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Based on interview, closed record review, review of the facility's Governing Board By-Laws, and review of Kentucky Revised Statute (KRS) 620.030, it was determined the facility failed to have a Governing Body which was effective in carrying out its responsibilities for the conduct of the hospital.

Three (3) patients reported abuse to staff; however, there was no documented evidence these allegations were investigated per the facility's policy or reported to the appropriate regulatory agency in a timely manner. In addition, the facility failed to ensure the patient's safety after abuse was reported.

1. Record review, interview, and review of the facility's video revealed Patient #1 reported to staff, on 11/23/2021, Patient #2 (the roommate of Patient #1) had "raped" him/her during the night. When staff asked Patient #1 to define rape, Patient #1 was unable to define the word and then recanted the allegation, stating it was a dream, and Patient #2 was standing next to Patient #1's bed to awaken Patient #1 for breakfast. The Unit Manager/Assistant Director of Nursing (ADON)/Interim Chief Nursing Officer (CNO) instructed staff to keep Patient #1 separated from Patient #2. Interviews with staff revealed they were not aware or instructed to keep the patients separated. Review of the facility's video revealed Patient #1 and Patient #2 were not separated and allowed to continue to be roommates, spending unsupervised time in their room with the door closed without staff observation or monitoring. However, there was no documented evidence in the medical record Patient #1 had made the allegation, no documented evidence an incident report had been initiated, no documented evidence a thorough investigation was completed, no documented evidence interventions were implemented to protect the safety of the patients, and no documented evidence the facility reported the allegation to the appropriate authorities.

2. Record review, interview, and review of the facility's video revealed, on 11/24/2021, after two (2) peers reported to staff Patient #2 had exposed his/her genitals to them in the Gym, staff talked to Patient #2 who then reported Patient #1 (Patient #2's room mate) had sexually assaulted him/her on multiple occasions throughout his/her admission at the facility. There was no documented evidence a thorough investigation was completed to determine the extent of the allegation, and there was no documented evidence the allegation was reported in a timely manner to the appropriate regulatory agency per state regulations.

3. Record review and interview revealed, on 11/23/2021, Patient #3 reported to the Nurse Practitioner that Patient #4 had sexually assaulted him/her on 11/20/2021 when they were roommates; however, Patient #3 told the Nurse Practitioner he/she would tell nursing staff, but there was no documented evidence Patient #3 reported the allegation to the Nurse Practitioner. On 11/23/2021, Patient #3 did report to staff that Patient #4 had sexually assaulted him/her when they shared a room. The Unit Manager/ADON/Interim CNO verbally instructed staff to keep Patient #3 separated from Patient #4; however, interviews with staff revealed they were not aware of the instructions to keep the patients separated. Review of Patient #4's medical record revealed a Nurse's Note, dated 11/21/2021 at 10:56 AM, documenting that Patient #4 had been redirected about touching other children, most especially his/her roommate, who at the time was Patient #3. However, there was no documented evidence in the medical record Patient #3 had made the allegation, no documented evidence an incident report had been initiated, no documented evidence a thorough investigation was completed, no documented evidence interventions were implemented to protect the safety of the patients, and no documented evidence the facility reported the allegation of abuse to the appropriate regulatory agency.

The findings include:

Review of the facility's Governing Board By-Laws, last approved 08/2021, revealed the Board shall consist of a total of seven (7) members which included the Chief Executive Officer (CEO), the Chief Nursing Officer (CNO), the Medical Director of the Behavioral Health Hospital, and two other individuals. Continued review of the Governing Board By-Laws revealed "Annual meeting shall be to elect officers and to transact such other business as may properly come before the meeting. Regular meetings of the Governing Board shall be held quarterly at the Facility. And Special meetings of the Governing Board may be called at any time by the chairperson, the CEO, or any three (3) or more Governing Board Members." Further review revealed the "primary purpose of the Facility was to provide essential quality health care within the scope of its license." Further review revealed the facility was to be compliant with applicable laws and regulations, including, without limitation, applicable licensure requirements in accordance with local, state, tribal, and federal laws, and regulations.

Review of Kentucky Revised Statute (KRS) 620.030 related to reporting Child Abuse revealed the duty to report abuse. It stated any person who knew or had reasonable cause to believe that a child was dependent, neglected, or abused shall immediately cause an oral or written report to be made to a local law enforcement agency or to the Department of Kentucky State Police, the cabinet or its designated representative, the Commonwealth's attorney, or the county attorney by telephone or otherwise. In addition, any supervisor who received from an employee a report of suspected dependency, neglect, or abuse shall promptly make a report to the proper authorities for investigation. Per the regulation, if the cabinet received a report of abuse or neglect allegedly committed by a person other than a parent, guardian, fictive kin, person in a position of authority, person in a position of special trust, or person exercising custodial control or supervision, the cabinet shall refer the matter to the Commonwealth's attorney or the county attorney and the local law enforcement agency or the Department of Kentucky State Police.

Interview with the previous Chief Nursing Officer (CNO), on 11/29/2021 at 2:00 PM, revealed he was a Governing Body member. Per interview, it was his understanding he was to only report allegations of abuse which resulted in significant injuries. The CNO stated the facility's video was only reviewed when there was an investigation regarding a certain incident. The CNO stated there was not a mechanism in place to audit the nursing staff performing observational rounding to ensure patient safety.

Interview with the facility's Medical Director, on 12/08/2021 at 2:00 PM, revealed he was a Governing Body member. Continued interview revealed all allegations of abuse should be investigated and notifications should be made. The Medical Director stated he expected facility staff to know the correct reporting procedures per regulations for the state. The Medical Director stated he expected staff to be monitoring the patients per the policies and procedures of the facility to ensure a safe environment. The Medical Director stated he would expect Directors of the facility to be reviewing the facility's video periodically to ensure nursing staff were performing their duties as assigned and per the facility's policies and procedures.

Interview with the facility's Vice President of Performance Improvement and Risk Management Compliance Officer, on 12/13/2021 at 11:00 AM, revealed it was her expectation for the facility to report all allegations of abuse per the regulations of the state.

Interview with the Chief Executive Officer (CEO), on 12/16/2021 at 1:30 PM, revealed he was on the Governing Body. Per the interview, all incidents of abuse should be reported. The CEO stated the timeframe to report abuse was immediately. The CEO stated not all the recent allegations of abuse were reported immediately. The CEO stated he was not aware the facility was not reviewing the facility's video periodically to ensure compliance with facility's policies and procedures to ensure patient safety.

Refer to A-0145

Based on interview, record review, review of the facility's video, and review of the facility's policies, it was determined the facility failed to protect and promote patient rights and failed to provide care in a safe setting for three (3) of thirteen (13) sampled patients, Patient #1, Patient #2, and Patient #3.

Per interview with Registered Nurse (RN) #2, Patient #1 reported to staff, on 11/23/2021 at 10:00 AM, Patient #2 had raped him/her during the night; however, there was no documented evidence Patient #1 had reported the allegation, no documented evidence interventions were implemented for the patient's safety, no documented evidence staff initiated an incident report, and no documented evidence the facility conducted a thorough investigation of the allegation.

Review of the facility's video revealed, during the quiet time of 3:00 PM to 3:33 PM on 11/23/2021, Patient #1 and Patient #2 were allowed to share a bedroom with the door closed and unsupervised by staff, after the abuse allegation.

Continued review of the facility's video revealed Patient #1 and Patient #2 were allowed to share a bedroom the night of 11/23/2021, after the abuse allegation. Per review of the video, staff failed to ensure the patients were routinely observed every fifteen (15) minutes in compliance with Physician's orders and facility protocol. Per the video, there was up to fifty-nine (59) minutes between staff monitoring observations/supervision of Patient #1 and Patient #2 during the night of 11/23/2021.

Per the facility's Incident Report, dated 11/24/2021, Patient #2 reported to staff, on 11/24/2021, Patient #1 had sexually assaulted him/her multiple times during his/her admission; however, there was no documented evidence interventions were implemented for the patient's safety and no documented evidence the facility conducted a thorough investigation of the allegation.

Also, per interview with RN #2, Patient #3 reported to her, on 11/23/2021 at approximately 10:00 AM, that Patient #4 had sexually assaulted him/her when they had been roommates; however, there was no documented evidence of the allegation in Patient #3's medical record, no documented evidence interventions were implemented for the patient's safety, no documented evidence the facility initiated an incident report, and no documented evidence the facility conducted a thorough investigation of the allegation.

Refer to: A0145

Based on interview, record review, review of the facility's video recordings, and review of the facility's policies, it was determined the facility failed to ensure patients were free from abuse for three (3) of thirteen (13) sampled patients (Patient #1, #2, and #3).

Patient #1 reported to staff, on 11/23/2021, Patient #2 had raped him/her during the night. Also, on 11/23/2021, Patient #3 reported to staff Patient #4 had sexually assaulted him/her when they had been roommates. In addition, Patient #2 reported to staff, on 11/24/2021, Patient #1 had sexually assaulted him/her multiple times during his/her admission. However, there was no documented evidence the facility implemented interventions to protect the patients from further abuse, initiated incident reports or completed thorough investigations of the allegations.

The findings include:

Review of the facility's policy titled, "Abuse and Neglect Reporting", last revised 05/2021, revealed it was the facility's policy that "Patients had the right to be free from mental, physical, sexual, and verbal abuse, neglect, or exploitation." Continued review revealed "It was the policy of the facility to protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff members, volunteers, other patients, visitors, or family members." The policy further stated, "The hospital mandated that, under the guidance of applicable laws, any healthcare worker having reasonable cause to believe that any person was in the state of abuse, exploitation, or neglect shall report the information to the appropriate regulatory agency." Further review revealed, "All allegations, observations, or suspected cases of abuse, neglect, or exploitation that occurred in the facility would be investigated by the hospital." Additional review defined the term Neglectful Supervision, as "placing in, or failing to remove, the person from a situation that a reasonable individual would realize required judgment or actions beyond that child's level of maturity, physical condition, or mental abilities and that resulted in bodily injury or substantial risk of immediate harm to the person."

Continued review of the facility's policy titled, "Abuse and Neglect Reporting", Procedure Section, revealed, "Cases of suspected sexual assault, physical abuse, or neglect would be given priority and would be investigated thoroughly." In addition, the policy stated, "All cases of suspected abuse/neglect must be reported to authorities." Further review revealed, "To protect the patient from real or suspected mental, physical, sexual, and verbal abuse, neglect and/or exploitation, staff would safeguard the patient from the offending individual(S). "

Review of the facility's policy titled, "Levels of Observation and Precaution Levels", last revised 05/2021, revealed, "All patients would be routinely observed in compliance with physician's orders and prescribed protocols." Continued review revealed the minimum level of observation for all patients was every fifteen (15) minutes, with the direction for staff to document the findings from the observations on the Patient Observation Record. Further review revealed, "Sleeping patients would be observed at close enough proximity to confirm they were in no physical distress." To do this, the policy stated staff would observe the patient at a minimum arm's length distance to ensure the ability to clearly see the patient's identity and respiration.

1. Review of Patient #1's medical record revealed the facility admitted the patient, on 11/16/2021, with a diagnosis of Unspecified Mood (Affective) Disorder. Per the medical record, Patient #1 was discharged on 11/24/2021.

Per interview with Registered Nurse #2, on 12/02/2021 at 10:25 AM, Patient #1 reported to her that on 11/23/2021 at 10:00 AM that Patient #2 (patient #1's room mate) had "raped" him/her during the night. She stated she immediately reported this to the Unit Manager/Assistant Director of Nursing (ADON)/Interim Chief Nursing Officer (CNO); however, she did not document the sexual abuse allegation in the patient's medical record.

Continued review of Patient #1's medical record revealed there was no documented evidence in the medical record Patient #1 had made an allegation of sexual abuse, no documented evidence an incident report had been initiated, no documented evidence a thorough investigation was completed and no documented evidence interventions were implemented to protect the safety of the patients.

Review of the facility's video revealed, on 11/23/2021 at 3:00 PM, and after Patient #1's allegation of abuse, Patient #1 and Patient #2 had been allowed in their shared bedroom with the door closed and without staff supervision, from 3:00 PM to 3:33 PM, when Patient #1 and Patient #2 exited their room.

Continued review of the facility's video, revealed beginning at 9:00 PM on 11/23/2021, Patient #1 and Patient #2 were allowed to be in the bedroom together overnight. Per the video, Patient #1 and Patient #2's observation checks were not completed every fifteen (15) minutes as policy required and were only completed every twenty (20) to fifty-nine (59) minutes. Continued review revealed the staff completing the observations failed to consistently enter the patient's rooms and failed to use a flashlight for their observations, per the facility's policy.

2. Review of Patient #2's medical record revealed the facility admitted the patient, on 11/16/2021, with a diagnosis of Major Depression, Recurrent Severe. Continued review revealed, on 11/24/2021, at 5:45 PM, after two (2) peers reported to staff that Patient #2 had exposed his/her genitals to them in the Gym, staff talked to Patient #2 who then reported Patient #1 (Patient #2's roommate) had sexually assaulted him/her on multiple occasions throughout his/her admission at the facility. The record revealed the facility notified the parents as they were driving to the facility for the patient's discharge, documented by the House Supervisor on 11/24/2021 at 10:00 PM. There was no documented evidence a thorough investigation was completed to determine the extent of the allegation.

Review of the facility's Incident Report, dated 11/24/2021, revealed Patient #2 had gone down to the gym with peers the afternoon of 11/24/2021 and had exposed his/her genitals to other peers. Continued review of the Incident Report revealed upon returning to the unit, Patient #2 admitted to exposing his/herself and then proceeded to tell the nurse his/her roommate (Patient #1) had threatened to kill the patient if Patient #2 did not perform oral sex. Patient #2 reported he/she performed the sexual act. Per the Incident Report, the nurse notified the house supervisor of the allegations. Further review of the Incident Report revealed Patient #2 stated the sexual abuse happened a few times on different days in the bathroom of the room they shared. However, there was no documented evidence a thorough investigation was completed to determine the extent of the allegation to determine if other patients were abused.

Review of Patient #2's medical record from Facility #2, signed by Emergency Department (ED) Physician #1, on 11/25/2021 at 12:06 AM, revealed Patient #2 was admitted to the facility's Emergency Department, on 11/24/2021 at 9:54 PM, for alleged sexual assault. Per the medical record a visual examination was completed by the ED Physician. The medical record revealed Patient #2 reported rectal pain and the results of the examination was a small amount of erythema (redness of the skin or mucous membranes) without any tears, no bleeding or discharge was noted to the rectum. Continued review revealed Patient #2 was advised they would need to go to Facility #3 for a Pediatric Sexual Assault Examination.

Review of Patient #2's medical record from Facility #3 revealed, on 11/25/2021 at 12:15 AM, Patient #2 was seen at the facility's Emergency Department for a Pediatric Sexual Assault Nurse Examination (P-SANE). Review of the record revealed a physical exam was performed on Patient #2 with a small amount erythema to the left glans/distal penile shaft noted. Continued review revealed normal appearing external genitalia, perineum, and anus without bruising, bleeding, or lacerations. Further review revealed two (2) three (3) millimeter (mm) abrasions medial to the left nipple was noted. The provider note was signed on 11/25/2021 at 3:36 AM.

3. Review of Patient #3's medical record revealed the facility admitted the patient, on 11/15/2021, with a diagnosis of Dissociative Identity Disorder. Continued review of the medical record revealed the facility discharged Patient #3 on 11/23/2021.

Interview with RN #2, on 12/02/2021 at 10:25 AM, revealed Patient #3 reported to her, on 11/23/2021 at approximately 10:00 AM, that Patient #4 had sexually assaulted him/her when they shared a room. RN #2 stated she notified the Unit Manager/Assistant Director of Nursing (ADON)/Interim Chief Nursing Officer (CNO); immediately of the allegations. RN #2 stated the Unit Manager/ADON/Interim CNO and the Director of Clinical Services (DCS) came to the unit and talked with Patient #3; however, she did not document the allegation in the medical record.

Interview with the Director of Clinical Services (DCS) on 12/02/2021 at 10:40 AM, revealed the Unit Manager/ADON/Interim CNO had informed her of the allegations and asked her to interview the patients. The DCS interviewed Patient #3 and asked the patient to write a statement. The DCS stated when she reviewed Patient #3's statement, she discovered the time of the incident Patient #3 had written down was prior to the time Patient #4 was admitted to the unit. The DCS stated she interviewed Patient #4 who denied the allegations.

On 12/02/2021 the State Survey Agency (SSA) Surveyor requested a copy of Patient #3's written statement, dated 11/23/2021; however, it was not provided by the facility.

Continued review of Patient #3's medical record revealed there was no documented evidence in the medical record Patient #3 had made the sexual abuse allegation, no documented evidence an incident report had been initiated, no documented evidence a thorough investigation was completed, no documented evidence interventions were implemented to protect the safety of the patients and no documented evidence the facility reported the allegation to the appropriate authorities.

Review of Patient #3's Physician/Practitioner Progress Reports revealed no documented evidence Patient #3 reported the sexual abuse allegation to the Nurse Practitioner.

Review of Patient #4's medical record revealed the facility admitted the patient, on 11/20/2021, with a diagnosis of Disruptive Dysregulation Disorder. Continued review of the record revealed a Nurse's Note, dated 11/21/2021 at 10:56 AM, documenting that Patient #4 had been redirected about touching other children, most especially his/her roommate, who at the time was Patient #3; however, there was no documented evidence of the sexual abuse allegation and no documented evidence of interventions implemented to increase supervision.

Interview with the Director of Performance Improvement /Risk Management (PI/RM), on 12/01/2021 at 2:40 PM, revealed no staff members nor other patients were interviewed after the allegations were made by Patient #2 because she thought these interviews would be a violation of the Health Insurance Portability and Accountability Act (HIPAA) and stated she needed to protect the privacy of the patients involved.

Interview with the Director of Clinical Services (DCS), on 12/02/2021 at 10:40 AM, revealed she was not usually the person who would interview and investigate allegations of abuse. The DCS stated since Patient #1 recanted the alleged abuse allegations, she did not think the facility needed to take further action. The DCS stated in regard to Patient #3's allegations, since the alleged abuse supposedly happened prior to Patient #4's admission, she did not think further action, monitoring or interventions, were necessary.

Interview with the Unit Manager/ADON/Interim CNO, on 12/02/2021 at 11:00 AM, revealed she and the DCS were asked to assist with the alleged abuse allegations since the Director of Performance Improvement/Risk Management was working with State Survey Agency (SSA) Surveyors regarding a facility self-reported incident. The Unit Manager/ADON/Interim CNO stated she did not think further investigation was necessary since Patient #1 allegedly recanted the allegations, and Patient #3's allegations were prior to Patient #4 being admitted. The Unit Manager/ADON/Interim CNO stated both Patient #1 and Patient #3 were to be discharged later on 11/23/2021, so she verbally instructed staff to keep Patient #1 separated from Patient #2 and to keep Patient #3 separated from Patient #4; however, she did not document the allegations or document to keep the patients separated in the medical record and did not initiate an incident report.

Interview with the Nurse Practitioner (NP), on 12/02/2021 at 2:20 PM, revealed she was aware of the abuse allegation made by Patient #1 on 11/23/2021, but she was not involved in the investigation and did not address the allegations with Patient #1 or Patient #2. The NP stated she was informed of the sexual allegations by Patient #3, on 11/23/2021, but stated Patient #3 told her he/she was going to talk to a staff member about the allegation. However, there was no documented evidence in Patient #3's medical record of this allegation being reported to the NP. The NP stated she was not made aware of Patient #2's sexual allegations until after both patients involved had been discharged.

Interview with the Attending Physician, on 12/07/2021 at 11:25 AM, revealed he was not informed of the sexual allegations made by Patient #1 and Patient #3 on 11/23/2021. The Attending Physician stated both patients were being followed by the NP, and he was not sure if she was aware or not. The Attending Physician stated he was informed of the abuse allegations made by Patient #2, on 11/24/2021, while he/she was being discharged. The Attending Physician stated he was not aware of facility staff not completing the fifteen (15) minute checks on patients as required by the facility's policy. The Attending Physician stated the standard of care would be to follow the policy in regard to care. The Attending Physician stated if staff members were aware of an order and failed to follow the order, it could be considered neglect.

Additional interview with RN #2, on 12/08/2021 at 10:30 AM, revealed she was instructed by the Unit Manager/ADON/Interim CNO to keep the alleged victim separated from the alleged perpetrators until staff could talk with each patient. RN #2 stated she left the unit at 3:00 PM on 11/23/2021, and she did not give report to the oncoming shift since the other day shift nurse was remaining on the unit, and the DCS was still interviewing the patients.

Interview with the Medical Director, on 12/08/2021 at 2:00 PM, revealed he was aware of the abuse allegations, but he was not informed on the dates the patients reported their allegations to staff. The Medical Director stated all allegations of abuse should be thoroughly investigated and notifications made. The Medical Director stated the patients should have been separated with extra monitoring put in place to ensure each patient's safety.

Interview with Mental Health Technician (MHT) #3, on 12/13/2021 at 12:15 PM, revealed she was assigned to Patient #1, Patient #2, and Patient #3's unit, on 11/23/2021 from 7:00 AM to 7:00 PM. MHT #3 stated she was never told to keep Patient #1 separated from Patient #2 nor was she told to keep Patient #3 separated from Patient #4.

Interview with RN #8, on 12/15/2021 at 2:20 PM, revealed she arrived on the unit at 7:00 PM on 11/23/2021. RN #8 stated she was never told to keep Patient #1 separated from Patient #2. RN #8 stated she was told during report that two (2) patients were talking about sexual stuff, but it had already been investigated and everything was fine. RN #8 stated she was not informed of the identities of the patients that had been talking.

Interview with the Chief Executive Officer (CEO), on 12/16/2021 at 1:30 PM, revealed all incidents of abuse should be reported to the appropriate authority and should be thoroughly investigated by the facility. Per the interview, the timeframe to report abuse was immediately. The CEO stated not all the recent allegations of abuse were reported immediately but should have been.

The facility submitted an acceptable Immediate Jeopardy (IJ) Removal Plan, on 12/16/2021, alleging the IJ was corrected, on 12/15/2021. An on-site validation of the IJ Removal Plan determined the IJ was removed on 12/15/2021 prior to exit on 12/16/2021.

The corrective actions the facility undertook to remove the IJ were as follows:

A. On 12/10/2021, Nursing Department staff education was created by the Director of Performance Improvement/Risk Management (PI/RM), Unit Manager/Assistant Director of Nursing (ADON)/Interim Chief Nursing Officer (CNO), and the Corporate Vice President (VP) of PI/RM for all Registered Nurses (RN's), Licensed Practical Nurses (LPN's), and Mental Health Technicians (MHT's).

B. The Director of Clinical Services (DCS), House/Nursing Supervisors, Assistant Directors of Nursing (ADON's), and the Staff Development Coordinator (SDC) received education on the training requirements and education to be provided to the Nursing Department staff on abuse. This was completed, on 12/10/2021, by the Director of PI/RM and Unit Manager/Assistant ADON/Interim CNO.

C. Education with all Nursing Department staff began on 12/11/2021. All Nursing Department staff would sign an attestation acknowledging receipt and understanding of the education received. On 12/14/2021, and forward, all staff would receive this education prior to their next shift. Education was being completed by the Director of PI/RM, DCS, Intake Director, Unit Manager/Assistant ADON/Interim CNO, House/Nursing Supervisors, ADON's, and the SDC. The policy for Abuse and Neglect Reporting would also include a post-test.

D. Starting on 12/14/2021, all other staff would receive education regarding Abuse and Neglect reporting. On 12/14/2021, The Director of PI/RM provided education to each department director/head regarding abuse and neglect reporting as well as education regarding how to provide the education to their respective department staff members. Each department director/head would ensure, starting on 12/14/2021, that every staff member in their respective departments, would receive abuse and neglect reporting education which included a post-test to ensure understanding of the education provided prior to their next shift.

E. On 12/10/2021, the Corporate VP of PI/RM re-educated the Director of PI/RM regarding reporting requirements, timing guidelines, and subsequent investigations for allegations of abuse and neglect. The Director of PI/RM would ensure Incident Reports were completed for any reported allegation of abuse/neglect, that the allegation was reported to the appropriate regulatory agency as required by state, federal, and local guidelines, and that an investigation was completed. The Corporate VP of PI/RM would provide oversight to the Director of PI/RM to ensure reporting was completed per guidelines and that investigations were completed.

F. The Director of PI/RM, DCS, Unit Manager/ADON/Interim CNO, Intake Director, Nursing/House Supervisors, and ADON's would ensure that any allegation of abuse/neglect was addressed immediately upon receipt of information and appropriate interventions taken to help ensure patient safety, beginning on 12/10/2021.

G. On 12/13/2021, education was provided by the Director of PI/RM and Chief Executive Officer (CEO) to all hospital directors regarding the process for reporting abuse/neglect allegations to clinical leadership, and to the Director of PI/RM. Education was also provided to all directors on how to educate their respective staff regarding the abuse and neglect policy.

Interview with the Human Resources (HR) Director, on 12/16/2021 at 1:10 PM, revealed he had re-education on abuse by the Director of PI/RM. The HR Director stated the process had been implemented, and moving forward, no staff would work until they had the abuse and neglect education. The HR Director stated he had an on-going list of staff members and how they had received education on the facility's Abuse and Neglect policy.

Interview with the Director of Health Information Management (HIM) and Privacy Officer, on 12/16/2021 at 1:14 PM, revealed she had one (1) full-time person and other part-time staff and had already completed the training on abuse and neglect as well as a posttest to ensure compliance.

Interview with the Director of Dietary, on 12/16/2021 at 1:16 PM, revealed she had received the training from the Director of PI/RM on the abuse policy. The Director of Dietary stated she had eight (8) staff members and had already met with the group, gave the education, and followed up with the post-test.

Interview with the Chief Financial Officer (CFO), on 12/16/2021 at 1:20 PM, revealed she had received the abuse training from the Director of PI/RM. She stated she knew to always believe the patients and to report it.

Interview with ADON #2, on 12/16/2021 at 1:21 PM, revealed she had received the training from the Director of PI/RM about abuse. ADON #2 stated all staff members were required to be trained before the shift they worked. ADON #2 stated she was able to run reports to ensure all staff were educated. ADON #2 stated she felt staff members were knowledgeable about abuse. ADON #2 stated she felt the training had been a positive experience for all staff members.

Interview with the Nurse Manager, on 12/16/2021 at 1:24 PM, revealed she had received training on abuse recently from the Director of PI/RM. The Nurse Manger stated she would ask the staff how to report abuse and/or neglect. The Nurse Manager stated she felt everyone was "on board" with this retraining.

Interview with the Unit Manager/ADON/Interim CNO, on 12/16/2021 at 1:28 PM, revealed she had received the training from the Director of PI/RM on abuse. The Unit Manager/ADON/Interim CNO stated she and the other ADON's had been training staff and keeping a master log of the training.

Interview with the CEO, on 12/16/2021 at 1:32 PM, revealed he had received retraining on abuse. The CEO stated all incidents of abuse were to be reported immediately. The CEO stated there were now corrections in place to prevent situations from occurring where abuse allegations were not reported immediately, prior to this training. The CEO stated staff members were being retrained as well. The CEO stated staff members would sign the document attesting to the training and take a post-test as well, to verify understanding.

Interview with the Director of Facility Services, on 12/16/2021 at 1:42 PM, revealed he had the training on abuse from the Director of PI/RM. The Director of Facility Services stated he supervised six (6) staff members, four (4) in maintenance and two (2) in housekeeping. He stated he had recently given the training on abuse to his staff members, and they understood the importance of the training.

Interview with the Director of Clinical Services (DCS), on 12/16/2021 at 1:45 PM, revealed she had training on abuse from the Director of PI/RM. The DCS stated she had twenty-four (24) staff members that she supervised, and all but three (3) had received the training. The DCS stated she was still in the process and had given those three (3) staff members the training materials. She stated she would meet with them before they went to work on the unit.

Interview with ADON #3, on 12/16/2021 at 1:49 PM, revealed she recently received training on abuse. ADON #3 stated she reviewed the education with the staff, gave them the post-test, and then had them sign they had completed the training. She stated she arrived before staff members began their shift to go over the new training.

Interview with the Director of Utilization Management (UM), on 12/16/2021 at 1:52 PM, revealed she recently had training on abuse given by the Director of PI/RM. The Director of UM stated she supervised six (6) staff members, and all had received their training on abuse. She stated her staff understood the importance of reporting abuse.

Interview with the Director of Admitting/Intake, on 12/16/2021 at 1:55 PM, revealed he recently had training on abuse, given by the Director of PI/RM. He stated he supervised twenty-four (24) to twenty-six (26) staff members for all three (3) shifts. The Director stated his manager also received the training from the Director of PI/RM. He stated the manager had met with almost all staff members except PRN (as needed), and they could not work without meeting with her.

Interview with the Patient Advocate, on 12/16/2021 at 2:00 PM, revealed she recently had training on abuse, given by the Director of PI/RM. The Patient Advocate stated all allegations of abuse would be thoroughly investigated and reports would be made timely.

Interview with the Intake Manager, on 12/16/2021 at 2:05 PM, revealed she recently had training on abuse. The Intake Manager stated she was trained by Nursing Leadership. The Intake Manager stated she was arriving at the facility before the start of her staff's shifts to do the training. She stated she had trained the majority of her staff.

Interview with the Staff Development Coordinator (SDC), on 12/16/2021 at 2:08 PM, revealed he was responsible for the education of the staff. The SDC stated he recently had training on abuse and reporting given by the Unit Manager/ADON/Interim CNO and the Corporate VP of PI/RM. He stated the education would be on-going with new hires and would be included in the staff's annual competencies.

Interview with the Discharge Planner, on 12/16/2021 at 2:16 PM, revealed she recently had training on abuse by her supervisor, the DCS. The Discharge Planner stated it was important to over report rather than under report allegations of abuse.

Interview with RN #9, on 12/16/2021 at 2:19 PM, revealed she had recently received training on abuse provided by her Unit Manager.

Interview with the Maintenance and Information Technology (IT) staff member, on 12/16/2021 at 2:23 PM, revealed he had training on abuse by his Director. He also stated he had training during new hire orientation, and if anything happened, he knew the protocol.

Interview with the Housekeeper, on 12/16/2021 at 2:24 PM, revealed she recently had training on abuse by her Director. She stated she was around staff and patients all the time, and it was important for all staff to have the training.

Interview with the Licensed Professional Clinical Counselor (LPCC), National Certified Counselor (NCC), on 12/16/2021 at 2:26 PM, revealed she recently had training on abuse given by her supervisor, the DCS.

Interview with RN #10, on 12/16/2021 at 2:28 PM, revealed she had training on abuse, on 12/13/2021, by ADON #3 and her Unit Manager. She stated she reviewed the information and took the post-test.

Interview with the Dietician, on 12/16/2021 at 2:32 PM, revealed she recently had training on abuse. She stated the Dietary Director gave the training. The Dietician stated everyone knew the correct thing to do and what to do if witnessing or being told about abuse.

Interview with RN #11 and RN #12, on 12/16/2021 at 2:33 PM, revealed both had recent training on abuse given by the Unit Manager/ADON/Interim CNO, the Corporate VP of PI/RM, and ADON #3.

Interview with MHT #2, LPN #2, RN #4, and RN #13, on 12/16/2021 at 2:41 PM, revealed all had training by their supervisors on abuse recently.

Interview with the Intake Clerk/Ambulance Bay and the Registrar, on 12/16/2021 at 2:46 PM, revealed they recently had training on abuse given by their Manager.

Interview with MHT #6 and MHT #10, on 12/16/2021 at 2:47 PM and 3:08 PM respectively, revealed they had recently received training on abuse by ADON #3.

Interview with MHT #7, RN #14, RN #15, and MHT #8, on 12/16/2021 at 2:52 PM, revealed all had recent training on abuse by the Unit Manager/ADON/Interim CNO.

Interview with RN #16, MHT #9, and RN #17, on 12/16/2021 at 3:03 PM, revealed all had training on abuse by the Unit Manager/ADON/Interim CNO and the Corporate VP of PI/RM. They stated the Unit Manager/ADON/Interim ADON printed out the policy and went over it well.

Interview with the Director of Outpatient Services, on 12/16/2021 at 3:12 PM, revealed she had recently received training on abuse by the Director of PI/RM. The Director stated she was responsible for staff and clinical supervision of Outpatient Services. She stated she had completed all training for her staff expect for one (1) part-time person who would receive the training before she began her next shift.

Review of the facility's documentation, on 12/16/2021, revealed updated education, attestation forms signed by staff, and post-tests, which demonstrated the facility had been compliant with their IJ Removal plan.

Based on observation, interview, record review, review of the facility's video, and review of the facility's policies, it was determined the governing body failed to have an effective system in place to ensure the Quality Assurance Performance Improvement program performed appropriate monitoring and audits to ensure patient's rights were protected and promoted. The facility failed to ensure patients had the right to receive care in a safe setting and be free of abuse for three (3) of thirteen (13) sampled patients, Patient #1, Patient #2 and Patient #3.

Record review, interview, and review of the facility's video revealed the facility failed to provide care in a safe setting and ensure Patient #1 was free from abuse. On 11/23/2021, Patient #1 reported an allegation of sexual abuse to staff. The Unit Manager/Assistant Director of Nursing (ADON)/Interim Chief Nursing Officer (CNO) instructed staff to keep Patient #1 separated from Patient #2. Interviews with staff revealed they were not aware or instructed to keep the patients separated. Review of the facility's video revealed Patient #1 and Patient #2 were not separated and were allowed to continue to be roommates, spending unsupervised time in their room with the door closed without staff observation or monitoring. However, there was no documented evidence in the medical record Patient #1 had made the allegation, no documented evidence an incident report had been initiated, no documented evidence a thorough investigation was completed, no documented evidence interventions were implemented to protect the safety of the patients, and no documented evidence the facility reported the allegation to the appropriate authorities.

Record review, interview, and review of the facility's video revealed, the facility failed to provide care in a safe setting and ensure Patient #2 was free from abuse. On 11/24/2021, Patient #2 reported Patient #1 had sexually assaulted him/her multiple time throughout his/her admission. There was no documented evidence a thorough investigation was completed to determine the extent of the allegation, and there was no documented evidence the allegation was reported in a timely manner to the appropriate regulatory agency per state regulations.

Record review and interview revealed the facility failed to provide care in a safe setting and ensure Patient #3 was free from abuse. On 11/23/2021, Patient #3 reported to staff and the Nurse Practitioner that Patient #4 had sexually assaulted him/her on 11/20/2021 when they were roommates. The Unit Manager/ADON/Interim CNO verbally instructed staff to keep Patient #3 separated from Patient #4; however, interviews with staff revealed they were not aware of the instructions to keep the patients separated. Review of Patient #4's medical record revealed a Nurse's Note, dated 11/21/2021 at 10:56 AM, documenting that Patient #4 had been redirected about touching other children, most especially his/her roommate, who at the time was Patient #3. However, there was no documented evidence, in Patient #3's medical record, he/she had made the allegation, no documented evidence an incident report had been initiated, no documented evidence a thorough investigation was completed, no documented evidence interventions were implemented to protect the safety of the patients, and no documented evidence the facility reported the allegation of abuse to the appropriate regulatory agency.

The findings include:

Review of the facility's document titled, "Organizational Performance Improvement Plan", revised 12/2021, under Methodology, revealed performance measures for processes that were known to jeopardize the safety of patients or associated with sentinel events would be monitored every week. Still further review revealed at a minimum, performance measures related to the following processes, as appropriate to care and services provided, were monitored with the approval and at the suggested frequency of the Performance Improvement Committee.

Review of the facility's policy titled, "Levels of Observation and Precaution Levels", last revised 05/2021, revealed, "All patients would be routinely observed in compliance with Physician's orders and prescribed protocols." Continued review of the policy revealed the minimum level of observation for all patients was every fifteen (15) minute observations, with the direction for staff to observe the patients every fifteen (15) minutes and document on the Patient Observation Record. Further review of the policy revealed sleeping patients would be observed at close enough proximity to confirm they were in no physical distress. The policy stated staff would observe the patient at a minimum arm's length distance to ensure the ability to clearly see the patient's identity and respirations.

Interview with the previous Chief Nursing Officer (CNO), on 11/29/2021 at 2:00 PM, revealed he was on the QAPI committee. Per interview, it was his understanding he was to only report allegations of abuse which resulted in significant injuries. Continued interview revealed the committee had not audited or monitored staff for abuse policy adherence.

Interview with the facility's Medical Director, on 12/08/2021 at 2:00 PM, revealed he was on the QAPI committee. Continued interview revealed all allegations of abuse should be thoroughly investigated and notifications should be made. Per the interview, he was unaware of the staff's failure to perform observational monitoring supervision checks per the facility's policy. The Medical Director stated he expected facility staff to know the correct reporting procedures per the regulations of the state. He stated he was unaware the facility's videos were not being monitored to ensure staff compliance with the facility's policies and procedures.

Interview with the Chief Executive Officer (CEO), on 12/16/2021 at 1:30 PM, revealed he was part of the QAPI committee. Per the interview, all incidents of abuse should be reported. The CEO stated the timeframe to report abuse was immediately. The CEO stated not all the recent allegations of abuse had been reported immediately. He stated he was unaware the facility's videos were not being monitored to ensure staff compliance with the facility's policies and procedures.

Refer to A-286

Based on interview, record review, review of the facility's video recordings, and review of the facility's policy, it was determined the facility failed to implement an effective Quality Assurance Performance Improvement Program (QAPI) to ensure the patient's right to receive care in a safe setting for three (3) of thirteen (13) sampled patients, Patient #1, Patient #2 and Patient #3.

The findings include:

Review of the facility's "Organizational Performance Improvement Plan", last reviewed 12/2020, revealed the purpose of the organizational Performance Improvement Plan was to ensure the Governing Body, Medical Staff and employed/contracted staff demonstrated a consistent endeavor to deliver safe, effective, optimal patient care and services in an environment of minimal risk. Continued review revealed the organizational program, established by the Medical Staff and interdisciplinary Performance Improvement Committee, with support and approval from the Governing Body, had the responsibility for monitoring every aspect of patient care and services (including contracted services), from the time the patient entered the hospital through diagnosis, treatment, recovery, and discharge in order to identify and resolve any breakdowns that might result in suboptimal patient care and safety, while striving to continuously improve and facilitate positive patient outcomes.

Review of the facility's policy titled, "Abuse and Neglect Reporting", last revised 05/2021, revealed it was the facility's policy that patients had the right to be free from mental, physical, sexual, and verbal abuse, neglect, or exploitation. Continued review revealed it was the policy of the facility to protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff members, volunteers, other patients, visitors, or family members. The policy further stated the facility mandated that, under the guidance of applicable laws, any healthcare worker having reasonable cause to believe that any person was in the state of abuse, exploitation, or neglect shall report the information to the appropriate regulatory agency. Further review revealed all allegations, observations, or suspected cases of abuse, neglect, or exploitation that occurred in the facility would be investigated by the facility. Additional review defined the term Neglectful Supervision, as placing in, or failing to remove, the person from a situation that a reasonable individual would realize required judgment or actions beyond that child's level of maturity, physical condition, or mental abilities and that resulted in bodily injury or substantial risk of immediate harm to the person.

Continued review of the facility's policy titled, "Abuse and Neglect Reporting", Procedure Section, revealed cases of suspected sexual assault, physical abuse, or neglect would be given priority and would be investigated thoroughly. In addition, the policy stated all cases of suspected abuse/neglect must be reported to authorities. Further review revealed to protect the patient from real or suspected mental, physical, sexual, and verbal abuse, neglect and/or exploitation, staff would safeguard the patient from the offending individual(s).

Review of the facility's policy titled, "Levels of Observation and Precaution Levels", last revised 05/2021, revealed all patients would be routinely observed in compliance with physician's orders and prescribed protocols. Continued review revealed the minimum level of observation for all patients was every fifteen (15) minutes, with the direction for staff to document the findings from the observations on the Patient Observation Record. Further review revealed sleeping patients would be observed at close enough proximity to confirm they were in no physical distress. To do this, the policy stated staff would observe the patient at a minimum arm's length distance to ensure the ability to clearly see the patient's identity and respiration.

1. Review of Patient #1's medical record revealed the facility admitted the patient, on 11/16/2021, with a diagnosis of Unspecified Mood (Affective) Disorder. Per the medical record, Patient #1 was discharged on 11/24/2021.

Per interview with Registered Nurse (RN) #2, on 12/02/2021 at 10:25 AM, revealed Patient #1 reported to her that on 11/23/2021 at 10:00 AM that Patient #2 had "raped" him/her during the night. She stated she immediately reported this to the Unit Manager/Assistant Director of Nursing (ADON)/Interim Chief Nursing Officer (CNO); however, she did not document the sexual abuse allegation in the patient's medical record.

Continued review of Patient #1's medical record revealed there was no documented evidence in the medical record Patient #1 had made an allegation of sexual abuse, no documented evidence an incident report had been initiated, no documented evidence a thorough investigation was completed and no documented evidence interventions were implemented to protect the safety of the patients.

Review of the facility's video revealed, on 11/23/2021 at 3:00 PM, and after Patient #1's allegation of abuse, Patient #1 and Patient #2 had been allowed in their bedroom with the door closed and without staff supervision, from 3:00 PM to 3:33 PM, when Patient #1 and Patient #2 exited their room.

Continued review of the facility's video, beginning at 9:00 PM on 11/23/2021, revealed Patient #1 and Patient #2 were allowed to be in the bedroom together overnight. Per the video, Patient #1 and Patient #2's observation checks were not completed every fifteen (15) minutes as policy required and were only completed every twenty (20) to fifty-nine (59) minutes. Continued review revealed the staff completing the observations failed to consistently enter the patient's rooms and failed to use a flashlight for their observations, per the facility's policy.

2. Review of Patient #2's medical record revealed the facility admitted the patient, on 11/16/2021, with a diagnosis of Major Depression, Recurrent Severe. Continued review revealed, on 11/24/2021 at 5:45 PM, after two (2) peers reported to staff that Patient #2 had exposed his/her genitals to them in the Gym, staff talked to Patient #2 who then reported Patient #1 had sexually assaulted him/her on multiple occasions throughout his/her admission at the facility. Per the medical record, the facility notified the parents as they were driving to the facility for the patient's discharge, documented by the House Supervisor on 11/24/2021 at 10:00 PM. There was no documented evidence a thorough investigation was completed to determine the extent of the allegation.

Review of the facility's Incident Report, dated 11/24/2021, revealed Patient #2 had gone to the Gym with peers the afternoon of 11/24/2021 and had exposed his/her genitals to other peers. Continued review of the Incident Report revealed upon returning to the unit, Patient #2 admitted to exposing his/herself and then proceeded to tell the nurse his/her previous roommate (Patient #1) had threatened to kill the patient if Patient #2 did not perform oral sex. Patient #2 reported he/she performed the sexual act. Per the Incident Report, the nurse notified the house supervisor of the allegations. Further review of the Incident Report revealed Patient #2 stated the sexual abuse happened a few times on different days in the bathroom of the room they shared. However, there was no documented evidence a thorough investigation was completed to determine the extent of the allegation.

Review of Patient #2's medical record from Facility #2, signed by Emergency Department Physician #1, on 11/25/2021 at 12:06 AM, revealed Patient #2 was admitted to the facility's Emergency Department on 11/24/2021 at 9:54 PM for alleged sexual assault. Per the medical record a visual examination was completed by the ED Physician. The medical record revealed Patient #2 reported rectal pain and the results of the examination was a small amount of erythema (redness of the skin or mucous membranes) without any tears, no bleeding or discharge was noted to the rectum. Continued review revealed Patient #2 was advised they would need to go to Facility #3 for a Pediatric Sexual Assault Examination.

Review of Patient #2's medical record from Facility #3 revealed, on 11/25/2021 at 12:15 AM, Patient #2 was seen at the facility's Emergency Department for a Pediatric Sexual Assault Nurse Examination (P-SANE). Review of the record revealed a physical exam was performed on Patient #2 with a small amount of erythema left glans/distal penile shaft noted. Continued review revealed normal appearing external genitalia, perineum, and anus without bruising, bleeding, or lacerations. Further review revealed two (2) three (3) millimeter (mm) abrasions medial to the left nipple noted. The provider note was signed on 11/25/2021 at 3:36 AM.

3. Review of Patient #3's medical record revealed the facility admitted the patient, on 11/15/2021, with a diagnosis of Dissociative Identity Disorder. Continued review of the medical record revealed the facility discharged Patient #3 on 11/23/2021.

Interview with RN #2, on 12/02/2021 at 10:25 AM and 12/08/2021 at 10:30 AM, revealed Patient #3 reported to her, on 11/23/2021 at approximately 10:00 AM that Patient #4 had sexually assaulted him/her when they shared a room. RN #2 stated she notified the Unit Manager/ADON/Interim CNO immediately of the allegations. RN #2 stated the Unit Manager/ADON/Interim CNO and the Director of Clinical Services (DCS) came and talked with Patient #3. RN #3 stated she was instructed by the Unit Manager/ADON/Interim CNO to keep the alleged victims separated from the alleged perpetrators until the Director or Clinical Services could talk with the patients. RN #2 stated she left the unit at 3:00 PM on 11/23/2021 and she did not give report to the oncoming shift since the other day shift nurse was remaining on the unit.

Interview with the DCS, on 12/02/2021 at 10:40 AM, revealed the Unit Manager/ADON/Interim CNO had informed her of the allegations and asked her to interview the patients. The DCS interviewed Patient #3 and asked the patient to write a statement. The DCS stated when she reviewed Patient #3's statement, she discovered the time Patient #3 had written down was prior to Patient #4 being admitted to the unit. The DCS stated she interviewed Patient #4 who denied the allegations.

On 12/02/2021 requested a copy of Patient #3's written statement, dated 11/23/2021; however, not provided by the facility.

Continued review of Patient #3's medical record revealed there was no documented evidence in the medical record Patient #3 had made the sexual abuse allegation, no documented evidence an incident report had been initiated, no documented evidence a thorough investigation was completed, no documented evidence interventions were implemented to protect the safety of the patients and no documented evidence the facility reported the allegation to the appropriate authorities.

Review of Patient #3's Physician/Practitioner Progress Reports revealed no documented evidence Patient #3 reported the sexual allegation of abuse to the Nurse Practitioner.

Review of Patient #4's medical record revealed the facility admitted the patient, on 11/20/2021, with a diagnosis of Disruptive Dysregulation Disorder. Continued review of the record revealed a Nurse's Note, dated 11/21/2021 at 10:56 AM, documenting that Patient #4 had been redirected about touching other children, most especially his/her roommate, who at the time was Patient #3; however, there was no documented evidence of the sexual abuse allegation.

Interview with the previous Chief Nursing Officer (CNO), on 11/30/2021 at 11:30 AM, revealed the video of the unit's hallway was not routinely reviewed and monitored. The CNO stated the facility's videos were only reviewed after an incident was reported to gather information related to that incident. The facility did not have system in place to review the facility's videos for monitoring and auditing.

Interview with the Unit Manager/ADON/Interim CNO, on 11/30/2021 at 11:30 AM, 12/02/2021 at 11:00 AM and 12/07/2021 at 11:05 AM, revealed she and the DCS were asked to assist with the alleged abuse allegations since the Director of Performance Improvement/Risk Management (PI/RM) was working with State Surveyors regarding a facility self-reported incident. The Unit Manager/ADON/Interim CNO stated she did not think further investigation was necessary since Patient #1 allegedly recanted the allegations and Patient #3's time of the allegation was prior to the time Patient #4 was admitted to the unit. The Unit Manager/ADON/Interim CNO stated both Patient #1 and Patient #3 were to be discharged later on 11/23/2021 so she verbally instructed staff to keep Patient #1 separated from Patient #2 and to keep Patient #3 separated from Patient #4; however, she did not document the allegations or document to keep the patients separated in the medical record and did not initiate an incident report. Per interview the video of the unit's hallway was not routinely reviewed and monitored. The Unit Manager/ADON/Interim CNO stated she did not have access to view the unit's video. She stated supervisors would take call over the weekends when management was not in the facility. Unit Manager/ADON/Interim CNO stated she would come in during her off hours, at times, to check on the unit and staff since she lived close to the facility.

Interview with the Director of Performance Improvement and Risk Management (PI/RM), on 12/01/2021 at 2:40 PM, revealed the facility did not have a system in place to view the facility's videos for performance monitoring or audits. She stated there were supervisors in the facility who were making rounds throughout the units to monitor staff for compliance. Continued interview revealed no staff members nor other patients were interviewed after the sexual abuse allegations were made by Patient #2 because she thought these interviews would be a violation of the Health Insurance Portability and Accountability Act (HIPAA) and stated she needed to protect the privacy of the patients involved.

Interview with the Medical Director, on 12/08/2021 at 2:00 PM, revealed he was aware of the abuse allegations but stated he was not informed on the dates the patients reported their allegations to staff. The Medical Director stated all allegations of abuse should be thoroughly investigated and notifications made. The Medical Director stated the patients should have been separated with extra monitoring put into place to ensure each patient's safety. Continued interview revealed he was unaware the facility's videos were not being reviewed for monitoring purposes. The Medical Director stated the facility's videos should be reviewed periodically, at random dates and times, for Quality Improvement. The Medical Director further stated he felt there should be cameras in the patients' rooms for added safety measures.

Interview with Mental Health Technician (MHT) #3, on 12/13/2021 at 12:15 PM, revealed she worked on the unit on 11/23/2021 from 7:00 AM to 7:00 PM. MHT #3 stated she was never told to keep Patient #1 separated from Patient #2 nor was she told to keep Patient #3 separated from Patient #4.

Interview with RN #8, on 12/15/2021 at 2:20 PM, revealed she arrived on the unit at 7:00 PM on 11/23/2021. RN #8 stated she was never told to keep Patient #1 separated from Patient #2. RN #8 stated she was told during verbal report that two (2) patients were talking about sexual stuff but that it had already been investigated and everything was fine. RN #8 stated she was not informed of the identities of the patients.

Interview with the Chief Executive Officer (CEO), on 12/16/2021 at 1:30 PM, revealed all incidents of abuse should be reported to the appropriate authority and should be investigated by the facility. The CEO stated not all the recent allegations of abuse were reported immediately but should have been. He stated he was not aware the facility's videos were not being reviewed and monitored. The CEO stated there should be a system in place to review the facility's videos to monitor and ensure the staff were providing the appropriate care and safety for the patients.

The facility submitted an acceptable Immediate Jeopardy (IJ) Removal Plan, on 12/16/2021, alleging the IJ was corrected, on 12/15/2021. An on-site validation of the IJ Removal Plan determined the IJ was removed on 12/15/2021 prior to exit on 12/16/2021.

The corrective actions the facility undertook to remove the IJ were as follows:

A. The policy "Plan for Provision of Care" was reviewed by the Director of Performance Improvement/Risk Manager (PI/RM), and she determined there was a need for a more detailed description of shift assignment sheets, including completion of every fifteen (15) minute observations. The Director of PI/RM worked with the Corporate Senior Vice President (SVP) of Clinical Services to revise the policy. The policy was revised and approved by the Corporate Vice President (VP) of PI/RM and the Corporate SVP of Clinical Services on 12/20/2021. The Corporate VP of PI/RM educated the policy change to the Unit Manager/ADON/Interim CNO, Director of PI/RM, and the CEO on 12/10/2021.

B. The policy "Levels of Observation and Precaution Levels" was reviewed by the Corporate VP of PI/RM. It was determined the policy required clarification of performing observation rounds when patients were in their rooms. The policy was updated on 12/10/2021. The policy revision was approved by the Corporate VP of PI/RM and the Corporate SVP of Clinical Services. The policy change was educated to the Unit Manager/ADON/Interim CNO, the Director of PI/RM, and the CEO by the Corporate VP of PI/RM on 12/10/2021.

C. On 12/10/2021, the Corporate VP of PI/RM re-educated the Director of PI/RM regarding reporting requirements, timing guidelines, and subsequent investigations for allegations of abuse and neglect. The Director of PI/RM would ensure Incident Reports were completed for any reported allegation of abuse/neglect, that the allegation was reported to the appropriate regulatory agency as required by state, federal, and local guidelines, and that an investigation was completed. The Corporate VP of PI/RM would provide oversight to the Director of PI/RM to ensure reporting was completed per guidelines and that investigations were completed. In addition, the Director of PI/RM, DCS, Unit Manager/ADON/Interim CNO, Intake Director, Nursing/House Supervisors, and ADON's would ensure that any allegation of abuse/neglect was addressed immediately upon receipt of information and appropriate interventions taken to help ensure patient safety.

D. On 12/10/2021, Nursing Department staff education was created by the Director of Performance Improvement/Risk Management (PI/RM), Unit Manager/Assistant Director of Nursing (ADON)/Interim Chief Nursing Officer (CNO), and the Corporate Vice President (VP) of PI/RM for all Registered Nurses (RN's), Licensed Practical Nurses (LPN's), and Mental Health Technicians (MHT's). The education would be on the facility's Abuse policy requirements and on the required observation checks/rounds of the patients to keep patients safe. The education would also have a post-test given to validate knowledge of the subject material.

E. The Director of Clinical Services (DCS), Intake Director, House/Nursing Supervisors, Assistant Directors of Nursing (ADON's), and the Staff Development Coordinator received education on the training requirements and education to be provided to the Nursing Department staff. This was completed, on 12/10/2021, by the Director of PI/RM and Unit Manager/Assistant ADON/Interim CNO.

F. Education with all Nursing Department staff began on 12/11/2021. All nursing department staff members would sign an attestation acknowledging receipt and understanding of the education received. On 12/14/2021, and forward, all staff would receive this education prior to their next shift. Education was being completed by the Director of PI/RM, DCS, Intake Director, Unit Manager/Assistant ADON/Interim CNO, House/Nursing Supervisors, ADON's, and the Staff Development Coordinator.

Interview with ADON #2, on 12/16/2021 at 1:21 PM, revealed she had received the training from the Director of PI/RM about abuse and performing every fifteen (15) minute checks per policy. ADON #2 stated all staff members were required to be trained before the shift they worked. ADON #2 stated she was able to run reports to ensure all staff were educated. ADON #2 stated she felt staff members were knowledgeable about abuse and performing every fifteen (15) minute checks. ADON #2 stated she felt the training had been a positive experience for all staff members.

Interview with RN #9, on 12/16/2021 at 2:19 PM, revealed she had recently received training on abuse and every fifteen (15) minute observation checks/rounding from her Unit Manager.

Interview with RN #10, on 12/16/2021 at 2:28 PM, revealed she had training on abuse and every fifteen (15) minute rounding, on 12/13/2021, by ADON #3 and her Unit Manager. She stated she reviewed the information and took the post-test.

Interview with the Licensed Professional Clinical Counselor (LPCC), National Certified Counselor (NCC), on 12/16/2021 at 2:26 PM, revealed she recently had training on abuse and every fifteen (15) minute rounds given by her supervisor, the DCS.

Interview with RN #11 and RN #12, on 12/16/2021 at 2:33 PM, revealed both had recent training on abuse and every fifteen (15) minute checks given by the Unit Manager/ADON/Interim CNO, the Corporate VP of PI/RM, and ADON #3. They stated the system was better now, more detailed and specified, so everyone knew their responsibilities.

Interview with MHT #2, LPN #2, RN #4, and RN #13, on 12/16/2021 at 2:41 PM, revealed all had training by their supervisors on abuse and every fifteen (15) minute checks recently. They stated they felt the new system was good for staff accountability.

Interview with the Intake Clerk/Ambulance Bay and the Registrar, on 12/16/2021 at 2:46 PM, revealed they recently had training on abuse and every fifteen (15) minute checks given by their Manager. They stated the training was important to keep eyes on the patients to make sure they were always safe.

Interview with MHT #6 and MHT #10, on 12/16/2021 at 2:47 PM and 3:08 PM respectively, revealed they had recently received training by ADON #3 and the SDC on abuse and every fifteen (15) minute checks/rounding. MHT #10 stated she liked the new assignment sheets; it was more specific, and everyone knew their responsibilities.

Interview with MHT #7, RN #14, RN #15, and MHT #8, on 12/16/2021 at 2:52 PM, revealed all had recent training on abuse and every fifteen (15) minute checks by the Unit Manager/ADON/Interim CNO.

Interview with RN #16, MHT #9, and RN #17, on 12/16/2021 at 3:03 PM, revealed all had training on abuse by the Unit Manager/ADON/Interim CNO and the Corporate VP of PI/RM. They stated the Unit Manager/ADON/Interim ADON printed out the policy and went over it well. They also stated that all had received training on every fifteen (15) minute checks/rounding by the SDC. They stated they liked the new rounding system. They stated it provided more accountability for staff.

Interview with the Director of Clinical Services (DCS), on 12/16/2021 at 1:45 PM, revealed she had training on abuse and every fifteen (15) minute checks from the Director of PI/RM. The DCS stated she had twenty-four (24) staff members that she supervised and all but three (3) had received the training. The DCS stated she was still in the process and had given those three (3) staff members the training materials. She stated she would meet with them before they went to work on the unit.

Interview with ADON #3, on 12/16/2021 at 1:49 PM, revealed she recently received training on abuse and every fifteen (15) minute checks. ADON #3 stated she reviewed the education with the staff, gave them the post-test, and then had them sign they had completed the training. She stated she arrived before staff members began their shift to go over the new training.

Interview with the Director of Utilization Management (UM), on 12/16/2021 at 1:52 PM, revealed she recently had training on abuse and every fifteen (15) minute checks/rounding given by the Director of PI/RM. The Director of UM stated she supervised six (6) staff members, and all had received their training on abuse and every fifteen (15) minute checks/rounding. She stated her staff understood the importance of reporting abuse and doing the correct observational checks.

Interview with the Director of Admitting/Intake, on 12/16/2021 at 1:55 PM, revealed he recently had training on abuse and every fifteen (15) minute checks/rounding by the Director of PI/RM. He stated he supervised twenty-four (24) to twenty-six (26) staff members for all three (3) shifts. The Director also stated his manager received this training from the Director of PI/RM. He stated the manager had met with almost all staff members except PRN (as needed) and they could not work without meeting with her.

Interview with the Intake Manager, on 12/16/2021 at 2:05 PM, revealed she recently had training on abuse and every fifteen (15) minute checks/rounding. The Intake Manager stated she was trained by Nursing Leadership. The Intake Manager stated she was arriving at the facility before the start of her staff's shifts to do the training. She stated she had trained the majority of her staff.

Interview with the Discharge Planner, on 12/16/2021 at 2:16 PM, revealed she recently had training on abuse and every fifteen (15) minute observation rounding by her supervisor, the DCS. The Discharge Planner stated it was important to over report than under report allegations of abuse and to do the fifteen (15) minute checks timely to ensure patients were where they were supposed to be.

G. The Leadership team, consisting of the CEO, Director of PI/RM, Unit Manager/ADON/Interim CNO, Corporate VP of PI/RM, and Corporate SVP of Clinical Services, met on 12/10/2021 to develop a plan for auditing compliance with every fifteen (15) minute observation rounding. Starting on 12/13/2021, the Director of PI/RM or designee(s) would perform audits:

a. A retrospective camera/video audit of one (1) hour of every fifteen (15) minute observation compliance would be completed daily on each unit and each shift;

b. Various times would be chosen. Audits would be completed using the camera review;

c. Audits would continue for thirty (30) days;

d. The Director of PI/RM would ensure that every fifteen (15) minute audits were completed and would maintain documentation of results. Results would be shared with appropriate directors as needed;

e. After thirty (30) days, the need for continued audits would be based on the findings;

f. Results would be shared in the monthly Performance Improvement Committee (QAPI);

g. Ad-Hoc Performance Improvement Committee meetings would be held on a more frequent basis to review results of audits and address concerns as needed.

h. If lack of compliance was found, staff would receive re-education as an initial step. Further incidents, in collaboration with the CEO, Unit Manager/ADON/Interim CNO, and Director of Human Resources, would be addressed by either education or by the progressive disciplinary process, as appropriate

H. On 12/13/2021, education was provided by the Director of PI/RM and Chief Executive Officer (CEO) to all hospital directors regarding the process for reporting abuse/neglect allegations to clinical leadership and to the Director of PI/RM. Education was also provided to all directors on how to educate their respective staff regarding the abuse and neglect policy.

I. Starting on 12/14/2021, all other staff would receive education regarding Abuse and Neglect reporting. On 12/14/2021, The Director of PI/RM provided education to each department director/head regarding abuse and neglect reporting and how to provide the education to their respective department staff members. Each department director/head would ensure, starting on 12/14/2021, that every staff member in their respective departments, would receive abuse and neglect reporting education prior to their next shift.

Interview with the Human Resources (HR) Director, on 12/16/2021 at 1:10 PM, revealed he had re-education on abuse by the Director of PI/RM. HR Director stated the process had been implemented and moving forward, no staff would work until they had the abuse and neglect education. The HR Director stated he had an on-going list of staff members and how they had received education on the facility's Abuse and Neglect policy.

Interview with the Director of Health Information Management (HIM) and Privacy Officer, on 12/16/2021 at 1:14 PM, revealed she had one (1) full-time person and other part-time staff and had already completed the training on abuse and neglect as well as a posttest to ensure compliance.

Interview with the Director of Dietary, on 12/16/2021 at 1:16 PM, revealed she had received the training from the Director of PI/RM on the abuse policy. The Director of Dietary stated she had eight (8) staff members and had already met with the group, gave the education, and followed up with the posttest.

Interview with the Chief Financial Officer (CFO), on 12/16/2021 at 1:20 PM, revealed she had received the training on abuse from the Director of PI/RM. She stated she knew to always believe the patients and to report it.

Interview with the Director of Facility Services, on 12/16/2021 at 1:42 PM, revealed he had the training on abuse from the Director of PI/RM. The Director of Facility Services stated he supervised six (6) staff members, four (4) in maintenance and two (2) in housekeeping. He stated he had recently given the training in abuse to his staff members, and they understood the importance of the training.

Interview with the Maintenance and IT staff member, on 12/16/2021 at 2:23 PM, revealed he had training on abuse by his Director. He also stated he had training during new hire orientation, and if anything happened, he knew the protocol.

Interview with the Housekeeper, on 12/16/2021 at 2:24 PM, revealed she recently had training on abuse by her Director. She stated she was around staff and patients all the time, and it was important for all staff to have the training.

Interview with the Dietician, on 12/16/2021 at 2:32 PM, revealed she recently had training on abuse. She stated the Dietary Director gave the training. The Dietician stated everyone knew the correct thing to do and what to do if witnessing or being told about abuse.

Interview with the Director of Outpatient Services, on 12/16/2021 at 3:12 PM, revealed she had recently received training on abuse by the Director of PI/RM. The Director stated she was responsible for staff and clinical supervision of Outpatient Services. She stated she had completed all training for her staff expect for one (1) part-time person who would receive the training before she began her next shift.

J. Starting on 12/14/2021, Nursing Leadership, including the Unit Manager/ADON/Interim CNO, ADON's, and Nursing/House Supervisors would complete rounds on each unit and each shift daily to ensure shift assignment sheets were competed and all staff members were aware of their assigned responsibilities. The Leadership Observation Rounding form would be completed and submitted to the Director of PI/RM. This would continue for thirty (30) days and be reported in the Performance Improvement Committee (QAPI) meeting. Additional Ad-hoc Performance Improvement Committee meetings would be held on a more frequent basis to review results of rounding and address concerns as needed.

Interview with the Patient Advocate, on 12/16/2021 at 2:00 PM, revealed she recently had training on abuse and every fifteen (15) minute checks/rounding given by the Director of PI/RM. The Patient Advocate stated all allegations of abuse would be thoroughly investigated and reports would be made timely. The Patient Advocate stated she knew what to look for during the video. She stated the video reviews were looking better now than before. The Patient Advocate stated staff members were using a flashlight at night and during the day, and the observation checks were being done timely.

Interview with the Staff Development Coordinator (SDC), on 12/16/2021 at 2:08 PM, revealed he was responsible for the education of the s

Based on interview, record review, review of the facility's job descriptions, review of the facility's video, and review of the facility's policies and procedures, it was determined the facility failed to provide adequate nursing supervision and a safe environment free from abuse for three (3) of thirteen (13) sampled patients, Patient #1, Patient #2 and Patient #3.

Patient #1 reported to staff, on 11/23/2021 at 10:00 AM, Patient #2 had raped him/her during the night; however, there was no documented evidence Patient #1 had reported the allegation, no documented evidence interventions were implemented for the patient's safety, no documented evidence staff initiated an incident report, and no documented evidence the facility conducted a thorough investigation of the allegation.

Review of the facility's video revealed, during the quiet time of 3:00 PM to 3:33 PM on 11/23/2021, and after the reported abuse, Patient #1 and Patient #2 were allowed to share a bedroom with the door closed and unsupervised by staff.

Continued review of the facility's video revealed Patient #1 and Patient #2 were allowed to share a bedroom the night of 11/23/2021, after the abuse allegation. Per review of the video, staff failed to ensure the patients were routinely observed every fifteen (15) minutes in compliance with Physician's orders and facility protocol. Per the video, there was up to fifty-nine (59) minutes between staff monitoring observations/supervision of Patient #1 and Patient #2 during the night of 11/23/2021.

Patient #2 reported to staff, on 11/24/2021, Patient #1 had sexually assaulted him/her multiple times during his/her admission; however, there was no documented evidence interventions were implemented for the patient's safety and no documented evidence the facility conducted a thorough investigation of the allegation.

Also, on 11/23/2021, Patient #3 reported to staff that Patient #4 had sexually assaulted him/her when they had been roommates; however, there was no documented evidence of the allegation in Patient #3's medical record, no documented evidence interventions were implemented for the patient's safety, no documented evidence the facility initiated an incident report, and no documented evidence the facility conducted a thorough investigation of the allegation.

Review of the facility's policy titled, "Levels of Observation and Precaution Levels", revealed, during the hours of sleep, night staff would make safety observations using a flashlight, observing and counting three (3) respirations, noting the patient's behavior/activity, and verifying the location of the patient every fifteen (15) minutes.

Review of the job descriptions for the Nursing Department revealed the Mental Health Technician (MHT) was the staff member specifically designated to do every fifteen (15) minute safety Observation Checks (OC's) on the patients. In addition, review of the positions of Registered Nurse (RN), House Supervisor, Manager of Nursing Services, and Chief Nursing Officer (CNO) revealed all were responsible for providing a therapeutic, safe milieu; following the facility's policies; and providing quality care.


Refer to: A-0395 and A-0396

Based on interview, record review, review of the facility's job descriptions, review of the facility's video recordings, and review of the facility's policy, it was determined the facility failed to supervise and evaluate the nursing care provided for each patient. The facility failed to adequately supervise nursing personnel so patient care would be provided in a safe non-abusive environment for three (3) of thirteen (13) sampled patients, Patient #1, Patient #2 and Patient #3.

The findings include:

Review of the facility's policy titled, "Abuse and Neglect Reporting", last revised 05/2021, revealed it was the facility's policy that "Patients had the right to be free from mental, physical, sexual, and verbal abuse, neglect, or exploitation." Continued review revealed "It was the policy of the facility to protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff members, volunteers, other patients, visitors, or family members." The policy further stated, "The hospital mandated that, under the guidance of applicable laws, any healthcare worker having reasonable cause to believe that any person was in the state of abuse, exploitation, or neglect shall report the information to the appropriate regulatory agency." Further review revealed, "All allegations, observations, or suspected cases of abuse, neglect, or exploitation that occurred in the facility would be investigated by the hospital." Additional review defined the term Neglectful Supervision, as "placing in, or failing to remove, the person from a situation that a reasonable individual would realize required judgment or actions beyond that child's level of maturity, physical condition, or mental abilities and that resulted in bodily injury or substantial risk of immediate harm to the person."

Continued review of the facility's policy titled, "Abuse and Neglect Reporting", Procedure Section, revealed, "Cases of suspected sexual assault, physical abuse, or neglect would be given priority and would be investigated thoroughly." Further review revealed, "To protect the patient from real or suspected mental, physical, sexual, and verbal abuse, neglect and/or exploitation, staff would safeguard the patient from the offending individual(s). "

Review of the facility's policy titled, "Levels of Observation and Precaution Levels", last revised 05/2021, revealed during the hours of sleep, night staff would make safety observations using a flashlight, by observing and counting three (3) respirations, and noting the patient's behavior/activity and location.

Review of the facility's Mental Health Technician (MHT) Job Description, dated 08/2019, under the department of Nursing, revealed the position responsibilities included the MHT was to perform patient safety checks at scheduled times and document appropriately. Per the job description, the MHT was to perform fifteen (15) minute observation rounds of each patient and document appropriately.

Review of the facility's Registered Nurse (RN) Job Description, dated 04/2019, revealed responsibilities included to maintain a therapeutic milieu that was safe and focused on delivering quality of care. This included leading the team that was working the shift through appropriate assignments and thorough communication.

Review of the facility's House Supervisor Job Description, dated 04/2019, under the department of Nursing, revealed the position responsibilities included supervising and leading the nursing team in adhering to department policies and protocols. According to the job description, the House Supervisor was to round through all open departments to ensure they were functioning without problems and to conduct hospital rounds on nights and weekends to ensure the hospital was secure and safe.

Review of the facility's Manager of Nursing Services Job Description, dated 04/2019, revealed the position responsibilities of maintaining a therapeutic milieu that was safe and focused on delivering quality patient care. According to the job description, the Nurse Manager supervised and led the nursing team in adhering to departmental policies and protocols.

Review of the facility's Chief Nursing Officer (CNO) Job Description, dated 04/2019, revealed the position responsibilities of supporting the education and compliance for hospital policy and being actively involved in reviewing and providing feedback for changes as needed. The CNO was responsible for maintaining a therapeutic milieu that was safe and focused on delivering quality patient care.

1. Review of Patient #1's clinical record revealed the facility admitted the patient, on 11/16/2021, with a diagnosis of Unspecified Mood (Affective) Disorder. Per the medical record, Patient #1 was discharged on 11/24/2021.

Interview with Registered Nurse (RN) #2, on 12/02/2021 at 10:25 AM, revealed Patient #1 reported to her that on 11/23/2021 at 10:00 AM, Patient #2 (Patient #1's roommate) had "raped" him/her during the night. She stated she immediately reported this to the Unit Manager/Assistant Director of Nursing (ADON)/ Interim Chief Nursing Officer (CNO); however, she did not document the sexual abuse allegation in the patient's medical record.

Continued review of Patient #1's medical record revealed there was no documented evidence, in the medical record, Patient #1 had made an allegation of sexual abuse, no documented evidence an incident report had been initiated, no documented evidence a thorough investigation was completed, and no documented evidence interventions were implemented to protect the safety of the patients.

Review of the facility's video revealed, on 11/23/2021 at 3:00 PM, and after Patient #1's allegation of abuse, Patient #1 and Patient #2 had been allowed in their shared bedroom with the door closed and without staff supervision, from 3:00 PM to 3:33 PM, when Patient #1 and Patient #2 exited their room.

Continued review of the facility's video, revealed on 11/23/2021, and after the allegation of abuse, Patient #1 and Patient #2 were allowed to be in the bedroom together overnight. Review of the facility's video revealed beginning at 9:00 PM on 11/23/2021, no staff used a flashlight while making observations, per the facility's policy. Per the video, the first observation check was made at 9:23 PM without entering the room, twenty-three (23) minutes after the start of the video. The next observation check (OC) was at 9:46 PM, twenty-three (23) minutes after the first check. The next OC was at 10:15 PM by a staff member who looked in the room while walking by the door, twenty-nine (29) minutes after the previous OC. The next OC was at 10:46 PM, thirty-one (31) minutes after the previous check. The next OC was at 11:17 PM, thirty-one (31) minutes after the previous check. The next few OC's were at 11:29 PM, 11:44 PM, 11:49 PM, and 12:09 AM, twenty (20) minutes after the previous OC. The next OC was at 12:29 AM, twenty (20) minutes after the previous OC. The next few OC's were 12:42 AM, 12:58 AM, 1:15 AM, 1:28 AM, 1:37 AM, 1:49 AM, 2:02 AM, and 2:04 AM. Then next OC was at 2:31 AM, by staff just walking by the door twenty-seven (27) minutes after the previous OC. The next OC was at 2:45 AM. The next OC was at 3:44 AM, fifty-nine (59) minutes after the previous OC. The next few OC's were at 3:57 AM, 4:13 AM, 4:32 AM, 4:44 AM, 5:06 AM, 5:13 AM, then 5:46 AM, thirty-three (33) minutes after the previous check. The OC's continued at 5:57 AM, and 6:18 AM, twenty-one (21) minutes after the previous check. The last OC seen on the video was at 6:42 AM on 11/24/2021, twenty-four (24) minutes after the previous OC. The video was stopped at this time since Patient #1 and Patient #2 came out of their room and into the dayroom of the unit.

2. Review of Patient #2's medical record revealed the facility admitted the patient, on 11/16/2021, with a diagnosis of Major Depression, Recurrent Severe. Continued review revealed, on 11/24/2021 at 5:45 PM, after two (2) peers reported to staff that Patient #2 had exposed his/her genitals to them in the Gym, staff talked to Patient #2 who then reported Patient #1 (Patient #2's roommate) had sexually assaulted him/her on multiple occasions throughout his/her admission at the facility. The record revealed the facility notified the parents as they were driving to the facility for the patient's discharge, documented by the House Supervisor on 11/24/2021 at 10:00 PM. There was no documented evidence a thorough investigation was completed to determine the extent of the allegation.

Review of the facility's Incident Report, dated 11/24/2021, revealed Patient #2 had gone down to the Gym with peers the afternoon of 11/24/2021 and had exposed his/her genitals to other peers. Continued review of the Incident Report revealed upon returning to the unit, Patient #2 admitted to exposing his/herself and then proceeded to tell the nurse his/her previous roommate (Patient #1) had threatened to kill the patient if Patient #2 did not perform oral sex. Patient #2 reported he/she performed the sexual act. Per the Incident Report, the nurse notified the house supervisor of the allegations. Further review of the Incident Report revealed Patient #2 stated the sexual abuse happened a few times on different days in the bathroom of the room they shared. However, there was no documented evidence a thorough investigation was completed to determine the extent of the allegation.

Review of Patient #2's medical record from Facility #2, signed by Emergency Department (ED) Physician #1, on 11/25/2021 at 12:06 AM, revealed Patient #2 was admitted to the facility's Emergency Department, on 11/24/2021 at 9:54 PM, for alleged sexual assault. Per the medical record a visual examination was completed by the ED Physician. The medical record revealed Patient #2 reported rectal pain, and the results of the examination was a small amount of erythema (redness of the skin or mucous membranes) without any tears, no bleeding or discharge was noted to the rectum. Continued review revealed Patient #2's family was advised they would need to go to Facility #3 for a Pediatric Sexual Assault Examination.

Review of Patient #2's medical record from Facility #3 revealed, on 11/25/2021 at 12:15 AM, Patient #2 was seen at the facility's Emergency Department for a Pediatric Sexual Assault Nurse Examination (P-SANE). Review of the record revealed a physical exam was performed on Patient #2 with a small amount of erythema left glans/distal penile shaft noted. Continued review revealed normal appearing external genitalia, perineum, and anus without bruising, bleeding, or lacerations. Further review revealed two (2) three (3) millimeter (mm) abrasions medial to the left nipple was noted. The provider note was signed on 11/25/2021 at 3:36 AM.

3. Review of Patient #3's medical record revealed the facility admitted the patient, on 11/15/2021, with a diagnosis of Dissociative Identity Disorder. Continued review of the medical record revealed the facility discharged Patient #3 on 11/23/2021.

Interview with RN #2, on 12/02/2021 at 10:25 AM, revealed Patient #3 reported to her, on 11/23/2021 at approximately 10:00 AM, that Patient #4 had sexually assaulted him/her when they shared a room. RN #2 stated she notified the Unit Manager/ADON/Interim CNO immediately of the allegations. RN #2 stated the Unit Manager/ADON/Interim CNO and the Director of Clinical Services (DCS) came to the unit and talked with Patient #3; however, she did not document the allegation in the medical record.

Interview with the Director of Clinical Services (DCS), on 12/02/2021 at 10:40 AM, revealed the ADON had informed her of the allegations and asked her to interview the patients. The DCS interviewed Patient #3 and asked the patient to write a statement. The DCS stated when she reviewed Patient #3's statement, she discovered the time of the incident Patient #3 had written down was prior to the time Patient #4 was admitted to the unit. The DCS stated she interviewed Patient #4 who denied the allegations.

On 12/02/2021 the State Survey Agency (SSA) Surveyor requested a copy of Patient #3's written statement, dated 11/23/2021; however, it was not provided by the facility.

Continued review of Patient #3's medical record revealed there was no documented evidence, in the medical record, Patient #3 had made the sexual abuse allegation, no documented evidence an incident report had been initiated, no documented evidence a thorough investigation was completed, and no documented evidence interventions were implemented to protect the safety of the patients.

Review of Patient #4's medical record revealed the facility admitted the patient, on 11/20/2021, with a diagnosis of Disruptive Dysregulation Disorder. Continued review of the record revealed a Nurse's Note, dated 11/21/2021 at 10:56 AM, documenting that Patient #4 had been redirected about touching other children, most especially his/her roommate, who at the time was Patient #3; however, there was no documented evidence of the sexual abuse allegation.

Interview with the previous Chief Nursing Officer (CNO), on 11/30/2021 at 11:30 AM and 2:00 PM, revealed the facility's videos of the units were not reviewed unless there was an incident to investigate. Per the interview, it was his understanding he was to only report allegations of abuse which resulted in significant injuries.

Interview with the Director of Performance Improvement/Risk Management (PI/RM), on 12/01/2021 at 2:40 PM, revealed no staff members or other patients were interviewed after the allegations were made by Patient #2 because she thought these interviews would be a violation of the Health Insurance Portability and Accountability Act (HIPAA), and she needed to protect the privacy of the patients involved.

Interview with the Director of Clinical Services (DCS), on 12/02/2021 at 10:40 AM, revealed she was not usually the person who would interview and investigate allegations of abuse. The DCS stated since Patient #1 allegedly recanted the alleged abuse allegations, she did not think the facility needed to take further action. The DCS stated in regard to Patient #3's allegations, since the alleged abuse supposedly happened prior to Patient #4 admission, she did not think further action, monitoring or interventions, were necessary.

Interview with the Unit Manager/Assistant Director of Nursing (ADON)/Interim Chief Nursing Officer (CNO), on 12/02/2021 at 11:00 AM, revealed she and the DCS were asked to assist with the alleged abuse allegations since the Director of PI/RM was working with the SSA Surveyor regarding a facility self-reported incident. The Unit Manager/ADON/Interim CNO stated she did not think further investigation was necessary since Patient #1 allegedly recanted the allegations, and Patient #3's allegations were prior to the time Patient #4 was admitted. The Unit Manager/ADON/Interim CNO stated both Patient #1 and Patient #3 were to be discharged later on 11/23/2021 so she verbally instructed staff to keep Patient #1 separated from Patient #2 and to keep Patient #3 separated from Patient #4. However, she did not document the allegations or to keep the patients separated in the medical record and did not initiate an incident report.

Interview with the Attending Physician, on 12/07/2021 at 11:25 AM, revealed he was not informed of the sexual allegations made by Patient #1 and Patient #3 on 11/23/2021. The Attending Physician stated both patients were being followed by the Nurse Practitioner, and he was not sure if she was aware or not. The Attending Physician stated he was informed of the abuse allegations made by Patient #2, on 11/24/2021, while he/she was being discharged. The Attending Physician stated he was not aware of facility staff not completing the fifteen (15) minute checks on patients as required by the facility's policy. The Attending Physician stated the standard of care would be to follow the policy in regard to care. The Attending Physician stated if staff members were aware of an order and failed to follow the order, it could be considered neglect.

Additional interview with RN #2, on 12/08/2021 at 10:30 AM, revealed she was instructed by the Unit Manager/ADON/Interim CNO to keep the alleged victims (Patient #1 and Patient #3) separated from the alleged perpetrators (Patient #2 and Patient #4) until staff could talk with each patient. RN #2 stated she left the unit at 3:00 PM on 11/23/2021, and she did not give report to the oncoming shift since the other day shift nurse was remaining on the unit, and the DCS was still interviewing the patients.

Interview with the Medical Director, on 12/08/2021 at 2:00 PM, revealed he was not aware staff was not performing the Observations Checks per the facility's policy. The Medical Director stated he felt the videos should be viewed periodically to ensure compliance for patient safety. The Medical Director further stated it was the Registered Nurse's responsibility to ensure staff was following the facility's policy and performing Observations Checks (OC)on time. The Medical Director stated all allegations of abuse should be thoroughly investigated and notifications made. The Medical Director stated the patients should have been separated with extra monitoring put in place to ensure each patient's safety

Interview with the Chief Executive Officer (CEO), on 12/16/2021 at 1:30 PM, revealed all incidents of abuse should be reported to the appropriate authority and should be thoroughly investigated by the facility. Per the interview, the timeframe to report abuse was immediately. The CEO stated not all the recent allegations of abuse were reported immediately but should have been. The CEO stated staff should be following the policies and procedures in regard to Observational Checks (OC). The CEO stated he was unaware the facility's videos were not being monitored to ensure compliance with policies and procedures to ensure patient safety.

The facility submitted an acceptable Immediate Jeopardy (IJ) Removal Plan, on 12/16/2021, alleging the IJ was corrected, on 12/15/2021. An on-site validation of the IJ Removal Plan determined the IJ was removed, on 12/15/2021, prior to exit on 12/16/2021.

The corrective actions the facility undertook to remove the IJ were as follows:

A. The policy "Plan for Provision of Care" was reviewed by the Director of Performance Improvement/Risk Manager (PI/RM), and she determined there was need for a more detailed description of shift assignment sheets, including completion of the every fifteen (15) minute observations. The Director of PI/RM worked with the Corporate Senior Vice President (SVP) of Clinical Services to revise the policy. The policy was revised and approved by the Corporate Vice President (VP) of PI/RM and the Corporate SVP of Clinical Services on 12/20/2021. The Corporate VP of PI/RM educated the policy change to the Unit Manager/ADON/Interim CNO, Director of PI/RM, and the CEO on 12/10/2021.

B. The policy "Levels of Observation and Precaution Levels" was reviewed by the Corporate VP of PI/RM. It was determined the policy required clarification of performing observation rounds when patients were in their rooms. The policy was updated on 12/10/2021. The policy revision was approved by the Corporate VP of PI/RM and the Corporate SVP of Clinical Services. The policy change was educated to the Unit Manager/ADON/Interim CNO, the Director of PI/RM, and the CEO by the Corporate VP of PI/RM on 12/10/2021.

C. The Director of Clinical Services (DCS), House/Nursing Supervisors, Assistant Directors of Nursing (ADON's), and the Staff Development Coordinator (SDC) received education on the training requirements and education on the every fifteen (15) minute observational checks/rounding to be provided to the Nursing Department staff. This was completed, on 12/10/2021, by the Director of PI/RM and Unit Manager/ADON/Interim CNO.

D. Education with all Nursing Department staff began on 12/11/2021. All Nursing Department staff members would sign an attestation acknowledging receipt and understanding of the education received. On 12/14/2021, and forward, all staff would receive this education prior to their next shift. Education was being completed by the Director of PI/RM, DCS, Intake Director, Unit Manager/ADON/Interim CNO, House/Nursing Supervisors, ADON's, and the SDC.

E. The Leadership team, consisting of the CEO, Director of PI/RM, Unit Manager/ADON/Interim CNO, Corporate VP of PI/RM, and Corporate SVP of Clinical Services, met on 12/10/2021 to develop a plan for auditing compliance with every fifteen (15) minute observation rounding. Starting on 12/13/2021, the Director of PI/RM or designee(s) would perform audits:

a. A retrospective camera/video audit of one (1) hour of every fifteen (15) minute observation compliance would be completed on each unit and each shift daily;

b. Various times would be chosen. Audits would be completed using the camera review;

c. Audits would continue for thirty (30) days;

d. The Director of PI/RM would ensure that every fifteen (15) minute audits were completed and would maintain documentation of results. Results would be shared with appropriate directors as needed;

e. After thirty (30) days, the need for continued audits would be based on the findings;

f. Results would be shared in the monthly Performance Improvement Committee (QAPI);

g. Ad-Hoc Performance Improvement Committee meetings would be held on a more frequent basis to review results of audits and address concerns as needed;

h. If lack of compliance was found, staff would receive re-education as an initial step. Further incidents, in collaboration with the CEO, Unit Manager/ADON/Interim CNO, and Director of Human Resources, would be addressed by either education or by the progressive disciplinary process, as appropriate.

F. Starting on 12/14/2021, Nursing Leadership, including the Unit Manager/ADON/Interim CNO, ADON's, and Nursing/House Supervisors would complete rounds on each unit and each shift daily to ensure shift assignment sheets were competed and all staff members were aware of their assigned responsibilities. The Leadership Observation Rounding form would be completed and submitted to the Director of PI/RM. This would continue for thirty (30) days and be reported in the Performance Improvement Committee (QAPI) meeting. Additional Ad-hoc Performance Improvement Committee meetings would be held on a more frequent basis to review results of rounding and address concerns as needed.

Interview with ADON #2, on 12/16/2021 at 1:21 PM, revealed she had received the training from the Director of PI/RM about performing the every fifteen (15) minute checks per policy. ADON #2 stated all the staff members were required to be trained before working their shifts. ADON #2 stated she could run reports to ensure all staff members were educated. ADON #2 stated she felt staff were conscious of every fifteen (15) minute checks being performed. ADON #2 stated she felt the training had been a positive experience for all staff members.

Interview with the Nurse Manager, on 12/16/2021 at 1:24 PM, revealed she had received training on every fifteen (15) minute checks and rounding recently by the Director of PI/RM.

Interview with the Unit Manager/ADON/Interim CNO, on 12/16/2021 at 1:28 PM, revealed she had received the every fifteen (15) minute checks training from the Director of PI/RM. The Unit Manager/ADON/Interim CNO stated she and the other ADON's had been giving this training to staff and had been keeping a master log. The Unit Manager/ADON/Interim CNO stated she had been performing audits, via video review, of the every fifteen (15) minute checks being performed. She stated the requirements were to do one (1) audit on the 7:00 AM to 7:00 PM shift, and one (1) audit on the 7:00 PM to 7:00 AM shift. The Unit Manager/ADON/Interim CNO stated she would come to the facility and perform night audits as well. The Unit Manager/ADON/Interim CNO stated she felt the training was going well, and it gave her a chance to speak with staff members to ensure every fifteen (15) minute checks were being done properly.

Interview with the CEO, on 12/16/2021 at 1:32 PM, revealed he had received training on every fifteen (15) minute checks/observation rounding. The CEO stated the facility had on-going monitoring, in the moment, of staff performing every fifteen (15) minute checks/observation rounds and stated nursing leadership was performing video monitoring. The CEO stated staff members would sign a document stating they had received the training and take a post-test to validate knowledge.

Interview with the Director of Clinical Services (DCS), on 12/16/2021 at 1:45 PM, revealed she had training on every fifteen (15) minute checks from the Director of PI/RM. The DCS stated she had twenty-four (24) staff members that she supervised and all but three (3) had received the training. The DCS stated those three (3) had received the training materials, and she would instruct them before they worked again.

Interview with ADON #3, on 12/16/2021 at 1:49 PM, revealed she recently received training on every fifteen (15) minute checks. ADON #3 stated she reviewed the education with staff members, gave them the post-test, then had them sign they had completed the training. She stated she arrived before staff members began their shift to go over the new training.

Interview with the Director of Utilization Management, on 12/16/2021 at 1:52 PM, revealed she recently had training on every fifteen (15) minute checks/rounding given by the Director of PI/RM. The Director of UM stated she supervised six (6) staff members, and all had received their training on every fifteen (15) minute checks/rounding.

Interview with the Director of Admitting/Intake, on 12/16/2021 at 1:55 PM, revealed he recently had training on every fifteen (15) minute checks/rounding by the Director of PI/RM. He stated he supervised twenty-four (24) to twenty-six (26) staff members for all three (3) shifts. The Director also stated his manager also received the training from the Director of PI/RM. He stated the manager had met with almost all staff members except PRN (as needed), and they could not work without meeting with her.

Interview with the Patient Advocate, on 12/16/2021 at 2:00 PM, revealed she recently had training on every fifteen (15) minute checks/rounding by the Director of PI/RM. The Patient Advocate stated she knew what to look for during the video. She stated the video reviews were looking better now than before. The Patient Advocate stated staff members were using a flashlight at night and during the day, the OC's were being done timely.

Interview with the Intake Manager, on 12/16/2021 at 2:05 PM, revealed she recently had training on every fifteen (15) minute checks/rounding. The Intake Manager stated she was trained by Nursing Leadership. The Intake Manager stated she was arrived at the facility before the start of her staff's shifts to do the training. She stated she had trained most of her staff.

Interview with the Staff Development Coordinator (SDC), on 12/16/2021 at 2:08 PM, revealed he was responsible for the education of the staff. The SDC stated he recently had training by the Interim CNO and the Corporate VP of PI/RM regarding the every fifteen (15) minute observations checks. He stated the education would be on-going with new hires and would be included in the staff's annual competencies. The SDC stated he had been reviewing the videos and was aware of what to look for during the audits.

Interview with the Discharge Planner, on 12/16/2021 at 2:16 PM, stated she recently had training on every fifteen (15) minute observation rounding by her supervisor, the DCS. The Discharge Planner stated it was important to do the fifteen (15) minute checks timely to ensure patients were where they were supposed to be.

Interview with RN #9, on 12/16/2021 at 2:19 PM, revealed she had recent training, provided by her Unit Manager, on the every fifteen (15) minute observational checks.

Interview with the Licensed Professional Clinical Counselor (LPCC), National Certified Counselor (NCC), on 12/16/2021 at 2:26 PM, revealed she recently had training on the every fifteen (15) minute rounds given by her supervisor, the DCS.

Interview with RN #10, on 12/16/2021 at 2:28 PM, revealed she had training on the every fifteen (15) minute rounding, on 12/13/2021, by ADON #3 and her Unit Manager. She stated she reviewed the information and took the post-test.

Interview with RN #11 and RN #12, on 12/16/2021 at 2:33 PM, revealed both had recent training on the every fifteen (15) minute checks given by the Unit Manager/ADON/Interim CNO, the Corporate VP of PI/RM, and ADON #3. They stated the system was better now, more detailed and specified, so everyone knew their responsibilities.

Interview with MHT #2, LPN #2, RN #4, and RN #13, on 12/16/2021 at 2:41 PM, revealed all had recent training by their supervisors on the every fifteen (15) minute checks. They stated they felt the new system was good for staff accountability.

Interview with the Intake Clerk/Ambulance Bay and the Registrar, on 12/16/2021 at 2:46 PM, revealed they recently had training from their Manager on the every fifteen (15) minute checks. They stated the training was important to keep eyes on the patients to make sure they were always safe.

Interview with MHT #6, on 12/16/2021 at 2:47 PM, revealed she recently had training by ADON #3 on the every fifteen (15) minute checks/rounding. MHT #3 stated she liked the changes that had been made.

Interview with MHT #7, RN #14, RN #15, and MHT #8, on 12/16/2021 at 2:52 PM, revealed all had recent retraining on the every fifteen (15) minute checks by the Unit Manager/ADON/Interim CNO.

Interview with RN #16, MHT #9, and RN #17, on 12/16/2021 at 3:03 PM, revealed all had training on the every fifteen (15) minute checks/rounding by SDC. They stated they liked the new rounding system. They stated it provided more accountability for staff.

Interview with MHT #10, on 12/16/2021 at 3:08 PM, revealed she was recently given training on the every fifteen (15) minute checks/rounding by the SDC. MHT #10 stated she liked the new assignment sheets; it was more specific, and everyone knew their responsibilities.

Review of the facility's documentation, on 12/16/2021, revealed updated education, attestation forms signed by staff, post-tests, and audits of videos demonstrated the facility had been compliant with their IJ Removal plan.

Based on interview, record review, review of the facility's video, and review of the facility's policy, it was determined the facility failed to update the current plan of care for two (2) of thirteen (13) sampled patients, Patient #1 and Patient #2.

Per interview, Patient #1 and Patient #2 reported allegations of sexual abuse and Management staff directed unit staff to keep the patients separated. However, review of their care plans did not indicate this as a current plan of care for each patient. In addition, review of the facility's video revealed Patient #1 and Patient #2 were not separated. Interview with nursing staff members revealed they were not aware of this new plan of care intervention for Patient #1 and Patient #2.

The findings include:

Review of the facility's policy titled, "Treatment Plan/Plan of Care," last revised 12/2020, revealed, "Interventions were required for all problems." Continued review of the facility's policy revealed, "Short- and long-term goals and objectives would be re-evaluated and, as necessary, revised based on changes in the patient's condition, problems, needs, and responses to care, treatment, and services."

Review of Patient #1's medical record revealed the facility admitted the patient, on 11/16/2021, with a diagnosis of Unspecified Mood (Affective) Disorder. Per the medical record, Patient #1 was discharged on 11/24/2021.

Per interview with Registered Nurse (RN) #2, on 12/02/2021 at 10:25 AM, Patient #1 reported to her that on 11/23/2021 at 10:00 AM, Patient #2 (Patient #1's roommate) had "raped" him/her during the night. She stated she immediately reported this to the Unit Manager/Assistant Director of Nursing (ADON)/Interim Chief Nursing Officer (CNO); however, she did not document the sexual abuse allegation in the patient's medical record.

Interview with the Unit Manager/ADON/Interim Chief Nursing Officer (CNO), on 12/02/2021 at 11:00 AM, revealed she instructed staff to keep Patient #1 and Patient #2 separated until Patient #1 was discharged later in the day, on 11/23/2021. However, review of the unit's video revealed Patient #1 and Patient #2 were not separated and shared the same room the evening of 11/23/2021, when Patient #1 was not discharged as planned.

Review of Patient #1's care plan, dated 11/16/2021, revealed Intervention #1 was to increase patient watch status as appropriate; however, there was no documented evidence the care plan was updated/revised to include interventions to keep Patient #1 and Patient #2 separated after Patient #1 alleged he/she was sexually abused by Patient #2.

Review of Patient #2's medical record revealed the facility admitted the patient, on 11/16/2021, with a diagnosis of Major Depression, Recurrent Severe. Continued review revealed, on 11/24/2021 at 5:45 PM, after two (2) peers reported to staff that Patient #2 had exposed his/her genitals to them in the Gym, staff talked to Patient #2 who then reported Patient #1 (Patient #2's roommate) had sexually assaulted him/her on multiple occasions throughout his/her admission at the facility. The record revealed the facility notified the parents as they were driving to the facility for the patient's discharge, documented by the House Supervisor on 11/24/2021 at 10:00 PM.

Review of Patient #2's care plan, dated 11/16/2021, revealed Intervention #2 was to provide a safe and supportive environment each shift; however, there was no documented evidence the care plan was updated/revised to include interventions to keep Patient #1 and Patient #2 separated after allegations of sexual abuse.

Interview with RN #2, on 12/13/2021 at 12:05 PM, revealed she was instructed to keep Patient #1 and Patient #2 separated while the investigation was in process. RN #2 stated she left the unit at 3:00 PM, and the Director of Clinical Services was still in the process of investigating the incident. RN #2 stated she did not give report or update the care plan since the other nurse was staying until 7:00 PM.

Interview with RN #4, on 12/08/2021 at 2:40 PM, revealed at change of shift, the nurses review the shift reports. She stated the facility's process was to provide an oral and written report about each patient to the oncoming shift. RN #4 stated the care plans should be kept updated in regard to abuse allegations.

Interview with the Mental Health Technician (MHT) #3, on 12/13/2021 at 12:15 PM, revealed she was not informed/instructed of any interventions to keep Patient #1 and Patient #2 separated.

Interview with the Evening House Supervisor, on 12/02/2021 at 3:15 PM, revealed she started her shift at 3:00 PM on 11/23/2021 and was not informed of any abuse allegations being made on the unit and was unaware Patient #1 and Patient #2 had any interventions in place to be kept separated.

Interview with the Director of Clinical Services, on 12/13/2021 at 12:30 PM, revealed she was assisting with the investigation of the abuse allegations. The Director stated she was unaware that Patient #1 and Patient #2 had any interventions in place to be kept separated.

Interview with RN #8, on 12/15/2021 at 2:20 PM, revealed when she started her shift at 7:00 PM, on 11/23/2021, she was given report of two (2) patients that had been talking about sexual stuff, but it had been investigated and everything was "fine." RN #8 stated she was not given the names of the patients nor was she given any instructions to keep Patient #1 and Patient #2 separated from each other. RN #8 stated when she returned for her shift, on 11/24/2021, and heard the allegations Patient #2 had made, RN #8 stated she was angry she was not given full details during the report on 11/23/2021.

Continued interview with the Unit Manager/ADON/Interim CNO, on 12/02/2021 at 11:00 AM, revealed when the incident was first reported, she told staff to keep Patient #1 and Patient #2 separated. The Unit Manager/ADON/Interim CNO stated she gave this instruction to the Charge Nurse, who was RN #2. The Unit Manager/ADON/Interim CNO stated it was the nurse's responsibility to pass this information to the oncoming shift. She stated the nursing staff should update the care plans, and the care plans should be current to ensure appropriate care was provided to each patient.