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Based on interview and record review the facility failed to protect the rights of patients for 2 of 10 patients (#1, #2) requiring a safe environment resulting in the potential for all current and future patients at risk for loss of their rights.

Findings include:

1. The facility failed to provide a safe environment for 2 of 10 patients (#1, #2) requiring 15-minute safety checks resulting in patients #1 and #2 not being monitored for an extended period and engaging in inappropriate sexual behavior. (See A-144).

Based on interview and record review, the facility failed to provide a safe environment for 2 of 10 patients (#1, #2) requiring 15-minute safety checks resulting in patients #1 and #2 not being monitored for an extended period and engaging in inappropriate sexual behavior. Findings include:

On 04/19/18 at 1430 a review of the medical record and facility safety and security report dated 04/11/18 was completed. This report indicated on 04/11/18 at 2230 on Unit Mod A (co-ed unit) during 15-minute rounds Patient (Pt) #2 was found having sexual intercourse with Pt #1 inside Pt #1's bedroom. This report indicated both patients "kept going" after being discovered and started laughing after being separated by staff. This report indicated the sexual behavior was consensual and, soon afterwards, Pt #2 was transferred to a separate all-female unit in the facility. The record indicated Pt #1 was transferred to a separate all-male unit in the facility. This report indicated mental health assistant (Staff L) was a witness to the events.

During an interview with Pt #1 on 04/19/18 at 0925, Pt #1 said she engaged in consensual sexual behavior with Pt #2 inside her bedroom on 04/11/18 during the late evening hours. Pt #1 said she did not have a roommate at the time the sexual behavior occurred. Pt #1 denied any penile penetration by Pt #2, however, she allowed Pt #2 to penetrate her vagina with a finger. Pt #1 denied being physically abused by Pt #2 but felt "uncomfortable" when (Pt #2) began touching her groin area, however, she allowed the sexual behavior to continue. Pt #1 said, "I wasn't in the right state of mind" when engaging in the sexual behavior. Pt #1 said she was alone with Pt #2 inside her room for "a long time" with no staff monitoring them. Pt #1 said she refused an initial examination by the SANE nurse (Sexual Assault Nurse Examiner), however, after consulting with a family member, consented to the SANE nurse examination the next day.

Pt #1's medical record was reviewed on 04/19/18 at 1400. The record revealed Pt #1 had a physician order written 03/11/18 at 1731 placing Pt #1 on 15-minute checks.

Note Pt #2 discharged from the facility on 04/14/18 and could not be interviewed. Pt #2's medical record was reviewed on 04/19/18 at 1450. The patient progress notes dated 04/13/18 at 1507, indicated Pt #2, now on the all-male unit, claimed he and Pt #1 "were becoming closer and sharing notes and art on the unit". The record revealed Pt #2 had a physician order written 04/10/18 at 2349 placing Pt #2 on 15-minute checks.

During an interview with the facility director (Staff A) on 04/19/18 at 0945, Staff A indicated the facility was still investigating the incident between Pt #1 and Pt #2 and a final report had not been completed. Staff A said Staff L was assigned to complete the 15-minute safety check monitoring of Pt #1 and Pt #2 during the time frames the incident occurred. Staff A indicated all patients in the facility receive at least 15-minute safety monitoring checks with the expectation that staff complete these checks every 15 minutes within a variance of +/- (plus or minus) 5 minutes.

During an interview with recipient rights staff (Staff G) on 04/19/18 at 1305, Staff G indicated recipient rights had filed a grievance case regarding the incident between Pt #1 and Pt #2, however, the investigation was still in process and the final report had not been completed.

On 04/19/18 at 1015, with Staff A present, a review of the video recorded by the facility during the time frames of the incident was reviewed. The video recorded the hallway on the unit as well as staff and patient movement in and out of rooms and hallways. Note, the time line format is documented in Date/Military Time/Seconds. The results are, as follows:

04/11/18 at 2158:24, Staff L is seen ambulating in the hallways of the Mod A Co-ed Unit completing 15-minute safety checks. Pt #1 enters her assigned room. Staff L makes visual contact with Pt #1 at this time.

04/11/18 at 2200:00, Pt #2 is ambulating in hallway, peeks into Pt #1's room and continues walking in hallway.

04/11/18 at 2204:10, Pt #2 enters into Pt #1's room. Staff L does not visualize Pt #2 entering Pt #1's room.

04/11/18 at 2213:26, Pt #2 departs Pt #1's room.

04/11/18 at 2213:34, Staff L makes visual contact with Pt #2 in hallway, however, Staff L does not acknowledge that Pt #2 just emerged from Pt #1's room.

04/11/18 at 2213:44, Pt #2 re-enters Pt #1's room while Staff L, sitting in a chair across from nursing station in hallway, is checking own blood pressure with a cuff.

04/11/18 at 2215:00, Staff L, still sitting in chair in hallway, does not make required 15" minute safety checks. Pt #2 remains inside Pt #1's room.

04/11/18 at 2218:00, Staff L, still sitting in chair in hallway, does not make any 15" minute safety checks. Pt #2 remains inside Pt #1's room.

04/11/18 at 2228:00, Staff L stands up, ambulates down hallway and speaks to other patients in hallway. Staff L does not make any visualization inside of Pt #1's room, though Pt #2 remains inside.

04/11/18 at 2229:33, Staff L opens laundry room door at far end of hallway allowing other patients to enter.

04/11/18 at 2230:06, Staff L walks back down hallway toward chair. Staff L walks right by Pt #1's bedroom, however, does not stop or slow down to make visualization inside of Pt #1's room. Pt #2 remains inside Pt #1's room. Staff L sits back down in chair.

04/11/18 at 2234:13, Staff L stands from chair and walks down hallway to Pt #1's room. Staff L open Pt #1's bedroom door, peeks inside and summons for staff assistance.

04/11/18 at 2234:40, multiple staff are present at the entry of Pt #1's bedroom.

04/11/18 at 2235:53, Pt #2 emerges from Pt #1's room fully clothed except for a missing sock.

Based on this video review, Pt #1 was visualized by staff on 04/11/18 at 2158 and not visualized again until 04/11/18 at 2234. This accounts for a total time of approximately 36 minutes in which Pt #1 was not monitored by staff.

Based on this video review, Pt #2 entered Pt #1's room twice, first on 04/11/18 from 2204 to 2213 (approximately 9 minutes) and, after a brief exit from Pt #1's room, Pt #2 re-entered Pt #1's room again on 04/11/18 from 2213 to 2234. The video showed no evidence that Staff L or any staff were aware that Pt #2 entered Pt #1's room during these timeframes, despite staff sitting well within visualization range. The video showed evidence that staff became aware Pt #2 was inside Pt #1's room, however, this was not until 04/11/18 at 2234. This accounts for a total time of approximately 21 minutes in which Pt #2 was not monitored by staff. Note, the video did not show any evidence that the general milieu was busy or highly acute.

During an interview with Staff L on 04/19/18 at 1205, Staff L said he was assigned to complete 15-minute safety checks for Pt #1 and Pt #2 during the time frames the incident occurred. Staff L said, during safety rounds, he discovered Pt #1 and Pt #2 having sexual intercourse inside Pt #1's room and, once discovered, multiple staff arrived to help. Staff L said, previous to the discovery, he was not aware Pt #2 was inside Pt #1's bedroom. When asked if 15-minute safety check monitoring was completed timely that shift, Staff L admitted he "skipped a check" because the unit was "busy".

On 04/19/18 at 1315 a review of facility policy titled, "Tier 2 - Safety Rounds" last revised 07/28/16 was completed. This policy indicated, under policy section, "Patient safety is a priority in a psychiatric setting; hence frequent monitoring will be conducted". This policy also indicated, under procedure section, "1. To mitigate safety risk on the units, patients are monitored at 15 minute increments with a variance of +/- 5 minutes ...".

On 04/19/18 at 1320 a review of facility job descriptions for the Mental Health Assistant dated January 2017 was completed. This job description indicated, under principle duties and responsibilities, within the service section, "3. Demonstrates, supports, and assumes personal accountability for consistently upholding team members to the standards across the System and adhering to HFHS policies and procedures.".