HospitalInspections.org

Based on review of documentation and interview, the facility failed to ensure that patients receive care in a safe setting as evidence by failing to ensure that a patient with reported sexually inappropriate behavior was appropriately being monitored for sexually acting out behavior.

Findings included:

Facility policy entitled Sexually Acting Out Precautions stated in part,
"I. Purpose

To provide guidance for the observation of patient with a known history of sexually acting out and/or those who have a high probability of demonstrating such behaviors....

3...Any patient who has demonstrated sexually inappropriate behavior during hospitalization will be placed on SAO precautions and remain on SAO precautions for the remainder of the hospitalization...

4. SAO precautions must be addressed on the Master Treatment Plan, and will be noted on the Observation Record, Nursing Shift Assessment, and Report Sheets."

Review of medical records revealed the following:
* Patient #1 reported their roommate Patient #2 had made sexually advances in their shared bedroom.
* Patient #2 confirmed that there was sexual contact.
* The facility separated the two patients and placed Patient # 2 on sexually acting out precautions.
* On 10/20/16 at 1050, a physician order placed Patient # 2 on "SAO precautions to include private room".
* The Master Treatment Plan for Patient # 2 included a problem sheet for "Sexually Acting Out", per facility policy, dated 10/20/16 which stated there was report of sexual misconduct with a goal to "not have SAO incident during treatment stay".
* Patient #2's sexually acting out precautions were not marked or addressed on the observation record from 10/20/16 through their discharge on 10/26/16, per facility policy. The observation record from 10/20/16 through 10/26/16 had "suicidal/self harm" marked as the reason for observation, not sexually acting out.
* Patient #2's sexually acting out precautions were not documented or addressed on the nursing shift assessment from 10/20/16 through their discharge on 10/26/16, per facility policy.

Due to the fact that Patient # 2's sexually acting out precautions were not documented, per facility policy, on the observation record or nursing shift assessment, it is unknown if this patient was appropriately being monitored for sexually acting out behavior.

The above findings were confirmed in an interview with staff member #1 on 04/26/17.