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Based on review of documentation it was determined that the hospital failed to ensure that patients were protected from harm (sexually inappropriate behaviors).

Findings were:
The hospital failed to provide an environment which protected patients from inappropriate sexual behaviors. Patient #1 and #2 engaged in sexually inappropriately behavior on 6/15/2018. Both patient's medical records contained documentation of sexual inappropriate behaviors prior to the 6/15/2018 incident.

Review of the medical record (first admission) for patient #1 revealed:
Psychiatrist Progress Notes
4/9/18 at 1435 stated: "6 foot rule from boys- acting inappropriately."

Nursing Progress Notes
4/9/18 at 1545 hours: "She is flirtatious with male peers, requiring redirection. Dr. wrote order for 6 foot restriction from male peers d/t sexually inappropriate behavior over weekend."

Nursing Progress Notes
4/18/18 at 1717 hours: "During morning group therapy session, staff noticed that a male peers hand was in patients lap underneath the table and out of view of the therapist that was running the group. Staff went into the dayroom and reminded patients of their boundaries and to not touch one another. The male patient got agitated and was asked to leave the group. (Name of patient #1 here) was later pulled aside by staff and a therapist who she told that the male peer did touch her vagina and (overclothes) that it was not consensual. When nurse asked for a witness statement from patient she said she did not want to get him in trouble because he is her friend. She said that she "lied" to staff previously about it not being consensual and that she actually "didn't mind it." Nursing supervisor, Director of Nursing, and clinical Director have been made aware of the situation, as well as patient's mother. A CPS report will be filed as the patient is 13 and the peer accused of touching is 17."

Review of medical record for patient #1 (second admission) revealed:
Physician Orders
6/13/18 at 1600 hours, 6 foot restriction from peers, the rationale was listed as boundaries, safety. This order was d/c'ed on 6/14/18 at 845am
6/15/18 at 1801 hours, May not program w/male peers, 6 foot rule from males, Q 5 obs for SAO
6/16/18 at 1630 hours, 6 foot rule from male peers, therapeutic rationale was listed as SAO
6/17/18 at 1230 hours, 6 foot from male peers, therapeutic rationale was listed as SAO

Review of Psychiatrist Progress Notes
6/14/18 at 1100 hours stated: "She appears to be cheerful & interactive with peers, also with poor boundary, needed to be placed on 6 foot rule.

Review of Nursing Progress Notes
6/13/18 at 1320 hours: "Pt has poor boundaries with male peer and when male peers are around pt bullying another peer. Pt placed on 6 foot restriction per MD order."

6/14/18 at 9:30 hours: "Pt denies contact with in one relationships, however per staff pt is inappropriate with male peers. Due to continued poor boundaries with male peers despite redirection, MD ordered 6 ft restriction from male peers. RN will continue to monitor pt closely

Review of medical record for patient #2 revealed:
Physician Orders
5/9/2018 at 1715 hours, Unit restriction for SAO for 24 hours.

5/1/2018 at 0910 hours, 6 ft distance from all peers for SAO Behavior

4/26/2018 at 0930 hours, #1 SAO precaution, #2 Q 5 min observation for SAO Behavior, #3 Unit Restriction for SAO Behav.

4/27/2018 at 0915, No group for 3 days - SAO towards Staff/Aggression towards Staff/Therapist

4/18/2018 at 1813 hours, 6 ft distance from peer- SAO Behavior. Sexual Precaution for SAO behavior.

Psychiatrist Progress Notes
4/18/18 at 1530 hours, "Pt denies any new issues. Staff reports he has problem with boundaries & he is making other girls feel uncomfortable around him, will place a 6 ft - distance rule on him. Denies SI/HI. Still waiting for CPS placement."

Nursing Progress Notes
4/18/18 at 1846 hours: "During morning group therapy session, staff noticed that patient's hand was on a female peers thigh under the table and out of view of the therapist who was running the group. Staff went into dayroom and reminded patients of their boundaries and to not touch one another. Patient became agitated and was asked to leave the group. Female patient was later pulled aside by staff and therapist who she told that the patient did touch her vagina (over clothes) and that it was not consensual. The female peer later old staff that she didn't want to get the patient in trouble because he is her friend and that she had lied to staff about it not being consensual and that she actually "didn't mind it." Nursing supervisor, Director of Nursing, Clinical Director and CPS Caseworker of patient have been notified, as well as the mother of female peer. CPS will be notified of the situation, as patient is 17 and peer is 13."

Patient Observation sheets
Review of these documents revealed that patient #2 had on at least 52 separate occasions to include: 4/9/2018, 4/10/2018, 4/11/2018, 4/26/2018, 4/27/2018, 4/28/2018, 4/29/2018, 4/30/2018, 5/01/2018, 5/02/2018, 5/03/2018, 5/04/2018, 5/05/2018, 5/06/2018, 5/07/2018, 5/08/2018, 5/09/2018, 5/10/2018, 5/11/2018, 5/12/2018, 5/13/2018, 5/14/2018, 5/16/2018, 5/17/2018, 5/18/2018, 5/19/2018, 5/20/2018, 5/21/2018, 5/22/2018, 5/23/2018, 5/24/2018, 5/25/2018, 5/26/2018, 5/27/2018, 5/28/2018, 5/29/2018, 5/30/2018, 5/31/2018, 6/01/2018, 6/02/2018, 6/03/2018, 6/04/2018, 6/05/2018, 6/06/2018, 6/07/2018, 6/08/2018, 6/09/2018, 6/10/2018, 6/11/2018, 6/12/2018, 6/13/2018, 6/14/2018 was documented as being on sexual acting out precautions.

Review of documentation (Email, dated 6/20/2018 which was provided to surveyor by facility staff) stated: "On the morning of 06/18/18 I spoke with (name of patient #1 here) concerning the alleged incident between her and a male peer on unit B. (Name of patient #1 here) was resistant to speak with me at first when I asked her what happened. She stated "I don't know what to say because I don't want to get him in trouble". I told her that I was only interested in the truth so I could get any accurate depiction of the events for future performance improvement processes. She stated "it was my idea, I wanted him to do it". I asked her if she was admitting that the alleged event was true. She shrugged her shoulders and stated "yeah". She again made clear that it was consensual and she wanted him to do it. I spoke with her about respecting her own body and how important it was for her not to engage in any sexual activity while she was receiving treatment at our facility. She stated she understood."

Review of hospital policy entitled: "Sexual Acting Out Precautions" NO: PC-055 stated under the purpose section: "The purpose of this policy is to provide a safe environment for all patients and staff." The policy section stated: "Cross Creek Hospital is committed to providing a safe environment for all patients and staff. Patients who are believed to have a history of sexual behavior will be observed closely and every attempt will be made to protect others from such conduct. Patients with a history of SAO are identified prior to admission and during the assessment process after admission. The degree of sexual allegations and observation are determined and reviewed continually during the treatment planning process."

Based on review of documentation and interview it was determined that the hospital failed to ensure that the physician signed the medication consent forms for patient #1.

Findings were:
The physician did not sign the medication consent forms for patient #1. Review of Medication Consent- Psychotropic's, 3 separate medication consent forms were found in the chart. One was for Abilify (dated 4/16/18), another was for Prozac (dated 4/5/18), and a third medication consent was Melatonin (hand written and dated 4/4/18). The back side of each of these consent forms had an area where family and staff were to sign. The required signatures were to include: Patient or Legal Representative, Nurse, Witness, Physician. On all three of these medication consent forms the area where the Physician was to sign was found to be blank with no signature from the physician.

Review of Policy entitled: "Documentation Protocol" NO: HIM-012 stated under the policy section: "Cross Creek Hospital records, reports, charts and documents are to be accurate, truthful and complete. Staff is to document accurately our services provided, patient interactions, and all financial transactions. Every staff who creates or reviews documentation in a medical record, or responds to or implements orders or directives contained in a medical record, ensures the medical record complies with this Protocol. This duty to ensure accuracy of medical records applies to the entire medical record, not just documentation a staff individually creates, reviews or acts upon." Item 3. Authentication, under the Procedure section stated: "Medical record entries are to be authenticated by the author of the entry. Entries are to be confirmed by written signature, date, time and credentials." Item 6. Compliance stated: "If staff finds that records, reports, charts and documents are not accurate, truthful and complete or documentation protocols are not implemented appropriately, staff is to follow the chain of command in communication with his/her supervisor. If staff feels that he/she cannot communicate with his/her supervisor, the anonymous reporting opportunity of the Corporate Compliance hotline is continuously available."

In an interview with staff member #1 on the morning of 7/24/2018 it was confirmed that the above referenced medication consents had not been signed by the physician.

Based on review of documentation and interview it was determined that the hospital failed to ensure the medical record was completed.

Findings were:
The treatment plan for patient #2 was incomplete as there were multiple areas in the treatment plan which had not been signed or were incomplete. Review of Interdisciplinary Treatment Plan Update revealed on 4/19/18 that the area where the Physician was to sign and date/time was blank with no signature found.

Review of Interdisciplinary Treatment Plan Update revealed on 5/3/18 that the area where the Physician was to sign and date/time was blank with no signature found. Additionally the area where the physician was to: "Indicate Reason(s) Patient Continues to Need Hospitalization" contained 9 areas which could be checked by the physician, none had been checked.

Review of Interdisciplinary Treatment Plan Update revealed on 5/15/18 that the area where the Physician was to sign and date/time was blank with no signature found. Additionally the area where the physician was to: "Indicate Reason(s) Patient Continues to Need Hospitalization" contained 9 areas which could be checked by the physician, none had been checked.

Review of Interdisciplinary Treatment Plan Update revealed on 6/14/18 that the area where the
Therapist was to sign and date/time was blank with no signature found. Additionally the area where the "Activity/Recreational Therapy" contained options which could be checked by the therapist, none had been checked. This area also contained the comment: "Complete Section Below." It was not completed.

Review of Interdisciplinary Treatment Plan Update revealed on 6/21/18 that the area where Nursing was to complete was blank and the area where nursing staff was to sign, date enter the time of their signature was also found to blank with no signature found.

Review of hospital policy entitled: "Treatment Planning" NO: PC-047 stated under the policy section: "Each patient's treatment shall be guided by a multidisciplinary treatment plan. The treatment plan is the tool used by the physician and multi-disciplinary treatment team to implement the physician ordered services and move the patient toward the expected outcomes and goals." The policy stated under the procedure section: "2.0 The nursing staff is responsible for developing the Initial Treatment Plan with twenty-four (24) hours of admission." Section "4.0 Guidelines of Treatment Plans: 4.1 The treatment plan shall be an accurate and functional representation of the patient's treatment experience." "4.3.3 Treatment plan goals shall be modified and resolved as treatment progresses." "5.0 Treatment plan updates shall be documented at least weekly, as the physician and treatment team asses (sic) the patient's current clinical status, reviews progress towards treatment plan goals, and make necessary modifications." "6.0 The Treatment Plan shall be reviewed in the Multidisciplinary Treatment Team meeting, The treatment team includes the physician, unit nurse, and clinical staff." "7.0 A review of the patient's Treatment Plan following any major clinical change shall be conducted, and appropriate modifications made." "9.0 The overall responsibility for the Treatment Plan is assigned to the attending physician who must indicate approval by signature."

Review of hospital policy entitled: "Documentation Protocol" NO: HIM-012 stated under the policy section: "Cross Creek Hospital records, reports, charts and documents are to be accurate, truthful and complete. Staff is to document accurately our services provided, patient interactions, and all financial transactions. Every staff who creates or reviews documentation in a medical record, or responds to or implements orders or directives contained in a medical record, ensures the medical record complies with this Protocol. This duty to ensure accuracy of medical records applies to the entire medical record, not just documentation a staff individually creates, reviews or acts upon." Item 3. Authentication, under the Procedure section stated: "Medical record entries are to be authenticated by the author of the entry. Entries are to be confirmed by written signature, date, time and credentials." Item 6. Compliance stated: "If staff finds that records, reports, charts and documents are not accurate, truthful and complete or documentation protocols are not implemented appropriately, staff is to follow the chain of command in communication with his/her supervisor. If staff feels that he/she cannot communicate with his/her supervisor, the anonymous reporting opportunity of the Corporate Compliance hotline is continuously available."

In an interview with hospital staff member #1 on the morning of 7/24/2018 it was confirmed that the treatment plan for patient #2 had not been completed as there were missing signatures as well as areas that had not been completed in the treatment plan.

Based on review of documentation and interview it was determined that the hospital failed to ensure the treatment plan for patient #2 was updated to accurately reflect the patient's behavior(s) and progress.

Findings were:
The treatment plan for patient #2 did not accurately reflect the patient's behavior(s) and progress. Patient #2 was admitted to the hospital on 4/15/2018 and discharged on 6/28/2018, a period of approximately 75 days. During the hospitalization, there was significant documentation in the medical record concerning sexually inappropriate behaviors (see below) but the only documentation in the treatment plan stated on 4/16/18 the comment: "Pt is attending (illegible lettering) regularly. Pt is disruptive 90% of the time AEB inappropriate boundaries, hyper-verbosity, verbal aggression, side conversations and vulgar language."

Additional documentation found in the medical record of patient #2 regarding sexually inappropriate behaviors included:

Review of the Patient Observation Sheets revealed that patient #2 was on precautions for sexually acting out for the majority of the hospitalization. Hospitalization dates were from 4/15-6/28/2018.

Review of Psychiatrist Progress Notes revealed:
6/18/18, "Pt is doing Ok now, Staff reported some SAO behavior over the weekend (illegible word) on peer. Apparently provoked by the peer (illegible) was placed on 6ft rule. Pt is doing ok at this time. Waiting for placement 0 new issues."

4/18/18 at 1530 hours, "Pt denies any new issues. Staff reports he has problem with boundaries & he is making other girls feel uncomfortable around him, will place a 6 ft - distance rule on him. Denies SI/HI. Still waiting for CPS placement."

Review of the Nursing Notes revealed:
4/18/18 at 1846 hours: "During morning group therapy session, staff noticed that patient's had was on a female peers thigh under the table and out of view of the therapist who was running the group. Staff went into dayroom and reminded patients of their boundaries and to not touch one another. Patient became agitated and was asked to leave the group. Female patient was later pulled aside by staff and therapist who she told that the patient did touch her vagina (over clothes) and that it was not consensual. The female peer later old staff that she didn't want to get the patient in trouble because he is her friend and that she had lied to staff about it not being consensual and that she actually "didn't mind it." Nursing supervisor, Director of Nursing, Clinical Director and CPS Caseworker of patient have been notified, as well as the mother of female peer. CPS will be notified of the situation, as patient is 17 and peer is 13."

6/15/18 at 1230 hours: "It was reported to staff that over the weekend patient "fingered" a female peer and the female peer touched patient's penis. This was not observed by staff. Therapist, doctor, DON, CEO, and house supervisor have all been notified of the incident. A CPS report has been made due to the age difference of the patient's and it will be reported to the state as well. CPS confirmation # is (case number here). It has been ordered that patient is not to program with the female patients. A voicemail has been left with caseworker, (name of case worker here) to call back regarding incident. Will continue to closely monitor to ensure this does not happen again."

6/16/18 at 1700 hours: "17:00- Pt disruptive in groups, inappropriate with boundaries with female peers, uncooperative at times. Requires frequent redirection. Denies SI/HI/AVH today. Compliant with AM meds, denies notable side effects, confirms efficacy for mood stability. Pt had visit with mother today. Reports all went well, positive visit. Pt received vistaril d/t anxiety. Staff cont. to enforce boundaries and distance from female peers. Staff will cont to monitor for safety."

Review of hospital policy entitled: "Treatment Planning" NO: PC-047 stated under the policy section: "Each patient's treatment shall be guided by a multidisciplinary treatment plan. The treatment plan is the tool used by the physician and multi-disciplinary treatment team to implement the physician ordered services and move the patient toward the expected outcomes and goals." The policy stated under the procedure section: "2.0 The nursing staff is responsible for developing the Initial Treatment Plan with twenty-four (24) hours of admission." Section "4.0 Guidelines of Treatment Plans: 4.1 The treatment plan shall be an accurate and functional representation of the patient's treatment experience." "4.3.3 Treatment plan goals shall be modified and resolved as treatment progresses." "5.0 Treatment plan updates shall be documented at least weekly, as the physician and treatment team asses (sic) the patient's current clinical status, reviews progress towards treatment plan goals, and make necessary modifications." "6.0 The Treatment Plan shall be reviewed in the Multidisciplinary Treatment Team meeting, The treatment team includes the physician, unit nurse, and clinical staff." "7.0 A review of the patient's Treatment Plan following any major clinical change shall be conducted, and appropriate modifications made." "9.0 The overall responsibility for the Treatment Plan is assigned to the attending physician who must indicate approval by signature."

In an interview with staff member #1 on the morning of 7/24/2018 the surveyor was told by staff #1 that anytime there is a significant change in patient behaviors to include: restraint, seclusion, self injurious behaviors or sexually inappropriate behaviors the treatment plan should be updated. It was confirmed in the same interview that the treatment plan for patient #2 should have been updated to accurately reflect the behaviors and issues that patient #2 was exhibiting.