HospitalInspections.org

Based on a review of medical records, a review of incident reports, a review of the facility ' s policy and procedures, and interviews with staff, it was determined the Governing Body failed to provide a safe caring environment for one (P#1) out of six patients sampled. P#1 was allowed to enter another patient ' s private room leading to allegations of sexual misconduct.

Cross Reference A-0063 as it relates to the Governing Body's failure of ensuring care in a safe setting when P#1 entered another patients room leading to allegations of sexual misconduct.

Based on a review of medical records, a review of incident reports, a review of the facility ' s policy and procedures, and interviews with staff, it was determined the Governing Body failed to provide a safe caring environment for one (P#1) out of six patients sampled. P#1 was allowed to enter another patient ' s private room leading to allegations of sexual misconduct.

A review of the medical record (MR) revealed Patient P #1 was a 24-year-old female who was admitted to the facility on 8/4/20 on a 1013 (involuntary admission) for Suicidal ideation (thoughts of harming self). P#1 ' s admitting diagnosis was schizoaffective disorder (a combination of schizophrenia and mood disorder characterized by hallucinations or delusions and mania and depression), bipolar disorder (manic depression), and developmental delay.

A review of the progress note dated 8/5/20 revealed that Licensed Practical Nurse (LPN) CC had to redirect P#1 to the correct room and advised P#1 that patients did not go into other patients' rooms. P#1 presented guarded, childlike, and suspicious, but was generally cooperative with staff. P#1 had a reserved affect.

A review of the progress note by MD MM dated 8/7/20 revealed that P#1 continued to demonstrate paranoia, mostly towards a male peer with whom she had been shouting from across the hallway.

A review of a progress note dated 8/9/20 revealed that P#1 was observed standing in the hallway yelling at a male peer as he was walking up and down the hallway. P#1 was provided active listening and was verbally redirected. P#1 went to the male peer's room while the male peer was lying on his bed. The staff was able to redirect P#1 after multiple attempts. P#1 walked to the day area and sat in a chair. P#1 and the male peer began yelling at each other. The staff was able to verbally redirect P#1, and education was provided for healthy coping skills.

A review of a progress note dated 8/9/20 revealed that P#1 was standing behind a male peer while he was using the telephone. P#1 was verbally redirected from standing closely behind the male peer. The male peer ended the phone call and proceeded down the hallway. P#1 began following the male peer. The male peer entered his room. P#1 proceeded back up the hallway to the day area and sat in a chair.

A progress note dated 8/9/2020 revealed a nurse reported that she educated P#1 on personal boundaries and for P#1 to concentrate on P#1's recovery and treatment.

A review of a progress note by MD MM, dated 8/10/20, revealed that P#1 was engaging in inappropriate touching and hugging behavior with one of the male peers. P#1 was overheard telling her mother that the other patient was pursuing her. Continued review revealed that P#1 had some disorganized thinking and was somewhat tangential, with very poor insight. P#1 appeared to be tolerating medication but had required redirection for behavior reasons.

A review of incident report #62712 revealed that Clinical Manager (CM) BB entered the incident details and conducted an investigation, including reviewing the environment and notifying the supervisor. Further review of a brief description of the incident revealed that P#1's grandmother called the facility and reported that P#1 entered into another male patient's (P#2) room and went into the bathroom together. P#1 administered oral sex to P#2. Further review of the notifications revealed the Administrator was notified on 8/13/2020 at 4:55 p.m.

A review of the follow-up summary dated 8/17/20 at 4:13 p.m. revealed Administrator AA referred file to CM BB for follow-up. The follow-up summary further revealed that CM BB conducted an investigation on 8/18/20 at 8:39 that revealed that on 8/5/20, P#1 came out of her room on the long hallway around 9:30 a.m. and entered the short hallway. P#1 went directly to P#2's room and stood outside P#2's door talking to him. P#2 then motioned for P#1 to come in and pointed toward the bathroom. P#1 entered the room and went into the bathroom. P#2 then got up out of bed and entered the bathroom. P#1 and P#2 were in the bathroom for a full minute. P#2 then reemerged and looked out into the hallway, shut his room door again, and returned to the bathroom. P#1 and P#2 were in the bathroom for 4 minutes. P#2 came out of the bathroom first, followed by P#1, and they exited the room separately. MD MM documented that P#1 was developmentally delayed and functioned at a second-grade level. It was also documented by nursing staff and MD MM that P#1 had been following other male patients around the unit. P#1 would stand outside their doors, and staff had to redirect P#1 continuously. Further review revealed that Administrator AA and CM BB closed the incident investigation on 8/19/2020 at 12:59.

A review of the Detailed Incident Report dated 8/13/20 revealed P#1 was named in the report as the "person affected". Continued review revealed that the incident took place on 8/5/20 between 7:01 a.m. and 11:00 a.m. in the Adult Psychology unit of the facility.

A review of the policy titled "Level of Observation," dated 1/2017 and last revised on 2/21, revealed that the level of observation was intended to provide the patient with the maximum freedom of movement and privacy with the least amount of restriction possible while ensuring the safety of that patient and others on the unit. Continued review revealed that Peer Precautions was a level of observation implemented for patients whose interaction needed to be restricted towards other peer/peers for therapeutic or clinical reasons. This could be used for patients threatening another patient, sexually acting out, or exhibiting poor boundaries. The criteria for a potential increased level of observation and factors to be considered included, but were not limited to, the inability to maintain appropriate personal space boundaries (excessive physical contact, hugging, touching, sexual gestures, sexual contact).

An interview was conducted with Registered Nurse (RN) EE on 3/22/22 at 3:20 p.m. in the conference room. RN EE stated it was the responsibility of the nurses on duty to care for their patients, which included hourly monitoring, evaluations, medication administration, and any healthcare needs the patient had. She continued to say that it was the charge nurse's responsibility to make the nurse assignments for the shift. The number of patients and their acuity (alertness) levels determined how many patients each nurse would be responsible for during the shift. RN EE said to ensure all patients were observed and remained safe on the unit, the Mental Health Technicians (MHT) monitored patients every 15 minutes and recorded their observations on an Observation Sheet. She stated that the nurses would conduct safety checks every hour and document their observations in the electronic medical record. RN EE said she was kept up to date on changes in the unit and training through daily team meetings and annual HealthStream training, including de-escalation training.

An interview was conducted with Mental Health Technician (MHT) HH on 3/23/22 at 1:20 p.m. in the conference room. MHT HH stated he had worked at the facility for five years. MHT HH explained that it was his responsibility as an MHT to keep the unit functioning and the patients safe during his shift. MHT HH said that he was responsible for performing safety checks every 15 minutes on the patients assigned and documenting their location and behavior on the Observation Sheet. He explained that safety checks for the patients included making sure you saw them and monitored what they were doing at that specific time. MHT HH stated that if a patient on the unit began to display inappropriate behavior, such as not setting boundaries, anger, or sexually acting out, he would redirect the patient into another activity or to another area on the unit. MHT HH said that if redirecting the patient was not working, he would bring the issue to the nurse's attention on the floor, who may need to intervene (get involved) with medication or contact the patient's physician for additional direction.

An interview was conducted with Clinical Manager (CM) BB on 3/24/22 at 2:45 p.m. in the conference room. CM BB stated that she recalled receiving a message from P#1's grandmother after P#1 was discharged from the facility regarding a complaint of a sexual assault. CM BB said that she could recall that the grandmother was shouting on the phone and stated that she just wanted the facility to know what had happened, and then she hung up the phone. CM BB said she could not recall returning P#1's grandmother's call after completing her investigation.

Based on a review of medical records, a review of incident reports, a review of the facility ' s policy and procedures, and interviews with staff, it was determined the facility failed to maintain patient ' s rights for one out of six patients sampled(P#1), when P#1 was not monitored appropriately and was documented entering another patient ' s private room without staff supervision.


Cross-reference A-0144 as it relates to P#1 not being monitored by staff and entering a male patient ' s room without staff supervision putting P#1 patient ' s rights at risk.

Based on a review of medical records, a review of incident reports, a review of the facility ' s policy and procedures, and interviews with staff, it was determined the facility failed to provide care in a safe setting for one (P#1) out of six patients sampled. P#1 was not monitored appropriately and was documented entering another patient ' s private room without staff supervision.


A review of the medical record (MR) revealed Patient P #1 was a 24-year-old female who was admitted to the facility on 8/4/20 on a 1013 (involuntary admission) for Suicidal ideation (thoughts of harming self). P#1 ' s admitting diagnosis was schizoaffective disorder (a combination of schizophrenia and mood disorder characterized by hallucinations or delusions and mania and depression), bipolar disorder (manic depression), and developmental delay.

A review of the progress note dated 8/5/20 revealed that Licensed Practical Nurse (LPN) CC had to redirect P#1 to the correct room and advised P#1 that patients did not go into other patients' rooms. P#1 presented guarded, childlike, and suspicious, but was generally cooperative with staff. P#1 had a reserved affect.

A review of the progress note by MD MM dated 8/7/20 revealed that P#1 continued to demonstrate paranoia, mostly towards a male peer with whom she had been shouting from across the hallway.

A review of a progress note dated 8/9/20 revealed that P#1 was observed standing in the hallway yelling at a male peer as he was walking up and down the hallway. P#1 was provided active listening and was verbally redirected. P#1 went to the male peer's room while the male peer was lying on his bed. The staff was able to redirect P#1 after multiple attempts. P#1 walked to the day area and sat in a chair. P#1 and the male peer began yelling at each other. The staff was able to verbally redirect P#1, and education was provided for healthy coping skills.

A review of a progress note dated 8/9/20 revealed that P#1 was standing behind a male peer while he was using the telephone. P#1 was verbally redirected from standing closely behind the male peer. The male peer ended the phone call and proceeded down the hallway. P#1 began following the male peer. The male peer entered his room. P#1 proceeded back up the hallway to the day area and sat in a chair.

A progress note dated 8/9/2020 revealed a nurse reported that she educated P#1 on personal boundaries and for P#1 to concentrate on P#1's recovery and treatment.

A review of a progress note by MD MM, dated 8/10/20, revealed that P#1 was engaging in inappropriate touching and hugging behavior with one of the male peers. P#1 was overheard telling her mother that the other patient was pursuing her. Continued review revealed that P#1 had some disorganized thinking and was somewhat tangential, with very poor insight. P#1 appeared to be tolerating medication but had required redirection for behavior reasons.

A review of incident report #62712 revealed that Clinical Manager (CM) BB entered the incident details and conducted an investigation, including reviewing the environment and notifying the supervisor. Further review of a brief description of the incident revealed that P#1's grandmother called the facility and reported that P#1 entered into another male patient's (P#2) room and went into the bathroom together. P#1 administered oral sex to P#2. Further review of the notifications revealed the Administrator was notified on 8/13/2020 at 4:55 p.m.

A review of the follow-up summary dated 8/17/20 at 4:13 p.m. revealed Administrator AA referred file to CM BB for follow-up. The follow-up summary further revealed that CM BB conducted an investigation on 8/18/20 at 8:39 that revealed that on 8/5/20, P#1 came out of her room on the long hallway around 9:30 a.m. and entered the short hallway. P#1 went directly to P#2's room and stood outside P#2's door talking to him. P#2 then motioned for P#1 to come in and pointed toward the bathroom. P#1 entered the room and went into the bathroom. P#2 then got up out of bed and entered the bathroom. P#1 and P#2 were in the bathroom for a full minute. P#2 then reemerged and looked out into the hallway, shut his room door again, and returned to the bathroom. P#1 and P#2 were in the bathroom for 4 minutes. P#2 came out of the bathroom first, followed by P#1, and they exited the room separately. MD MM documented that P#1 was developmentally delayed and functioned at a second-grade level. It was also documented by nursing staff and MD MM that P#1 had been following other male patients around the unit. P#1 would stand outside their doors, and staff had to redirect P#1 continuously. Further review revealed that Administrator AA and CM BB closed the incident investigation on 8/19/2020 at 12:59.

A review of the Detailed Incident Report dated 8/13/20 revealed P#1 was named in the report as the "person affected". Continued review revealed that the incident took place on 8/5/20 between 7:01 a.m. and 11:00 a.m. in the Adult Psychology unit of the facility.

A review of the policy titled "Level of Observation," dated 1/2017 and last revised on 2/21, revealed that the level of observation was intended to provide the patient with the maximum freedom of movement and privacy with the least amount of restriction possible while ensuring the safety of that patient and others on the unit. Continued review revealed that Peer Precautions was a level of observation implemented for patients whose interaction needed to be restricted towards other peer/peers for therapeutic or clinical reasons. This could be used for patients threatening another patient, sexually acting out, or exhibiting poor boundaries. The criteria for a potential increased level of observation and factors to be considered included, but were not limited to, the inability to maintain appropriate personal space boundaries (excessive physical contact, hugging, touching, sexual gestures, sexual contact).

An interview was conducted with Registered Nurse (RN) EE on 3/22/22 at 3:20 p.m. in the conference room. RN EE stated it was the responsibility of the nurses on duty to care for their patients, which included hourly monitoring, evaluations, medication administration, and any healthcare needs the patient had. She continued to say that it was the charge nurse's responsibility to make the nurse assignments for the shift. The number of patients and their acuity (alertness) levels determined how many patients each nurse would be responsible for during the shift. RN EE said to ensure all patients were observed and remained safe on the unit, the Mental Health Technicians (MHT) monitored patients every 15 minutes and recorded their observations on an Observation Sheet. She stated that the nurses would conduct safety checks every hour and document their observations in the electronic medical record. RN EE said she was kept up to date on changes in the unit and training through daily team meetings and annual HealthStream training, including de-escalation training.

An interview was conducted with Mental Health Technician (MHT) HH on 3/23/22 at 1:20 p.m. in the conference room. MHT HH stated he had worked at the facility for five years. MHT HH explained that it was his responsibility as an MHT to keep the unit functioning and the patients safe during his shift. MHT HH said that he was responsible for performing safety checks every 15 minutes on the patients assigned and documenting their location and behavior on the Observation Sheet. He explained that safety checks for the patients included making sure you saw them and monitored what they were doing at that specific time. MHT HH stated that if a patient on the unit began to display inappropriate behavior, such as not setting boundaries, anger, or sexually acting out, he would redirect the patient into another activity or to another area on the unit. MHT HH said that if redirecting the patient was not working, he would bring the issue to the nurse's attention on the floor, who may need to intervene (get involved) with medication or contact the patient's physician for additional direction.

An interview was conducted with Clinical Manager (CM) BB on 3/24/22 at 2:45 p.m. in the conference room. CM BB stated that she recalled receiving a message from P#1's grandmother after P#1 was discharged from the facility regarding a complaint of a sexual assault. CM BB said that she could recall that the grandmother was shouting on the phone and stated that she just wanted the facility to know what had happened, and then she hung up the phone. CM BB said she could not recall returning P#1's grandmother's call after completing her investigation.

Based on a review of medical records, a review of incident reports, a review of the facility's policy and procedures, and interviews with staff, it was determined the facility failed to provide adequate nursing staff supervision for one (P#1) out of six patients sampled. P#1 was not monitored appropriately and was documented entering another patient 's private room without staff supervision.

Cross Reference A-0392 as it relates to nursing staff being aware of P#1 ' s behavior and not providing the proper monitoring. The lack of monitoring allowed P#1 to enter another patient ' s private room leading to allegations of sexual misconduct.

Based on a review of medical records, a review of incident reports, a review of the facility ' s policy and procedures, and interviews with staff, it was determined the facility failed to provide care in a safe setting for one (P#1) out of six patients sampled. P#1 was not monitored appropriately and was documented entering another patient ' s private room without staff supervision.

A review of the medical record (MR) revealed Patient P #1 was a 24-year-old female who was admitted to the facility on 8/4/20 on a 1013 (involuntary admission) for Suicidal ideation (thoughts of harming self). P#1 ' s admitting diagnosis was schizoaffective disorder (a combination of schizophrenia and mood disorder characterized by hallucinations or delusions and mania and depression), bipolar disorder (manic depression), and developmental delay.

A review of the progress note dated 8/5/20 revealed that Licensed Practical Nurse (LPN) CC had to redirect P#1 to the correct room and advised P#1 that patients did not go into other patients' rooms. P#1 presented guarded, childlike, and suspicious, but was generally cooperative with staff. P#1 had a reserved affect.

A review of the progress note by MD MM dated 8/7/20 revealed that P#1 continued to demonstrate paranoia, mostly towards a male peer with whom she had been shouting from across the hallway.

A review of a progress note dated 8/9/20 revealed that P#1 was observed standing in the hallway yelling at a male peer as he was walking up and down the hallway. P#1 was provided active listening and was verbally redirected. P#1 went to the male peer's room while the male peer was lying on his bed. The staff was able to redirect P#1 after multiple attempts. P#1 walked to the day area and sat in a chair. P#1 and the male peer began yelling at each other. The staff was able to verbally redirect P#1, and education was provided for healthy coping skills.

A review of a progress note dated 8/9/20 revealed that P#1 was standing behind a male peer while he was using the telephone. P#1 was verbally redirected from standing closely behind the male peer. The male peer ended the phone call and proceeded down the hallway. P#1 began following the male peer. The male peer entered his room. P#1 proceeded back up the hallway to the day area and sat in a chair.

A progress note dated 8/9/2020 revealed a nurse reported that she educated P#1 on personal boundaries and for P#1 to concentrate on P#1's recovery and treatment.

A review of a progress note by MD MM, dated 8/10/20, revealed that P#1 was engaging in inappropriate touching and hugging behavior with one of the male peers. P#1 was overheard telling her mother that the other patient was pursuing her. Continued review revealed that P#1 had some disorganized thinking and was somewhat tangential, with very poor insight. P#1 appeared to be tolerating medication but had required redirection for behavior reasons.

A review of incident report #62712 revealed that Clinical Manager (CM) BB entered the incident details and conducted an investigation, including reviewing the environment and notifying the supervisor. Further review of a brief description of the incident revealed that P#1's grandmother called the facility and reported that P#1 entered into another male patient's (P#2) room and went into the bathroom together. P#1 administered oral sex to P#2. Further review of the notifications revealed the Administrator was notified on 8/13/2020 at 4:55 p.m.

A review of the follow-up summary dated 8/17/20 at 4:13 p.m. revealed Administrator AA referred file to CM BB for follow-up. The follow-up summary further revealed that CM BB conducted an investigation on 8/18/20 at 8:39 that revealed that on 8/5/20, P#1 came out of her room on the long hallway around 9:30 a.m. and entered the short hallway. P#1 went directly to P#2's room and stood outside P#2's door talking to him. P#2 then motioned for P#1 to come in and pointed toward the bathroom. P#1 entered the room and went into the bathroom. P#2 then got up out of bed and entered the bathroom. P#1 and P#2 were in the bathroom for a full minute. P#2 then reemerged and looked out into the hallway, shut his room door again, and returned to the bathroom. P#1 and P#2 were in the bathroom for 4 minutes. P#2 came out of the bathroom first, followed by P#1, and they exited the room separately. MD MM documented that P#1 was developmentally delayed and functioned at a second-grade level. It was also documented by nursing staff and MD MM that P#1 had been following other male patients around the unit. P#1 would stand outside their doors, and staff had to redirect P#1 continuously. Further review revealed that Administrator AA and CM BB closed the incident investigation on 8/19/2020 at 12:59.

A review of the Detailed Incident Report dated 8/13/20 revealed P#1 was named in the report as the "person affected". Continued review revealed that the incident took place on 8/5/20 between 7:01 a.m. and 11:00 a.m. in the Adult Psychology unit of the facility.

A review of the policy titled "Level of Observation," dated 1/2017 and last revised on 2/21, revealed that the level of observation was intended to provide the patient with the maximum freedom of movement and privacy with the least amount of restriction possible while ensuring the safety of that patient and others on the unit. Continued review revealed that Peer Precautions was a level of observation implemented for patients whose interaction needed to be restricted towards other peer/peers for therapeutic or clinical reasons. This could be used for patients threatening another patient, sexually acting out, or exhibiting poor boundaries. The criteria for a potential increased level of observation and factors to be considered included, but were not limited to, the inability to maintain appropriate personal space boundaries (excessive physical contact, hugging, touching, sexual gestures, sexual contact).

An interview was conducted with Registered Nurse (RN) EE on 3/22/22 at 3:20 p.m. in the conference room. RN EE stated it was the responsibility of the nurses on duty to care for their patients, which included hourly monitoring, evaluations, medication administration, and any healthcare needs the patient had. She continued to say that it was the charge nurse's responsibility to make the nurse assignments for the shift. The number of patients and their acuity (alertness) levels determined how many patients each nurse would be responsible for during the shift. RN EE said to ensure all patients were observed and remained safe on the unit, the Mental Health Technicians (MHT) monitored patients every 15 minutes and recorded their observations on an Observation Sheet. She stated that the nurses would conduct safety checks every hour and document their observations in the electronic medical record. RN EE said she was kept up to date on changes in the unit and training through daily team meetings and annual HealthStream training, including de-escalation training.

An interview was conducted with Mental Health Technician (MHT) HH on 3/23/22 at 1:20 p.m. in the conference room. MHT HH stated he had worked at the facility for five years. MHT HH explained that it was his responsibility as an MHT to keep the unit functioning and the patients safe during his shift. MHT HH said that he was responsible for performing safety checks every 15 minutes on the patients assigned and documenting their location and behavior on the Observation Sheet. He explained that safety checks for the patients included making sure you saw them and monitored what they were doing at that specific time. MHT HH stated that if a patient on the unit began to display inappropriate behavior, such as not setting boundaries, anger, or sexually acting out, he would redirect the patient into another activity or to another area on the unit. MHT HH said that if redirecting the patient was not working, he would bring the issue to the nurse's attention on the floor, who may need to intervene (get involved) with medication or contact the patient's physician for additional direction.

An interview was conducted with Clinical Manager (CM) BB on 3/24/22 at 2:45 p.m. in the conference room. CM BB stated that she recalled receiving a message from P#1's grandmother after P#1 was discharged from the facility regarding a complaint of a sexual assault. CM BB said that she could recall that the grandmother was shouting on the phone and stated that she just wanted the facility to know what had happened, and then she hung up the phone. CM BB said she could not recall returning P#1's grandmother's call after completing her investigation.