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Based on record review and interview, the hospital failed to ensure that the nursing staff developed an individualized nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs. This deficient practice is evidenced by the failure to update the care plans of 3 (#1, #2, and #4) of 5 patients sampled.
Findings;

The hospital's Policy CS-44 titled, "Sexual Acting Out (SAO) Identification and Precautions" revealed in part:
Purpose - To provide staff a framework for identifying patients who are at risk for exhibiting sexually inappropriate behavior and to provide guidance for the implementation of precautions to ensure the safety of all patients.
Policy - Sexual behavior of any kind is prohibited in the facility. All reports or allegations of sexual behavior or sexual acting out will investigated by the Facility.
Sexual Precautions are defined as intensified levels of staff awareness and attention to patient safety/security related to acting out behaviors. Sexual Precautions require varying levels of observing patients and the initiation of specific protocols and supplemental documentation, when warranted.
15. Communicate incident at shift report; update Treatment plan for each patient.

The hospital's Policy CS-02 titled, "Treatment Planning; Integrated/Multidisciplinary" revealed in part: Policy - The Treatment Plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with patient involvement throughout the course of treatment.
2. Revising and developing nursing and medical components of the treatment plan based on additional findings from patient assessments, problems, needs, strengths and limitations, and physician's orders.
Revising the plan based on changes in condition and physicians orders. All physician orders will be incorporated into the treatment plan.

Review of the hospital's Incident/Accident Log and Self-Reporting documentation revealed Patients #1 and #2 had a sexual encounter on 08/18/2023 that was reported by Patient #1 on 08/20/2023.

Review of Patients #1 and #2's medical record with S2Clinical Director failed to reveal their Care Plans were updated following the 08/20/2023 reporting of the sexual encounter to the hospital staff.

In an interview on 09/12/2023 at 10:28 a.m., S2Clinical Director acknowledged the Care Plans for Patients #1 and #2 were not updated according to policy.

Review of Patient #4's medical record on 09/12/2023 revealed an order dated 09/08/2023 for Nitrofurantoin 100 milligrams twice daily by mouth following positive bacteria and white blood cells noted in a urine specimen. Further review of the Care Plan failed to reveal it was revised following the physician orders.

In an interview on 09/12/2023 at 3:30 p.m., S1RNDirector of Quality acknowledged Patient #4's Care Plan was not updated according to policy.

Based on policy/procedure review, observations and interviews, the hospital failed to ensure the prevention and control of Hospital Acquired Infections (HAIs), including auditing of adherence to infection prevention and control policies and procedures by hospital personnel as evidenced by failing to ensure staff sanitized their hands between patient contact for 5 of 5 patients observed during medication administration (Patients #3, #5, R1, R2 and R3).
Findings:

Review of the hospital's Policy IC-02.01 titled, "Infection Control" revealed in part: Hand Hygiene - For hand hygiene, use plain soap for routine hand washing or a hand sanitizer. Hand hygiene should be performed: between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments.

Observations on 09/12/2023 from beginning at 8:43 a.m. and accompanied by S1RN Director of Quality revealed S3LPN touching the arms of Patients #3, #5, R1, R2 and R3 while scanning their arm bands prior to medication administration. S3LPN failed to sanitize her hand between patient contacts for 5 of 5 patients observed.

Interview 09/12/2023 at 10:14 a.m., S1RN Director of Quality acknowledged S3LPN did not sanitize her hands between patient contacts.