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Based on record review and interview, the facility failed to ensure the rights of 2 of 2 patients (Patient #1 & #2) to be free of potential abuse and neglect as shown by:

A. Staff not closely monitoring patients on Sexually Acting Out (SAO) Precautions via Line-of-Sight per physician orders (Patient #1), allowing opportunity for a male and female patient to be in a bathroom together, and

B. Nursing staff not monitoring PCA assignments, allowing a male Patient Care Technician (PCA-Staff #A) to perform 1-to-1 monitoring for a female patient on Sexually Acting Out Precautions (SAO-Patient #1).


Findings included:


Review of facility policy titled "Sexually Acting Out (SAO)", #13572466, last revised 12/2019 stated that Sexual Precautions are defined as intensified levels of staff awareness and attention to patient safety/security related to sexual acting out behaviors. SAO Precautions are physician orders and include Line-of-sight (LOS) and 1:1 (one-to-one) monitoring.

Review of another facility policy titled "Levels of Observation and Precautions", # 13048351, last revised 2/2023 showed that LOS observation is very restrictive and involves continuous monitoring of the patient at all times by staff; staff must be within visual contact with the patient at all times. 1-to-1 Observation is the most restrictive; staff must be within arms-length reach to the patient at all times, including during toileting and/or showering to continuously monitor patient behavior.

Record review of Patient #1's clinical progress notes showed the following: Patient #1 had a physician's order for LOS observation. On 12/14/23, the patient went into a common bathroom in the facility's adolescent unit's seclusion room that staff had been allowing patients to use. It was then brought to the attention of staff who were supposed to be monitoring the patient that a peer, Patient #2 had been in the bathroom with Patient #1 together at the same time.

Facility investigation revealed that the two patients were in the bathroom together for approximately 20 minutes and Patient #1 was not being properly monitored via LOS by PCA-Staff #J. Video review showed both patients sneaking into the same bathroom. Patient #2 reported they were touching each other over clothes and Patient #1 reported that sexual intercourse had occurred. Both patients were subsequently treated prophylactically for sexually transmitted infection.

In an interview on the afternoon of 12/19/23, DQ-Staff #C stated that Staff #J was not following her assignment and the event should not have been allowed to occur.

Further record review of Patient #1's clinical chart showed that due to the event occurring 12/14/23, she was placed on 1-to-1 close observation monitoring by her physician due to sexually acting out. On 12/16/23, a male PCA (Patient Care Assistant technician)-Staff #A, who was not assigned to care for the patient for 1-to-1 monitoring, switched assignments with female PCA-Staff #K to care for the patient from 12:00 am to 2:00 am. Later in the morning at approximately 7:30 am, Patient #1 reported to PCA staff on duty that during the night, PCA-Staff #A showed her a pornographic video on his cellphone of himself having sex with a woman. Patient #1 then stated that they both had oral sex and intercourse together and that PCA-Staff #A requested she shower afterwards. Patient #1's roommate, Patient #11, during interview with facility staff investigating incident, stated she heard PCA-Staff #A ask Patient #1 if she wanted to watch a video. In addition, Patient #11 stated she overheard PCA-Staff #A argue with other PCA staff during that night, insisting that he should be the person doing the 1-to-1 monitoring of Patient #1. Patient #11 also reported that the patient had showered in the early evening then again, in the early morning.

Video review showed PCA-Staff #A, while performing 1-to-1 monitoring for Patient #1 during 12:00 am to 2:00 am on 12/16/23, visualized him coming to the patient's door several times from inside the bedroom, looking back and forth down the adolescent halls and nurse's station, then re-entering Patient#1's bedroom.

Record review of the patient's written statement describing the event on 12/16/23 included graphic details of sexual interaction with PCA-Staff #A and included a written telephone number. Review of PCA-Staff #A's HR files showed that the telephone number submitted by the patient in her written statement matched his phone number.

In an interview on 12/20/23 at 2:00 pm, Staff #C stated that nursing staff should have been monitoring the PCA assignments and having the male PCA care for the patient in this case should nave have been allowed to occur.