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Based on record review and interview the facility failed failed to protect the rights to receive care in a safe setting for 3 of 8 (Patient #1, #2,#3) patients.

Patient #1 was on one-to-one staff observation for his sexually aggressive behavior. Patient #1 was assigned to be a roommate to Patient #2, a 5-year old who had also been ordered one-to one staff observational status due to his age and for his safety. Both patients were left by staff unsupervised for close to an hour on 02/11/24 when the younger patient was sexually assaulted by the older patient.

2. Patient #1 was administered Hydroxyzine 25mg PO as needed (PRN) medication on 02/05/24 at 06:38 PM. Patient #1 was administered Tylenol 325mg PO PRN on 02/06/24 at 02:13 PM. The medical record did not reflect the reason for the medication administration nor a response to the medication.
Patient #3. On 02/05/24 the MAR reflected Patient #3 received Ibuprofen 400mg PO at 01:00 PM and 06:40 PM. The medication was not listed on the PRN and First Dose Medication Documentation list. There was not documentation of the reason the medication was given and no response to the medication was documented.


Cross Refer Tag A0144.

Based or record review and interview the facility failed to provide care in a safe setting.

1. The Mental Health Techs (MHT) failed to provide one-to-one (1:1) observation for 2 of 2 (Patient #1 and #2) preadolescent patients that were ordered 1:1 staff observation as a precautionar measure for the patient's safety. The patients were left unattended for 58 minutes, and an 8-year-old male performed oral sex on a 5-year-old male.
2. After administering as needed (PRN) medication to 2 of 8 patients (Patient #1 and Patient #3) nursing staff failed to document the reason for the medication administration or a patient response.

Findings included:

1. The Preliminary Summary of the investigation reflected on 02/11/24 at 01:30 PM Patient #2 made an outcry to Personnel #7 that Patient #1 had placed his mouth on Patient #2's penis while sitting on the bed in room 220. The Preliminary Summary of the investigation reflected..."pt (Patient #1) stated 'I did, but I don't know why?'..."

Patient #1, an 8-year-old male was admitted to the facility on 02/04/24 according to the patient information face sheet. The Physician Orders dated 02/07/24 at 03:29 PM reflected..."1:1 (observation). SAO (sexually acting out)...". The Physician Orders for 02/08/24, 02/09/24, 02/10/24 and 02/11/24 reflected the orders for 1:1 observation were renewed.

Patient #2, a 5-year-old male, was admitted to the facility on 02/07/24. The Physician Orders dated 02/07/24 at 05:25 PM reflected..."1:1 for safety/age..." The Physician Orders dated 02/09/24, 02/10/24 and 02/11/24 reflected the order for 1:1 observation was renewed.

A review of camera footage for the pediatric unit reflected on 02/11/24 at 11:56 AM Patient #1 and Patient #2 entered room 220 for a nap. The video did not reflect any adults entered the room to provide 1:1 observation. Personnel #7, assigned to provide 1:1 observation to Patient #2, and Personnel #8, assigned 1:1 observation of Patient #1, sat at a table in the day area in front of the nursing station. There was not a direct line of sight into room 220 from the table where Personnel #7 and Personnel #8 sat. At 12:04 PM a MHT briefly entered room 220 and then walked back out. Personnel #8 handed Personnel #7 their observation sheet at 12:48 PM and Personnel #8 exited the unit. Personnel #7 continued to sit at a table in the day room. The video reflected Patient #2 exited room 220 at 01:02 PM and Personnel #7 returned Patient #2 to room 220 at 01:07 PM. The video reflected that patient #1 exited room 220 at 01:18 PM and leaned against a chair in the day room. The video reflected Patient #2 exited the room at 01:19 PM and approached the nurse's station. At 01:30 PM Personnel #9 was observed leaving the nurse's station and walking toward the day room and Patient #1 and Patient #2. There was no evidence that any staff was in direct visualization with the patients between 12:04 and 01:02 and observed them according to the physician-ordered precaution level.

The facility's policy titled Patient Observations, reviewed 08/11/22 reflected..."One-to-One Observation(1:1) Patients on 1:1 observation require continuous around the clock supervision until discontinued by a physician's order. Staff assigned to perform 1:1 observation shall maintain continual visual observation with the ability to immediately respond..."

During an interview on 02/14/24 beginning at 10:36 AM Personnel #1 stated that Personnel #7 and Personnel #8 assigned to provide 1:1 observation for Patient #1 and Patient #2 did not follow hospital policy. Patients #1 and #2 should have been in Personnel #7's and Personnel #8's line of sight at all times. Personnel #1 stated that when Personnel #8 exited the unit, Personnel #9 should have taken their place for 1:1 observation. Personnel #1 stated when Patient #2 approached the nurse's station at 01:30 PM he told Personnel #7 that Patient #1 had touched him inappropriately.

2. Patient #1. On 02/05/24 the Medication Administration Record (MAR) reflected Patient #1 received Hydroxyzine 25mg PO (by mouth) at 06:38 PM. The medication was not listed on the PRN (as needed) and First Dose Medication Documentation list. There was not documentation of the reason the medication was given and no response to the medication was documented. On 02/06/24 the MAR reflected Patient #1 received Tylenol 325mg PO at 02:13 PM. The medication was not listed on the PRN and First Dose Medication Documentation list. There was not documentation of the reason the medication was given and no response to the medication was documented.

Patient #3. On 02/05/24 the MAR reflected Patient #3 received Ibuprofen 400mg PO at 01:00 PM and 06:40 PM. The medication was not listed on the PRN and First Dose Medication Documentation list. There was not documentation of the reason the medication was given and no response to the medication was documented.

The policy titled Medication Management reviewed 01/2024 reflected..."4.2 The nurse who administers the 'PRN' medication will document, in the appropriate section of the patient record, the purpose for which the medication was given.
During an interview on 02/14/24 at 03:02 PM Personnel #2 verified the above findings.