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Based on record review, document review, and staff interview, it was determined the facility failed to ensure care in a safe setting, by not following the notification process of law enforcement, and inadequate supervision, in three (3) out of ten (10) patients, patients #1, 2, and 3 (See Tag A 144). This failure has the potential to cause great harm and/or death to any patient receiving care at the facility, and staff providing care at the facility. As a result of this failure, an Immediate Jeopardy (IJ) was identified and the facility was notified on 10/12/22 at 4:45 p.m. The facility submitted and implemented an acceptable plan to remove the IJ, which was verified by the State Agency Program Manager on 10/13/22 at 12:45 p.m.

The following interventions were implemented to resolve the IJ:

Education of all direct care staff on Patient Observation Rounds, one to one (1:1) monitoring including paper documentation of the observation, "Forts" are prohibited, the nursing responsibilities for one to one (1:1) monitoring, and reporting of suspected sexual abuse of patients to law enforcement. Training will continue until 100% of direct care staff are educated. Patient #1 will be on two to one (2:1) monitoring until discharge. Leadership rounds will be performed daily and include no 'fort' construction, and ensure staff are following one to one (1:1) policies/procedures.

Based on record review, document review, and staff interview, it was determined the facility failed to ensure care in a safe setting, by not following notification process by law enforcement in three (3) out of ten (10) patients, patients #1, 2, and 3. This failure has the potential to cause great harm and/or death to any patient receiving care at the facility, and staff providing care at the facility.

Findings include:

A record review was conducted for patient #1. The patient was admitted to the facility on 06/21/22 with a diagnosis of major depressive disorder. The patient had several incidents of attacks on staff and peers. On 06/23/22 at 6:47 p.m., the patient was ordered "Social isolation due to aggressive behavior." On 06/24/22 at 9:01 p.m., the patient was ordered "One to One [1:1] Monitoring Around the Clock, Client safety." On 08/14/22 at 7:29 p.m., the patient was ordered "Sexually Acting Out Precaution" by physician #1 for "Two female peers reported that [patient #1] has been inappropriate with boundaries." On 09/15/22 at 11:41, a Nursing shift note by Registered Nurse (RN) #1 stated in part: "It was reported to a BHT [Behavioral Health Technician] staff that this patient sexually molested [patient #2] and attempted to sexually molest [patient #3]. Physician on call was notified at 10:39 p.m. Nursing Supervisor was notified at 9:00 p.m. DHHR Abuse Hotline was notified at 10:59 p.m." The patient remains hospitalized on the unit.

A record review was conducted for patient #2. The patient was admitted to the facility on 09/02/22 with a diagnosis of depression. On 09/15/22 at 10:14 p.m., a Nursing shift note by RN #1 stated in part: "Patient escorted to lobby by [facility] staff and discharged to Foster [family]." On 09/15/22 at 11:40 p.m., a Nursing note by RN #1 stated in part: "It was reported to a BHT that [patient #1] sexually molested [patient #2] and attempted to sexually molest [patient #3]. Physician on call was notified at 10:39 p.m. Nursing Supervisor was notified at 9:00 p.m. The DHHR Abuse Hotline was notified at 10:59 p.m."

A record review was conducted for patient #3. The patient was admitted to the facility on 09/12/22 with a diagnosis of major depressive disorder. On 09/16/22, a progress note by physician #2 stated in part: "Pt [patient] was involved in an incident yesterday evening where it was reported [patient #3] along with two [gender] peers made a "tent fort" in the day room. Pt reported that the other two (2) [gender] peers 'had sex' in the fort and [patient #3] watched them. Patient is laughing as recounts the incident. [Patient #3] denies being involved in the reported sexual activity. Patient was transferred to another level of care on 09/19/22."

An investigation was conducted by the facility. BHT #1 was terminated for failure to adhere to hospital policy. Informal re-education was provided to the unit staff on physician orders, social isolation, and one to one (1:1) observation. No additional staff were disciplined. Child Protective Services (CPS) was notified. No law enforcement was notified.

Review of policy titled "Allegations of patient Abuse," last reviewed 2/2022, revealed the policy states in part: "Procedure ... 7. Any person who has reasonable cause to suspect that a child is neglected or abused or observes the child being subjected to conditions that are likely to result in abuse or neglect will file immediately not more than [twenty-four] 24 hours after evidence of suspected abuse or neglect the circumstances and cause a report to be made to the Department of Health and human resources. In any case where the reporter believes that the child suffered serious physical abuse sexual abuse or sexual assault the reporter shall also immediately report or cause a report to be made to the state police and any law enforcement agency having jurisdiction to investigate the complaint. Report to the office of health facilities and licensure will also be made in accordance with state law."

West Virginia state law states in part: "Article 2. State Responsibilities for Children. §49-2-803. Persons mandated to report suspected abuse and neglect; requirements.(a) Any medical, dental, or mental health professional, Christian Science practitioner, religious healer, school teacher or other school personnel, social service worker, child care or foster care worker, emergency medical services personnel, peace officer or law-enforcement official, humane officer, member of the clergy, circuit court judge, family court judge, employee of the Division of Juvenile Services, magistrate, youth camp administrator or counselor, employee, coach or volunteer of an entity that provides organized activities for children, or commercial film or photographic print processor who has reasonable cause to suspect that a child is neglected or abused, including sexual abuse or sexual assault, or observes the child being subjected to conditions that are likely to result in abuse or neglect shall immediately, and not more than [twenty-four] 24 hours after suspecting this abuse or neglect, report the circumstances to the Department of Health and Human Resources. In any case where the reporter believes that the child suffered serious physical abuse or sexual abuse or sexual assault, the reporter shall also immediately report, to the State Police and any law-enforcement agency having jurisdiction to investigate the complaint. Any person required to report under this article who is a member of the staff or volunteer of a public or private institution, school, entity that provides organized activities for children, facility, or agency shall also immediately notify the person in charge of the institution, school, entity that provides organized activities for children, facility, or agency, or a designated agent thereof, who may supplement the report or cause an additional report to be made: Provided, That notifying a person in charge, supervisor, or superior does not exempt a person from his or her mandate to report suspected abuse or neglect."

An interview was conducted with the Director of Risk Management (DRM) on 10/11/22 at 10:57 a.m. The DRM confirmed no police were notified, only CPS.

Based on record review, observation, document review, and staff interview, it was determined the facility failed to ensure staff was supervised by a Registered Nurse for three (3) out of ten (10) patients, patients #1, 2, and 3 (See Tag A 395). This failure has the potential to cause great harm and/or death to any patient receiving care at the facility, and staff providing care at the facility. As a result of this failure, Immediate Jeopardy (IJ) was identified and the facility was notified on 10/12/22 at 4:45 p.m. The facility submitted and implemented an acceptable plan to remove the IJ, which was verified by the State Agency Program Manager on 10/13/22 at 12:45 p.m.

Education of all direct care staff on Patient Observation Rounds, one to one (1:1) monitoring including paper documentation of the observation, "Forts" are prohibited, the nursing responsibilities for one to one (1:1) monitoring, and reporting of suspected sexual abuse of patients to law enforcement. Training will continue until 100% of direct care staff are educated. Patient #1 will be on two to one (2:1) monitoring until discharge. Leadership rounds will be performed daily and include no 'fort' construction, and ensure staff are following one to one (1:1) policies/procedures.

Based on record review, observation, document review, and staff interview, it was determined the facility failed to ensure staff was supervised by a Registered Nurse (RN) for three (3) out of ten (10) patients, patients #1, 2, and 3. This failure has the potential to cause great harm and/or death to any patient receiving care at the facility, and staff providing care at the facility.

Findings include:

A record review was conducted for patient #1. The patient was admitted to the facility on 06/21/22 with a diagnosis of major depressive disorder. The patient had several incidents of attacks on staff and peers. On 06/23/22 at 6:47 p.m., the patient was ordered "Social isolation due to aggressive behavior." On 06/24/22 at 9:01 p.m., the patient was ordered "One to One [1:1] Monitoring Around the Clock, Client safety." On 08/14/22 at 7:29 p.m., the patient was ordered "Sexually Acting Out Precaution" by physician #1 for "Two female peers reported that [patient #1] has been inappropriate with boundaries." On 09/15/22 at 11:41, a Nursing shift note by RN #1 stated in part: "It was reported to a BHT [Behavioral Health Technician] staff that this patient sexually molested [patient #2] and attempted to sexually molest [patient #3]. Physician on call was notified at 10:39 p.m. Nursing Supervisor was notified at 9:00 p.m. DHHR Abuse Hotline was notified at 10:59 p.m." The patient remains hospitalized on the unit.

A record review was conducted for patient #2. The patient was admitted to the facility on 09/02/22 with a diagnosis of depression. On 09/15/22 at 10:14 p.m., a Nursing shift note by RN #1 stated in part: "Patient escorted to lobby by [facility] staff and discharged to Foster [family]." On 09/15/22 at 11:40 p.m., a Nursing note by RN #1 stated in part: "It was reported to a BHT that [patient #1] sexually molested [patient #2] and attempted to sexually molest [patient #3]. Physician on call was notified at 10:39 p.m. Nursing supervisor was notified at 9:00 p.m. The DHHR Abuse Hotline was notified at 10:59 p.m."

A record review was conducted for patient #3. The patient was admitted to the facility on 09/12/22 with a diagnosis of major depressive disorder. On 09/16/22, a progress note by physician #2 stated in part: "Pt [patient] was involved in an incident yesterday evening where it was reported [patient #3] along with two [gender] peers made a "tent fort" in the day room. Pt reported that the other two (2) [gender] peers 'had sex' in the fort and [patient #3] watched them. Patient is laughing as recounts the incident. [Patient #3] denies being involved in the reported sexual activity. Patient was transferred to another level of care on 09/19/22."

Review of video was conducted for 09/15/22 from 5:00 p.m. through 6:00 p.m. Patients #1, 2 and 3 were in a dayroom with BHT #1. They appeared to be constructing a chair and blanket fort in the corner of the room. On 5:16:34 p.m., patients #1, 2, and 3 were under the 'chair and blanket fort' with the entrance covered by a blanket, not in view of BHT #1. At 5:18:00 p.m., patient #1 exits the fort. At 5:18:31 p.m., patient #1 re-enters. At 5:19:28 p.m., patient #3 exits. At 5:20:27 p.m. through 5:23:25 p.m., patient #3 enters and exits the fort multiple times. At 5:24:47 p.m., patient #2 exits the fort. The patients remain in the dayroom with BHT #1 until they all exit at 5:47:16 p.m.

An investigation was conducted by the facility. BHT #1 was terminated for failure to adhere to hospital policy. Informal re-education was provided to the unit staff on physician orders, social isolation, and one to one (1:1) observation. No additional staff were disciplined. Child Protective Services (CPS) was notified. No law enforcement was notified.

A review was conducted of policy titled "Patient Observation Rounds," last approved 10/07/22. The policy states in part: "Levels of Special Observation ... Definition: One staff is assigned the single responsibility of maintaining one patient under constant supervision to be readily available and accessible at all times to the patient. a) Staff is not assigned duties other than the one to one (1:1)."

A policy titled "Precautions and Observation Levels," last approved 10/06/22, was reviewed. The policy states in part: "I. Precautions ... f. Sexually Acting Out (SAO) - Patients who have a history of sexual acting out or sexual assault or are identified at risk for sexual aggression, sexualized Behavior or accusations will be placed on precautions based on the level of risk assessed and may include ... vii. Staff are to observe patient behavior and discourage inappropriate contact/conversation."

An interview was conducted with the Director of Risk Management (DRM) and Quality Improvement on 10/11/22 at 10:57 a.m. Regarding the investigation involving patients #1, 2, and 3, the DRM stated, "I first became aware of the incident the day after it happened. I launched into an investigation. We reviewed the video and interviewed all employees involved with the the CNO [Chief Nursing Officer]. When we interviewed [BHT #1], [BHT#1] stated 'I recall all the staff were busy. I was trying just to let them play. If [patient #1] doesn't get what [patient #1] wants [patient #1] hits and attacks us.' The therapist spoke with the [patients]. [BHT #1] had been suspended immediately, and then terminated upon the results of the investigation. The only other discipline I'm aware of is the other staff would be reminded that [patient #1] was on social separation."

A telephone interview was conducted with RN #1 on 10/11/22 at 2:42 p.m. Regarding the incident with patients #1, 2 and 3, RN #1 stated, "I had went back to give [patient #1] six o'clock [6:00 p.m.] meds [medications]. I saw other kids in the room. [BHT #1] was in the room with [patient #1] with two (2) other kids [patients #2, and 3]. The kids were in the room, and I told [BHT #1] to get the kids out of the room, [patient #1] was a one to one (1:1) and on social isolation. A couple hours later the kids said that [patient #1] inappropriately touched them while in a 'blanket fort'. It was really busy. When I went in the room, there was no blanket fort in the room at the time. The blanket fort went up in the room after I left the room. What was on my mind, I had meds to finish passing. I don't have time to do everything I have to do and double check. If the BHT needed help [BHT #1] could've yelled up the hallway and someone else could've went back and assisted. If I stop and do all the BHT duties all the time, then my med pass doesn't get done. I don't remember who was doing the safety checks, it was either [BHT #2 or BHT #3]. Either one of the other BHTs could've taken the patients out of the room. Everyone on the unit knew [patient #1] was on a social isolation. No one reported to me there was any issue after I left the room. Then one (1) of the BHTs reported what had happened. We talked to the patients, and they kept going back and forth on if something happened or it didn't. We notified the physician, [RN #3], the guardians, and the AOC [Administrator on call]. I did not do any assessment on the patients. After this incident, the whole unit was re-educated on social isolation and one to one (1:1) observation."

A telephone interview was conducted with BHT #3 on 10/11/22 at 3:45 p.m. Regarding the incident with patients #1, 2, and 3, BHT #3 stated, "I didn't know anything had happened until about 10 p.m. that night when I was sitting with [patient #1]. I heard the other BHTs talking about it. That day, I had seen the fort afterwards when [BHT #1] started taking it down. [BHT #2] and I both had tablets that day. I had assumed that the other two (2) [patients #2, and 3] were with [BHT #2] in the shower. I knew [patient #1] was on social isolation. [BHT #1] had asked me what to do about it since the other [patients] were in the room, and I told [BHT #1] to tell the other kids to leave and take [patient #1] to [patients #1]'s room. [BHT #1] said [BHT #1] needed to get the other staff to help [BHT #1] take the [patients] out, but [BHT #1] didn't ask me to do it because I am [medical condition]."

An interview was conducted with the Director of Human Resources (DHR) on 10/11/22 at 4:22 p.m. Regarding the investigation after the incident with patients #1, 2, and 3 occurred, the DHR stated, "[BHT #1] received a letter of termination on 09/21/22. No other staff were disciplined. There was just to be a unit huddle about one to one (1:1) and social isolation."

A telephone interview was conducted with physician #2 on 10/12/22 at 11:05 p.m. Regarding the incident with patients #1, 2, and 3, physician #2 stated, "I was on that week. I remember being told the day after that the patients had built a blanket fort and [patient #1] allegedly had sex with another patient. [Patient #1] denied it happening. I was not notified at the time it happened because I was not on call. The patient was on social isolation, and it's more of a global thing if they are having issues with multiple peers and we just try to keep [patient #1] away from other peers. [Patient #1] was pinching and threatening. We try to keep [patient #1] on one side of the unit away from the other patients for the safety of the other peers. [Patient #1] still has the ability to go to school and outdoor time to be physically active. [Patient #1] should have not been allowed to play with other children or build a blanket fort. It's also a violation of the one to one (1:1) observation."

An interview was conducted with RN #3 on 10/12/22 at 12:28 p.m. RN #3 confirmed there is no documentation done by the staff responsible for the one to one (1:1) observation. The only documentation would be by the other staff performing the fifteen (15) minute safety checks.

An interview was conducted with BHT #2 on 10/12/22 at 2:52 p.m. Regarding the incident with patients #1, 2, and 3, BHT #2 stated, "I was doing my rounds, and everything was fine. [Patients #1, 2, and 3] were in the day room. They were playing with race cars. I told [BHT #1] [patient #1] was on one to one (1:1) and social isolation. I told [patients #2 and 3] they had to come with me. [BHT #1] said they were fine if there was a problem [BHT #1] would let me know. Later that evening, I heard [patient #3] saying [patient #1] tried to touch my [privates] but I left. I asked [patient #3] to tell me what you know, and [patient #3] told me they were back there building a fort, but [patient #3] left the fort. [Patient #3] saw [patient #1] touching [patient #2]. [Patient #2] was leaving that night. I had called [RN #2] to report it and then I spoke with [patient #2]. At first [patient #2] said nothing happened, but then said yes I was in the fort [patient #1] touched my private part. I wrote a statement. [Patient #2] said [patient #1] played with and touched [private parts under clothing]. [Patient #2] was teary-eyed when [patient #2] was talking to me. This was just a little bit before [patient #2] was getting discharged. I wrote a statement and filled out the incident reports on all three (3). I talked to [RN #3] that night. I turned in the reports to [RN #2]. [RN #1] was really busy that night. When we are one to one (1:1) observation, there's no documentation, we just have to keep the patient in sight and stay about an arm's length away."

An interview was conducted with RN #2 on 10/12/22 at 3:05 p.m. Regarding the incident with patients #1, 2, and 3, RN #2 stated, "Earlier that evening there was an all call on [patient #1]. [Patient #1] was supposed to be socially separated on the other side of the unit. When I went up [BHT #1 and 2] were holding [patient #1] on [patient #1]'s side of the unit. [Patient #1] had been play wrestling with other kids. I told them [patient #1] was not supposed to be around the other kids. Later that evening, I was called by [BHT #2]. [BHT #2] had overheard the kids talking that this thing happened in the fort. I reiterated to keep [patient #1] over there, keep [patient #1] away from the other kids. I helped [BHT #2] fill out the incident sheets. [Patient #2] was leaving to be discharged. I spoke with the administrator, and they told me I could tell the foster parent about what happened. When [foster parent] came to pick up [patient #2] I told [foster parent]. [Foster parent] appreciated that I had told [foster parent] what had happened. The nurse working the unit would have called the physician and the CPS hotline. The patient was already one to one (1:1) and on social isolation." When asked if the physician verified the patient could be discharged after finding out about the incident, RN #2 stated, "I don't know, [RN #1] would have called the physician. [RN #1] did the incident sheet. [RN #1] is very thorough."