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Based on observations, record reviews, and staff interviews it was determined the facility failed to ensure Patient # 1 received care in an environment that a reasonable person would consider to be safe for one (1) of ten (10) sampled patients. Patient # 1, who was admitted to the Acute Care Psychiatric Hospital under a court ordered commitment on 04/04/14, was placed on a unit with twenty (20) male residents and she was the only female patient present on the floor, at the time of the complaint allegation.

The findings include:

Record review revealed Patient #1 was a female patient admitted to the hospital on 04/04/14 with diagnoses which included Bi -Polar Disorder, Alcohol Dependence, Opiate Abuse, Hypertension, Hyperlipidemia, COPD, and Asthma. Further record review revealed Patient #1 and Patient #2 were both their own responsible parties.

Record review revealed Patient #1 was sent to a newly changed co-ed unit on 04/04/14; however Patient #1 was the only female patient with twenty (20) male patients.

During an interview with Patient #1 on 04/09/13 at 3:15 PM she related that when she was the only women on the unit she was still "pretty loopy" and did not feel very safe.

Review of the facility report revealed on 04/06/14 at approximately 4:22 PM Patient #1 was observed exiting the bedroom of Patient #2, a male patient. Review of the facility's investigation revealed Patient #1 as seen my staff entering Patient #2's room at approximately 4:17 PM, Patient #1 was clothed when exiting the room but had wet hair. She reported to staff that she had sex with Patient #2 for a "joint" and handed staff a rolled tobacco cigarette. The investigation revealed Patient #2 stated Patient #1 gave him a kiss for the cigarette. Further review of the investigation revealed the facility took appropriate action following the incident.

During an interview with Registered Nurse (RN) #1 at 10:30 AM on 04/09/14 he revealed he was assigned to the unit during Patient #1's admission and stated the patient was flirty with other men, before and after the incident on 04/06/14. She was confused before the incident and she was the only woman at the time on the floor; they had just started to integrate the co-ed area on this floor. She was the only female patient and there were twenty (20) male patients on the floor.

Interview with Mental Health Associate (MHA) #1 at 11:40 AM on 04/09/14 revealed she was trained on that floor in November 2013 and it was an all male floor, the co-ed floor just stated a couple of weeks ago. MHA #1 further stated before the incident Patient # 1 was peeking into the different rooms, but was never actually observed going into other rooms.

Interview with the Nurse Administrator for the hospital at 11:00 AM on 04/10/14 revealed he did not know how one (1) female patient was with twenty (20) male patients on the same unit. He related he would look into the admission procedure to make sure the male/female ratios were more equal.