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Based on review of policy and procedures, medical record, and staff interview, the facility staff failed to ensure accurate history and updates to inpatient treatment plans for 1 of 12 patients` treatment plans reviewed (Patient #1).

The findings included:

Review on 07/26/2019 of the facility policy titled, "TREATMENT PLANNING," effective date 02/05/2018, revealed "Purpose: ...B. The treatment plan is individualized to meet the patient`s needs ... Policy: ... 8. The patient`s interdisciplinary treatment team reviews data from progress notes and other relevant documentation regularly and modifies the treatment plan as needed ...E. Treatment Plan Reviews- outside of regular time frames: 1. It is required that the treatment plan will be reviewed and/ or revised in response to clinically significant circumstances ..."

Medical record review on 07/24/2019 of Patient #1, revealed a 15-year-old female patient admitted on 05/14/2019 involuntarily for suicidal ideations and self-injurious behaviors. Review of the Psychiatric Initial Assessment dated 05/19/2019, revealed Patient #1 had extensive psychiatric history to include Major Depressive Disorder, Anxiety, Post Traumatic Stress Disorder (PTSD), and Borderline Personality Disorder. Review revealed Patient #1 had history of sexual abuse and psychological trauma. Further review revealed the sending facility reported that she had homicidal ideations towards her stepfather. Review revealed Patient #1`s medications included Prazosin (for sleep and nightmares), and sertraline (for PTSD). Further review of the Psychiatric Initial Assessment revealed Patient #1`s psychosocial stressors included "troubled relationship with mother and stepfather who she reports sexually abused her in the past." Review revealed Patient #1 reported on 05/20/2019 at 1952 to a staff member that a male peer pulled his pants down and grabbed her head towards his private area to perform a sexual act without her consent. Review of the Psychiatry Progress Review Summary dated 05/20/2019 at 1955, revealed Principal Diagnosis: PTSD. Review of the Psychiatry Inpatient Note dated 05/21/2019 at 1359, revealed "She [Patient #1] has alleged and there has been reported video evidence that a male peer exposed his penis in close proximity to her face (per [named patient] to have placed his penis in her mouth) ... Then called her grandfather, also a legal guardian with father, and informed him of the confirmed allegation ..." Review of the Initial Psychiatric Master Treatment Plan dated 05/21/2019 at 1051, revealed diagnoses included PTSD. Review of the Crisis Plan within the Psychiatric Master Treatment Plan revealed " ...She [Patient #1] cites bullying, stress about family, interpersonal conflict, and remembering traumatic events as triggers for her distress and decompensation." There were no goals or interventions specific to history of traumatic events- sexual abuse. Review of the Psychiatric Master Treatment Plan dated 05/28/2019 at 1358, revealed diagnoses included PTSD. Review of the Crisis Plan within the Psychiatric Master Treatment Plan revealed " ...She [Patient #1] cites bullying, stress about family, interpersonal conflict, and remembering traumatic events as triggers for her distress and decompensation." Review revealed no goals or interventions specific to history of traumatic events- sexual abuse. Review of the Psychiatric Master Treatment Plan dated 06/11/2019 at 1051, revealed diagnoses included PTSD. Review of the Crisis Plan within the Psychiatric Master Treatment Plan revealed " ...She [Patient #1] cites bullying, stress about family, interpersonal conflict, and remembering traumatic events as triggers for her distress and decompensation." Review revealed no goals or interventions specific to history of traumatic events- sexual abuse. Review of the Psychiatric Master Treatment Plan dated 06/25/2019 at 1051, revealed diagnoses included PTSD. Review of the Crisis Plan within the Psychiatric Master Treatment Plan revealed " ...She [Patient #1] cites bullying, stress about family, interpersonal conflict, and remembering traumatic events as triggers for her distress and decompensation." Review revealed no goals or interventions specific to history of traumatic events- sexual abuse. Review of the Psychiatric Master Treatment Plan dated 07/09/2019 at 1051, revealed diagnoses included PTSD. Review of the Crisis Plan within the Psychiatric Master Treatment Plan revealed " ...She [Patient #1] cites bullying, stress about family, interpersonal conflict, and remembering traumatic events as triggers for her distress and decompensation." Review revealed no goals or interventions specific to history of traumatic events- sexual abuse. Patient #1 was discharged on 07/23/2019.

Interview on 07/26/2019 at with the Psychiatrist caring for Patient #1, revealed no changes were made to Patient #1`s treatment plan after the alleged and confirmed sexual encounter because the treatment plan "was already targeting her sexual abuse in the past." The Psychiatrist stated, "Everything was in place." The Psychiatrist revealed the treatment plan and the support given to her was adequate.

NC00153909, NC00153923, NC00152115, NC00152136, NC00152222