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Based on record review and interviews the facility failed to measure, analyze, and track ...adverse patient events ... for 1 of 1 patients (Patient #13) in that the facility failed to complete an incident report on an allegation of sexual acting out.

Findings included:

In Patient #1's medical record a Progress Note from 12/8/2022 at 2:34 PM, reflected the following by Personnel #6, "Today during class Patient #1 communicated to me that Patient #13 is sexually harassing other patients by touching on the legs inappropriately. Informed nurse on duty today." After reviewing the Incident Report Log for December, it was identified that no Incident Report had been created for Patient #1's allegations.

During an interview on 12/19/2022 at 1:45 PM, Personnel #3 confirmed that an Incident Report had not been completed by Personnel #6.

Facility policy "Incident Reporting" last revised on 5/30/2019 stated " ...an Incident Report is to completed for every occurrence which meets the following definition: any happening not consistent with the routine care or operation of the facility, or the desired routine care of the patient and/or operation of the facility, which places the Company at an increased risk for liability ...The Incident Report must be completed by the employee(s) who witnessed or discovered the event as soon as possible following an event which meets the above mentioned reporting definition. Occurrences must be reported by the end of the shift in which the event occurred ...The following categories, not limited to, are reported on the incident report form: ...Sexual familiarity with peer or staff ..."

Based on record review and interview the facility failed to maintain an accurately written medical record in that 2 of 2 (Patient #1 and Patient #11) patient medical records did not evidence all reported patient information.

Findings included:

Review of the medical records for Patient #1 and Patient #11 did not evidence any of the information disclosed during an interview with Personnel #4 on 12/19/2022 at 11:36 AM. Patient #11 had disclosed to Personnel #4 on 12/12/2022 that Patient #11 had requested a 1:1 session to discuss issues related to Patient #1. Patient #11 told Personnel #4 that Patient #1 was making him uncomfortable. Patient #1 was telling Patient #11 that he was having dreams of kissing him. Patient #1 told Patient #11 that when they got out that he would have to split his time 50/50 between him and his girlfriend. Patient #11 told Personnel #4 to keep Patient #1 away from him. Personnel #4 informed staff to keep them separated. Patient #1 told Personnel #4 that Patient #11 had feelings for him and that the feelings were mutual. Patient #1 asked Personnel #4 what would happen if he spoke to Patient #11. Personnel #4 told Patient #1 it was no longer an option. Personnel #4 stated that approximately 5-10 minutes later Patient #11 could be heard yelling to get Patient #1 out of his room and that is when the tech on the unit placed a chair between the day room and Patient #11's room to make sure Patient #1 could not get to Patient #11's room. Personnel #4 was told by staff the next day that Patient #1 was manipulating some of the other patients on the unit to go to Patient #11's room to speak for him to tell Patient #11 that he was sorry and tell him that Patient #1 was crying.

Review of the medical record for Patient #1 evidenced that Patient #1 was placed on SAO (sexually acting out) room block per a physician order written by Personnel #5 on 12/11/2022 at 2:00 PM. A review of Patient #1's Progress Notes did not evidence any sexual acting out.

During an interview on 12/19/2022 at 1:11 PM, Personnel #5 confirmed that he wrote the order, but could not find any documentation in the medical record regarding the need for SAO precautions. Personnel #5 stated that he thinks the nurse may have told him that there may be an issue with another patient. He stated that he could not find any documentation or remember the exact details.

During an interview with Personnel #3 in the 1st floor conference room on 12/21/2022 at 10:05 AM stated the following, the video footage from 12/12/2022 was reviewed and after the therapist had a 1:1 with Patient #11, all the staff got together and discussed a plan for Patient #11. Patient #11 was off the unit and the staff decided what to do. The therapist walked Patient #11 to his room and got him coloring pages and crayons. Patient #11 stayed in his room. The techs went and sat in the day area, and they saw Patient #1 going towards Patient #11's room. Patient #1 poked his head into Patient #11's room and the tech immediately got up and went over and pulled Patient #1 away. The tech moved his chair closer to Patient #11's door to prevent Patient #1 from entering Patient #11's room."

Facility policy "Documentation" last reviewed on 8/10/2022 stated "It is the policy of Dallas Behavioral Healthcare Hospital to assure that the maximum possible information about a patient is available to the professional staff providing care, subsequent caregivers, regulatory/accrediting bodies and utilization review. ...Social work progress notes are recorded for each individual, group, or family/significant other session. Notes should include a brief and concise description of the patient's condition, e.g., behavior and mental status, particularly as related to problems identified on the treatment plan. ...Specialized documentation is utilized to document precautions or special procedures."