suicidal ideation. He was discharged to his home on 6/23/16.

Patient #4's record included a "SECLUSION/PHYSICAL RESTRAINT/EMERGENCY USE OF MEDICATION NURSING DOCUMENTATION," dated 6/14/16, and signed by the RN in charge. The document stated a physical hold was initiated at 7:00 PM and lasted until 7:02 PM. It stated the purpose of the hold was to administer emergency medication to Patient #4, however, it did not include a clear description of the specific behaviors that warranted the use of restraint.

The Charge Nurse that completed the report was interviewed on 10/17/16 at 12:35 PM. She reviewed the restraint documentation. She confirmed there was no clear documentation of Patient #4's behavior that warranted the use of restraint.

2. Patient #5 was a 16 year old male admitted voluntarily by his parents on 9/06/16, for manic behaviors, aggressive behaviors, violence and bestiality. His diagnoses included schizoaffective disorder bipolar type, a history of physical and potential sexual abuse, and attention deficit hyperactivity disorder. Additionally, he had a medical history of seizure disorder. Patient #5's parents brought him to the hospital because he had been running away and was aggressive towards family. He was transferred to another psychiatric hospital on 10/02/16.

Patient #5's record included a "SECLUSION/PHYSICAL RESTRAINT/EMERGENCY USE OF MEDICATION NURSING DOCUMENTATION," dated 9/22/16, and signed by the RN in charge. The document stated a physical hold was initiated at 11:47 AM and lasted until 11:52 AM. However, it did not include a clear description of the specific behaviors that warranted the use of restraint.

The DON was interviewed on 10/14/16 beginning at 9:00 AM. She confirmed documentation of Patient #5's behavior prior to his second physical restraint was unclear.

The hospital failed to ensure documention reflected the need for Patients #4 and #5 to be restrained.

Based on medical record review, policy review, and staff interview, it was determined the hospital failed to ensure thorough and accurate nursing care plans were developed, and/or followed, for 4 of 10 patients (Patients #2, #3, #4, and #5) whose care plans were reviewed. Lack of a complete nursing care plan had the potential to result in patient care needs that were not addressed, and interfered with coordination of patient care among disciplines. Findings include:

The hospital's policy "Treatment Planning Process," last revised 12/2015, stated "Initial Treatment Plans are developed by the members of the treatment team to begin treatment and will be completed within 24 hours of admission. Nursing will effectively begin the treatment planning process through the use of problem-directed problem list and the initial treatment plan."

1. Patient #4 was a 16 year old female to male transgender admitted voluntarily on 6/14/16, for suicidal thoughts and concerns about safety. Patient #4's diagnoses included major depressive disorder, severe, with psychosis and gender identity disorder. He was receiving regularly scheduled ECT treatments. Patient #4 came to the hospital based on a recommendation from his personal physician due to increased suicidal ideation. He was discharged to his home on 6/23/16.
presented directly to the hospital as recommended by his personal physician due to increasing suicidal ideation. He was discharged to his home on 6/23/16.

Patient # 4's record included admission orders dated 6/14/16. The orders included precautions of suicide and self-harm and an order for 15 minute observation checks.

Patient #4's record included a treatment plan "SUICIDE IDEATION (RISK LEVELS)." The section titled "PRECIPITATING RISK FACTORS" was blank. The section designating his risk level was blank.

2. Patient #2 was a 62 year old male who was admitted involuntarily on hold on 4/18/16, in a paranoid, agitated and psychotic state. His diagnoses included bipolar disorder, depressed with manic psychotic symptomatology, a broken right hand, and ruling out history of PTSD. He was brought to the hospital by police because he had been threatening his neighbors with harm. He was discharged to his home on 5/20/16.

Patient #2's admission orders included precautions for suicide, assault, and behavior and an order for 15 minute observation checks.

Patient #2's record included a "SUICIDE IDEATION (RISK LEVELS)" treatment plan. The section designating his risk level was blank.

3. Patient #5 was a 16 year old male admitted voluntarily by his parents on 9/06/16, for manic behaviors, aggressive behaviors, violence and bestiality. His diagnoses included schizoaffective disorder, bipolar type, a history of physical and potential sexual abuse, and attention deficit hyperactivity disorder. Additionally, he had a medical history of seizure disorder. Patient #5 was brought to the hospital by his parents because he had been running away and was aggressive towards family. He was transferred to another psychiatric hospital on 10/02/16.

Patient # 5's admission orders included suicide, assault, and behavior precautions and an order for 15 minute observation checks.

Patient #5's record included a "SUICIDE IDEATION (RISK LEVELS)" treatment plan. The section designating his risk level was blank.

The Director of Nursing was interviewed starting at 9:00 am, on 10/14/16. She reviewed the care plans of Patient #2, Patient #4, and Patient #5, and stated there were no suicide risk levels documented on their Treatment Plans.

The hospital failed to ensure patients' treatment plans were complete.

4. Patient #3 was a 57 year old female who was admitted involuntarily to the hospital on 3/11/16, and placed on a legal hold. She was transferred to another psychiatric hospital on 4/12/16. Her diagnoses included bipolar disorder, suicidal ideations, and history of physical and sexual abuse. She was admitted to the hospital from an ER where she was treated following an attempted suicide.

Patient #3's record included admission orders received from her psychiatrist and signed by the RN on 3/11/16. The orders included a regular diet with food allergies to milk, nuts, beans, onions and shellfish. Her record included an admission assessment dated 3/11/16, and signed by the RN. The assessment stated she was allergic to milk, onions, nuts, shellfish and all peppers. Patient #3's record included an H&P completed on 3/12/16, and signed by an NP. The H&P stated she was allergic to milk, beans, onions, shellfish and peanuts.

Patient #3's record included a treatment plan titled "ALLERGIES TO FOODS," dated 3/11/16, and signed by the RN. The plan stated she was allergic to peppers, milk, beans, onions and shellfish. The treatment plan did not include her allergy to nuts or peanuts.

Patient #3's record included a "NUTRITION SERVICES REFERRAL REQUEST" dated 3/11/16, and signed by the RN. The request stated she was allergic to shellfish, beans, onions, peppers, and milk. It did not include her allergy to nuts or peanuts.

During an interview on 10/14/16 at 8:05 AM, the DON reviewed Patient #3's record. She confirmed Patient #3's treatment plan did not include her allergy to nuts or peanuts. She stated the dietary department was notified of patients' allergies or other dietary restrictions through the "NUTRITION SERVICES REFERRAL REQUEST" sent by the RN. The DON confirmed Patient #3's treatment plan and nutrition services request did not include all of her food allergies and stated the dietary department was not notified of her nut or peanut allergy. The DON stated when the dietary department is notified of a patient with a peanut allergy the hospital stops serving peanut products to all patients during the allergic patient's hospital admission. She stated this did not occur during Patient #3's admission, as the dietary department was unaware of her allergy.

Patient #3's treatment plan, completed by the RN, did not include all of her food allergies. Therefore, the dietary department was not notified of her allergy to nuts or peanuts.

Based on patient record review, policy review and staff interview, it was determined the hospital failed to ensure menus met the needs of patients for 1 of 2 patients (Patient #3) who had food allergies and whose records were reviewed. This had the potential to place patients at risk for poor nutritional outcomes.

The hospital's policy "Ordering Routine and Special Diets," last revised 12/2015, stated "Nursing Staff will prepare and send to Food Services a Diet Order Form for specialized diets/allergies/needs..." Additionally, it stated nursing staff should use the Nutrition Consult Form to request the Registered Dietitian to consult with the patient.

Patient #3 was a 57 year old female who was admitted involuntarily to the hospital on 3/11/16, and placed on a legal hold. She was transferred to another psychiatric hospital on 4/12/16. Her diagnoses included bipolar disorder, suicidal ideations, and history of physical and sexual abuse. She was admitted to the hospital from an ER where she was treated following an attempted suicide.

Patient #3's record included admission orders received from her psychiatrist and signed by the RN on 3/11/16. The orders included a regular diet with food allergies to milk, nuts, beans, onions, and shellfish. Her record included an admission assessment dated 3/11/16, and signed by the RN. The assessment stated she was allergic to milk, onions, nuts, shellfish and all peppers. Patient #3's record included an H&P completed on 3/12/16, and signed by an NP. The H&P stated she was allergic to milk, beans, onions, shellfish, and peanuts.

Patient #3's record included a treatment plan titled "ALLERGIES TO FOODS," dated 3/11/16, and signed by the RN. The plan stated she was allergic to peppers, milk, beans, onions and shellfish. The treatment plan did not include her allergy to nuts or peanuts.

Patient #3's record included a "NUTRITION SERVICES REFERRAL REQUEST" dated 3/11/16, and signed by the RN. The request stated she was allergic to shellfish, beans, onions, peppers and milk. It did not include her allergy to nuts or peanuts. Additionally, it did not include a request for a dietician consultation.

Patient #3's record did not include documentation of a dietician consultation to verify her food allergies, and to ensure she was not served foods which may cause an allergic reaction.

During an interview on 10/14/16 at 8:05 AM, the DON reviewed Patient #3's record. She stated the dietary department was notified of patients' allergies or other dietary restrictions through the "NUTRITION SERVICES REFERRAL REQUEST" sent by the RN. The DON confirmed Patient #3's nutrition services request did not include all her food allergies, and stated the dietary department was not notified of her nut or peanut allergy. Additionally, she stated the RN who completed the referral request did not request a dietician consultation. She confirmed the dietician did not meet with Patient #3 during her hospitalization. The DON stated when the dietary department is notified of a patient with a peanut allergy the hospital stops serving peanut products to all patients during the allergic patient's hospital admission. She stated this did not occur during Patient #3's admission, as the dietary department was unaware of her allergy.

The hospital failed to ensure Patient #3's nutritional needs were met.

482.28(b)

Based on staff interview and review of medical records, occurrence reports, hospital policies, and food allergy and dietary information, it was determined the hospital failed to ensure care was provided in a safe manner. This directly impacted the safety of 4 of 10 patients (#3, #4, #6 and #8,) whose records were reviewed, and had the potential to affect the safety of all patients. The failure to appropriately evaluate and monitor patients based on their individual needs had the potential to interfere with patient safety. Findings include:

1. The hospital's policy, "Level of Observation Orders," last revised on 7/08/16, stated "All patients will be closely observed in compliance with physician orders and prescribed protocols...Patients will be actively assessed and monitored for changes in their behavior and/or when medical conditions arise that may warrant a change in level of observation: 15 Minute Observations, Dedicated Observations, One-one (1:1) Observations...The RN, in consultation with the RN Manager/RN Supervisor may increase the level of observation...Employees will monitor hallways and be able to view the entire unit to eliminate problems with inappropriate patient activity..."

The hospital's practice guidelines, "Practice Guidelines for Levels of Observation," last revised on 7/08/16, was attached to the policy regarding levels of observation. It stated patients should have adequate impulse control and be able to express insight into their behavior if 15 minute checks are ordered.

The hospital did not adhere to the policy and guidelines as follows:

a. Patient #8 was a 13 year old female who was admitted voluntarily to the hospital on 9/26/16 and discharged home on 10/07/16. Her diagnoses included major depressive disorder, posttraumatic stress disorder, obsessive-compulsive disorder, conduct disorder, cannabis use disorder, alcohol use disorder and child victim of sexual abuse. She presented to the hospital as a transfer from a local ER, where she was assessed for suicidal ideations, self-harm behavior and significant substance use.

A "BH-HEALTHCARE PEER REVIEW REPORT," dated 9/30/16 at 8:00 PM and completed by an RN, was reviewed during the survey. The report was regarding Patient #8 and included a section "SEXUAL ALLEGATION." Contained within this section were descriptive terms with check boxes beside each item. The boxes beside Misconduct: Pt/Pt, and Intercourse: Pt/Pt were marked. The form also included documentation indicating the incident took place in a "Pt's bedroom," and her physician and parents were notified. The form also indicated a report was filed with local authorities, and the local office for sexual assault victims was notified.

Patient #8's admission orders, dated 9/26/16 at 2:20 PM and signed by a physician, included precaution orders for suicide and self harm. Also included on admission was an order for 15 minute checks. On 9/27/16, precaution orders for behavior, elopement, assault, sexual acting out, sexual victimization and sexual aggression were added. There was no corresponding order on 9/27/16 to elevate the level of observation for Patient #8. She remained on 15 minute checks.

An "ABUSE REPORT DOCUMENTATION" form, dated 9/30/16 at 7:45 PM and signed by an RN, stated Patient #8 reported to staff she had intercourse with a male adolescent peer (Patient #6) on 9/29/16. The form stated Patient #8 said she had "just gotten out of the shower and Patient #6 came into her bathroom." The form stated Patient #8's mother was notified and a report was submitted to CPS.

A "PHYSICIAN ORDERS" form, dated 9/30/16 at 7:15 PM and signed by a physician, ordered tests for HIV, chlamydia and gonorrhea. Also included were orders for the "morning after pill" and an order to transport patient for a "rape kit." Orders stated Patient #8's mother was notified and consented verbally to all orders.

An "EMERGENCY ROOM TRANSFER REPORT," dated 9/30/16 at 8:00 PM and signed by a physician and an RN, stated Patient #8 was transferred to a local ER for a "Rape Kit." The form included Patient #8 was on suicide precautions, self-injury precautions, assault/aggression precautions, elopement precautions and behavior precautions at the time of the transfer.

A "NURSING FLOW SHEET," dated 9/30/16 at 12:00 PM and unsigned, stated Patient
#8 returned from the local ER accompanied by law enforcement, who reported she made the statement "she wanted to kill herself." The note stated Patient #8 was placed in the "obs [observation] room with no sheets...Will continue to monitor Q15 min and more for her safety..." Though Patient #8 was placed in an observation room, her level of observation was not elevated to "Dedicated Observations or One-one (1:1) Observations." She remained on 15 minute checks.

The hospital failed to ensure policies and practices were followed by staff and were adequate to protect the safety of patient #8.

b. Patient #6 was a 17 year old male who was admitted voluntarily to the hospital on 9/19/16 and discharged home on 9/30/16. His diagnoses included generalized anxiety disorder, autism spectrum disorder and severe marijuana abuse. He presented to the hospital with multiple legal, educational, social and family difficulties related to abuse of marijuana. This was his second psychiatric hospitalization.

A "BH-HEALTHCARE PEER REVIEW REPORT," dated 9/30/16 at 8:00 PM and completed by an RN was reviewed during the survey. The report was regarding Patient #6 and included a section "SEXUAL ALLEGATION." Contained within this section were descriptive terms with check boxes beside each. The boxes beside Misconduct: Pt/Pt, and Intercourse: Pt/Pt were marked. The form also included documentation indicating the incident took place in a "Pt's bedroom," and his physician and parents were notified.

Patient #6's admission orders, dated 9/19/16 at 6:15 PM and signed by a physician, included precaution orders for self harm and behavior. Also included on admission was an order for 15 minute checks. On 9/30/16, precaution orders for sexual acting out and sexual aggression were added. There was no corresponding order on 9/30/16 to elevate the level of observation for Patient #6. He remained on 15 minute checks.

An "OVERFLOW CHARTING NOTES" form, dated 9/29/16 at 11:20 PM and signed by a PT, stated Patient #6 was found in the room of a female peer. The form stated Patient #6 was confronted and said he was helping the female peer with her assignments. The form stated he experienced a "level demotion" and "...will continue to monitor Q15." Patient #6's level of observation was not elevated as a result of the incident.

An "ADOLESCENT DAILY TRACKING SHEET," dated 9/30/16 and signed by a PT, stated at 3:00 PM, "found notes from female peer, Pt threatened staff, punched wall, sent to ER"

A "PHYSICIAN ORDERS" form, dated 9/30/16 and untimed, included an order to transfer Patient #6 to a local ER for evaluation of his right hand.

A "PHYSICIAN ORDERS" form, dated 9/30/16 at 7:15 PM and signed by a physician, ordered tests for HIV, chlamydia and gonorrhea. Orders stated Patient #6's mother was notified and consented verbally to all orders.

A "NURSING FLOW SHEET," dated 9/30/16 at 8:00 PM and signed by an RN, stated "Staff were informed about sexual misconduct on the unit. After reviewing video it did show pt went into another pt's room for about ten minutes. Before this was reported he did hit the wall and had to be sent to the ER. Pt did fracture right hand..."

The hospital failed to ensure policies and practices were followed by staff and were adequate to protect the safety of patient #6.

A male PT, who was assigned to the male patient hallway on the evening of 9/29/16, was interviewed on 10/13/16, beginning at 1:40 PM. He stated there were 3 PTs assigned to the adolescent unit on the evening of 9/29/16. He stated he was assigned to the male hallway, a female PT was assigned to the female hallway, and a second female PT was assigned to float between the hallways. He said Patient #8 was the only female patient assigned to the male hallway at that time. He sta

Based on staff interview and review of patient records, hospital policies and occurrence reports, the hospital failed to identify potential risk and prevent an incident of sexual abuse of 1 of 5 psychiatric adolescent patients (#8) whose closed records were reviewed. This interfered with the hospital's plan and policy to fully protect all vulnerable patients from any type of abuse, neglect and/or harassment. Findings include:

The hospital's policy, "Sexualized Behavior Precautions and Occurrence," last revised 12/2015, included the policy statement "To identify risk, prevent and safely resolve any incidences of sexualized behavior during hospitalization." The policy stated "A&R and admitting nurse on the unit will assess risk during the admission assessment and document results...Precipitating factors may include, but are not limited to...History of sexual abuse..." Also included in the policy was "...Once a patient has been identified as a potential risk for sexualized behavior, the physician or Registered Nurse will initiate sexual behavior precautions-SBP...Increase observations per the situation and review room assignments with every shift and with reassessments...Sexualized Behavior Precautions include, but may not be limited to...Staff is to monitor patient whereabouts and behavior every 15-minutes...Room assignment will be made based on the patient's clinical picture..."

The hospital did not adhere to this policy. Consequently, the hospital did not identify potential risk or prevent an incident of sexual abuse as follows:

Patient #8 was a 13 year old female who was admitted voluntarily to the hospital on 9/26/16 and discharged home on 10/07/16. Her diagnoses included major depressive disorder, posttraumatic stress disorder, obsessive-compulsive disorder, conduct disorder, cannabis use disorder, alcohol use disorder and child victim of sexual abuse. She presented to the hospital as a transfer from a local ER, where she was assessed for suicidal ideations, self-harm behavior and significant substance use.

A "BH-HEALTHCARE PEER REVIEW REPORT," dated 9/30/16 at 8:00 PM and completed by an RN was reviewed during the survey. The report was regarding Patient #8 and included a section "SEXUAL ALLEGATION." Contained within this section were descriptive terms with check boxes beside each item. The boxes beside "Misconduct: Pt/Pt and Intercourse: Pt/Pt" were marked. The form also included documentation indicating the incident took place in a "Pt's bedroom," and her physician and parents were notified. The form also indicated a report was filed with local authorities and the local office for sexual assault victims was notified.

Patient #8's admission orders, dated 9/26/16 at 2:20 PM and signed by a physician, included precaution orders for suicide and self harm. Also included on admission was an order for 15 minute checks. On 9/27/16, precaution orders for behavior, elopement, assault, sexual acting out, sexual victimization and sexual aggression were added. There was no corresponding order on 9/27/16 to elevate the level of observation for Patient #8. She remained on 15 minute checks.

A "Flash Report by Unit by Bed" for the adolescent unit, dated 9/29/16, was reviewed. The report indicated Patient #8 was the only female on a hallway with 7 adolescent male patients.

An "ABUSE REPORT DOCUMENTATION" form, dated 9/30/16 at 7:45 PM and signed by an RN, stated Patient #8 reported to staff that she had intercourse with an adolescent male peer (Patient #6) on 9/29/16. The form stated Patient #8 said she had "just gotten out of the shower and Patient #6 came into her bathroom." The form stated Patient #8's mother was notified and a report was submitted to CPS.

A "PHYSICIAN ORDERS" form, dated 9/30/16 at 7:15 PM and signed by a physician, ordered tests for HIV, chlamydia and gonorrhea. Also included were orders for the "morning after pill" and an order to transport patient for a "rape kit." Orders stated Patient #8's mother was notified and consented verbally to all orders.

An "EMERGENCY ROOM TRANSFER REPORT," dated 9/30/16 at 8:00 PM and signed by a physician and an RN, stated Patient #8 was transferred to a local ER for a "Rape Kit." The form stated Patient #8 was on suicide precautions, self-injury precautions, assault/aggression precautions, elopement precautions and behavior precautions at the time of the transfer.

A "NURSING FLOW SHEET," dated 9/30/16 at 12:00 PM and unsigned, stated Patient
#8 returned from the local ER accompanied by law enforcement, who reported she made the statement "she wanted to kill herself." The note stated Patient #8 was placed in the "obs room with no sheets...Will continue to monitor Q15 min and more for her safety..." Though Patient #8 was placed in an observation room, her level of observation was not elevated to "Dedicated Observations or One-one (1:1) Observations." She remained on 15 minute checks.

A male PT, who was assigned to the male patient hallway on the evening of 9/29/16, was interviewed on 10/13/16, beginning at 1:40 PM. He stated there were 3 PTs assigned to the adolescent unit on the evening of 9/29/16. He stated he was assigned to the male hallway, a female PT was assigned to the female hallway, and a second female PT was assigned to float between the hallways. He said Patient #8 was the only female patient assigned to the male hallway at that time. He stated the female PTs were responsible for performing 15 minute checks on Patient #8 and attending to her ADL needs, but he was responsible for observing the male hallway. He stated the incident of sexual misconduct must have occurred during the time he was passing out ADL supplies in preparation for showers. He stated the incident occurred as he was moving the "ADL cart" down the hallway, from male room to male room, while delivering ADL supplies. He stated there was a period of time when his back was turned to the rooms containing Patient #6 and Patient #8. He stated staff was allowed to review the 9/29/16 footage from the video camera that was on the male hallway. Based on review of the video footage, it was determined male adolescent Patient #6 crossed the hallway and entered the female adolescent Patient #8's room during the time he was distributing ADL supplies and was unable to visualize the entire hallway. The male PT confirmed it was not possible for him to keep the entire hallway under observation "during ADL time." He also confirmed it was not possible to maintain constant observation of the entire hallway during the time he was responsible for performing 15 minute checks on the male patients.

A female PT, who performed 15 minute checks on female Patient #8 on the evening of 9/29/16, was interviewed on 10/12/16, beginning at 2:00 PM. She stated she was performing a 15 minute check on female Patient #8 when she entered her room and heard the shower running. She stated she knocked on the bathroom door, called Patient #8's name and announced she was entering the bathroom for 15 minute checks. She stated Patient #8 wrapped part of the shower curtain around herself and displayed the upper part of her body outside the shower. The PT stated she was able to visualize only the upper part of Patient #8's body and a small area of the shower. She stated she did not ask Patient #8 to step aside and allow her to visualize the entire shower space. She stated after watching the video, she knew Patient #6 was in Patient #8's room during the time of the 15 minute shower check. She stated the only place he could have been was in the part of the shower she did not visualize.

A Program Manager was interviewed on 10/17/16, beginning at 10:30 PM. She recounted the incident on the evening of 9/29/16 between Patient #8 and Patient #6. When asked why Patient #8 was assigned a room on the male hallway, she explained Patient #8 was being treated for head lice. She stated Patient #8 was placed in a room on the male hallway because there was not a private room available on the female hallway. She confirmed there were other options available to staff which may have prevented the incident. She co