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I. Based on observations, document review, video footage, and staff interviews, the hospital failed to protect the rights of all patients in the Behavior Health Unit when they failed to protect a court committed patient with an intelectual disability from sexual activity. Problem identified for 1 of 10 patients (Patient #2) on 1 of 3 Behavior Health Units.

1. Behavioral health staff failed to identify and prevent three sexual acting out behaviors. Two incidents occurred in Patient #1's room and one incident occurred in a common TV/lounge room. (A-0144)

2. Behavioral health staff members failed to be unpredictable in the 15 minute rounding checks, which allowed Patient #1 & Patient #2 time and opportunity to engage in sexual acts without staff interruption or identification. (A-0144)

3. Behavioral health staff failed to implement additional precautions when Patient #2 showed interest in patients of the opposite sex. (A-0144)

4. Administrative staff of the hospital failed to develop and implement a policy and procedure to address precautions. (i.e.., sexual acting out, assault, homicide, and elopement) and to educate behavioral health care staff in the precautions. (A-0144)

II. The complaint investigation (64466-C), identified an Immediate Jeopardy (IJ) situation, a situation that placed the patients in an unsafe environment, related to Condition of Participation, Patient Rights (42 CFR 482.13).

1. While onsite, the survey staff identified an Immediate Jeopardy (IJ) situation and notified the administrative staff on 12/8/16. The Administrative staff promptly took action to abate the immediacy of the situation. Facility staff removed the immediacy prior to exiting the incident/complaint investigation on 12/9/16 when they took the following actions.

a. In response to the IJ the hospital administrative staff successfully abated the immediacy of the situation by submitting an acceptable abatement plan involving staff training, policy modification and video monitoring teaching tool implementation prior to the complaint investigation exit date of December 9, 2016. The following condition level deficiency remained (A 115) for the Condition of Patient Rights; see (A-0144) for findings.

Based on observations, document review, video recordings, and staff interviews, the hospital failed to ensure a safe environment for all patients in the Behavior Health Unit. On 11/27/16, a court committed patient with an intellectual disability, admitted from a group home setting reported having sex with another patient in the unit. Problem identified with 1 of 10 (Patient # 2) patients on 1 of 3 Behavior Health Units.

Findings include:

1. Nursing progress notes dated 11/27/16 at 11:41 PM, by Staff V revealed at approximately 10:45 PM, Patient #2 reported having sexual intercourse with Patient #1 in Patient #2's bathroom. Staff notified the charge nurse, Staff L, RN, who moved notification up the chain of command including the on call physician and unit manager, and Patient #2's guardian. Staff notified security and asked them to rewind the camera's video recordings to verify if either patient had entered the other ' s room. The video footage showed 3 occasions where Patient #1 and #2 had opportunity for sexually acting out.

During an interview on 12/5/16 at 3:30 PM, Staff V, RN (Registered Nurse) Behavioral Health, reported Patient #2 was looking for Patient #1 and became visibly upset saying, I don't want to get us into trouble. Patient #2 told Staff V that Patient #1 and Patient #2 had sex. Staff V was unaware of this until Patient #2 reported it. Staff V reported receiving notification of the incident on 11/27/16 between 8:00 and 9:00 PM. According to Staff V, at times Patient #2 would seek out men; however, staff never had to separate the patient from others.

2 Review of Patient #2 ' s medical record revealed the following information.
-A twenty-two year-old patient Admitted to the behavior health unit of the hospital via court committal on 11/01/1 6 at 8:08 PM.
- A Behavioral Health Admission Assessment completed on 11/01/16 at 8:46 PM, by Staff K, Screening RN for Behavioral Health revealed the following information. Patient #2 had mild mental retardation and a fixation about having children. Patient #2's guardian believed the patient was escalating in delusional thinking and aggression, and felt the patient needed long-term placement for treatment of borderline personality disorder, related to history of abuse and trauma. Patient #2 was previously in a group home due to Post Traumatic Stress Disorder, depression, bipolar disorder and Attention-Deficit Hyperactivity Disorder. Patient #2 sees ghosts when depressed or crying, and reported having twins, a boy and a girl, born 3 weeks ago and they are with the children's other parent.

3. Review of Patient #1's medical record revealed the following information.
-Patient #1 was a voluntary admission on 11/25/16 at 8:36 PM.
-On 11/25/16 at 9:40 PM, Staff W, RN Behavioral Health, documented, a 37-year-old patient admitted to 2 North with suicidal ideation and a plan to stab them self in the neck and a recent discharge from a local psychiatric facility. The Patient reported recent cocaine use, and came into the ED (Emergency Department) wanting admission.
-The Admitting plan included care in a safe setting, close observation, and assist with plan of care.
-On 11/26/16 at 3:00-11:30 PM, Staff V RN, Behavioral Health, documented the following information in the nurse ' s notes. Patient #1 on the unit socializing with peers. Patient #1 is particularly interested in a patient of the opposite sex (Patient #2). Staff members called security to keep an eye on the cameras as well as closing the hallway doors between the two patient's rooms, due to Patient #1 hovering and getting too close to other patients. Staff informed Patient #1 of the concern.

- On 11/27/16 at 7:00 AM to 11:00 AM, Staff V, documented that staff had to provide Patient #1 frequent reminders about getting to close to a patient of the opposite sex on the unit in the nurse's notes.

- On 11/27/16 at 3:00 PM to 8:15 PM, Staff V documented that Patient #1 was on the unit with peers and required continued frequent reminders about getting too close to a particular patient on the unit, as well as, several other patients of the opposite sex. Patient #1 continued to need redirection. Staff notified Security of the situation and requested they pay close attention to cameras and notify staff of any mishaps. The charge RN notified the physician on call of this situation. Staff V's documentation included Staff confined Patient #1 to their room and could only come out for meals.

4. Review of the recorded footage dated 11/26/16 from 9:39 PM to 9:51 PM showed Patient #1 enter their room and Patient #2 enter the same room a few seconds later. At 9:51 PM, Patient #2 left Patient #1's room and a few seconds later Patient #1 followed.

Review of recorded footage of the 2 North Lounge dated 11/26/16 from 7:29 PM to 7:32 PM showed Patient #1 remove a sweatshirt and place it on Patient #2's lap and Patient #2 move closer to Patient #1. Patient #1 placed a hand under the sweatshirt and into the lap of Patient #2. The sweatshirt fell from Patient #2's lap revealing open pants and exposed skin. Patient #2 moved away from Patient #1 just as a Staff entered the area.

Review of recorded footage dated 11/27/16 from 7:20 PM to 7:26 PM revealed Patient #1 entering their room at 7:20 PM, and Patient #2 entering the same room at 7:21 PM. At 7:26 PM, both patients separately exit the room.

5. A Physician's order dated 11/30/16 at 11:03 AM, revealed Staff O, Psychiatrist ordered Constant Observation for Patient #2.

During an interview on 12/1/16 at 9:20 AM, Staff O, Psychiatrist reported that Patient #2 had mild intellectual disability from fetal alcohol syndrome. This diagnosis focuses on certain thoughts and Patient #2 focused on having children. Patient #2 never stated rape or sexual assault occurred but believed the incidents were consensual. However, Staff O, Psychiatrist did order one-to-one observation for Patient #2 on 11/30/16. Additionally, Staff O was not sure why there was a delay when the incidents occurred 11/26 - 11/28/16.

6. Review of facility policy titled, Observation Levels, reviewed/revised date 10/16, requires the following levels of observation and states, in part. ' Purpose: levels of observation are instituted to maintain the safety of each patient, using a system of progressive intensity of observation and oversight based on patient acuity, symptoms, and overall needs.
-Three levels of patient observation are utilized. The levels are designed to provide increasing intensity of observation, precaution, and oversight commensurate with physician and staff assessment of the patient ' s conditions, symptoms, behaviors, and safety needs.
-Three levels of staff observation are provided: Standard observation, line of sight, and one to one.
-The appropriate observation level is implemented: All patients will be placed on Standard Observation unless they require a higher level of observation. If line of sight or one to one observation is indicated, the attending physician will be notified within one hour to obtain orders for the appropriate level.
-Standard Observation: The staff member will observe and check in with the patient at least every 15 minutes and document the patient's location and status at each interval.
-Line of sight: A staff member will keep patient within line of sight at all times and document the patient ' s location and status a minimum of 15 minutes. Criteria for this level of observation may include: Patient who required frequent redirection, prompting, and encouragement to maintain control. Clinical symptoms that indicate a moderate risk of self harm or harm to others.
-One on one: the patient is assigned to one staff member who is in constant visual contact at all times and will maintain a distance that allows for safety of the patient and staff. Criteria for this level of observation may include: ... Patient is highly volatile, impulsive, and/or suicidal requiring constant observation. '

According to documentation in Patient #1 ' s medical record, the patient was admitted with suicidal ideation and a plan to stab them self in the neck. Additionally, the documentation showed that staff had identified Patient #1 was particularly interested in a patient t of the opposite sex, hovered too close, and required frequent redirection about getting to close to a patient of the opposite sex. These identified behaviors meet the requirement set forth in the facility ' s Observation Level policy for line of site and/or one- on-one.

7. Observations in the 2 North Unit on 11/29/16 at 3:00 PM, 11/30/16 at 2:30 PM, revealed behavioral health staff completing 15-minute rounding checks. Staff made visual contact of patients during rounding; start times varied from 10-15 minutes between checks, and rounds started with lounges and completed with patient rooms.

-Staff's failure to offset the time and place they started and ended rounds allowed patients to predict when they needed to be visualized for 15-minute checks. Review of the facility documentation on the observation rounds sheets and the video recordings showed Patient #1 and #2 ensured they were visibly available for their 15-minute checks.
-On 11/26/16 documentation showed staff visualized both patients at 7:00, 7:15, 7:30, and 7:45 PM. The video footage for 11/26/16 showed the two patients sexually acting out in the 2 North lounge from 7:29 to 7:32 PM.
-On 11/26/16, documentation showed staff visualized both patients at 9:00, 9:15, 9:30, and 9:45 PM. The video footage for 11/26/16 from 9:31 to 9:51 PM showed both patients were in Patient #1 ' s room.
-On 11/27/16 documentation showed staff visualized both patients at 7:00, 7:15, 7:30, and 7:45 PM. The video footage for 11/27/16 from 7:20 to 7:26 PM showed both patients in Patient #1 ' s room.

8. During an interview on 11/30/16 at 1:00 PM, Staff A, Interim Behavior Health Manager, reported that Patient #2 had been on one-to-one since 11/30/16, per physician order. Staff A reported the facility ' s observation level addresses the various precaution levels. Staff reports any risky behaviors at the change of shift during report; all staff is required to attend the change of shift report. One-to-one observation is one staff to one patient; where as a line of site can be with one staff watching two patients. Nurses have shift report sheets that indicate if a patient is on a one-to-one or line of site precautions. According to Staff A, this communication sheet is shredded and not part of the permanent record. All patients are at risk for suicide and placed on 15-minute checks at the time of admission and this continues until discharge. During an additional interview on 12/1/16 at 7:40 AM, Staff A reported on 11/26-27/16 no behavioral health patients were on line of sight, one-to-one, or on sexual acting out precautions.

During an interview on 12/3/16 at 3:15 PM, Staff U, BHT (Behavioral Health Tech), reported being aware of Patient #2's interest in patients of the opposite sex as there was talk of it at change of shift report. Staff U reported completing 15-minute checks in random directions.

During a telephone interview on 12/5/16 at 3:10 Staff T, RN Behavioral Health reported having no awareness that anything had happened between Patient #1 and Patient #2. According to Staff T, BHTs usually complete the rounds. Staff complete patient rounding every 15 minutes, you start at one room and go around and visualize all patients.

During an interview on 12/5/16 at 3:30 PM, Staff V, RN Behavioral Health, also provided the following information related to 15-minute rounds. All staff must visualize all patients during rounds. The time varies (as long as it is within 15 minutes) along with the starting points.

During an interview on 12/6/16 at 3:25 PM, Staff FF, BHT reported that staff was made aware of Patient's #2 attraction to patients of the opposite sex during shift report. All patients become friends in this environment, but no patients are allowed in another patient's room.

Interview on 12/6/16 at 4:00 PM, with Staff GG, BHT reported being aware, that Patient #1 and Patient #2 were spending a lot of time together. There were no direct signs that anything was going on, we tried to keep an eye on both patients. The 15-minute rounding checks are completed every 15 minutes; you start at one door and make a complete circle.

I. Based on observations, document review, video footage, and staff interviews, the hospital failed to protect the rights of all patients in the Behavior Health Unit when they failed to protect a court committed patient with an intelectual disability from sexual activity. Problem identified for 1 of 10 patients (Patient #2) on 1 of 3 Behavior Health Units.

1. Behavioral health staff failed to identify and prevent three sexual acting out behaviors. Two incidents occurred in Patient #1's room and one incident occurred in a common TV/lounge room. (A-0144)

2. Behavioral health staff members failed to be unpredictable in the 15 minute rounding checks, which allowed Patient #1 & Patient #2 time and opportunity to engage in sexual acts without staff interruption or identification. (A-0144)

3. Behavioral health staff failed to implement additional precautions when Patient #2 showed interest in patients of the opposite sex. (A-0144)

4. Administrative staff of the hospital failed to develop and implement a policy and procedure to address precautions. (i.e.., sexual acting out, assault, homicide, and elopement) and to educate behavioral health care staff in the precautions. (A-0144)

II. The complaint investigation (64466-C), identified an Immediate Jeopardy (IJ) situation, a situation that placed the patients in an unsafe environment, related to Condition of Participation, Patient Rights (42 CFR 482.13).

1. While onsite, the survey staff identified an Immediate Jeopardy (IJ) situation and notified the administrative staff on 12/8/16. The Administrative staff promptly took action to abate the immediacy of the situation. Facility staff removed the immediacy prior to exiting the incident/complaint investigation on 12/9/16 when they took the following actions.

a. In response to the IJ the hospital administrative staff successfully abated the immediacy of the situation by submitting an acceptable abatement plan involving staff training, policy modification and video monitoring teaching tool implementation prior to the complaint investigation exit date of December 9, 2016. The following condition level deficiency remained (A 115) for the Condition of Patient Rights; see (A-0144) for findings.

Based on observations, document review, video recordings, and staff interviews, the hospital failed to ensure a safe environment for all patients in the Behavior Health Unit. On 11/27/16, a court committed patient with an intellectual disability, admitted from a group home setting reported having sex with another patient in the unit. Problem identified with 1 of 10 (Patient # 2) patients on 1 of 3 Behavior Health Units.

Findings include:

1. Nursing progress notes dated 11/27/16 at 11:41 PM, by Staff V revealed at approximately 10:45 PM, Patient #2 reported having sexual intercourse with Patient #1 in Patient #2's bathroom. Staff notified the charge nurse, Staff L, RN, who moved notification up the chain of command including the on call physician and unit manager, and Patient #2's guardian. Staff notified security and asked them to rewind the camera's video recordings to verify if either patient had entered the other ' s room. The video footage showed 3 occasions where Patient #1 and #2 had opportunity for sexually acting out.

During an interview on 12/5/16 at 3:30 PM, Staff V, RN (Registered Nurse) Behavioral Health, reported Patient #2 was looking for Patient #1 and became visibly upset saying, I don't want to get us into trouble. Patient #2 told Staff V that Patient #1 and Patient #2 had sex. Staff V was unaware of this until Patient #2 reported it. Staff V reported receiving notification of the incident on 11/27/16 between 8:00 and 9:00 PM. According to Staff V, at times Patient #2 would seek out men; however, staff never had to separate the patient from others.

2 Review of Patient #2 ' s medical record revealed the following information.
-A twenty-two year-old patient Admitted to the behavior health unit of the hospital via court committal on 11/01/1 6 at 8:08 PM.
- A Behavioral Health Admission Assessment completed on 11/01/16 at 8:46 PM, by Staff K, Screening RN for Behavioral Health revealed the following information. Patient #2 had mild mental retardation and a fixation about having children. Patient #2's guardian believed the patient was escalating in delusional thinking and aggression, and felt the patient needed long-term placement for treatment of borderline personality disorder, related to history of abuse and trauma. Patient #2 was previously in a group home due to Post Traumatic Stress Disorder, depression, bipolar disorder and Attention-Deficit Hyperactivity Disorder. Patient #2 sees ghosts when depressed or crying, and reported having twins, a boy and a girl, born 3 weeks ago and they are with the children's other parent.

3. Review of Patient #1's medical record revealed the following information.
-Patient #1 was a voluntary admission on 11/25/16 at 8:36 PM.
-On 11/25/16 at 9:40 PM, Staff W, RN Behavioral Health, documented, a 37-year-old patient admitted to 2 North with suicidal ideation and a plan to stab them self in the neck and a recent discharge from a local psychiatric facility. The Patient reported recent cocaine use, and came into the ED (Emergency Department) wanting admission.
-The Admitting plan included care in a safe setting, close observation, and assist with plan of care.
-On 11/26/16 at 3:00-11:30 PM, Staff V RN, Behavioral Health, documented the following information in the nurse ' s notes. Patient #1 on the unit socializing with peers. Patient #1 is particularly interested in a patient of the opposite sex (Patient #2). Staff members called security to keep an eye on the cameras as well as closing the hallway doors between the two patient's rooms, due to Patient #1 hovering and getting too close to other patients. Staff informed Patient #1 of the concern.

- On 11/27/16 at 7:00 AM to 11:00 AM, Staff V, documented that staff had to provide Patient #1 frequent reminders about getting to close to a patient of the opposite sex on the unit in the nurse's notes.

- On 11/27/16 at 3:00 PM to 8:15 PM, Staff V documented that Patient #1 was on the unit with peers and required continued frequent reminders about getting too close to a particular patient on the unit, as well as, several other patients of the opposite sex. Patient #1 continued to need redirection. Staff notified Security of the situation and requested they pay close attention to cameras and notify staff of any mishaps. The charge RN notified the physician on call of this situation. Staff V's documentation included Staff confined Patient #1 to their room and could only come out for meals.

4. Review of the recorded footage dated 11/26/16 from 9:39 PM to 9:51 PM showed Patient #1 enter their room and Patient #2 enter the same room a few seconds later. At 9:51 PM, Patient #2 left Patient #1's room and a few seconds later Patient #1 followed.

Review of recorded footage of the 2 North Lounge dated 11/26/16 from 7:29 PM to 7:32 PM showed Patient #1 remove a sweatshirt and place it on Patient #2's lap and Patient #2 move closer to Patient #1. Patient #1 placed a hand under the sweatshirt and into the lap of Patient #2. The sweatshirt fell from Patient #2's lap revealing open pants and exposed skin. Patient #2 moved away from Patient #1 just as a Staff entered the area.

Review of recorded footage dated 11/27/16 from 7:20 PM to 7:26 PM revealed Patient #1 entering their room at 7:20 PM, and Patient #2 entering the same room at 7:21 PM. At 7:26 PM, both patients separately exit the room.

5. A Physician's order dated 11/30/16 at 11:03 AM, revealed Staff O, Psychiatrist ordered Constant Observation for Patient #2.

During an interview on 12/1/16 at 9:20 AM, Staff O, Psychiatrist reported that Patient #2 had mild intellectual disability from fetal alcohol syndrome. This diagnosis focuses on certain thoughts and Patient #2 focused on having children. Patient #2 never stated rape or sexual assault occurred but believed the incidents were consensual. However, Staff O, Psychiatrist did order one-to-one observation for Patient #2 on 11/30/16. Additionally, Staff O was not sure why there was a delay when the incidents occurred 11/26 - 11/28/16.

6. Review of facility policy titled, Observation Levels, reviewed/revised date 10/16, requires the following levels of observation and states, in part. ' Purpose: levels of observation are instituted to maintain the safety of each patient, using a system of progressive intensity of observation and oversight based on patient acuity, symptoms, and overall needs.
-Three levels of patient observation are utilized. The levels are designed to provide increasing intensity of observation, precaution, and oversight commensurate with physician and staff assessment of the patient ' s conditions, symptoms, behaviors, and safety needs.
-Three levels of staff observation are provided: Standard observation, line of sight, and one to one.
-The appropriate observation level is implemented: All patients will be placed on Standard Observation unless they require a higher level of observation. If line of sight or one to one observation is indicated, the attending physician will be notified within one hour to obtain orders for the appropriate level.
-Standard Observation: The staff member will observe and check in with the patient at least every 15 minutes and document the patient's location and status at each interval.
-Line of sight: A staff member will keep patient within line of sight at all times and document the patient ' s location and status a minimum of 15 minutes. Criteria for this level of observation may include: Patient who required frequent redirection, prompting, and encouragement to maintain control. Clinical symptoms that indicate a moderate risk of self harm or harm to others.
-One on one: the patient is assigned to one staff member who is in constant visual contact at all times and will maintain a distance that allows for safety of the patient and staff. Criteria for this level of observation may include: ... Patient is highly volatile, impulsive, and/or suicidal requiring constant observation. '

According to documentation in Patient #1 ' s medical record, the patient was admitted with suicidal ideation and a plan to stab them self in the neck. Additionally, the documentation showed that staff had identified Patient #1 was particularly interested in a patient t of the opposite sex, hovered too close, and required frequent redirection about getting to close to a patient of the opposite sex. These identified behaviors meet the requirement set forth in the facility ' s Observation Level policy for line of site and/or one- on-one.

7. Observations in the 2 North Unit on 11/29/16 at 3:00 PM, 11/30/16 at 2:30 PM, revealed behavioral health staff completing 15-minute rounding checks. Staff made visual contact of patients during rounding; start times varied from 10-15 minutes between checks, and rounds started with lounges and completed with patient rooms.

-Staff's failure to offset the time and place they started and ended rounds allowed patients to predict when they needed to be visualized for 15-minute checks. Review of the facility documentation on the observation rounds sheets and the video recordings showed Patient #1 and #2 ensured they were visibly available for their 15-minute checks.
-On 11/26/16 documentation showed staff visualized both patients at 7:00, 7:15, 7:30, and 7:45 PM. The video footage for 11/26/16 showed the two patients sexually acting out in the 2 North lounge from 7:29 to 7:32 PM.
-On 11/26/16, documentation showed staff visualized both patients at 9:00, 9:15, 9:30, and 9:45 PM. The video footage for 11/26/16 from 9:31 to 9:51 PM showed both patients were in Patient #1 ' s room.
-On 11/27/16 documentation showed staff visualized both patients at 7:00, 7:15, 7:30, and 7:45 PM. The video footage for 11/27/16 from 7:20 to 7:26 PM showed both patients in Patient #1 ' s room.

8. During an interview on 11/30/16 at 1:00 PM, Staff A, Interim Behavior Health Manager, reported that Patient #2 had been on one-to-one since 11/30/16, per physician order. Staff A reported the facility ' s observation level addresses the various precaution levels. Staff reports any risky behaviors at the change of shift during report; all staff is required to attend the change of shift report. One-to-one observation is one staff to one patient; where as a line of site can be with one staff watching two patients. Nurses have shift report sheets that indicate if a patient is on a one-to-one or line of site precautions. According to Staff A, this communication sheet is shredded and not part of the permanent record. All patients are at risk for suicide and placed on 15-minute checks at the time of admission and this continues until discharge. During an additional interview on 12/1/16 at 7:40 AM, Staff A reported on 11/26-27/16 no behavioral health patients were on line of sight, one-to-one, or on sexual acting out precautions.

During an interview on 12/3/16 at 3:15 PM, Staff U, BHT (Behavioral Health Tech), reported being aware of Patient #2's interest in patients of the opposite sex as there was talk of it at change of shift report. Staff U reported completing 15-minute checks in random directions.

During a telephone interview on 12/5/16 at 3:10 Staff T, RN Behavioral Health reported having no awareness that anything had happened between Patient #1 and Patient #2. According to Staff T, BHTs usually complete the rounds. Staff complete patient rounding every 15 minutes, you start at one room and go around and visualize all patients.

During an interview on 12/5/16 at 3:30 PM, Staff V, RN Behavioral Health, also provided the following information related to 15-minute rounds. All staff must visualize all patients during rounds. The time varies (as long as it is within 15 minutes) along with the starting points.

During an interview on 12/6/16 at 3:25 PM, Staff FF, BHT reported that staff was made aware of Patient's #2 attraction to patients of the opposite sex during shift report. All patients become friends in this environment, but no patients are allowed in another patient's room.

Interview on 12/6/16 at 4:00 PM, with Staff GG, BHT reported being aware, that Patient #1 and Patient #2 were spending a lot of time together. There were no direct signs that anything was going on, we tried to keep an eye on both patients. The 15-minute rounding checks are completed every 15 minutes; you start at one door and make a complete circle.