HospitalInspections.org

Based on observation, document review, record review and staff interview it was determined the hospital failed to maintain the patient's right to be involved in treatment and care decisions (see Tag A 131); failed to ensure care was provided in a safe setting (see Tag A 144); failed to establish a safe method for making room assignments (see Tag A 145); and, failed to follow abuse policies when allegations were made (see Tag A 145).

Based on staff interview and record review it was determined the hospital failed to maintain the patient's right to be involved in treatment and care decisions for one (1) of two (2) patients reviewed who made allegations of abuse (patient #1). This failure resulted in a violation of rights and could potentially result in rights' violations for other patients.

Findings include:

1. Separate interviews with Behavioral Health Technicians (BHT) #1 and #2 and Day Shift Registered Nurse (RN) #1 in the afternoon of 5/1/17 and with Licensed Practical Nurse (LPN) #1 in the morning of 5/3/17 revealed patient #1, who is a minor, made allegations of sexual abuse in the afternoon of 4/26/17.

2. Review of the clinical record for patient #1 revealed there was no documentation related to abuse allegations or any interventions related to abuse allegations. The record reflected the patient was discharged home with his mother at 4:19 p.m. on 4/26/17. The record reflected the patient/patient representative were not afforded the information needed in order to make informed decisions related to the abuse allegations.

3. The above findings were reviewed with the Children's Unit Program Manager in the morning of 5/2/17 and she agreed with the findings.

Based on observation, record review, document review and staff interview it was determined the hospital failed to ensure care was provided in a safe setting for one (1) of one (1) patients reviewed who was admitted to a room with a patient with a history of inappropriate sexual behaviors and later made allegations of abuse (patient #1). This failure creates a potential for unsafe care for all patients.

Findings include:

1. Review of the clinical record for patient #2 revealed he was admitted on 4/5/17. Physician #1 wrote an order on 4/5/17 for "Private room d/t sexual inappropriateness."

2. Review of the clinical record for patient #1 revealed he was admitted in the evening of 4/21/17. Review of the 4/21 to 4/22/17 monitoring sheets documented by staff revealed patient #1 was assigned to the same room as patient #2, who was ordered to be placed in a private room.

3. An interview with the Admitting Registered Nurse (RN) for patient #1 was conducted at 9:00 a.m. on 5/3/17. She acknowledged she did not check orders prior to making room assignments and assigned patient #1 to the same room as patient #2. The RN stated she did not know patient #2 had an order for a private room.

4. A tour and observation was conducted on the Children's Unit from 11:00 a.m. to 11:45 a.m. on 5/1/17. During the tour an interview was conducted at 11:10 a.m. with Day Shift RN #1 who was the only RN on the Unit. She stated there were five (5) patients on the unit with private room orders. She was asked if private room status is reviewed in the nursing shift report. She stated, "No, not always." She provided the Children's Unit Daily Shift Report for 4/21/17 and 5/1/17. The Daily Report did not reflect patient #2 had an order for a private room.

5. An interview was conducted with the Children's Unit Manager at 10:00 a.m. on 5/1/17. She stated she was made aware patient #1 reported he was sexually abused by patient #2 on 4/26/17. The Manager stated she investigated the allegation on 4/27/17 after patient #1 was discharged. She confirmed her investigation revealed the nurse did not check orders and assigned patient #1 to the same room as patient #2. She stated patient #2 was moved to a private room as a result of the investigation, but confirmed no other steps were taken to address the process issues which allowed the mistake to occur.

6. On 5/1/17 at 1:00 p.m. the Medical Director was interviewed. He confirmed he was not aware of the incident. He stated he would immediately ensure that each nursing unit initiated a private room list that would be kept current and reviewed prior to any room changes or assignments.

7. The Chief Executive Officer (CEO) was interviewed at 9:15 a.m. on 5/2/17. She stated the hospital was making changes to introduce necessary processes that hadn't been in place in the past. She confirmed the immediate corrections to abate the Immediate Jeopardy had been put in place on 5/1/17. The CEO acknowledged the electronic record system utilized for the quality analysis program was not user friendly. She stated abuse allegations were currently tracked but not trended. She also acknowledged the hospital had not recognized and responded accordingly to the abuse allegation. She stated the hospital was looking to update the electronic record system and implement an immediate priority based system for incident reporting and investigation. She stated more corrective actions would be taken to address mistakes and ensure provision of safe care in the future.

A. Based on record review, document review and staff interview it was determined the hospital failed to establish a safe method for making room assignments. This deficient practice impacted one (1) of one (1) patients reviewed who had an inappropriate room assignment which placed him at risk for abuse (patient #1). This failure has the potential to increase the risk of abuse for all patients.

Findings include:

1. Review of the clinical record for patient #2 revealed Physician Assistant #1 wrote a 4/5/17 order for a "Private room d/t sexual inappropriateness."

2. An interview was conducted with the Admitting Registered Nurse (RN) for patient #1 at 9:00 a.m. on 5/3/17. She acknowledged she did not check orders prior to making room assignments and assigned patient #1 to the same room as patient #2 on the evening of 4/21/17. She stated she did not know patient #2 had an order for a private room.

3. An interview was conducted with the Children's Unit Program Manager at 10:00 a.m. on 5/1/17. She stated she was made aware on 4/26/17 that patient #1 alleged sexual abuse by patient #2. She confirmed she didn't investigate the allegation until 4/27/17 which was after patient #1 was discharged. The Manager stated her investigation revealed patient #1 was assigned to the same room as patient #2 on admission. She stated the room numbers were not entered correctly in the electronic record but handwritten room check sheets for 4/21 and 4/22/17 and staff interview confirmed the patients were placed in the same room. She stated she could not rule out that the abuse may have occurred.

Additional investigation during the course of the survey revealed patient #1 was not moved out of the room of patient #2 until the evening shift on 4/22/17. Patient #1 spent the evening shift and night shift on 4/21/17 and day shift and evening shift on 4/22/17 with the patient #2. Nursing staff never identified the mistaken room assignment. The patient was moved, per his request, away from patient #2. The Manager stated information was gained through phone interview with the weekend RN as it was not documented in the clinical record.

4. An interview was conducted with RN #1 at 11:10 a.m. on 5/1/17 while touring the Children's Unit. She confirmed there were five (5) current patients with orders for private rooms due to dangerous behaviors. She stated private room orders for patients are not always reviewed during nursing shift report. She provided the daily nursing reports for both 4/21/17 and 5/1/17, neither of which indicated patient #2 had a private room order.

B. Based on document review, record review and staff interview it was determined the hospital failed to follow abuse policies when allegations were made for one (1) of two (2) patients reviewed who alleged abuse (patient # 1). This failure places all patients at increased risk of abuse.

Findings include:

1. The "Allegations of Patient Abuse," policy, revised 3/17, was provided for review. The policy states, in part: "Any allegations by patient or others, of patient abuse...will be viewed with the utmost seriousness. All allegations will be fully investigated...The individual receiving the allegation will immediately notify the Administrator of the allegation, complete an incident report regarding the allegations as soon as possible and forward to the Administrator...The physician will be responsible for making an immediate assessment of the patient and provide for any care...A written report, including any recommendations, regarding the allegations will be completed and given to the Administrator within 48 hours following receipt of the allegations...Any person who has reasonable cause to suspect that a child is neglected or abused...will fine immediately, not more than 48 hours after evidence of suspected abuse or neglect, the circumstances and cause a report to be made to the Department of Health and Human Resources."

2. The "Abuse Reporting-Adult/Child and Documentation" policy, last reviewed 5/16, was provided for review. The policy states, in part: "Suspected incidents of adult or child abuse, neglect, or emergency situations will be reported as mandated under West Virginia Adult Protective Services Law, Chapter 9, Article 6 and West Virginia Child Protective Law, Chapter 49 of the State Code. A Child Protective Services/Adult Protective Services Form will be completed and sent to DHHR following any report of suspected and/or neglect of patients."

3. Separate interviews with Behavioral Health Technicians (BHT) #1 and #2 and Day Shift Registered Nurse (RN) #1 in the afternoon of 5/1/17 and with Licensed Practical Nurse (LPN) #1 in the morning of 5/3/17 revealed patient #1, who is a minor, made allegations of sexual abuse in the afternoon of 4/26/17.

4. Review of the clinical record for patient #1 revealed there was no documentation related to abuse allegations or any interventions related to abuse allegations.

5. Interviews with the Interim Director of Nursing and Director of Quality at 9:45 a.m. on 5/1/17 revealed they were not familiar with the abuse allegation made by patient #1.

6. Separate interviews with both the Medical Director and Attending Psychiatrist for patient #1, in the early afternoon of 5/1/17, revealed neither was aware of the abuse allegation.

7. An interview with the Chief Executive Officer was conducted at 9:15 a.m. on 5/2/17. She acknowledged she was not aware of the abuse allegation. She stated the hospital was in midst of multiple process changes which were meant to improve the quality of care. She stated the hospital would make necessary changes to the incident reporting/investigation system.

Based on document review and staff interview it was determined the hospital failed to identify, investigate and respond to an allegation of sexual abuse in a timely and thorough manner as required by policy (see Tag A 283); the governing body failed to ensure administrative staff were accountable for clear expectations of safety (see Tag A 286); and, the governing body failed to maintain on-going performance improvement efforts which adequately address patient safety needs (see Tag A 309).

Based on document review, record review and staff interview it was determined the hospital failed to identify, investigate and respond to an allegation of sexual abuse of a patient in a timely and thorough manner as required by policy. The deficient practice occurred in one (1) of two (2) patients reviewed who made allegations of abuse (patient #1). This failure creates the potential for an adverse effect on health outcomes, patient safety and quality of care.

Findings include:

1. Separate interviews with Behavioral Health Technicians (BHT) #1 and #2 and Day Shift Registered Nurse (RN) #1 in the afternoon of 5/1/17 and with Licensed Practical Nurse (LPN) #1 in the morning of 5/3/17 revealed patient #1 made allegations of sexual abuse in the afternoon of 4/26/17.

2. Review of the clinical record for patient #1 revealed there was no documentation related to abuse allegations or any interventions related to abuse allegations.

3. Interviews with the Director of Risk and Interim Director of Nursing at 9:45 a.m. on 5/1/17 revealed neither were familiar with abuse allegations made by patient #1.

4. Separate interviews with both the Medical Director and Attending Psychiatrist for patient #1, in the early afternoon of 5/1/17, revealed neither were aware of the abuse allegations.

5. Interview with the Children's Unit Program Manager at 8:40 a.m. on 5/2/17 revealed she initiated the investigation into the abuse allegations on 4/27/17 after patient #1 was discharged. She stated her investigation confirmed patient #1 may have been sexually abused due to being mistakenly assigned to another patient's room who was supposed to have a private room due to a history of inappropriate sexual history. She stated she discussed the findings with the Director of Quality on 4/27/17.

6. At the time of entrance in the morning of 5/1/17, no steps had been taken to address the nursing process that resulted in admission of patient #1 to the room of patient #2 (the patient who had a history of sexual inappropriateness and allegedly sexually abused patient #1). Additionally, the investigation notes did not identify the failure to initiate a timely investigation at the time of the allegations of 4/26/17, nor the failure of staff to document the allegation in the clinical record and follow policy for staff notification, assessment, follow-up, notification of guardian and Child Protective Services as required.

7. An interview was conducted with the Director of Quality at 9:00 a.m. 4/2/17. She stated she had discussed the quality review process with the Chief Executive Officer and changes would need to be made.

Based on record review, document review and staff interview it was determined the governing body failed to ensure administrative staff were accountable for clear expectations of safety. This deficient practice was identified in one (1) of two (2) patients reviewed who alleged abuse (patient #1). This failure has the potential to result in patient needs not being met and can negatively impact the quality of care for all patients.

Findings include:

1. The "Allegations of Patient Abuse," policy, revised 3/17, was provided for review. The policy states, in part: "Any allegations by patient or others, of patient abuse...will be viewed with the utmost seriousness. All allegations will be fully investigated...The individual receiving the allegation will immediately notify the Administrator of the allegation, complete an incident report regarding the allegations as soon as possible and forward to the Administrator...The physician will be responsible for making an immediate assessment of the patient and provide for any care...A written report, including any recommendations, regarding the allegations will be completed and given to the Administrator within 48 hours following receipt of the allegations...Any person who has reasonable cause to suspect that a child is neglected or abused...will fine immediately, not more than 48 hours after evidence of suspected abuse or neglect, the circumstances and cause a report to be made to the Department of Health and Human Resources."

2. The "Abuse Reporting-Adult/Child and Documentation" policy, last reviewed 5/16, was provided for review. The policy states, in part: "Suspected incidents of adult or child abuse, neglect, or emergency situations will be reported as mandated under West Virginia Adult Protective Services Law, Chapter 9, Article 6 and West Virginia Child Protective Law, Chapter 49 of the State Code. A Child Protective Services/Adult Protective Services Form will be completed and sent to DHHR following any report of suspected and/or neglect of patients."

3. An interview with the Director of Quality at 9:50 a.m. on 5/1/17 revealed she was not familiar with abuse allegations made by patient #1.

4. Review of the clinical record for patient #2 revealed Physician Assistant #1 wrote orders on 4/5/17 for "Private room d/t sexual inappropriateness."

5. An interview was conducted with the Admitting Registered Nurse (RN) for patient #1 at 9:00 a.m. on 5/3/17. She acknowledged she did not check orders prior to making room assignments and assigned patient #1 to the same room as patient #2. She stated she did not know patient #2 had an order for private room.

6. Separate interviews with Behavioral Health Technicians (BHT) #1 and 2 and Day Shift RN #1 in the afternoon of 5/1/17 and with Licensed Practical Nurse (LPN) #1 in the morning of 5/3/17 revealed patient #1, who is a minor, made allegations of sexual abuse in the afternoon of 4/26/17.

7. An interview was conducted with the Children's Unit Program Manager in both the morning of 5/1/17 and morning of 5/2/17. She provided investigation notes on 5/1/17 and stated she investigated the sexual abuse allegation on 4/27/17 after patient #1 had been discharged. She stated she could not rule out the abuse had occurred. The Manager confirmed she discussed the findings of the investigation with the Director of Quality on 4/27/17.

The Manager confirmed no steps had been taken to address the nursing process that resulted in the error in room assignment at admission. She confirmed there was no documentation of the allegation in the clinical record for patient #1. She confirmed the hospital had failed to follow the abuse policy, including the failure to report the abuse allegation to Child Protective Services as required by law.

8. An interview was conducted with the Director of Quality at 9:00 a.m. 5/2/17. She stated she had discussed the quality review process with the Chief Executive Officer and changes would need to be made.

Based on staff interview it was determined the hospital's governing body failed to maintain on-going performance improvement efforts which adequately addressed patient safety needs in one (1) of two (2) records reviewed (patient #1). This failure places all patients at increased risk of harm.

Findings include:

1. An interview was conducted with the Children's Unit Program Manager in both the morning of 5/1/17 and morning of 5/2/17. She provided investigation notes on 5/1/17 and stated she investigated a 4/26/17 sexual abuse allegation made by patient #1 on 4/27/17 after the patient had been discharged. She stated she confirmed there was an error by the nurse when bed assignments were made and she could not rule out the abuse may have occurred. The Manager confirmed she discussed findings of the investigation with the Director of Quality on 4/27/17.

The Manager confirmed no steps had been taken to address the nursing process that resulted in the room assignment error at admission. She confirmed there was no documentation of the allegation in the clinical record for patient #1. She also confirmed the hospital had failed to follow the abuse policy, including the failure to report the abuse allegation to Child Protective Services as required by law.

2. An interview was conducted with the Director of Quality at 9:00 a.m. 5/2/17. She stated that as a result of the survey findings, she had discussed the quality review process with the Chief Executive Officer. The Director stated changes would need to be made to prioritize incidents to ensure adequate steps are taken to address issues in a timely manner.

Based on observation, document review, record review and staff interview it was determined nursing services failed to ensure nursing needs for room assignment were met (see Tag A 392); failed to ensure nursing needs for assessment and follow-up related to potential abuse were met (see Tag A 392); the registered nurse failed to supervise and evaluate the nursing care of a newly admitted patient (see Tag A 395); the registered nurse failed to supervise and evaluate the care of a patient who alleged sexual abuse (see Tag A 395); and, the registered nurse failed to assign nursing care in accordance with competence of available staff (see Tag A 397).

A. Based on observation, record review, document review staff interview it was determined nursing services failed to ensure nursing needs for room assignment were met for one (1) of one (1) patients who had an inappropriate room assignment which placed him at an increased risk for abuse (patient #1). This resulted in a failure to meet safety needs and has the potential to adversely impact the safety of all patients.

Findings include:

1. Review of the clinical record for patient #2 revealed he was admitted on 4/5/17. The clinical record revealed the patient was previously removed from his home by Child Protective Services (CPS) due to physical/emotional abuse and neglect. The patient had been in foster care and had been aggressive towards younger siblings. The record reflected CPS suspected the patient was sexually abusing a younger sibling. Further review of the record revealed Physician Assistant #1 wrote a 4/5/17 order for a "Private room d/t sexual inappropriateness."

2. Review of the clinical record for patient #1 revealed he was admitted in the evening of 4/21/17 to patient #2's room.

3. An interview was conducted with the Admitting Registered Nurse (RN) for patient #1 at 9:00 a.m. on 5/3/17. She acknowledged she did not check orders prior to making room assignments and assigned patient #1 to the same room as patient #2. She stated she did not know patient #2 had an order for a private room.

4. A tour and observation was conducted on the Children's Unit between 11:00 a.m. and 11:45 a.m. on 5/1/17. During the tour an interview was conducted at 11:10 a.m. with Day Shift RN #1 who was the only RN on the Unit. She stated there were five (5) patients on the unit with private room orders. When asked if private room status was reviewed in nursing shift report, she stated, "No, not always." She provided the Children's Unit Daily Shift Report for 4/21/17 and 5/1/17. The Daily Report did not reflect patient #2 had an order for a private room.

5. A tour and observation of the Unit was conducted with the Children's Unit Program Manager. The tour revealed the unit currently had four (4) private rooms as two (2) rooms were closed for repairs.

6. An interview was conducted with the Children's Program Manager at 10:00 a.m. on 5/1/17. She stated she was made aware patient #1 reported he was sexually abused by patient #2 on 4/26/17. She stated she investigated the allegation on 4/27/17 after patient #1 was discharged and confirmed patient #1 was assigned to a room with patient #2. She stated that even though the patients were checked every fifteen (15) minutes while in the room, she could not rule out the abuse may have occurred. She acknowledged her investigation revealed the admitting RN indicated she did not check orders and did not know patient #2 had an order for private room. When asked what had been done to prevent the reoccurrence of the error she stated patient #2 was placed back in a private room. When asked what had been done to prevent a future mistake by nursing staff when making room assignments she confirmed the mistake had not been addressed with nursing staff nor had any process changes been made.

The Program Manager was informed the continuing risk to patients from unsafe room assignments still existed and the process must be corrected before the surveyor left the premises. The Program Manager stated the corrections would be made.

7. On 5/1/17 at 1:00 p.m. the Medical Director was interviewed. He had not been made aware of the incident involving patient #1. He stated he would immediately ensure that each nursing unit initiated a private room list that would be kept current and reviewed prior to any room changes or assignments.

8. On 5/1/17 at 1:50 p.m. documented evidence of corrective steps were provided to the surveyor by the Interim Director of Nursing (DON). The information was shared with the State Agency. The DON stated all nursing staff in the building (both day and evening shift) were being educated on the private room list/procedure. He also provided a related e-mail directive which was sent to every RN on staff. He stated the current private room list would now be reviewed at every shift change, starting with the afternoon shift change on 5/1/17. The Immediate Jeopardy was abated at this time.

B. Based on document review, record review and staff interview it was determined nursing services failed to ensure nursing needs for assessment and follow-up related to potential abuse were met for one (1) of one (1) patients reviewed who alleged sexual abuse during hospitalization (patient #1). This resulted in a failure to meet nursing needs and creates the potential for unmet nursing needs for all patients.

Findings include:

1. The "Allegations of Patient Abuse," policy, revised 3/17, was provided for review. The policy states, in part: "Any allegations by patient or others, of patient abuse...will be viewed with the utmost seriousness. All allegations will be fully investigated...The individual receiving the allegation will immediately notify the Administrator of the allegation, complete an incident report regarding the allegations as soon as possible and forward to the Administrator...The physician will be responsible for making an immediate assessment of the patient and provide for any care...A written report, including any recommendations, regarding the allegations will be completed and given to the Administrator within 48 hours following receipt of the allegations...Any person who has reasonable cause to suspect that a child is neglected or abused...will fine immediately, not more than 48 hours after evidence of suspected abuse or neglect, the circumstances and cause a report to be made to the Department of Health and Human Resources."

2. The "Abuse Reporting-Adult/Child and Documentation" policy, last reviewed 5/16, was provided for review. The policy states, in part: "Suspected incidents of adult or child abuse, neglect, or emergency situations will be reported as mandated under West Virginia Adult Protective Services Law, Chapter 9, Article 6 and West Virginia Child Protective Law, Chapter 49 of the State Code. A Child Protective Services/Adult Protective Services Form will be completed and sent to DHHR following any report of suspected and/or neglect of patients."

3. An interview was conducted with Behavioral Health Technician (BHT) #2 at 1:17 p.m. on 5/1/17. She stated patient #1 reported to her that patient #2 sexually abused him. She stated the allegation was made in the early afternoon of 4/26/17. The BHT stated she reported it to the nurse and was told to complete an incident form.

4. An interview was conducted with BHT #1 at 1:36 p.m. on 5/1/17. He stated patient #1 reported to him that patient #2 sexually abused him. The BHT stated he reported this to the nurse.

5. Review of the clinical record for patient #1 revealed there was no documentation related to a report of sexual abuse.

6. An interview was conducted with Licensed Practical Nurse (LPN) #1 at 9:30 a.m. on 5/3/17. She stated BHT #2 called her on 4/26/17 to report that patient #1 alleged he was sexually abused by patient #2. She stated she felt it may have been around 1:40 p.m. The LPN stated she later went downstairs where the patients were in activities to give some medication. She stated she told the BHT to fill out an incident form but had no interaction with patient #1.

7. An interview was conducted with Day-Shift RN #1 at 2:20 p.m. on 5/1/17. She confirmed a BHT called the unit to report the sexual abuse allegation made by patient #1 on 4/26/17. She stated she got busy and forgot to record the allegation in the clinical record. She also confirmed she failed to assess the patient or report the allegation to the oncoming nurse at shift change. She acknowledged the hospital's abuse policy process was not followed as required.

8. An interview was conducted with the Evening Shift RN who discharged the patient. She stated she was not aware of the abuse allegation. Review of the clinical record for patient #1 revealed she documented the patient was discharged home with his mother at 4:19 p.m. on 4/26/17. She stated she was aware BHT #2 was documenting an incident. The RN stated Day-Shift RN #1 didn't mention anything about an incident in shift report and she didn't ask.

9. The allegation of sexual abuse by patient #1 was discussed with the Unit Program Manager at 10:20 a.m. on 5/1/17. She stated she was made aware of the abuse allegation while in a meeting in the afternoon of 4/26/17. She stated she investigated the allegation the next day, 4/27/17, after patient #1 was discharged home. She stated she determined the patient was placed in a room with patient #2 and she could not rule out the possibility the abuse occurred. When asked what corrective actions had been taken, she stated patient #2 was moved back into a private room. She confirmed no steps had been taken to address the nursing process that led to the error. The Manager confirmed the allegation was not documented in the clinical record and the abuse policy was not followed.

A. Based on record review and staff interview it was determined the registered nurse (RN) failed to supervise and evaluate the nursing care of the newly admitted patient for one (1) of one (1) patients reviewed who had an inappropriate room assignment which placed him at risk for abuse (patient #1). This resulted in a failure to evaluate care and creates the potential for an adverse impact on the care of all patients.

Findings include:

1. Review of the clinical record for patient #2 revealed Physician Assistant #1 wrote a 4/5/17 order for "Private room d/t sexual inappropriateness." Further review of the record revealed the patient's room assignment was not correctly identified as requiring a private room.

2. An interview was conducted with the Admitting RN for patient #1 at 9:00 a.m. on 5/3/17. She acknowledged she did not check orders prior to making room assignments and assigned patient #1 to the same room as patient #2. She stated she did know patient #2 had an order for private room.

3. An interview was conducted with the Program Manager of the Children's Unit at 10:00 a.m. on 5/1/17 and 8:40 a.m. on 5/2/17. She stated she had investigated the room assignment of patient #1 after he made allegations of sexual abuse by patient #2. She confirmed room numbers for patients in the records did not match check sheets completed by the Behavioral Health Technicians (BHT). She stated she determined the room numbers on the check sheets were correct and the ones in the clinical record were incorrect by reviewing video and interviewing staff. When asked how long patient #1 remained mistakenly assigned to a room with patient #2 the Program Manager stated she had to call the weekend RN to determine that the patient was moved out of the room of patient #2 per request in the evening on 4/22/17. She confirmed that multiple shifts of nursing staff did not identify the mistaken room assignment.

B. Based on record review and staff interview it was determined the registered nurse (RN) failed to supervise and evaluate the care of one (1) of two (2) patients reviewed who alleged abuse during hospitalization (patient #1). This failure resulted in a lack of clinical response/nursing intervention for one (1) patient and has the potential to adversely impact the care and condition of all patients.

Findings include:

1. Separate interviews with Behavioral Health Technicians (BHT) #1 and #2 and Day Shift RN #1 in the afternoon of 5/1/17 and Licensed Practical Nurse (LPN) #1 in the morning of 5/3/17 revealed patient #1, who is a minor, made allegations of sexual abuse in the afternoon of 4/26/17.

2. Review of the clinical record for patient #1 revealed there was no documentation related to the abuse allegations or any nursing interventions related to the abuse allegations. The record reflected the patient was discharged home at 4:19 p.m. on 4/26/17 without any nursing steps taken to address the abuse allegation.

3. An interview with the Day Shift RN #1 at 2:20 p.m. revealed she stated she forgot about the abuse allegations. She confirmed she did not interview or assess the patient in relation to the allegations.

4. An interview was conducted with LPN #1 at 9:30 a.m. on 5/3/17. She confirmed she was aware of the 4/26/17 abuse allegations made by patient #1. She stated she went downstairs (to where patients were in therapy) to administer medications after she was made aware of the allegation of abuse. She stated she had no interactions with patient #1.

5. An interview was conducted with the Program Manager of the Children's Unit at 8:40 a.m. on 5/2/17. She confirmed the nursing staff failed to address the abuse allegations made by patient #1.

Based on observation, document review, record review and staff interview it was determined the registered nurse (RN) failed to assign nursing care in accordance with competence of available staff. This deficient practice was identified in one (1) of one (1) patients reviewed who had an inappropriate room assignment which placed him at risk for abuse (patient #1). This failure has the potential to place all patients at a higher risk of abuse.

Findings include:

1. Review of the clinical record for patient #2 revealed he was admitted on 4/5/17. The clinical record revealed the patient was previously removed from his home by Child Protective Services (CPS) due to physical/emotional abuse and neglect. The patient had been in foster care and had been aggressive towards younger siblings. The record reflected CPS suspected the patient was sexually abusing a younger sibling. Further review of the record revealed Physician Assistant #1 wrote an order on 4/5/17 for "Private room d/t sexual inappropriateness."

2. Review of the clinical record for patient #1 revealed he was admitted in the evening of 4/21/17 to patient #2's room.

3. An interview was conducted with the Admitting RN for patient #1 at 9:00 a.m. on 5/3/17. She acknowledged she did not check orders prior to making room assignments and assigned patient #1 to the same room as patient #2. She stated she did not know patient #2 had an order for a private room.

4. A tour and observation was conducted on the Children's Unit between 11:00 a.m. and 11:45 a.m. on 5/1/17. During the tour an interview was conducted at 11:10 a.m. with Day Shift RN #1 who was the only RN on the Unit. She stated there were five (5) patients on the unit with private room orders. When asked if private room status was reviewed in nursing shift report, she stated, "No, not always." The RN provided the Children's Unit Daily Shift Report for 4/21/17 and 5/1/17. The Daily Report did not reflect patient #2 had an order for a private room.

5. A tour and observation of the Unit was conducted with the Children's Unit Program Manager. The tour revealed the unit currently had only four (4) private rooms as two (2) rooms were closed for repairs.

6. An interview was conducted with the Children's Program Manager at 10:00 a.m. on 5/1/17. She stated she investigated the allegation of abuse made by patient #1. She confirmed the investigation revealed the nurse did not check orders, was not aware patient #2 had an order for a private room and had assigned patient #1 to the room for patient #2. She also confirmed the nursing process which resulted in the mistake in room assignment had not been addressed.