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Based on a review of records, observation, and interview, the facility failed to protect and promote patient rights.

Findings:


A. The facility failed to follow its own policy and placed a 17-year-old adolescent male in a bedroom with a 14-year-adolescent male, a 36-month difference in age. The facility policy states there can be no more than a 24 month age difference when placing patients in the same room. The policy had no guidelines to assist the staff in room assignments on placing patients with a known history of sexual acting out with victims of sexual abuse.


B. Nursing failed to document an alleged sexual encounter of a minor in the facility's care when the physician and administrator was notified. There was no documentation by the nurse that the patient was placed in a separate room following the allegation, had been assessed for injuries, or how the patient was coping from the incident. There was no documentation in the patient medical records that the guardians and Child Protective Services (CPS) was notified.


C. Between the date of the alleged event 12/20/19 to the time of the onsite visit 01/8/2020, the facility failed to protect the patients by ensuring staff were reeducated in appropriate monitoring and following physician orders regarding observations. The facility continued to be out compliance with physician orders for monitoring safety for high risk patients. There were 5 out of 5 patients not observed at the level ordered by the physician on 1/8/2020.

Cross Refer to Patient Rights: CFR §482.13 Care in a Safe Setting

Cross Refer to Content of Record: §482.24(c)

Cross Refer to Patient Care Assignments §482.23(b)(5)

Based on review of documentation and interview, it was determined that the facility failed to ensure that a safe setting was maintained by following the facility's own room assignment policy, monitoring patients at the level ordered by their physician, and documentation of an alleged sexual encounter was carried out.

Findings:

The facility failed to follow its own policy regarding age differences in patients for room assignments. Failure to adhere to this policy resulted in a sexual encounter between two adolescents.

Review of Patient #1's chart revealed that the patient was a 17-year-old male admitted to the facility on 12/19/19. Review of the Nursing Intake form dated 12/19/19 revealed that the patient attempted suicide by putting a plastic bag over his head and smothering himself. The Intake Assessment stated in part, "Pt reports he has rage episodes and cusses people out and refuses to do stuff. Pt reports he has tried to kill himself four times in the past ... Pt reports a hx of self-abuse by cutting and scratching himself and banging his head against the wall ..." Review of Patient #1's intake assessment dated 12/19/19 revealed, he had a history of sexual abuse by foster parents and had exhibited self-injurious behavior.

Review of the medical record Patient #1, a 17-year-old adolescent male was placed on the adolescent floor and shared a room with Patient #2, a 14-year-old adolescent male.

Review of Patient #1's chart revealed physician orders written on 12/20/19, at 8:30 AM, reflect the patient was placed on line of sight precautions due to high risk of suicide.


Review of Patient #2's medical record revealed, he was admitted on 12/19/19 for Bipolar I depression severe with psychotic features, Post Traumatic Stress Disorder (PTSD), and unspecified anxiety. Review of the intake form dated 12/19/19 stated in part, "The patient is a 14-year-old male who reports on an Order of Emergency Detention (OED) with Suicidal Ideations (SI). The OED states that pt presents a substantial risk of serious harm to self. Pt's family reports pt wrote a note which stated he was running away tonight and he didn't want to be here anymore."

The Nursing Assessment for Patient #2 completed on 12/19/2019, stated, " ... Hx of SAOP (sexually acting out precautions) ..."

The Psychiatric Evaluation completed on 12/20/2020 revealed, Patient #2 had a history of sexual abuse. There is no documentation found by or provided to this surveyor that the patient's psychiatric provider was aware Patient #1 had a history of sexually acting out behavior.


Review of the medical record Patient #2, a 14-year-old adolescent male was placed on the adolescent floor and shared a room with Patient #1, a 17-year-old adolescent male.


Review of the facility policy entitled "Room Assignment" stated in part,
"a) Patient will be assigned a bed based on the following guidelines:
i) Age: Seventeen and under, primarily 24 months of age difference as long as the patient's age is within the same program (i.e., Latency or Adolescent Program.) ..."

The facility failed to follow this policy and placed a 17-year-old adolescent male with a 14-year-old adolescent male, a 36-month age difference. The policy had no guidelines to assist the staff in room assignments on placing patients with a known history of sexual acting out with victims of sexual abuse.


Review of the facility Incident Report revealed Patient #2 made a statement of sexual abuse against Patient #1 on 12/20/19. There was no documentation found in the nursing notes of alleged sexual assault between Patient #1 and #2.

The Practitioner Order Sheet dated 12/20/19 at 8:30 AM for Patient #2 stated in part, "1) Continue Q5 while awake
2) LOS while asleep." The indication noted by the physician for the increased level of observation was due to "suicide and elopement risk."


Review of the Behavioral Health Associate (BHA) note for Patient #2 dated 12/20/2019 stated in part, "9:00 PM Pt completed hygiene. Pt took night meds and completed group goals. After, group pt asked to go lay down. Pt was redirected for telling peers about what happened between him and another peer. Pt was in staff sight - at all times. No major issues to report. Will continue to monitor ..."

There was no further documentation of what the patient was telling peers and if the RN was notified. There is no evidence that Patient #1's physician was notified or that the patient was placed on sexually acting out precautions prior to the allegation of sexual abuse.


A review of the Psychiatric Progress Note for Patient #2 dated 12/21/2019 stated, "Q5 awake/LOS asleep D/C. Start LOS AAT. Boundary - sexually inappropriate behavior toward peer reported to staff ..." This is the only note that was found in the patient record to confirm the allegation of sexual abuse had occurred.


A Physician order for Patient #1 on 12/20/19 at 8:30 AM stated, "Continue LOS. Continue cottage restrictions. Suicidal, high and SRA (Suicide Risk Assessment)."


A review of the nursing assessments and progress notes for Patient #2 revealed no documentation that Patient #2 or Patient #1 were involved in an allegation of sexual assault. There was no documentation by the nurse that the patient was placed in a separate room following the allegation, had been assessed for injuries, how the patient was coping from the incident, or any notes on therapy interventions concerning the assault. Additionally, there is no evidence the incident was reported to CPS.


The observation sheet for Patient #2 dated 12/20/2019, the date of the alleged allegation of sexual abuse, revealed that this patient was not observed at the level (every 5 minutes) as ordered by the physician. The observation sheet was blank from 3:00 PM to 4:00 PM on 12/20/2019. Staff #3, Risk Manager reported the allegation of sexual assault was said to have occurred between 2:30 PM and 3:30 PM.


A review of the Interdisciplinary Treatment Plan for Patient #1 dated 12/17/19 reflects a history of physical, emotional, and sexual abuse. The alleged sexual encounter with a peer on 12/20/19 was not addressed in the treatment plan problem list, short term and long-term goals, or interventions throughout the duration of the patient's treatment.


A review Interdisciplinary Treatment Plan for Patient #2 dated 12/20/19 does not indicate the patient had a history of sexual abuse or sexually acting out behavior. The alleged sexual encounter on 12/20/19 with a peer was not addressed in the treatment plan problem list, short term and long-term goals, or interventions throughout the duration of the patient's treatment.


Review of the facility incident reports revealed no written statements dated 12/20/19 from Patient #1, Patient #2, Staff #4, and Staff #5.


Patient #2 statement revealed, he was approached by Patient #1 to kiss, perform oral sex, play "would you rather and 20 questions." Patient #2 reported, he complied with the requests by Patient #1. Patient #2 felt he had been violated because Patient #1 didn't want to "be with him" and that made him feel like he had been used. At this time Patient #2 began to self-harm by hitting himself. Patient #1 then reported the incident to staff.


A review of the facility Incident Report revealed, Staff #4 documented, "I was not responsible for the line of sight. I was responsible for the other pts. I was running a group. I was informed by another pt that another pt has feeling for another pt. The other pt did however come to me, and inform me because the other pt did state that pt did like the other pt. Pt said that they were trying to focus on themselves and didn't have any intent in the other pt. Pt was spoken to by staff and did state that pt could not display any attention like that towards any pt."


Review of the facility incident report revealed Staff # 5 (assigned to observed Patient #1 and Patient #2) documented, "Patient next to my line of sight (LOS) was getting mad and yelling at the patient across the Hall [sic] he go so mad he said he was going to kill himself went in the bathroom I went into the room open the bathroom door he had a pair of paper scrub pants acting like was going to wrap it around his neck I took it ways Two other employees came in and helped me he combed down I talked to the angry patient more as I was in the hallway watching the LOS the patient in the room next to the LOS ask me to go with him in the Doctors as she was ready him as Im [sic] walking with patient want me to go with them so heres [sic] Qs when I came out other staff member had the LOS patient told me that someone told him that two patient had feel for each other so we asked LOS patient questions and LOS patient told me more of the story [sic]."


Review of Staff #5's employee file revealed a Notice of Unsatisfactory Work Performance or Conduct for Staff #5, Behavioral Health Associate, stated in part, "On Friday December 20, 2019 ... Also, _____ (Staff #5) was not observing patients assigned to his care at the ordered level of observation: Line of Sight. These actions are in violation of policies ... 1000.17 Patient Observations ...
Summary of Consequences for Failing to Correct Problem:
_____ (Staff #5) actions result in breach of Acadia Policy HR - 250 Progressive Discipline, step three, Final Written Warning for serious policy(s) violation ..." There were no disciplinary actions for any other staff involved in the incident. There was no facility wide training on monitoring, documentation, safety, or Performance Improvements provided.


A tour of the Adolescent unit was conducted on the afternoon of 01/08/2019, at 3:46 PM. Staff #4, Behavioral Health Associate, was observed in a room with an adolescent patient and the unit nurse. Upon review of the observation sheets, it was revealed 5 out of 5 patients were not observed at the level ordered by the physician. The patient's observation records on the afternoon of 01/08/2019 at 3:46 PM revealed the following:

Patient #3's physician ordered every 5-minute observation precautions to be discontinued on 01/06/2019 at 8:30 AM. However, the new level of precaution was not indicated by the provider. A review of the observation for patient sheet on 01/08/29 revealed, the patient was being observed every 15-minutes. The observation sheet was blank from 3:00 PM to 3:46 PM. The record reflected the patient had not been observed for 46 minutes.

Patient #4 was ordered to be observed every 15 minutes by the admitting physician on 01/06/2020 at 8:00 AM for self-harm and moderate risk for suicide. A review of the observation record for Patient #4 on 01/08/29 revealed, the observation sheet was blank from 3:00 PM to 3:46 PM. The record reflected the patient had not been observed for 46 minutes.

Patient #5's physician ordered every 5-minute precautions to be discontinued on 01/05/2019 at 7:00 AM. However, the new level of precaution is not indicated by the provider. The last recorded observation was at 3:00 PM. The record reflected the patient had not been observed for 46 minutes.

Patient #6 was ordered by the physician to be on an increased observation level of every 5 minutes on 01/8/2019 at 11:12 AM for safety. The last recorded observation was at 2:15 PM. The record reflected the patient had not been observed for 1 hour and 31 minutes.

Patient #7 was ordered by the physician to be observed on an increased level of observation of every 5 minutes on 01/08/202 at 8:00 am for safety. The last recorded observation was at 2:25 PM. The record reflected the patient had not been observed for 1 hour and 21 minutes.


In an interview with Staff #1, Chief Executive Officer, revealed the document "Safety-T Protocol with C-SSRS" is a suicide risk assessment tool used to help determine the level of precautions. Staff #1 stated in part, "if they were on homicidal precautions or something else the physician would indicate that, but safety is used based on the suicide risk assessment."


There is no documented evidence the facility reported an alleged sexual abuse allegation between patient #1 and patient #2 on January 20, 2019 to Child Protective Services.

Staff #3, Risk Manager stated in part, "... We identified they had not self-reported and I pulled up the Texas abuse hotline and I self-reported. I was doing the report and my computer shut off, but I failed to close the loop after it came back on, so we didn't get the report in. I began it then failed to come back and close the loop."

Based on record review and interview, the facility failed to ensure nursing personnel assigned to the care of patients had the appropriate licensure and competence in order to meet the individual needs of each patient.

Findings:

A review of the personnel file for Staff #6 RN, revealed stipulations were set forth by the Texas Board of Nursing and The Terms of Order stated in part, " ... C. Direct Supervision: For the first year [four (4) quarters] of employment as a Nurse this order, RESPONDENT SHALL be directly supervised by a Registered Nurse... Direct supervision requires another nurse, as applicable, to be working on the same unit as RESPONDENT SHALL work only on regularly assigned, identified and predetermined unit(s). RESPONDENT SHALL NOT be employed by a nurse registry, temporary nurse employment agency, hospice, or home health agency. RESPONDENT SHALL NOT be self-employed or contract for services. Multiple employers are prohibited ..."

Staff #6 RN, signed the order on January 10, 2019, and in so agreed to the conditions of the order.


The facility document entitled "Staffing Variance Sheet" completed on 12/20/2019 for Unit 4 (the adolescent unit), revealed Staff #6 RN was assigned to be the Charge Nurse. Staff #6, RN did not have direct supervision of another registered nurse per the stipulations set forth by the Texas Board of Nursing.


In an interview with Staff #3, the Chief Nursing Officer stated in part, " ...The procedure has historically been to carefully review the stipulations with the HR Director and to basically take the stipulations in the totality of the hiring needs and the totality of our facility needs. Every stipulation is a little different ... This was an oversight ..."

Based on record review and interview, it was determined that the facility staff failed to document any assessments or progress notes reflecting an allegation of sexual encounter between two adolescents on 12/20/2019.

Finding:

The facility employee training module entitled "Pre-Service Training Strategies for Sexually Acting Out Behavior" stated in part,

" ... Sexual abuse committed by a child against another child. For the purpose of this subsection, sexual abuse is: conduct harmful to a child's mental, emotional or physical welfare, including nonconsensual sexual activity between children of any age, and consensual sexual activity between children with more than 24 months difference in age or when there is a significant difference in the developmental level of the children; or failure to make reasonable effort to prevent sexual conduct harmful to a child.

...Sexual Behavior reporting standards

*Sexual conduct must be reported if it is harmful to a patient's mental, emotional or physical welfare.

*If ANY of the following are noted in the conduct in question a report should be made:

*Reporting

*Coercion (by another child, or the caregiver, or another adult)

*Variation in age of 2 years or more (chronically or cognitively)

*Significant difference in size or strength

*Difference in mental ability

*A noted plan was in place (predator or victim)

*Any recent sexualized behavior, especially a pattern of behavior

*Any caregivers lack of supervision

*Fondling, over sex acts, threatening sexual statements or comments ..."


The facility policy entitled "Clinical Services Documentation" stated in part, "Procedure: The Registered Nurse will document in the Medical Record each shift and as necessary.

1. Clinical service staff will document as follows:

a. Patient interactions, group attendance and participation, and information received from collateral sources and the interdisciplinary treatment note ..."


The facility policy entitled "Nursing Documentation" stated in part, "Documentation of patient care rendered, and observations is a vital aspect for the delivery of safe, quality patient care as well as for continuity of care within the interdisciplinary team. Nursing Staff shall document patient care rendered on a daily basis.

Procedures:

1. Acute Care Units

*RNs will document on the Daily Nursing Assessment the care provided, assessments, observations, interventions, etc. a minimum of once per shift ...

*MHA's will complete the observation Q. 15" Check form on every patient observed and/ or assigned to the them by the RN during their shift, including the shift notes (SN) portion and the appropriate group notes."


The Elements of Effective Documentation in the New Hire Orientation and required for all new employees, stated in part,

" ... Basic Progress SOAP (sexually acting out precautions) Examples:

*Subjective/Summary: Info obtained from patient/family (generally a direct quote) ...

*Objective: Data or information that matches subjective/summary (observations, descriptions, etc - i.e. mental status, behaviors, labs)

*Assessment: Findings and needs identified based on subjective and objective information ...

*Plan: Specific interventions/actions taken or next steps to be taken ..."


Based on a review of the nursing assessment and progress notes revealed there was no documentation in the medical record for 2 (#1 and #2) out of 2 patients that were involved in an allegation of sexual encounter on 12/20/19 which resulted in one of the patient's self harm behavior. There was no documentation by the nurse that the patients were placed in separate rooms following the allegation, had been assessed for injuries, that the physician had been notified of the incident, or how the patients were coping from the incident.

Review of Patient #1's chart revealed that the patient was a 17-year-old male admitted to the facility on 12/19/19. The Intake Assessment dated 12/19/19 revealed, he had a history of sexual abuse by foster parents and had exhibited self-injurious behavior.

The Nursing Assessment for Patient #2 completed on 12/19/2019, stated, " ... Hx of SAOP (sexually acting out precautions) ..." The Psychiatric Evaluation completed on 12/20/2020 revealed, Patient #2 had a history of sexual abuse.

The above information was confirmed in an interview with Staff #3, Risk Manager.