HospitalInspections.org

Based on review of facility documents, review of medical records and staff interview, the facility failed to ensure each patient's treatment plan was based on an inventory of the patient's strengths and disabilities.

Findings included:

Facility policy titled "Patient Observation Levels" stated in part, "2. Special Observation: Any indication of ... or potential for sexual action out shall be immediately evaluated by a qualified staff member and action shall be taken immediately to ensure the safety of the individual ...
e. Special Observation status is communicated to all staff involved in the care of the patient(s)
...h. Special Observations must be included into the Master Treatment Plan."

Facility policy titled "Special Precautions" stated in part, "Procedure: ...12. Documentation of all Precautions should include the following: ...f. Entry in the treatment plan addressing corresponding to the precaution

Review of the medical record for patient #1 revealed admitting orders on 6/22/17 at 3:10 pm that stated in part, "Precaution status: ...Sexual Aggression ..."

The initial treatment plan signed by the nurse and patient #1 on 6/22/17 at 4:49 pm did not address the patient's sexual abuse history. The interdisciplinary master treatment plan dated 6/23/17 and signed by the psychiatrist, nurse, clinical therapist, expressive therapist and patient did not address the patient's sexual abuse history.

The above was confirmed in an interview with the director of risk management on the afternoon of 8/1/17.