HospitalInspections.org

Based on policy and procedure review, medical record review, observation during tour, internal documents review and staff interview, the facility's governing body failed to provide oversight and have systems in place to ensure the protection and promotion of patient's rights to ensure a safe environment for behavioral health patients and failed to have an organized Nursing Service to meet patient care and safety needs.

The findings include:

1. The facility's staff failed to promote and protect patients' rights by failing to maintain a safe environment for behavioral health patients that prevented patient elopement; and failing to supervise adolescent and adult patients to prevent patient to patient sexual contact.

~cross refer to 482.13(c)(2) Patients' Rights: Care in Safe Setting Tag A0144

2. The facility's nursing staff failed to have an effective nursing service providing oversight of day to day operations by failing to ensure systems were in place to supervise and provide safe delivery of care to behavioral health patients.

~cross refer to 482.23 (b)(3) Nursing Services Standard: RN Supervision, Tag A0395

Based on policy and procedure review, medical record review, observations during tour, incident report review, employee corrective action report review, and staff interview, the facility staff failed to promote and protect patients' rights by failing to maintain a safe environment for behavioral health patients that prevented patient elopement; and failing to supervise adolescent and adult patients to prevent patient to patient sexual contact.

The findings include:

1. The facility staff failed to ensure a safe environment by failing to identify and supervise patients who were at risk for elopement in 2 of 2 patients who eloped (Patient #24, Patient #25).

~cross refer to 482.13(c)(2) Patients' Rights: Care in Safe Setting Tag A0144

2. The facility staff failed to ensure mental health technicians (MHT) performed 15 minute observations in 5 of 5 patients that engaged in alleged sexual interactions. (Patient #10, Patient #12, Patient #14, Patient #28, and Patient #29)

~cross refer to 482.13(c)(2) Patients' Rights: Care in Safe Setting Tag A0144

Based on policy and procedure review, medical record review, observations during tour, incident report review, employee corrective action report review, and staff interview, facility staff failed to ensure a safe environment by failing to identify and supervise patients who were at risk for elopement in 2 of 2 patients who eloped (Patient #24, Patient #25); failed to ensure mental health technicians (MHT) performed 15 minute observations in 5 of 5 patients that engaged in alleged sexual interactions. (Patient #10, Patient #12, Patient #14, Patient #28, and Patient #29)

The findings include:

1. Review of facility policy "ELOPEMENTS: PREVENTION AND RESPONSE" last reviewed 07/20 revealed "POLICY: To minimize the potential for elopement from the facility and other outside facilities through prompt identification and intervention for patients at risk and to minimize risk in the event of an elopement...PROCEDURE: Assessment and Prevention...2. History of elopements from facilities or running away behaviors. If noted on admissions, staff will document on High Risk Notification...7. Universal prevention of elopements require the following: Two (2) staff members must be present for all off-unit group activities; When outdoors, one staff member will position themselves closest to the fence line... All outdoor furniture (tables & chairs) must be positioned away from walls and fences..."

Open medical record review of Patient #24 on 06/24/2021 revealed a 17 year old male admitted to the facility under IVC (involuntary commitment petition) on 06/21/2021 for "Substance use and running away from home". Review of the "High Risk Notification Alert" notification sheet revealed no high risk factors were identified. Review of Nursing Progress note by RN #13 on 06/22/2021 revealed "This RN (#13) (registered nurse) hears overhead pager called 'codewalker' around 1935. MHT #7 (mental health technician) on the unit informed pt (patient) ran away during outside activity time. A peer informed pt jumped off the fence..."

2. Open medical record of Patient #25 on 06/25/2021 revealed a 16 year old male admitted to the facility under IVC (involuntary commitment petition) on 06/22/2021 for "Ran away from named facility.. threatening to kill himself." Review of the "High Risk Notification Alert" notification sheet revealed suicide high risk factor was checked no other high risk factors were identified. Review of Nursing Progress note by RN #13 on 06/22/2021 revealed "This RN hears overhead pager called 'codewalker' around 1935. MHT #7 on the unit informed pt ran away during outside activity time. A peer informed pt jumped off the fence..."

Observation during tour at the South Campus on 06/24/2021 at 1140 revealed 12 patients with 2 staff members in the inner courtyard. Further observations at 1230 revealed 25 chairs remained in the inner courtyard. Observations at 1240 revealed workers removing chairs from the inner courtyard.

Interview on 06/24/2021 at 1105 with the Director of Admissions revealed any patient with a history of running away should be identified as an elopement risk. Interview revealed the "High Risk Notification Alert" tool is completed at admission as communication tool . Interview revealed it is used to bring attention to "high risk" factors in order for precautions to be ordered if needed. Interview revealed the tool is placed at the front of the admission packet to bring attention to any "High Risk" factors. Interview confirmed Patient #24 and Patient #25 should have been identified as "Elopement Risk" upon admission.

Interview on 06/24/2021 at 1150 with MHT #12 revealed he was asked by MHT #7 for assistance to take the patients outside on 06/22/2021. Interview revealed he escorted the patients outside at approximately 1910-1915. Interview revealed he was the only staff member outside with 12 patients. Interview revealed he did not witness any patients elope over the fence. Interview revealed none of the patients alerted him the patients had eloped. Interview revealed he was outside approximately 5 minutes when MHT #7 came outside so he could go help the charge nurse perform a search on a new admission. Interview confirmed there was 1(one) staff member in the courtyard with the patients.

Interview on 06/24/2021 at 1245 with 14 year old male patient. Interview revealed he witnessed Patient #24 and Patient #25 elope. Interview revealed a chair was already in the corner of the courtyard by the fence when the patients went outside. Interview revealed the two patients were "pretending to play basketball", throwing the ball back and forth from the corner of the fence to the basketball court. Interview revealed MHT #12 was sitting on the picnic table checking his phone. Interview revealed Patient #24 and Patient #25 jumped on to the chair, over the fence and ran to the right. Interview revealed all the patients watched the event and did not alert anyone at that time. Interview revealed MHT #12 went inside and when MHT #7 came outside the patients told her what happened. Interview confirmed there was 1 (one) staff member in the courtyard with the patients.

Interview on 06/24/2021 at 1615 with MHT #7 revealed she was asked by Patient #24 if they could go outside since they could not take showers at that time. Interview revealed she aked MHT #12 if he could take the patients outside. Interview revealed she was aware MHT #12 needed to help the charge nurse conduct a patient search. Interview revealed MHT #12 escorted the patients outside at approximately 1910 and at approximately 1913 she went outside to relieve him to help the charge nurse. Interview revealed the patients told her to look around the four corners of the courtyard. Interview revealed she noticed the chair by the fence and realized Patient #24 and Patient #25 were not in the courtyard. Interview revealed she made the charge nurse aware and the elopement was called. Interview confirmed there was 1(one) staff member in the courtyard with the patients.



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3. Review of facility policy titled "OBSERVATION (Levels of Observation)" last reviewed 04/2020 revealed, " ...ROUTINE OBSERVATION ... Direct observation of patient by staff, conducted 24/7 by to maintain (sic) safe environment and to observe patient behavior and note potential risk ... All individuals in care are observed for safety a minimum of every 15 minutes ..."

Review on 06/22/2021 of the closed medical record for Patient #10 revealed she was a 13-year-old female admitted on 05/19/2021 for suicidal and homicidal ideation. Review of RN #5's (registered nurse) progress note dated 05/25/2021 at 1600 revealed "Pt's (patients) Guardian told nurse over the phone that patient told her that she was 'raped last night.' Nurse spoke to pt who reported that a male peer asked her to come into his room, she went in and hid in the bathroom till 'the coast was clear.' Pt Claims that the male peer then had her give him oral sex in the bathroom shower. Pt says she did not consent to this. Pt says she was scared to tell staff about this. House supervisor made aware. Guardian called. Named Doctor made aware and gave orders to transfer pt to children's West. Police report has been made at this time." Review of Patient #10's observation rounds revealed documentation that staff had performed Q 15-minute checks during the time of the alleged incident. Patient #10 was discharged on 05/27/2021.

Review on 06/22/2021 of the closed medical record for Patient #12 revealed he was a 14-year-old male admitted on 05/21/2021 for suicidal ideation and depression. Review of RN #10's progress note dated 05/26/2021 at 1600 revealed "female peer reported to nurse that she was raped and had oral sex in pt's (patients) room after shower time last night. Pt denies alligations (sic) at this time. Guardian has been called. Dr. (Named) placed pt on sexual precautions. Police report made." Review of Patient #12's observation rounds revealed documentation that staff had performed Q 15-minute checks during the time of the alleged incident. Patient #12 was discharged on 05/28/2021.

Review of the "Employee Corrective Action Report" dated 05/26/2021 revealed MHT #6 had a "written warning ...Recent Incident(s) ...(box checked) Patient rooms were not checked/entered during Q15 minute rounds ...Briefly state what employee must do to improve: Re education (with symbol) LMHT 5/27/21 @ (at) 1530 make sure to do observations by policy." Further review revealed the corrective action was conducted "via telephone (with symbol) employee" and signed by NM #2.

Interview on 06/22/2021 at 1135 with the Director of Risk Management revealed she just started in that role two weeks ago. Interview revealed the previous risk manager conducted the investigation for the alleged sexual misconduct between Patient #10 and #12. Interview revealed no video footage was available due to the system only keeps up to 14 days of footage.

Interview on 06/23/2021 at 1000 with the Chief Nursing Officer (CNO) revealed she personally reviewed the video footage following the incident between Patient #10 and #12. Interview revealed during the review it was noted several of the patients were causing a distraction near Patient #12's room. Interview revealed Patient #10 managed to sneak into Patient #12's room without staff noticing during the commotion. Interview revealed the staff members seem distracted by the commotion on the unit and missed the patient sneaking in and out of Patient #12s room. Interview revealed based on the CNO's video review, she realized the MHT (MHT #6) had missed a Q15 minute observation check on Patient #10. Interview revealed the 2 MHT's (MHT #6 and MHT #7) on the unit were suspended and an investigation was conducted.

Interview on 06/23/2021 at 1600 with the Director of Nursing South campus (DON #1) revealed the MHTs (MHT #6 and MHT #7) on duty during Patient #10 & 12's incident were new employees and their lack of training contributed to the incident. Interview revealed they (hospital staff) probably should have not had two new MHTs on the unit at the same time, "that's something we should take ownership of."

Interview on 06/24/2021 at 0951 with MHT #6 revealed she was on duty the night of Patient #10 &12's incident. Interview revealed MHT #6 was performing Q15 minute checks on the patients during hygiene time. Interview revealed MHT #6 was assigned with another new MHT and had never done hygiene time by herself prior to that night. Interview revealed MHT #6 was trained not to enter the patient's room during hygiene time to complete the observation check due to privacy. Interview revealed MHT #6 did not observe Patient #10 entering Patient #12's room. Interview revealed MHT #6 completed Q15 minute observation check on Patient #12 during hygiene time but actually did not observe Patient #12 while in the shower.

Interview on 06/24/2021 at 1009 with the House Supervisor for Children's unit revealed Patient #10 was in the group room with MHT #7 and Patient #10 asked to go to her room and get something during hygiene time. Interview revealed during that time another patient began to cause a commotion on the unit and staff went to check on that patient. Interview revealed while staff were trying to de-escalate the other patient, Patient #10 snuck into Patient #12's room. Interview revealed Patient #10 managed to sneak in and out the Patient #12's room without staff noticing.

Interview on 06/24/2021 at 1052 with RN #5 revealed Patient #10's Guardian reported to RN #5 that the patient reported to her on the phone she had been raped the night before. The nurse stated she was under the impression it was sexual intercourse that had occurred without consent. Interview revealed the nurse told the guardian she would talk to the patient and inquire about what happened. The nurse stated following Patient #10s interview, the patient reported "they both went down on each other" and she didn't consent to it. Interview revealed the nurse call the guardian back and told her what Patient #10 had reported to her. Interview revealed the nurse separated the patients, notified the provider and Patient #10 was transferred to a different unit. Interview revealed that the police department was also notified.

Interview on 06/24/2021 at 1627 with MHT #7 revealed she was on duty the night of the incident. Interview revealed MHT #7 did not know anything had occurred that night and she learned of the incident the following shift. MHT #7 stated she was assigned to the day room patients during the hygiene time. MHT #7 was unsure of how Patient #10 entered Patient #12's room without staff noticing.



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4. Closed medical record review conducted on 06/22/2021 revealed Patient #14 was a 24-year-old female admitted to the hospital on 04/22/2021 at 1126 with a diagnosis of Schizoaffective disorder Bipolar Type. Review revealed an order was placed for Patient #14 to be observed by hospital staff every 15 minutes beginning on 04/22/2021 at 1200. Review of hospital observation sheets revealed no gaps in 15-minute staff observations during Patient #14's hospital admission, noting that on 04/27/2021 at 2130 through 2200 Patient #14 was documented as being in her unit's hallway by MHT (Mental Health Technician) #10; and on 04/28/2021 at 0900 through 1000 Patient #14 was documented as being in her unit's dayroom by MHT #9. Review of a nursing note written by Registered Nurse (RN) #11 on 04/28/2021 at 1200 revealed, " ...Pt (Patient) reports having sexual intercourse with another pt that was consensual. Advised pt that it is not appropriate both pt being moved and placed on SP (Sexual Precautions) ..."

Review of a hospital incident report written by the hospital's previous Director of Risk Management (undated) revealed, " ...Incident Type: Sexual Intercourse Patient to Multiple Patients and Sexual Boundary Violation Patient to Patient ... Brief Description of the incidents: Female Patient reported to staff that she had intercourse with two male patient on the unit after male was found with her in the shower fully clothed on 4/28/ at 0943. Initial report was just this incident. Further investigation revealed that two males entered her room a total of three time from 4/27/21 at 2152 until 4/28/21 at 0943 ... Incident One ... 4/27 (Patient #14 Named) and (Patient #29 Named) 21:53:33 Male patient enters female's room and female follow him in, the door is closed and they are uninterrupted for 13 minutes and 51 seconds. They leave without interaction with staff. Incident Two and Three ... 4/28 (Patient #14 Named) and (Patient #28 Named) ... 09:12:30 Female enters her room and male follows, door closes, they are uninterrupted for 5 minutes and 41 seconds. During this time male (MHT #9) does observation rounds and approaches the door and slightly opens it. There are 3 patients in the room (roommate). He continues on rounds. The roommate leaves the room, followed by the male peer, and then the female leaves the room. At 09:42:55 (patient #14 Named) again enters her room and (Patient #28 Named) follows her in. They are uninterrupted for 44 seconds. A rec (recreational) therapist opens the door to look for roommate and (MHT #9) follows her and calls out to male peer as he was not seen in the hall. Male peer answered and (MHT #9) entered room and saw them fully clothed behind the shower curtain. After this event (Patient #14 Named) states she had intercourse with (Patient #28 Named) and he confirmed. They both stated it was consensual. (Patient #14 Named) then said she had intercourse with (Patient #29 Named). As this encounter was only 44 seconds. I (Director of Risk Management) viewed video from overnight and found first and second events ... Investigation Findings/Risk Issues/Process Failures ... Failure to identify at risk behaviors that were clearly evident and intervene Failure to perform observation round appropriately Documentation of location of patients on observation sheets falsified ... No evidence on admission that patient had history of hyper-sexuality ..."

Review of Employee Corrective Action Report written on 05/07/2021 revealed, " ... (MHT #9 Named) ... Termination ... RECENT INCIDENT(S) Failure to adhere to policy and complete every 15 min (minute) checks-Failure to perform this duty allowed a sexual encounter between patients to occur. (MHT #9 Named) admits not opening door and checking room per policy ..."

Review of Employee Corrective Action Report written on 05/07/2021 revealed, " ... (MHT #10 Named) ... Termination ... RECENT INCIDENT(S) Review of video and documentation resulted in evidence of falsifying medical documentation ..."

Staff interview was conducted with RN #11 on 06/22/2021 at 1510. RN #11 recalled Patient #14. Interview revealed Patient #14 reported sexual activity between her and another male patient, who at the time denied the activity occurred. Interview revealed both patients were subsequently moved to different units and placed on SP. Interview revealed the incident was reported to RN #11's superiors, and there were no other incidents to RN #11's knowledge.

Staff interview was conducted with the hospital's current Director of Risk Management on 06/23/2021 at 1505. Interview revealed the allegations of sexual activity between hospital patients was investigated by the former Director of Risk Management, and her incident report was provided for review.

Staff interview was conducted with the Nursing Manager of Units 2 East and 2 West on 06/24/2021 at 0923. Interview confirmed she was the manager of the unit Patient #14 was assigned to. Interview revealed the MHT staff did not consistently open the door and physically enter the room to perform the required 15-minute patient checks. Interview revealed staff re-education was performed for 100% of the 2 East and 2 West unit staff employed at the time, however the education was not facility wide.

Based on policy and procedure review, medical record review, clinical feedback document review, employee corrective action review, house supervisor daily rounding sheets and staff interviews the hospital staff failed to monitor implemented corrective actions following an adverse event that resulted in patient to patient alleged sexual abuse for 2 of 7 sampled adolescent patients (#10 and #12).

The findings include:

Review of facility policy titled "Performance Improvement Plan" last revised on 02/1/2021 revealed, "Quality is a continuous effort and requires involvement by everyone at (named) Hospital to exceed the needs and expectations of patients, their families and those people whom directly and indirectly impact patient care...The purpose of the Performance Improvement Plan is to provide an ongoing process by which (named) Hospital objectively and systematically monitors and evaluates the quality and appropriateness of patient care, identifies acceptable levels of care, finds and implements opportunities to improve care, and resolves problems..."

Review of facility policy titled "OBSERVATION (Levels of Observation)" last reviewed 04/2020 revealed, " ...ROUTINE OBSERVATION ... Direct observation of patient by staff, conducted 24/7 by to maintain (sic) safe environment and to observe patient behavior and note potential risk ... All individuals in care are observed for safety a minimum of every 15 minutes (Q15 minutes) ...PROCEDURE: A. ROUTINE OBSERVATION -Checks conducted while patient is awake: ...c. Staff will identify the patient with certainty ..."

Review on 06/22/2021 of the closed medical record for Patient #10 revealed she was a 13-year-old female admitted on 05/19/2021 for suicidal and homicidal ideation. Review revealed Patient #10 was placed on Q15 minute checks on 05/19/2021 at 1500. Review of RN #5's (registered nurse) progress note dated 05/25/2021 at 1600 revealed "Pt's (patients') Guardian told nurse over the phone that patient told her that she was 'raped last night.' Nurse spoke to pt who reported that a male peer asked her to come into his room, she went in and hid in the bathroom till 'the coast was clear.' Pt Claims that the male peer then had her give him oral sex in the bathroom shower. Pt says she did not consent to this. Pt says she was scared to tell staff about this. House supervisor made aware. Guardian called. Named Doctor made aware and gave orders to transfer pt to children's West. Police report has been made at this time." Review of Patient #10's observation rounds revealed documentation that staff had performed Q 15-minute checks during the time of the alleged incident. Patient #10 was discharged on 05/27/2021.

Review on 06/22/2021 of the closed medical record for Patient #12 revealed he was a 14-year-old male admitted on 05/21/2021 for suicidal ideation and depression. Review of RN #10's progress note dated 05/26/2021 at 1600 revealed "female peer reported to nurse that she was raped and had oral sex in pt's (patients) room after shower time last night. Pt denies alligations (sic) at this time. Guardian has been called. Dr. (Named) placed pt on sexual precautions. Police report made." Review of a social services progress note dated 05/27/2021 at 1030 revealed "therapist followed up with pt an (sic) incident on the unit where pt was accused of sexual engagement with a peer. Pt stated the accusations were false..." Review of Patient #12's observation rounds revealed documentation that staff had performed Q 15-minute checks during the time of the alleged incident. Patient #12 was discharged on 05/28/2021.

Review of the "Clinical Feedback" document dated 05/27/2021 and signed by MHT (Mental Health Technician) #8 revealed MHT #8 provided re-education on "how to properly observe patients as per (Named) Hospital policy, on Q15's Rounds. How far to enter Rms (rooms) while conducting walking rounds. Staff will be monitored for the next 30 days to see improvements in these areas ....1:1 staff training with LMHT (lead-MHT #8) and demonstration on how to conduct walking rounds ..." Review revealed a "Clinical Feedback" was completed for both MHT #6 and #7 on 05/27/2021.

Review of the "Employee Corrective Action Report" dated 05/26/2021 revealed MHT #6 had a "written warning ...Recent Incident(s) ...(box checked) Patient rooms were not checked/entered during Q15 minute rounds ...Briefly state what employee must do to improve: Reeducation (with symbol) LMHT 5/27/21 @ (at) 1530 make sure to do observations by policy." Further review revealed the corrective action was conducted "via telephone (with symbol) employee" and signed by NM #2.

Review on 06/23/2021 of the "House Supervisor Daily Rounds" form (no date) revealed the following days were available (requested for all daily rounds completed since the incident on 05/26/2021): 06/02/2021, 06/03/2021, 06/08/21 and 06/09/2021. Further review revealed on 06/02/2021 no documentation for the 12am-8pm shift and 06/03/2021 no 8am-430pm documentation.

Interview on 06/22/2021 at 1135 with the Director of Risk Management revealed she just started in that role two weeks ago. Interview revealed the previous risk manager conducted the investigation for the alleged sexual misconduct between Patient #10 and #12. Interview revealed at the time of the incident the unit was coed and following the incident the unit had now been separated between boys and girls. Interview revealed prior to the incident house supervisors made unit rounds however there was no specific time to perform the rounds, now house supervisors rounded on the units at least every two hours. Interview revealed during the house supervisor rounds, the supervisors were supposed to complete a unit checklist to ensure safety of the unit was maintained.

Interview on 06/23/2021 at 1000 with the Chief Nursing Officer (CNO) revealed she personally reviewed the video footage following the incident between Patient #10 and #12. Interview revealed during the review it was noted several of the patients were causing a distraction near Patient #12's room. Interview revealed Patient #10 managed to sneak into Patient #12's room without staff noticing during the commotion. Interview revealed during the video review it was noted three staff members were on the hall performing Q 15-minute checks and monitoring the hallway. Interview revealed the staff members seem distracted by the commotion on the unit and missed the patient sneaking in and out of Patient #12s room. Interview revealed during the review, it was noted Patient #10 kept looking around as she was trying to find the right time to sneak into Patient #12's room. Interview revealed based on the CNO's video review, she realized the MHT (MHT #6) had missed a Q15 minute observation check on Patient #10. Interview revealed the 2 MHT's (MHT #6 and MHT #7) on the unit were suspended and an investigation was conducted. Interview revealed the 2 MHT's responsible for the Q 15-minute observation checks were re-educated one-on-one on properly conducting the Q15 minute checks and falsifying documents prior to returning to work. Interview revealed both MHTs were new employees. Interview revealed following the incident the male and females were placed on separate units, they no longer have an adolescent coed unit.

Interview 06/23/2021 at 1436 with the Nurse Manager (NM #2) of the Children's unit revealed following Patient #10 and #12s incident, the male and females had been moved to separate units. Interview revealed now during hygiene time all staff were required to be present, no one could leave the unit. Interview revealed MHT #8 which was a lead tech provided 1 on 1 reeducation to MHT #6 & #7. Interview revealed MHT #8, the lead tech, was providing the monitoring for MHT #6 & #7 for compliance. Interview revealed the house supervisor rounding tool had been updated following the incident and the supervisors were expected to round on the units at least every two hours. NM #2 stated the house supervisor rounding tool was expected to be filled out at least once every shift and turned into her. NM #2 was able to provide house supervisor rounding tools completed for the following days: 06/02/2021, 06/03/2021, 06/08/21 and 06/09/2021 following the incident. Interview reveal the house supervisors were usually on a unit during their shift, "they rarely go to their office." Interview revealed NM #2 communicated with MHT #8 periodically to see how the monitoring was going for MHT #6 & #7.

Interview on 06/23/2021 at 1600 with the Director of Nursing South campus (DON #1) reveal she had performed reeducation to her staff following Patient #10 and #12's incident. Interview revealed there were eight staff members as of June 21, 2021 left to submit their attestation that they had completed the reeducation. Interview revealed the following process changes had occurred following the incident, DON #1 had re-educated staff on not taking breaks during hygiene time, no staff were permitted to leave the unit during hygiene time, and if there were not enough staff to perform hygiene time at the allotted time, she encourage staff to call for additional help and wait to complete hygiene time. Interview revealed the unit had been changed from a coed unit to a female and male only unit now. Interview revealed A bed patients have hygiene time on one shift and B bed patients have hygiene time on a different shift. DON #1 stated they now made the patient's stay in their rooms until after hygiene time was over and then they were escorted to the group room with the other patients. Interview revealed the MHTs on duty during Patient #10 & 12's incident were new employees and their lack of training contributed to the incident. Interview revealed they (hospital staff) probably should have not had two new MHTs on the unit at the same time, "that's something we should take ownership of."

Interview on 06/24/2021 at 0951 with MHT #6 revealed she was on duty the night of Patient #10 &12's incident. Interview revealed MHT #6 was performing Q15 minute checks on the patients during hygiene time. Interview revealed MHT #6 was assigned with another new MHT and had never done hygiene time by herself prior to that night. Interview revealed MHT #6 was trained not to enter the patient's room during hygiene time to complete the observation check due to privacy. Interview revealed MHT #6 did not observe Patient #10 entering Patient #12's room. Interview revealed MHT #6 completed Q15 minute observation check on Patient #12 during hygiene time but actually did not observe Patient #12 while in the shower. MHT #6 stated she had been re-trained on how to properly perform Q15 minute checks by MHT #8, the lead technician. Interview revealed MHT #6 was not aware of any monitoring being done. Interview revealed the MHT #6 was suspended for a day, was retrained, and returned to work.

Interview on 06/24/2021 at 1009 with the House Supervisor for Children's unit revealed Patient #10 was in the group room with MHT #7 and Patient #10 asked to go to her room and get something during hygiene time. Interview revealed during that time another patient began to cause a commotion on the unit and staff went to check on that patient. Interview revealed while staff were trying to de-escalate the other patient, Patient #10 snuck into Patient #12's room. Interview revealed Patient #10 managed to sneak in and out the Patient #12's room without staff noticing. Interview revealed both MHT's were reeducated on how to perform observations during hygiene time. Interview revealed the house supervisor normally rounded on the unit at least every two hours if not more frequent. The house supervisor stated during those rounds she observed and monitored for staff in place on the unit and completing their Q15 minute observations as they should be done. Interview revealed following unit rounds, normally she completed the house supervisor rounding check off list. Interview revealed if she did not complete the check off sheet, she still performed the rounds.

Interview on 06/24/2021 at 1219 with lead MHT #8 revealed he re-trained MHT #6 & #7 prior to them returning to shift. Interview revealed MHT #8 showed the other MHTs to how to properly conduct the Q15 minute rounds, stand on the green check in the room and physically observe the patient. Interview revealed MHT #8 trained the MHTs to physically observe the patient's head while in the shower during hygiene time for the first Q15 minute check. MHT #8 stated if the patient was still in the shower for the second Q15 minute check, staff had to physically observe the patient with a towel around them to ensure they were not "self-harming." MHT #8 stated the MHTs monitoring was completed by the house supervisor or the nurse working on their shift. Interview revealed MHT #8 had not followed-up with MHT #6 & #7 following the 1:1 reeducation.

Interview on 06/24/2021 at 1627 with MHT #7 revealed she was on duty the night of the incident. Interview revealed MHT #7 did not know anything had occurred that night and she learned of the incident the following shift. MHT #7 stated she was assigned to the day room patients during the hygiene time. MHT #7 was unsure of how Patient #10 entered Patient #12's room without staff noticing. MHT #7 stated that she had received reeducation following the incident which included how to correctly perform Q15 minute checks and physically walk in the room to perform the checks.

Based on policy and procedure review, medical record review, observations during tour, incident report review, employee corrective action report review, and staff interview, the facility's nursing staff failed to have an effective nursing service providing oversight of day to day operations by failing to ensure systems were in place to supervise and provide safe delivery of care to behavioral health patients.

The findings include:

1. The facility's nursing staff failed to supervise and evaluate patient care by failing to identify and supervise patients who were at risk for elopement in 2 of 2 patients who eloped (Patient #24, Patient #25).

~cross refer to 482.23 (b)(3) Nursing Services Standard: RN Supervision, Tag A0395

2. The facility's nursing staff failed to ensure mental health technicians (MHT) performed 15 minute observations in 5 of 5 patients that engaged in alleged sexual interactions . (Patient #10, Patient #12, Patient #14, Patient #28, and Patient #29)

~cross refer to 482.23 (b)(3) Nursing Services Standard: RN Supervision, Tag A0395

Based on policy and procedure review, medical record review, observations during tour, incident report review, employee corrective action report review, and staff interview, the facility's nursing staff failed to supervise and evaluate patient care by failing to identify and supervise patients who were at risk for elopement in 2 of 2 patients who eloped (Patient #24, Patient #25); failed to ensure mental health technicians (MHT) performed 15 minute observations in 5 of 5 patients that engaged in alleged sexual interactions . (Patient #10, Patient #12, Patient #14, Patient #28, and Patient #29).

The findings include:

1. Review of facility policy "ELOPEMENTS: PREVENTION AND RESPONSE" last reviewed 07/20 revealed "POLICY: To minimize the potential for elopement from the facility and other outside facilities through prompt identification and intervention for patients at risk and to minimize risk in the event of an elopement...PROCEDURE: Assessment and Prevention...2. History of elopements from facilities or running away behaviors. If noted on admissions, staff will document on High Risk Notification...7. Universal prevention of elopements require the following: Two (2) staff members must be present for all off-unit group activities; When outdoors, one staff member will position themselves closest to the fence line... All outdoor furniture (tables & chairs) must be positioned away from walls and fences..."

Open medical record review of Patient #24 on 06/24/2021 revealed a 17 year old male admitted to the facility under IVC (involuntary commitment petition) on 06/21/2021 for "Substance use and running away from home". Review of the "High Risk Notification Alert" notification sheet revealed no high risk factors were identified. Review of Nursing Progress note by RN #13 on 06/22/2021 revealed "This RN (#13) (registered nurse) hears overhead pager called 'codewalker' around 1935. MHT #7 (mental health technician) on the unit informed pt (patient) ran away during outside activity time. A peer informed pt jumped off the fence..."

2. Open medical record of Patient #25 on 06/25/2021 revealed a 16 year old male admitted to the facility under IVC (involuntary commitment petition) on 06/22/2021 for "Ran away from named facility.. threatening to kill himself." Review of the "High Risk Notification Alert" notification sheet revealed suicide high risk factor was checked no other high risk factors were identified. Review of Nursing Progress note by RN #13 on 06/22/2021 revealed "This RN hears overhead pager called 'codewalker' around 1935. MHT #7 on the unit informed pt ran away during outside activity time. A peer informed pt jumped off the fence..."

Observation during tour at the South Campus on 06/24/2021 at 1140 revealed 12 patients with 2 staff members in the inner courtyard. Further observations at 1230 revealed 25 chairs remained in the inner courtyard. Observations at 1240 revealed workers removing chairs from the inner courtyard.

Interview on 06/24/2021 at 1105 with the Director of Admissions revealed any patient with a history of running away should be identified as an elopement risk. Interview revealed the "High Risk Notification Alert" tool is completed at admission as communication tool. Interview revealed it is used to bring attention to "high risk" factors in order for precautions to be ordered if needed. Interview revealed the tool is placed at the front of the admission packet to bring attention to any "High Risk" factors. Interview confirmed Patient #24 and Patient #25 should have been identified as "Elopement Risk" upon admission.

Interview on 06/24/2021 at 1150 with MHT #12 revealed he was asked by MHT #7 for assistance to take the patients outside on 06/22/2021. Interview revealed he escorted the patients outside at approximately 1910-1915. Interview revealed he was the only staff member outside with 12 patients. Interview revealed he did not witness any patients elope over the fence. Interview revealed none of the patients alerted him the patients had eloped. Interview revealed he was outside approximately 5 minutes when MHT #7 came outside so he could go help the charge nurse perform a search on a new admission. Interview confirmed there was 1(one) staff member in the courtyard with the patients.

Interview on 06/24/2021 at 1245 with 14 year old male patient. Interview revealed he witnessed Patient #24 and Patient #25 elope. Interview revealed a chair was already in the corner of the courtyard by the fence when the patients went outside. Interview revealed the two patients were "pretending to play basketball", throwing the ball back and forth from the corner of the fence to the basketball court. Interview revealed MHT #12 was sitting on the picnic table checking his phone. Interview revealed Patient #24 and Patient #25 jumped on to the chair, over the fence and ran to the right. Interview revealed all the patients watched the event and did not alert anyone at that time. Interview revealed MHT #12 went inside and when MHT #7 came outside the patients told her what happened. Interview confirmed there was 1 (one) staff member in the courtyard with the patients.

Interview on 06/24/2021 art 1615 with MHT #7 revealed she was asked by Patient #24 if they could go outside since they could not take showers at that time. Interview revealed she aked MHT #12 if he could take the patients outside. Interview revealed she was aware MHT #12 needed to help the charge nurse conduct a patient search. Interview revealed MHT #12 escorted the patients outside at approximately 1910 and at approximately 1913 she went outside to relieve him to help the charge nurse. Interview revealed the patients told her to look around the four corners of the courtyard. Interview revealed she noticed the chair by the fence and realized Patient #24 and Patient #25 were not in the courtyard. Interview revealed she made the charge nurse aware and the elopement was called. Interview confirmed there was 1(one) staff member in the courtyard with the patients.



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3. Review of facility policy titled "OBSERVATION (Levels of Observation)" last reviewed 04/2020 revealed, " ...ROUTINE OBSERVATION ... Direct observation of patient by staff, conducted 24/7 by to maintain (sic) safe environment and to observe patient behavior and note potential risk ... All individuals in care are observed for safety a minimum of every 15 minutes ..."

Review on 06/22/2021 of the closed medical record for Patient #10 revealed she was a 13-year-old female admitted on 05/19/2021 for suicidal and homicidal ideation. Review of RN #5's (registered nurse) progress note dated 05/25/2021 at 1600 revealed "Pt's (patients) Guardian told nurse over the phone that patient told her that she was 'raped last night.' Nurse spoke to pt who reported that a male peer asked her to come into his room, she went in and hid in the bathroom till 'the coast was clear.' Pt Claims that the male peer then had her give him oral sex in the bathroom shower. Pt says she did not consent to this. Pt says she was scared to tell staff about this. House supervisor made aware. Guardian called. Named Doctor made aware and gave orders to transfer pt to children's West. Police report has been made at this time." Review of Patient #10's observation rounds revealed documentation that staff had performed Q 15-minute checks during the time of the alleged incident. Patient #10 was discharged on 05/27/2021.

Review on 06/22/2021 of the closed medical record for Patient #12 revealed he was a 14-year-old male admitted on 05/21/2021 for suicidal ideation and depression. Review of RN #10's progress note dated 05/26/2021 at 1600 revealed "female peer reported to nurse that she was raped and had oral sex in pt's (patients) room after shower time last night. Pt denies alligations (sic) at this time. Guardian has been called. Dr. (Named) placed pt on sexual precautions. Police report made." Review of Patient #12's observation rounds revealed documentation that staff had performed Q 15-minute checks during the time of the alleged incident. Patient #12 was discharged on 05/28/2021.

Review of the "Employee Corrective Action Report" dated 05/26/2021 revealed MHT #6 had a "written warning ...Recent Incident(s) ...(box checked) Patient rooms were not checked/entered during Q15 minute rounds ...Briefly state what employee must do to improve: Re education (with symbol) LMHT 5/27/21 @ (at) 1530 make sure to do observations by policy." Further review revealed the corrective action was conducted "via telephone (with symbol) employee" and signed by NM #2.

Interview on 06/22/2021 at 1135 with the Director of Risk Management revealed she just started in that role two weeks ago. Interview revealed the previous risk manager conducted the investigation for the alleged sexual misconduct between Patient #10 and #12. Interview revealed no video footage was available due to the system only keeps up to 14 days of footage.

Interview on 06/23/2021 at 1000 with the Chief Nursing Officer (CNO) revealed she personally reviewed the video footage following the incident between Patient #10 and #12. Interview revealed during the review it was noted several of the patients were causing a distraction near Patient #12's room. Interview revealed Patient #10 managed to sneak into Patient #12's room without staff noticing during the commotion. Interview revealed the staff members seem distracted by the commotion on the unit and missed the patient sneaking in and out of Patient #12s room. Interview revealed based on the CNO's video review, she realized the MHT (MHT #6) had missed a Q15 minute observation check on Patient #10. Interview revealed the 2 MHT's on the unit were suspended and an investigation was conducted.

Interview on 06/23/2021 at 1600 with the Director of Nursing South campus (DON #1) revealed the MHTs on duty during Patient #10 & 12's incident were new employees and their lack of training contributed to the incident. Interview revealed they (hospital staff) probably should have not had two new MHTs on the unit at the same time, "that's something we should take ownership of."

Interview on 06/24/2021 at 0951 with MHT #6 revealed she was on duty the night of Patient #10 &12's incident. Interview revealed MHT #6 was performing Q15 minute checks on the patients during hygiene time. Interview revealed MHT #6 was assigned with another new MHT and had never done hygiene time by herself prior to that night. Interview revealed MHT #6 was trained not to enter the patient's room during hygiene time to complete the observation check due to privacy. Interview revealed MHT #6 did not observe Patient #10 entering Patient #12's room. Interview revealed MHT #6 completed Q15 minute observation check on Patient #12 during hygiene time but actually did not observe Patient #12 while in the shower.

Interview on 06/24/2021 at 1009 with the House Supervisor for Children's unit revealed Patient #10 was in the group room with MHT #7 and Patient #10 asked to go to her room and get something during hygiene time. Interview revealed during that time another patient began to cause a commotion on the unit and staff went to check on that patient. Interview revealed while staff were trying to de-escalate the other patient, Patient #10 snuck into Patient #12's room. Interview revealed Patient #10 managed to sneak in and out the Patient #12's room without staff noticing.

Interview on 06/24/2021 at 1052 with RN #5 revealed Patient #10's Guardian reported to RN #5 that the patient reported to her on the phone she had been raped the night before. The nurse stated she was under the impression it was sexual intercourse that had occurred without consent. Interview revealed the nurse told the guardian she would talk to the patient and inquire about what happened. The nurse stated following Patient #10s interview, the patient reported "they both went down on each other" and she didn't consent to it. Interview revealed the nurse call the guardian back and told her what Patient #10 had reported to her. Interview revealed the nurse separated the patients, notified the provider and Patient #10 was transferred to a different unit. Interview revealed that the police department was also notified.

Interview on 06/24/2021 at 1627 with MHT #7 revealed she was on duty the night of the incident. Interview revealed MHT #7 did not know anything had occurred that night and she learned of the incident the following shift. MHT #7 stated she was assigned to the day room patients during the hygiene time. MHT #7 was unsure of how Patient #10 entered Patient #12's room without staff noticing.



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4. Closed medical record review conducted on 06/22/2021 revealed Patient #14 was a 24-year-old female admitted to the hospital on 04/22/2021 at 1126 with a diagnosis of Schizoaffective disorder Bipolar Type. Review revealed an order was placed for Patient #14 to be observed by hospital staff every 15 minutes beginning on 04/22/2021 at 1200. Review of hospital observation sheets revealed no gaps in 15-minute staff observations during Patient #14's hospital admission, noting that on 04/27/2021 at 2130 through 2200 Patient #14 was documented as being in her unit's hallway by MHT (Mental Health Technician) #10; and on 04/28/2021 at 0900 through 1000 Patient #14 was documented as being in her unit's dayroom by MHT #9. Review of a nursing note written by Registered Nurse (RN) #11 on 04/28/2021 at 1200 revealed, " ...Pt (Patient) reports having sexual intercourse with another pt that was consensual. Advised pt that it is not appropriate both pt being moved and placed on SP (Sexual Precautions) ..."

Review of a hospital incident report written by the hospital's previous Director of Risk Management (undated) revealed, " ...Incident Type: Sexual Intercourse Patient to Multiple Patients and Sexual Boundary Violation Patient to Patient ... Brief Description of the incidents: Female Patient reported to staff that she had intercourse with two male patient on the unit after male was found with her in the shower fully clothed on 4/28/21 at 0943. Initial report was just this incident. Further investigation revealed that two males entered her room a total of three time from 4/27/21 at 2152 until 4/28/21 at 0943 ... Incident One ... 4/27 (Patient #14 Named) and (Patient #29 Named) 21:53:33 Male patient enters female's room and female follow him in, the door is closed and the are uninterrupted for 13 minutes and 51 seconds. They leave without interaction with staff. Incident Two and Three ... 4/28 (Patient #14 Named) and (Patient #28 Named) ... 09:12:30 Female enters her room and male follows, door closes, they are uninterrupted for 5 minutes and 41 seconds. During this time male (MHT #9) does observation rounds and approaches the door and slightly opens it. There are 3 patients in the room (roommate). He continues on rounds. The roommate leaves the room, followed by the male peer, and then the female leaves the room. At 09:42:55 (Patient #14 Named) again enters her room and (Patient #28 Named) follows her in. They are uninterrupted for 44 seconds. A rec (recreational) therapist opens the door to look for roommate and (MHT #9) follows her and calls out to male peer as he was not seen in the hall. Male peer answered and (MHT #9) entered room and saw them fully clothed behind the shower curtain. After this event (Patient #14 Named) states she had intercourse with (Patient #28 Named) and he confirmed. They both stated it was consensual. (Patient #14 Named) then said she had intercourse with (Patient #29 Named). As this encounter was only 44 seconds I viewed video from overnight and found first and second events ... Investigation Findings/Risk Issues/Process Failures ... Failure to identify at risk behaviors that were clearly evident and intervene Failure to perform observation round appropriately Documentation of location of patients on observation sheets falsified ... No evidence on admission that patient had history of hyper-sexuality ..."

Review of Employee Corrective Action Report written on 05/07/2021 revealed, " ... (MHT #9 Named) ... Termination ... RECENT INCIDENT(S) Failure to adhere to policy and complete every 15 min (minute) checks-Failure to perform this duty allowed a sexual encounter between patients to occur. (MHT #9 Named) admits not opening door and checking room per policy ..."

Review of Employee Corrective Action Report written on 05/07/2021 revealed, " ... (MHT #10 Named) ... Termination ... RECENT INCIDENT(S) Review of video and documentation resulted in evidence of falsifying medical documentation ..."

Staff interview was conducted with RN #11 on 06/22/2021 at 1510. RN #11 recalled Patient #14. Interview revealed Patient #14 reported sexual activity between her and another male patient, who at the time denied the activity occurred. Interview revealed both patients were subsequently moved to different units and placed on SP. Interview revealed the incident was reported to RN #11's superiors, and there were no other incidents to RN #11's knowledge.

Staff interview was conducted with the hospital's current Director of Risk Management on 06/23/2021 at 1505. Interview revealed the allegations of sexual activity between hospital patients was investigated by the former Director of Risk Management, and her incident report was provided for review.

Staff interview was conducted with the Nursing Manager of Units 2 East and 2 West on 06/24/2021 at 0923. Interview confirmed she was the manager of the unit Patient #14 was assigned to. Interview revealed the MHT staff did not consistently open the door and physically enter the room to perform the required 15-minute patient checks. Interview revealed staff re-education was performed for 100% of the 2 East and 2 West unit staff employed at the time, however the education was not facility wide.

Based on policy and procedure review, medical record reviews, staff and physician interviews, the facility staff failed to coordinate discharge planning needs for 1 of 20 patients` medical records reviewed. (Patient #11)

Findings included:

Review of the facility policy titled, "Discharge Planning (nursing)" reviewed 04/01/2021, revealed " ... Policy ... Registered Nurses ensure that the patient and, if appropriate, the patient's family, has an understanding of the discharge plans and provides the patient with a written document outlining these plans at the time of discharge ...Procedure ... 13 ...During the discharge process, if any part of the discharge plan changes or becomes unsafe (change in mental status, verbalization of lethality, issues with safe placement), the nurse will call the physician ... "

Closed medical record review on 06/23/2021 for Patient #11 revealed a 28-year-old male patient involuntarily admitted on 03/02/2021 for physical aggression, sexual assault of mother, assault of a family member, non-compliance with medications, symptoms of psychosis with bizarre and violent behavior and endorsed homicidal ideation towards his stepdad. Medical history included paranoid schizophrenia and diabetes. Review of the Physician orders included "blocked room for highly aggressive and sexual aggressivity." Review of the "Intake Assessment" dated 03/02/2021 revealed the patient refused for family to be contacted. Review revealed the patient was to be discharged to a rescue mission (shelter) in a surrounding county within North Carolina. Review revealed the discharge medications were forwarded to a pharmacy out of state. Review revealed no further documentation of prescriptions provided locally nor medications given to the patient. Review of a nursing progress note dated 03/06/2021 at 1400 revealed "Patient states that he is not going to a [nearby shelter] but is going to [named state]. Reports that he discussed this with the doctor and that is why he sent prescriptions to [named state] ... At 1405 "Patient stated he is not going to [named shelter] and did not need a cab but was going straight to [out of state] ... At 1410 "Patient taken downstairs to the lobby by MHT (#14) [Mental Health Technician] without discharge instructions. Nurse unaware when the patient left the floor." At 1426 "Notified house supervisor that pt left without discharge instructions stated to put discharge instructions back in the chart until he comes to pick them." Review of the Physician Discharge Summary dated 03/06/2021 revealed "...The patient returned to a city in North Carolina to the [named shelter], transported by cab to attend [named outpatient psychiatric] urgent care same day walk-in in [another city within the state] ..." Review revealed the patient was discharged to local shelter and referred to a local outpatient mental health service in adjoining city, and his prescriptions were sent to another state. Review revealed the patient did not receive his discharge papers upon leaving.

Interview on 06/23/2021 at 1115 with the Psychiatrist, revealed "Like many patients here, the patient denied the allegations. His focus was on discharge ... Patient was not getting along with his family. The patient was going to return to [named state]. I believed him. We made arrangements to accommodate his wishes... I agree the notes do not reflect significant changes. It looked like more of a psychosocial conflict versus psychosis. I see the documents (patients' medical record) and it paints that picture of patient being unstable and no significant changes. He was not extremely stable. He (patient) was angry about being constrained in the hospital. He was not getting along with patients, some social issues ... He would do better off a locked unit." Interview revealed "Yes" he was stable for discharge. Interview revealed "The patient was going to [named city in another state] after going to [named local shelter]. That was what I believed was going to happen."

Interview on 06/24/2021 at 1015 with the Director of Clinical Services, revealed "there is a disconnect" related to his discharge disposition and where his prescriptions were sent. Interview revealed there was an "inaccurate picture of the presentation within the medical record." Interview revealed the facility had the capability to assist with a discharge of a patient to another state, if there was verifiable support identified in the other state. Interview revealed if a patient was to travel to another state, prescriptions could have been filled locally before leaving the area, or written prescriptions handed to the patient at discharge. Interview revealed "patients definitely should have written discharge instructions." Interview confirmed the patients discharge was not coordinated per their policies or practice.

Interview on 06/24/2021 at 1300 with the Social Worker, whom cared for the patient, revealed "I do not recall the patient."

NC00175209; NC00176704; NC00177462; NC00176892; NC00176784; NC00176957; NC00177904; NC00176779; NC00177678; NC00177829; NC00178565