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Based on document review and interview the facility failed to implement adequate supervision for 2 of 12 patients (patient #1 and patient #2) reviewed. Patient #1 and patient #2, who were ages 17 and 13 respectively, were found in a hallway bathroom engaging in sexual intercourse.

Record review for patient #1 established diagnoses including post-traumatic stress disorder (PTSD), psychosis, and reactive attachment disorder. Patient #1 was admitted to the unit for delusional and aggressive behaviors, and was on the unit for three days prior to the incident. On the day of the incident, patient #1 had orders for observational checks by staff every thirty minutes.

Record review for patient #2 established diagnoses including mood disorder, attention deficit disorder, and Asperger's syndrome. Patient #2 was admitted to the unit for increased aggression and violence, and was on the unit for five days prior to the incident. On the day of the incident, patient #2 had orders for observational checks by staff every thirty minutes.

Patient #2 was interviewed on 6/6/2013 at 11:00 a.m. and stated that on 4/11/2013, he and patient #1 were talking about sex during lunch, and agreed to meet and have sex during the group therapy session that afternoon. He stated that following the conversation, he went to the hallway bathroom, and staff let him into the bathroom. When he left the bathroom, he did not close the door completely, and the staff person who was with him, did not make sure that the door was shut completely or locked. Patient #2 stated that he and patient #1 left the therapy session a few minutes apart, and met in the hallway bathroom, near his room. Patient #2 stated that he and patient #1 were in the bathroom for approximately five minutes, and did have sex during that time.

Patient #1 was unavailable to be interviewed during the course of the investigation.

Employee (F)/nurse was interviewed on 5/29/2013 at 12:00 p.m. and stated that on 4/11/2013, both patient #1 and patient #2 were on physician ordered thirty minute monitoring checks. Employee (F) stated that patient #1 and patient #2 were in a group therapy session, and five employees were in the hallway, monitoring patients and completing the safety checks on the patients. Employee (F) stated that, patient #1 and patient #2 had planned to meet in the hallway bathroom, and were found by a staff person approximately five minutes later engaging in sexual activity. Employee (F) stated that the hallway bathroom is in the hallway near patient #1 and patient #2's rooms. Employee (F) stated that the bathroom door should have been locked, at the time of the incident, and patient #1 and patient #2 should not have been able to access the bathroom without a staff person present. The door is now installed with an automatic close device to ensure the door always closes completely when a patient leaves the bathroom.

Employee (G)/Psychology Associate was interviewed on 5/29/2013 at 11:30 a.m. and stated that he spoke with patient #2 following the incident on 4/11/2013. Patient #2 told him that during lunch patient #1 "dared" him to have sex. Patient #2 stated that they made a plan to meet in the bathroom, and that patient #2 had left the bathroom door "cracked" after use at lunch. Employee (G) stated that it was five to ten minutes between the time they left the group session, to the time they were found by staff in the bathroom. Employee (G) stated that staff was in the hallway monitoring patients, but when patient #1 and patient #2 went down the hallway, staff was not aware that the bathroom door was open. Employee (G) stated that the hallway bathroom door is to be locked at all times, and only staff is to unlock the door to let patients into the hallway bathroom. The staff person is to stay with the patient until the patient exits the bathroom, and ensure that the door is closed and locked. He stated that it is difficult to see if the door is cracked open, and, at that time, the door was not equipped with an automatic door closer.

The policy entitled Safety and Security on Inpatient Secure Units-BHS, dated November 2012, verifies that "all doors to non-patient rooms will be locked at all times unless supervised by staff."

Based on document review and interview the facility failed to implement adequate supervision for 2 of 12 patients (patient #1 and patient #2) reviewed. Patient #1 and patient #2, who were ages 17 and 13 respectively, were found in a hallway bathroom engaging in sexual intercourse.

Record review for patient #1 established diagnoses including post-traumatic stress disorder (PTSD), psychosis, and reactive attachment disorder. Patient #1 was admitted to the unit for delusional and aggressive behaviors, and was on the unit for three days prior to the incident. On the day of the incident, patient #1 had orders for observational checks by staff every thirty minutes.

Record review for patient #2 established diagnoses including mood disorder, attention deficit disorder, and Asperger's syndrome. Patient #2 was admitted to the unit for increased aggression and violence, and was on the unit for five days prior to the incident. On the day of the incident, patient #2 had orders for observational checks by staff every thirty minutes.

Patient #2 was interviewed on 6/6/2013 at 11:00 a.m. and stated that on 4/11/2013, he and patient #1 were talking about sex during lunch, and agreed to meet and have sex during the group therapy session that afternoon. He stated that following the conversation, he went to the hallway bathroom, and staff let him into the bathroom. When he left the bathroom, he did not close the door completely, and the staff person who was with him, did not make sure that the door was shut completely or locked. Patient #2 stated that he and patient #1 left the therapy session a few minutes apart, and met in the hallway bathroom, near his room. Patient #2 stated that he and patient #1 were in the bathroom for approximately five minutes, and did have sex during that time.

Patient #1 was unavailable to be interviewed during the course of the investigation.

Employee (F)/nurse was interviewed on 5/29/2013 at 12:00 p.m. and stated that on 4/11/2013, both patient #1 and patient #2 were on physician ordered thirty minute monitoring checks. Employee (F) stated that patient #1 and patient #2 were in a group therapy session, and five employees were in the hallway, monitoring patients and completing the safety checks on the patients. Employee (F) stated that, patient #1 and patient #2 had planned to meet in the hallway bathroom, and were found by a staff person approximately five minutes later engaging in sexual activity. Employee (F) stated that the hallway bathroom is in the hallway near patient #1 and patient #2's rooms. Employee (F) stated that the bathroom door should have been locked, at the time of the incident, and patient #1 and patient #2 should not have been able to access the bathroom without a staff person present. The door is now installed with an automatic close device to ensure the door always closes completely when a patient leaves the bathroom.

Employee (G)/Psychology Associate was interviewed on 5/29/2013 at 11:30 a.m. and stated that he spoke with patient #2 following the incident on 4/11/2013. Patient #2 told him that during lunch patient #1 "dared" him to have sex. Patient #2 stated that they made a plan to meet in the bathroom, and that patient #2 had left the bathroom door "cracked" after use at lunch. Employee (G) stated that it was five to ten minutes between the time they left the group session, to the time they were found by staff in the bathroom. Employee (G) stated that staff was in the hallway monitoring patients, but when patient #1 and patient #2 went down the hallway, staff was not aware that the bathroom door was open. Employee (G) stated that the hallway bathroom door is to be locked at all times, and only staff is to unlock the door to let patients into the hallway bathroom. The staff person is to stay with the patient until the patient exits the bathroom, and ensure that the door is closed and locked. He stated that it is difficult to see if the door is cracked open, and, at that time, the door was not equipped with an automatic door closer.

The policy entitled Safety and Security on Inpatient Secure Units-BHS, dated November 2012, verifies that "all doors to non-patient rooms will be locked at all times unless supervised by staff."