HospitalInspections.org

Based on policy review, document review, medical record review, facility investigation and interview, the facility failed to ensure care was provided in a safe setting for 7 of 9 (Patient #1, #2, #3, #4, #5, #6, and #7) sampled patients; and failed to ensure patients had a physicians order for restraints for 1 of 3 (Patient #2) patients sampled with restraints.

The findings included:

1. Review of the hospital "PATIENT RIGHTS AND RESPONSIBILITIES" policy approved 12/2021 and reviewed 8/2022 revealed, " ...Patients have the right to be protected...from physical, verbal, and emotional abuse..."

2. Review of the hospital "OBSERVATIONS, PATIENT" policy approved 12/2021 and reviewed 8/2022 revealed, "...In order to maintain patient safety the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner...Q[Every] 5 Minute Observations (previously known as Line of Sight ...patient is placed on Q5 minute observation if their behavior is unpredictable and there is potential risk for harm to self or others...Patient is in visual range of assigned staff at all times..."

3. Review of the hospital "PRECAUTIONS, SEXUAL ACTING OUT" policy approved 10/2022 revealed, "...Patients shall not have sexual contact with one another..."

4. Review of the hospital "SMOKING POLICY" reviewed 1/2022 revealed, "...patients aged twenty one (21) years of age or older are permitted to smoke ..."

5. Review of a document provided by the hospital upon entrance, revealed the following reported incidents:
A. Patient #2 reported that she and Patient #1 had consensual intercourse.
B. Patient #3 reported Patient #4 came into her room, made her take her clothes off, and attempted to have sex with her.
C. Patient #5 reported Patient #2 touched her in her "privates" twice.

6. Medical record review for Patient #1, a 20 year old male, revealed an admission date of 10/28/2022 with diagnoses which included Schizoaffective Disorder, Bipolar Type and Asthma. Patient #1 was admitted to the unit at 3:00 PM on 10/28/2022. The admission physician orders revealed Patient #1 had orders for Q (every) 5 minute observation and precautions for high-risk suicide. By 8:06 PM on 10/28/2022, as documented by video evidence and interview, Patient #1 was alone in his room and unaccounted for and Patient #1 and #2 had sexual intercourse in Patient #1's room. BHA #2, assigned to Patient #1, failed to conduct observations as ordered by the physician and falsified documentation in the medical record.

7. Medical record review for Patient #2, a 25 year old female, revealed an admission date of 9/2/2022 with diagnoses which included Schizoaffective Disorder, Bipolar Type. The patient had a plan to starve herself while she was receiving in-patient services at the hospital. The admission physician orders revealed Patient #2 had orders for Q5 minute observation and precautions for high-risk suicide. The document listing incidents provided by the hospital upon entrance revealed Patient #2 reported she had intercourse with Patient #1. On 10/30/2022 Patient #2 reported she had sex with another patient while on Q5 minute observation. BHA #2 was assigned to Patient #2 and failed to conduct observations as ordered by the physician.

8. Medical record review revealed Patient #3, a 25-year-old female, was admitted to the hospital on 9/17/2022 with diagnoses which included Major Depressive Disorder, Recurrent Severe with Psychosis and past diagnosis included Autism and Mental Retardation. Patient #3's admission physician orders revealed Patient #3 was Q5 minute observation and precaution for high-risk suicide. A 9/19/2022 physicians order revealed Patient #3 was to be "...Q5 checks; 1:1 initiated. The document listing incidents provided by the hospital upon entrance revealed Patient #3 reported on 9/25/2022 Patient #4 attempted to have sex with her. At the time of the reported attempt for Patient #4 to have sex with Patient #3, Patient #3 was still on Q5 minute observation. Patient #3 was transported to the crisis center for evaluation. The crisis center's documentation referred to Patient #3 as a "vulnerable adult". Patient #3, a vulnerable adult, had physician's orders for 1:1 observation prior to 9/25/2022 which were changed to Q15 observations without a physician's order. Patient #3 was assaulted by Patient #4 who had a past history of rape.

9. Medical record review for Patient #4, a 30 year old male, revealed an admission date of 9/23/2022 with diagnoses which included Schizoaffective Disorder, Bipolar Type. Patient #4 has a history of incarceration for rape. Patient #4 was admitted to the hospital with physician's orders for Q5 minute observation and precautions for high-risk suicide. Patient #4 reported voices made him request to be shot by police. The document listing incidents provided by the hospital upon entrance revealed Patient #4 went into Patient #3's room on 9/25/2022 and attempted to have sex with her. Documentation on 9/27/2022 revealed the patient required increased level of observation due to sexually inappropriate behavior. Patient #4 was placed on 1:1 observation due to the sexually inappropriate behavior. On 9/28/2022 Patient #4 admitted to sexual intercourse with a female patient. Although Patient #4 was on Q5 minute observations, he was able to go into Patient #3's room and allegedly sexually assault her. The Q5 minute observation procedure failed to prevent Patient #4 from going into Patient #3's room.

10. Medical record review for Patient #5, a 28 year old female, revealed an admission date of 10/5/2022 with diagnoses which included Schizoaffective Disorder, Bipolar Type and Intellectual Disability. Patient #5 was admitted to the hospital after being found outside her group home hitting herself in the face. The admission physician orders revealed Patient #5 had orders for Q5 minute observation and precautions for high-risk suicide. Patient #5 had orders to be on Q5 minute observations. The facility decreased her level of observation to Q 15 minutes without an order, thereby increasing her risk.

11. Medical record review revealed Patient #6, an 18-year-old male, was admitted to the hospital on 11/12/2022 with diagnosis which included Schizophrenia, unspecified. The admission orders dated 11/12/2022 revealed Patient #6 was on Q5 minutes observations with suicide precautions for past but not current suicidal ideations. A Psychiatric Evaluation dated 11/13/2022 at 2:50 PM, revealed Patient #6 was actively responding to internal stimuli. On 11/15/2022 at 12:56 PM, Patient #6's level of observation was decreased to Q 15 minute per physician's order. Patient #6 was transferred to another unit on 11/18/2022 at 2:30 PM, due to verbally aggressive behavior. The Progress Notes dated 11/22/2022 at 7:45 AM, revealed the RN saw Patient #6's face swollen, red, and bleeding. 911 was called. Patient #6 was admitted to Hospital #1's ED [Emergency Department] on 11/22/2022 at 8:37 PM.
The ED Physician Note dated 11/22/2022 at 8:32 PM revealed, "...assault x PTA [prior to admission]...reports pt was struck in the head by an unknown object @ [named hospital]... Patient #6 was an 18-year old who was attacked in his room by his roommate. Patient #6 was taken to a local ED via 911 where he received treatment for his injuries.

12. Medical record review revealed Patient #7, a 33 year old male, was admitted to the hospital on 11/6/2022 with diagnosis which included Schizoaffective Disorder, Depressive Type. The admission orders dated 11/5/2022 at 11:25 PM, revealed Patient #7 had Q5 minutes observations with high suicide risk due to planning to starve self.
A physician's order dated 11/14/2022 at 1:13 revealed, Patient #7 was changed to Q15 minutes observations. A progress notes dated 11/22/2022 at 8:30 PM, revealed Patient #7 had sight swelling to his right hand. A psychiatry progress note dated 11/22/2022 at 12:50 PM revealed, "...Pt attacked roommate [Patient #6] while he was sleeping. States 'the voices told me to do it' and later said 'he called me a name'..." A note dated 11/23/2022 at 10:45 PM, revealed Patient #7 was responding to internal stimuli.
Refer to A 144.

13. The hospital "Restraint" policy approved 12/2021 revealed, "...Restraint may only be ordered by the attending physician or covering practitioner..."

14. Medical record review for Patient #2, a 25 year old female, revealed an admission date of 9/2/2022 with diagnoses which included Schizoaffective Disorder, Bipolar Type. A Psychiatric Evaluation dated 9/3/2022 at 2:25 PM, revealed Patient #2 reported hearing voices telling her to kill herself. The Seclusion/Restraint Packet Progress Note dated 9/3/2022 at 4:24 PM revealed, "...The patient refused to get up I held the patient's left arm, the tech...held the patient's right arm...and the tech... held the patient's legs as we carried her to seclusion..." The hospital was unable to provide an order for restraints for Patient #2. The hospital staff was using physician restraints to transport Patient #2 to seclusion without a physician's order.
Refer to A 168.

Based on policy review, document review, medical record review, facility investigation review, and interview, the facility failed to provide care in a safe setting for 7 of 9 (Patient #1, #2, #3, #4, #5, #6 and #7) sampled patients; failed to maintain patient observation levels prescribed by the physician for (Patient #1, #2, #3, and #5) who were at high-risk; failed to protect patients from patient-to-patient sexual abuse for (Patient #1, #2, #3, #4, and #5) and failed to protect patients from patient-to-patient physical abuse for (Patient #6 and #7).

The findings included:

1. Review of the hospital "PATIENT RIGHTS AND RESPONSIBILITIES" policy approved 12/2021 and reviewed 8/2022 revealed, "...Patients have the right to be protected...from neglect...from physical, verbal, and emotional abuse..."

2. Review of the hospital "OBSERVATIONS, PATIENT" policy approved 12/2021 and reviewed 8/2022 revealed, "...In order to maintain patient safety the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and/or confirmed with the DON [Director of Nursing]...PROCEDURE...The physician will order one of three levels of observation at time of admission and as the patient's condition warrants a change...1. 15 minute 2. Q [Every] 5 minute 3. One-to-one...The physician may also order a precaution level of observation for...1. Suicide 2. Assault 3. Elopement 4. Seizure 5. Fall 6. Sexual Acting Out...The nurse may not decrease the level of observation, i.e., change from 1:1 to Q5 minute without an order by the psychiatric practitioner...Documentation of Observations...Staff documents all levels of observation on each patient's observation form which becomes a part of the patient record. Each entry is to include the following...Level of observation...Precaution...Location...Behavior...Activity...Time...Staff initial signature... Documentation of the observation is to be completed once the patient has been observed...It is not permissible to complete in advance or to backfill time frames that were not completed in a timely manner...Q 5 Minute Observations (previously known as Line of Sight)...patient is placed on Q5 minute observation if their behavior is unpredictable and there is potential risk for harm to self or others...Patient is in visual range of assigned staff at all times...Nurse will assess patient minimum of every four hours in a progress note..."

3. Review of the hospital "PRECAUTIONS, SEXUAL ACTING OUT" policy approved 10/2022 revealed, "...provision of a safe, therapeutic environment of care includes the prevention of patient to patient sexual incidents. Patients shall not have sexual contact with one another...If the hospital determines that there has been an allegation of sexual familiarity (contact) between patients, an immediate investigation must take place..."

4. Review of the hospital "SMOKING POLICY" reviewed 1/2022 revealed, "...In accordance with Tenn. Code...patients aged twenty one (21) years of age or older are permitted to smoke in designated areas of the hospital..."

5. Medical record review for Patient #1, a 20 year old male, revealed an admission date of 10/28/2022 with diagnoses which included Schizoaffective Disorder, Bipolar Type and Asthma.

The Intake Assessment revealed the patient presented to the hospital as a walk-in, experiencing suicidal ideation with a plan to hang himself, and hearing voices telling him to kill himself and his brother, then dump his brother in the river.

Review of the admission physician's order dated 10/28/2022 at 1:30 PM, revealed Patient #1 had orders for Q5 minute observation, and precautions for high-risk suicide.

A document provided at entrance conference revealed a facility incident that Patient #1 had intercourse with Patient #2 on 10/28/2022.

Review of the "PATIENT OBSERVATIONS - 5 Minutes (1200-2355)" form dated 10/28/2022, revealed Behavioral Health Associate (BHA) #2 documented Patient #1 was outside smoking at 7:55 PM, 8:00 PM, and at 8:05 PM. On 10/28/20222 at 8:10 PM and 8:15 PM, BHA #2 documented Patient #1 was outside sitting/lying. The Q5 minutes observation form documented Patient #1 in his room at 8:35 PM. There were no behavioral observations documented on the Q5 minute observation forms for newly admitted Patient #1.

Review of the Nursing Reassessment dated 10/29/2022 at 8:16 AM revealed, "...New pt [patient]...is irritable. He wants to switch units b/c [because] his friends are over there. Outburst when told no..."

Review of the Psychiatric Evaluation dated 10/29/2022 at 11:50 AM revealed, Patient #1 was discharged from the hospital the prior month but had not taken his medications and wanted to be restarted on his medications.

Review of the Facility Investigation Report dated 11/17/2022, revealed Patient #1 indicated that he and Patient #2 agreed to have sexual intercourse with each other when she came to his room.

In an interview in the conference room on 11/14/2022 at 12:15 PM, Risk Manager #2 verified, per video footage, Patient #2 entered his room at 8:06 PM.

Patient #1 was newly admitted to the unit on 10/28/2022 at 3:00 PM with a plan to hang self with a sheet. Patient #1 was placed on Q5 minute observations. By 8:06 PM, as documented by video footage and interview, Patient #1 was alone in the room and unaccounted for when Patient #2 entered Patient #1's room and they had intercourse. BHA #2 failed to conduct Q5 minute observations as ordered by the physician and falsified documentation in the medical record when he documented Patient #1 was outside smoking.

6. Medical record review for Patient #2, a 25 year old female, revealed an admission date of 9/2/2022 with diagnoses which included Schizoaffective Disorder, Bipolar Type. Patient #2 had recently been discharged from this hospital 9/1/2022.

Review of the Intake Assessment revealed Patient #2 had a plan to starve herself while she was receiving in-patient services.

Review of the admission physician orders revealed Patient #2 was involuntarily admitted with orders for Q5 minute observation, and precautions for high-risk suicide.

Review of the Psychiatric Evaluation dated 9/3/2022 at 2:25 PM revealed, Patient #2's chief complaint was, "I want to kill myself."

Review of the "PATIENT OBSERVATIONS - 5 Minutes" forms dated 9/9/2022, revealed no behavioral observations were documented and the form was blank for 11:05 PM and 11:10 PM.

Review of the "PATIENT OBSERVATIONS - 5 Minutes" forms dated 9/10/2022, revealed no behavioral observations were documented and the form was blank for 11:35 PM and 11:40 PM.

Review of the "PATIENT OBSERVATIONS - 5 Minutes" forms dated 9/12/2022, revealed Patient #2 was "outside, smoking" from 1:05 PM until 3:30 PM.

Review of the "PATIENT OBSERVATIONS - 5 Minutes" forms dated 10/6/2022 beginning at 6:00 AM and Q5 minutes through 7:00 AM, revealed there were no observations of Patient #2 documented although staff initials were documented.

Review of the "PATIENT OBSERVATIONS" form dated 10/14/2022 and 10/15/2022 revealed Patient #2 was on 15-minute observations. There were no behavioral observations documented on the forms. There was no documentation of a physician's order to decrease Patient #2's level of observation to Q 15 minute.

The "NURSING REASSESSMENT" dated 10/16/2022 at 6:52 AM revealed, "...pt having suicidal thoughts...continue to monitor and provide support...pt currently on Q5..."

Review of the "PATIENT OBSERVATIONS" form dated 10/16/2022 and 10/17/2022 revealed Patient #2 was on 15-minute observations. There were no behavioral observations were documented on the forms. There was no documentation of a physician's order to decrease Patient #2's level of observation to Q 15-minute.

Review of the "PATIENT OBSERVATIONS - 5 Minutes" forms dated 10/27/2022 at 12:00 AM through 10/27/2022 at 11:55 PM, revealed no behavioral observations were documented on the forms. The form was blank from 11:05 PM through 11:55 PM.

The Progress Notes dated 10/27/2022 at 10:10 PM revealed, Patient #2 came to nurse's station. C/O [complains of] wanting to kill her self with a scratch on her inner right wrist area on her right arm. The patient started hitting head against wall.

A document provided at entrance conference revealed a facility incident where Patient #2 went into Patient #1's room then reported she had intercourse with Patient #1.

Review of the "PATIENT OBSERVATIONS - 5 Minutes (1200-2355)" form dated 10/28/22, revealed Behavioral Health Associate (BHA) #1 documented Patient #2 was outside smoking at 7:55 PM. The documentation location, activity, and behavior on 10/28/22 at 8:00 PM, 8:05 PM, and 8:10 PM, was illegible. At 8:15 PM, BHA #1 documented Patient #2 was outside sitting/lying and in her room at 8:20 PM.

Review of video recording of the East Hallway on 10/28/2022 at 8:13 PM, revealed Patient #2 knocked on Patient #1's door then entered his room. At 8:22 PM, Patient #2 exited Patient #1's room. Patient #2 was in Patient #1's room for 9 minutes.

Review of a handwritten note by Patient #2 dated 10/28/2022 revealed, "...having a good day today...feeling stressed and frustrated...I had intercourse with [named Patient #1] tonight..."

The Facility determined a sexual boundary violation did occur between Patient #1 and Patient #2 on 10/28/2022 at approximately 8:13 PM. Patient #2 remained in Patient #1's room until 8:22 PM.

The "NURSING REASSESSMENT" dated 10/29/2022 at 8:20 AM revealed, "...exhibits attention seeking behavior. Frequent outburst..."

Review of a Progress Note dated 10/30/2022 revealed, "... at Med pass patient reported that she had sex with another patient...She [Patient #2] asked if she should be placed on sexual precautions/1:1 due to incident...told the patient that she would not be placed on one to one due to her already being placed on Q5 minutes. Patient became upset after and started acting up trying to hurt herself and ran to her room and slammed the door and began screaming... banging on things in her room patient... had to be restrained by staff..."

The "NURSING REASSESSMENT" dated 10/30/2022 at 10:30 PM revealed, "...C/O not feeling good...much attention seeking..."

The "NURSING REASSESSMENT" dated 10/31/2022 at 8:40 PM revealed, "...To Rape Crisis/Police Facility for Evaluation...0115 [1:15 AM] Back on unit...0145 [1:45 AM] Tried to harm self [symbol for with] electrical outlet metal...0152 [1:52 AM] Placed in seclusion..."

The Psychiatry Progress Note dated 10/31/2022 at 2:00 PM revealed, "...Had a difficult weekend-alleged sexual encounter [symbol for with] another pt-Seclusion last night [secondary] aggression toward staff..."

The Progress Notes dated 11/2/2022 at 1:15 PM, revealed Patient #2 requested to leave Against Medical Advice (AMA). She was assessed and deemed competent enough to follow through with such request and it was approved.

Patient #2 was discharged on 11/3/2022 with diagnoses of Schizoaffective Disorder, Bipolar Type.

In an interview in the conference room on 11/14/2022 at 12:15 PM, Risk Manager #2 verified per video footage Patient #2 entered Patient #1's room at 8:06 PM.

Review of the Facility Investigation Report dated 11/17/2022, revealed [named] Police Department arrived at the facility on 10/31/2022 and took a statement from Patient #2 and then transported her to the crisis center.

Patient #2 reported she went to Patient #1's room where she kissed and made out with him took her clothes off and got on top of him then proceeded to have sex both vaginally and anally but didn't agree to.

The hospital failed to provide observations as ordered by the physician for Patient #2 which allowed Patient #2 to enter Patient #1's room and have intercourse.

7. Medical record review revealed Patient #3, a 25-year-old female, was admitted to the hospital on 9/17/2022 with diagnoses which included Major Depressive Disorder, Recurrent Severe with Psychosis.

Review of the Intake Assessment dated 9/17/2022 at 11:36 AM, revealed the patient reported worsening suicidal ideations and thoughts of hopelessness and worthlessness about the future. Past diagnosis included intermittent explosive disorder, autism, and "mental retardation."

Review of the admission physician orders revealed Patient #3 was involuntarily admitted to the in-patient unit, with orders for Q5 minute observation, and precautions for high-risk suicide.

Review of the "PSYCHIATRIC EVALUATION" dated 9/18/2022 at 10:00 AM, revealed the Chief Complaint of, "...I've been trying to kill myself..." Medical history of Fetal Alcohol Syndrome. Social History revealed the patient lived in a group home. Admitting diagnoses was changed to Schizoaffective Disorder and Depression.

The physicians order dated 9/19/2022 at 5:37 PM revealed, "...Q5 checks 1:1 initiated..."

The physicians order dated 9/20/2022 at 8:28 AM revealed, "...Transfer pt to East when bed comes available..."

Review of the "PATIENT OBSERVATIONS - 5 Minutes" forms dated 9/23/2022 revealed Patient #3 decreased from 1:1 observation to Q5 minute observations at 2:10 PM without a physician's order to decrease level of observation.

Review of the "PATIENT OBSERVATIONS - 5 Minutes" forms dated 9/23/2022 beginning at 2:15 PM through 9/ 24/2022 at 11:55 PM, revealed no behavioral observations were documented.

Review of the "PATIENT OBSERVATIONS - 5 Minutes" form dated 9/24/2022 revealed Patient #3 was in her room and appeared asleep at 10:30 AM, 10:35 AM, 10:40 AM, and 10:45 AM.

The facility determined a sexual boundary violation occurred between Patient #3 and Patient #4. They were found to be alone in her room on 9/24/2022 from 10:37 AM to 10:41 AM with the door closed.

A document provided at entrance conference revealed a facility incident on 9/25/2022 that Patient #3 reported Patient #4 came into her room, made her take her clothes off, and attempted to have sex with her.

Review of the Patient Observation form dated 9/25/2022 starting at 12:00 AM, revealed Patient #3 was on every 15-minute checks without a physician's order to decrease the level of observation.

The "NURSING REASSESSMENT" dated 9/25/2022 at 10:20 AM revealed, "...She has been cursing at staff and triggering the unit...destroying property and pulling plaster out of the wall...fighting other pts..."

Review of the Patient Observation form dated 9/26/2022 starting at 12:00 AM through 9/28/2022 at 9:20 AM, revealed there was no behavioral observations documented for the Q5 minute observations.

The Psychiatry Progress Note dated 9/27/2022 at 1:15 PM revealed, "...Says another pt forced his sexual advances toward her..."

The physicians order dated 9/28/2022 at 9:20 AM revealed, "...Place PT on 1:1 observation..."

The physicians order dated 9/28/2022 at 10:20 AM, revealed the patient could be transported to the crisis center for evaluation.

Review of the report from local Crisis Center #1 revealed, "...9/28/2022...The patient is a vulnerable adult...possible HIV exposure...the alleged assailant is a patient in the same facility as the victim..."

The physician's order dated 9/30/2022 at 3:40 PM, revealed to keep Patient #3 on 1:1 observations and discharge to group home.

Patient #3 was discharged on 10/3/2022.

Review of the Facility Investigation dated 10/4/2022 revealed Patient #3 reported to staff that she was sexually assaulted by a patient [Patient #4] on 9/26/2022 sometime before medication administration but after breakfast.

8. Medical record review for Patient #4, a 30 year old male, revealed an admission date of 9/23/2022 with diagnoses which included Schizoaffective Disorder, Bipolar Type.

The Intake Assessment dated 9/23/2022 at 2:22 AM revealed, Patient #4 was hearing auditory hallucinations with commands. Patient reported voices made him request to be shot by police.

Review of the admission physician orders revealed orders for Q5 minute observation, and precautions for high-risk suicide.

Review of the "PSYCHIATRIC EVALUATION" dated 9/23/2022 at 9:55 AM, revealed the Chief Complaint of, "I'm here to get reevaluated and reintegrated into the real world."

The "NURSING REASSESSMENT" dated 9/24/2022 at 9:00 AM revealed, paced the halls all day and responded to internal stimuli. His mood was anxious and labile, and he was compliant with medications.

A document provided at entrance conference revealed a facility incident on 9/25/2022, Patient #4 went into Patient #3's room, made her take her clothes off, and attempted to have sex with her.

Review of the "NURSING REASSESSMENT" dated 9/25/2022 at 12:00 PM revealed, Patient #4 paced the halls all day.

The "NURSING REASSESSMENT" dated 9/26/2022 at 8:48 AM, revealed Patient #4 was calm but guarded at times.

The "NURSING REASSESSMENT" dated 9/26/2022 at 8:00 PM, revealed Patient #4 spent much of his time in his room.

The Psychiatry Progress Note dated 9/27/2022 at 1:10 PM revealed, "...PT requires increased level of observation due to sexually inappropriate behavior..."

Review of a session note dated 9/27/2022 at 2:35 PM revealed, Patient #4 presented irritable and boastful. He initially was in denial about the sexual allegations but after "much encouragement" he validated his actions.

The physicians order dated 9/27/2022 at 3:42 PM revealed, "...Make PT on 1:1 for sexually inappropriate behavior..."

The Psychiatry Progress Note dated 9/28/2022 at 2:00 PM revealed, "...Pt states that he did indeed have sexual intercourse with a female patient..."

The Psychiatry Progress Note dated 9/29/2022 at 10:10 AM revealed, "...Asking to DC [discharge] AMA...continues to admit to sexual intercourse but insist it was consensual..."

Review of a session note dated 9/29/2022 at 11:30 AM revealed met with therapist to discuss treatment plan for sexual misconduct. Patient refused to sign the treatment plan update.

The Psychiatry Progress Note dated 10/3/2022 at 10:00 AM revealed, "...Irritable. Wants to come off 1:1..."

Review of a session note dated 10/4/2022 at 1:41 PM revealed, "...previous sex offender and has rape charges...accusations of sexual assault weeks ago while here inpatient...will remain 1:1...discharging to homeless shelter..."

The Psychiatry Progress Note dated 10/5/2022 at 1:15 PM revealed, "...'They told us charges of rape were dropped'...Pt remains on 1:1..."

The Psychiatry Progress Note dated 10/7/2022 at 1:15 PM revealed, "...Denies previous sexual allegation. Wants to know when he will be discharged..."

Patient #4 was discharged on 10/26/2022 with diagnoses which included Schizoaffective Disorder, Bipolar Type.

Although Patient #4 was admitted on Q5 minute observations, he was able to go into Patient #3's room and allegedly sexually assault Patient #3. The Q5 minute observation procedure failed to prevent the alleged assault.

9. Medical record review for Patient #5, a 28 year old female, revealed an admission date of 10/5/2022 with diagnoses which included Schizoaffective Disorder, Bipolar Type and Intellectual Disability.

Review of the Intake Assessment revealed Patient #5 presented to the hospital after being found outside her group home hitting herself in the face, causing bleeding, with paranoia, delusions, and audio hallucinations commanding her to kill herself.

Review of the admission physician orders revealed orders for Q5 minute observation, and precautions for high-risk suicide.

Review of the Psychiatric Evaluation dated 10/5/2022 at 12:30 PM revealed, Patient #5's chief complaint was, "...I was hearing voices and felt like I was being spied on so I punched myself in the nose..."

Review of the Patient Observation form dated 10/13/2022 starting at 12:00 AM, revealed Patient #5 was on every 15-minute checks without a physician's order to decrease level of observation to Q15 minute.

A document provided at entrance conference revealed a facility incident on 10/15/2022 that Patient #5 reported Patient #2 touched her in her "privates."

There was no documentation of a Patient observation form for Patient #5 for 10/16/2022 and 10/17.2022.

The "NURSING REASSESSMENT" dated 10/17/2022 at 10:33 AM revealed, "...frequent outburst. Argument [symbol for with] another pt this morning..."

The physicians order dated 10/17/2022 at 12:45 PM, revealed Patient #5 was transferred to another unit in the hospital. There was no documentation of a physician's order to decrease the level of observation.

Review of the Patient Observation form dated 10/18/2022 at 12:00 AM through 11:45 PM, revealed Patient #5 was on every 15-minute checks. There was no documentation of behaviors nor documentation of a physician's order to decrease the level of observation.

Review of the Facility Investigation dated 11/8/2022, revealed on 10/17/2022 Patient #5 reported that on 10/15/2022, Patient #2 grabbed her between the legs in the activity room.

Patient #5 had orders for Q5 minute observations on admission. The facility decreased the level of observation for Patient #5 to Q15 minute observations without a physician's order, thereby allowing time for Patient #2 to touch Patient #5 inappropriately.

10. Medical record review revealed Patient #6, an 18-year-old male, was admitted to the hospital on 11/12/2022 with diagnosis which included Schizophrenia, unspecified.

The admission orders dated 11/12/2022 at 4:47 PM, revealed was admitted with involuntary status on Q5 minutes observations with suicide precautions for past but not current suicidal ideations.

Review of the Psychiatric Evaluation dated 11/13/2022 at 2:50 PM, revealed Patient #6 answered "yes" to every question asked. He was actively responding to internal stimuli.

The physician orders dated 11/15/2022 at 12:56 PM, revealed to decrease the level of observations to Q 15 minute observations.

Review of the physician orders dated 11/18/2022 at 2:30 PM, revealed transfer Patient #6 to another unit due to verbally aggressive behavior.

The Psychiatry Progress Note dated 11/212022 at 11:45 AM revealed, "...Some aggression over the weekend-calm today-med compliant..."

Review of the Progress Notes dated 11/22/2022 at 7:45 AM by RN #2 revealed, "...BHA notified nurses that something had happened to a patient in room...BHA escorted patient...up the hallway. From the nurse's station I could see the patient's face swollen, red, and bleeding. Upon assessment of patient, he was bleeding from the nose and multiple cuts on his face where he had been hit constantly. Once...finish cleaning his face...called 911 to send patient out..."

Medical record review revealed Patient #6 was admitted to Hospital #1's ED [Emergency Department] on 11/22/2022 at 8:37 AM with the Chief Complaint of assault to head and face with unknown object.

Review of the ED Physician Note dated 11/22/2022 at 8:32 AM revealed, "... 18 year old..presents to ED via EMS following an assault x PTA [prior to admission], Pt c/o [complains of] left facial swelling, bleeding, and pain..."

Physical Exam revealed left jaw, malar (cheek), orbital, upper lift, and nasal swelling. There was a 2 cm laceration to the left malar region and a 2 cm laceration to the mucosal surfaces of the left upper lip. Eye was able to be opened manually. Patient #6 had a 2 cm laceration above and to the side of his left eyebrow.

Review of the CT of the head, face, and cervical spine dated 11/22/2022 at 9:30 AM, revealed no depressed or displaced skull fractures, no maxillofacial fractures or dislocations and no fractures of the spines. There was a finding of a large left frontal soft tissue hematoma of the face. The ED physician cleaned and repaired 4 superficial lacerations.

Patient #6 continued to be neurologically stable. The ED physician noted he had significant swelling to the left side of his face with several lacerations and the left eye was swollen shut. He was discharged back to the facility.

The "NURSING REASSESSMENT" dated 11/22/2022 at 11:45 AM revealed, "...Pt had to be sent to the ER [Emergency Room] d/t [due to] being attacked by another patient. Pt has returned and is now being sent to the...Unit..."

Review of the Progress Notes dated 11/22/2022 at 8:20 PM, revealed Patient #6 had significant swelling to his face and orbital area. Bruising and bleeding were noted. An ice pack was given for comfort.

The "NURSING REASSESSMENT" dated 11/22/2022 at 10:00 PM revealed, "...Head wound assessed...Bleeding & weeping noted...Neuro checks WNL [within normal limits] Significant swelling noted...Ice pack given for comfort..."

The Psychiatry Progress Note dated 11/23/2022 at 9:00 AM revealed, "...Doing OK [symbol for after] being attacked by peer..."

The "NURSING REASSESSMENT" dated 11/23/2022 at 9:30 AM revealed, "...calm & cooperative..."

Patient #6 was discharged home on 11/23/2022.

Patient #6 was a 18 year old who was attacked in his bed by his roommate as he slept. Patient #6 was transported via Emergency Medical Services (EMS) to a local ED where he received treatment for his injuries.

11. Medical record review revealed Patient #7, a 33 year old male, was admitted to the hospital on 11/6/2022 with diagnosis which included Schizoaffective Disorder, Depressive Type. The admission orders revealed Patient #7 was admitted to the in-patient unit with Q5 minutes observations with high suicide risk.

Review of the Psychiatric Evaluation revealed "...plan to starve himself & hallucinations...reports feeling overwhelmed by his thoughts & hallucinations...meds are no longer working...hearing voices...reports excessive anxiety..."

The physician order dated 11/14/2022 at 1:13 revealed, "...Change level of observations to q15 min...pt is now in a controlled/safe environment..."

Review of the Progress Notes dated 11/22/2022 at 8:30 PM, revealed Patient #7 was alert and cooperative with no complaints of pain. Patient #7 had sight swelling to his right hand.

The Psychiatry Progress Note dated 11/22/2022 at 12:50 PM revealed, "...Remains psychotic this AM. Pt attacked roommate while he was sleeping. States 'the voices told me to do it' and later said 'he called me a name'..."

The Psychiatry Progress Note dated 11/23/2022 at 10:45 PM revealed, "...Assaulted PT who was asleep previous day bc [because] 'the voices told me to do it'...Responding to internal stimuli..."

The Psychiatry Progress Note dated 11/25/2022 at 12:15 PM revealed, "...no episodes of violence since assaulting other PT on 11-22..."

Patient #7 was discharged on 11/30/2022.

Refer to A-0395.

Based on policy review, record review, and interview, the hospital failed to obtain a physician's order for the use of restraints for 1 of 3 (Patient #2) patients reviewed for restraints.

The findings included:

1. Review of the hospital "Restraint" policy approved 12/2021 revealed, "...Restraint means the use of manual method, physical or mechanical device, material or equipment that immobilizes the ability of a patient to move his arms, legs, body, or head freely...Restraint may only be ordered by the attending physician or covering practitioner..."

2. Medical record review for Patient #2, a 25 year old female, revealed an admission date of 9/2/2022 with diagnoses which included Schizoaffective Disorder, Bipolar Type.

Review of the Psychiatric Evaluation dated 9/3/2022 at 2:25 PM revealed, Patient #2's chief complaint was, "I want to kill myself." The evaluation revealed the patient was a rapid readmit with recent suicidal ideation with attempt. She reportedly attempted to commit suicide by cutting her wrist with metal pieces from a mask. Patient #2 sustained superficial scratches to left forearm. Patient #2 verbalized hearing voices telling her to kill herself.

Review of the "Seclusion/Restraint Packet" Progress Note dated 9/3/2022 at 4:24 PM revealed, "... the patient asked me to call doctor...to see if I could get her belongings back. I told the patient not right now... The patient...went outside with the other patients while they were smoking. I went outside and told the patient to come back inside... replied that she was going to leave and tried to climb the fence... unsuccessful...the patient...walks toward me with her fists balled up... The patient then made the facial motion of spitting her mouth...I told the patient not to spit on me and she proceeded to spit on me...The tech separated the patient away from me and she fell down in the grass...I told the patient to get up so she can go to seclusion. The patient refused to get up I held the patient's left arm, the tech...held the patient's right arm...and the tech...held the patient's legs as we carried her to seclusion..."

The hospital was unable to provide an order for restraints for Patient #2.

Review of a Progress Note dated 10/30/2022 revealed, "... at Med pass patient reported that she had sex with another patient ...(10/29)...[Patient #1] wrote a letter stating that she wanted to kill the therapist because he was not listening to her. She asked if she should be placed on sexual precautions/1:1 due to incident...told the patient that she would not be placed on one to one due to her already being placed on Q5 minutes. Patient became upset after and started acting up trying to hurt herself and ran to her room and slammed the door and began screaming. She also began banging on things in her room... patient continued to act [out] and was escorted to the seclusion room. Pt stated that she did not want to go to the seclusion and began fighting/attempting to spit on staff. Pt had to be restrained by staff by holding arms, legs..."

The hospital was unable to provide an order for restraints for Patient #2.

3. In a telephone interview on 12/8/2022 at 8:34 AM, Registered Nurse (RN) #1 verified facility staff members moved Patient #2 to the seclusion room.

In an interview in the conference room on 12/12/2022 at 11:35AM, the Quality Improvement Director verified there was no physician's order for restraints for Patient #2.

Refer to A-0395.

Based on Rules and Regulations of Registered Nurses, policy review, medical record review and interview, nursing services failed to ensure the whereabouts of patients on the unit at all times, failed to ensure observation rounds were made in accordance with physician's order and failed to ensure documentation of the observations rounds were accurate and real-time observations, failed to prevent sexual incidents, failed to ensure patients allowed to smoke met the requirement of age and/or failed to ensure a current physician's order to restrain a patient for 7 of 7 (Patient #1, 2, 3, 4, 5, 6, and 7) sampled patients reviewed.

The findings included:

1 . Review of "Rules of the Tennessee Board of Nursing Chapter 1000- 01, Rules and Regulations of Registered Nurses" revealed, "... 1000-01-.14(1)(b)7... Supervise others to whom nursing activities are delegated...." and "... 1000-01.14(1)(b)10... Demonstrate a respect for the dignity and rights of clients..."

2. Review of the hospital "PATIENT RIGHTS AND RESPONSIBILITIES" policy approved 12/2021 and reviewed 8/2022 revealed, "...Patients have the right to be protected...from neglect...from physical, verbal, and emotional abuse..."

3. Review of the hospital "OBSERVATIONS, PATIENT" policy approved 12/2021 and reviewed 8/2022 revealed, "...In order to maintain patient safety the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and/or confirmed with the DON [Director of Nursing]...PROCEDURE...The physician will order one of three levels of observation at time of admission and as the patient's condition warrants a change...1. 15 minute 2. Q [Every] 5 minute 3. One-to-one...The physician may also order a precaution level of observation for...1. Suicide 2. Assault 3. Elopement 4. Seizure 5. Fall 6. Sexual Acting Out...The nurse may not decrease the level of observation, i.e., change from 1:1 to Q5 minute without an order by the psychiatric practitioner...Documentation of Observations...Staff documents all levels of observation on each patient's observation form which becomes a part of the patient record. Each entry is to include the following...Level of observation...Precaution...Location...Behavior...Activity...Time...Staff initial signature... Documentation of the observation is to be completed once the patient has been observed...It is not permissible to complete in advance or to backfill time frames that were not completed in a timely manner...Q 5 Minute Observations (previously known as Line of Sight)...patient is placed on Q5 minute observation if their behavior is unpredictable and there is potential risk for harm to self or others...Patient is in visual range of assigned staff at all times...Nurse will assess patient minimum of every four hours in a progress note..."

4. Review of the hospital "PRECAUTIONS, SEXUAL ACTING OUT" policy approved 10/2022 revealed, "...provision of a safe, therapeutic environment of care includes the prevention of patient to patient sexual incidents. Patients shall not have sexual contact with one another...If the hospital determines that there has been an allegation of sexual familiarity (contact) between patients, an immediate investigation must take place..."

5. Review of the hospital "SMOKING POLICY" reviewed 1/2022 revealed, "...In accordance with Tenn. Code...patients aged twenty one (21) years of age or older are permitted to smoke in designated areas of the hospital..."

6. Medical record review for Patient #1, a 20 year old male, revealed an admission date of 10/28/2022 with diagnoses which included Schizoaffective Disorder, Bipolar Type and Asthma. Patient #1 was a voluntary admission experiencing suicidal ideation with a plan to hang self with a sheet. He reported he was hearing voices commanding him to kill himself and his brother and dump his brother in the river. Patient #1 also wanted to get back on his medications. Patient #1 was admitted with orders for Q5 minute observation, and precautions for high-risk suicide. Upon admission, the facility provided a document that revealed Patient #1 had intercourse with Patient #2 on 10/28/2022. On 10/28/2022, documentation of the Behavioral Health Associate (BHA) #2 revealed the patient was outside smoking during the same timeframe video footage showed Patient #2 was in Patient #1's room. Nursing services of the behavioral health hospital failed to provide supervision to ensure staff knew the whereabouts of the patients at all times, failed to ensure patients had no sexual contact with others, and failed to ensure documentation was accurate.

7. Medical record review for Patient #2, a 25 year old female, revealed an admission date of 9/2/2022 with diagnoses which included Schizoaffective Disorder, Bipolar Type. Patient #2 had recently been discharged from this hospital 9/1/2022. Patient #2 had a plan to starve herself while she was receiving in-patient services. Patient #2 was involuntarily admitted to the in-patient unit, with orders for Q5 minute observation, and precautions for high-risk suicide. Patient #2's chief complaint was, "I want to kill myself." Patient #2 reportedly attempted to commit suicide by cutting her wrist with metal pieces from a mask and sustained superficial scratches to left forearm. Patient #2 verbalized hearing voices telling her to kill herself. "Patient observation - 5 minutes" revealed no documentation of behaviors, some times and/or days were blank. The behavioral health staff decreased the level of observation for Patient #2 without a physician's order. A document provided at entrance conference revealed a facility incident where Patient #2 reported she had intercourse with Patient #1. According to the report both patients said it was consensual. Patient #2 went into Patient #1's room. Patient #2's "Patient Observations - 5 minutes" form documented the patient was outside smoking during the time video footage showed Patient #2 enter Patient #1's room. In a telephone interview on 12/8/2022 at 8:34 AM, Registered Nurse (RN) #1 was asked about Patient #2 and the reported sexual incident. Patient #2 told RN #1 it happened around medication pass when no one was paying attention. Nursing services of the behavioral health hospital failed to provide supervision to ensure staff knew the whereabouts of the patients at all times, failed to ensure patients had no sexual contact with others, and failed to ensure documentation was accurate.

8. Medical record review revealed Patient #3, a 25-year-old female, was admitted to the hospital on 9/17/2022 with diagnoses which included Major Depressive Disorder, Recurrent Severe with Psychosis. The patient reported worsening suicidal ideations and thoughts of hopelessness and worthlessness about the future. The Patient was involuntarily admitted to the in-patient unit, with orders for Q5 minute observation, and precautions for high-risk suicide. Review of the "Patient Observations - 5 minutes" revealed show the behavioral health staff decreased the level of observation for Patient #3 without a physician's order; several times and dates documented no behavioral observations on the observation forms. A document provided at entrance conference revealed a facility incident on 9/25/2022 that Patient #3 reported Patient #4 came into her room, made her take her clothes off, and attempted to have sex with her. Patient #3 and Patient #4. They were found to be alone in her room on 9/24/2022 from 10:37 AM to 10:41 AM with the door closed. Nursing services of the behavioral health hospital failed to provide supervision to ensure staff knew the whereabouts of the patients at all times, failed to ensure patients had no sexual contact with others, and failed to ensure documentation was accurate.

9. Medical record review for Patient #4, a 30 year old male, revealed an admission date of 9/23/2022 with diagnoses which included Schizoaffective Disorder, Bipolar Type. Patient #4 reported hearing auditory hallucinations with commands, and the patient reported the voices made him request to be shot by police. Patient #4 was admitted to the in-patient unit, with orders for Q5 minute observation, and precautions for high-risk suicide. Patient #4's Chief Complaint was, "I'm here to get reevaluated and reintegrated into the real world." Patient called police..." the patient punched himself in the face and stated, 'God told me to do that'..." A document provided at entrance conference revealed a facility incident on 9/25/2022, Patient #4 went into Patient #3's room, made her take her clothes off, and attempted to have sex with her. Review of a Psychiatry Progress Note dated 9/27/2022 at 1:10 PM revealed, "...PT requires increased level of observation due to sexually inappropriate behavior..." A physicians order dated 9/27/2022 at 3:42 PM revealed, "...Make PT on 1:1 for sexually inappropriate behavior..." A Witness Statement dated 9/28/2022 at 9:45 AM revealed Patient #4 stated he was in the hallway talking with Patient #3. They went into her room and sat on the bed. The statement revealed they had consensual sex and he left the room. During a session with the therapist, Patient #4 refused to sign an updated treatment plan for sexual misconduct.
Nursing services of the behavioral health hospital failed to provide supervision to ensure patient observations were performed in accordance with the physician's orders, know the whereabouts of the patients at all times, failed to ensure patients had no sexual contact with others, and failed to ensure documentation was accurate.

10. Medical record review for Patient #5, a 28 year old female, revealed an admission date of 10/5/2022 with diagnoses which included Schizoaffective Disorder, Bipolar Type and Intellectual Disability. Patient #5 presented to the hospital after being found outside her group home hitting herself in the face, causing bleeding, with paranoia, delusions, and audio hallucinations commanding her to kill herself. Patient #5 was admitted to the in-patient unit, with orders for Q5 minute observation, and precautions for high-risk suicide. Patient #5's chief complaint was, "...I was hearing voices and felt like I was being spied on so I punched myself in the nose..." Review of the Patient observation forms revealed staff were documenting observations on Patient #5 every 15-minute without a physician's order. A document provided at entrance conference revealed a facility incident on 10/15/2022 that Patient #5 reported Patient #2 touched her in her "privates." Review of Patient Observation forms revealed no documentation of behaviors on some days and times. When Patient #5 was transferred to another unit in the hospital, behavioral health staff continued to make every 15 - minute observations without a physician's order. Nursing services of the behavioral health hospital failed to provide supervision to ensure patient observations were performed in accordance with the physician's orders, know the whereabouts of the patients at all times, failed to ensure patients had no sexual contact with others, and failed to ensure documentation was accurate.

11. Medical record review revealed Patient #6, an 18-year-old male, was admitted to the hospital on 11/12/2022 with diagnosis which included Schizophrenia, unspecified. Patient #6 was admitted to the in-patient unit on involuntary status with Q5 minutes observations with suicide precautions for past but not current suicidal ideations.
A physician orders dated three days after the patient was admitted, revealed to decrease the level of observations to Q 15 minute observations. Patient #6 was transferred to another unit due to verbally aggressive behavior. A progress note written by RN #2 documented Patient #6 was bleeding from the nose and multiple cuts on his face where he had been hit constantly. The patient was taken to Hospital #1's ED [Emergency Department] on 11/22/2022 at 8:37 AM with the Chief Complaint of assault to head and face with unknown object. The patient was transported by Emergency Medical Services (EMS). An ED Physician Note documented, "... 18 year old..presents to ED via EMS following an assault x PTA [prior to admission], Pt c/o [complains of] left facial swelling, bleeding, and pain. Physical Exam revealed left jaw, malar (cheek), orbital, upper lift, and nasal swelling and lacerations to the face.
Review of the CT of the head, face, and cervical spine revealed no skull fractures, no maxillofacial fractures or dislocations and no fractures of the spines. There was a finding of a large left frontal soft tissue hematoma of the face. The patient was stable and returned to the behavioral health hospital. The patient was discharged home 11/23/2022. Nursing services of the behavioral health hospital's failure to monitor and know the whereabouts of all patients at all times resulted in Patient #6, an 18 year old, being attacked in his bed by his roommate as he slept.

12. Medical record review revealed Patient #7, a 33 year old male, was admitted to the hospital on 11/6/2022 with diagnosis which included Schizoaffective Disorder, Depressive Type. The admission orders revealed Patient #7 was admitted to the in-patient unit with Q5 minutes observations with high suicide risk. Patient #7 had "...plan to starve himself & [was having] hallucinations...reports feeling overwhelmed by his thoughts & hallucinations...meds are no longer working...hearing voices...reports excessive anxiety..." A physician order dated 11/14/2022 revealed, "...Change level of observations to q15 min...pt is now in a controlled/safe environment..." Patient #7 attacked Patient #6 while he was sleeping. Patient #7 stated States 'the voices told me to do it' and later said 'he called me a name'..." Patient #7 was discharged on 11/30/2022. Nursing services of the behavioral health hospital's failure to monitor and know the whereabouts of all patients at all times resulted in Patient #7 assaulting his 18 year old roommate, Patient #6, while he slept in the same room.

13. Review of the hospital "Restraint" policy approved 12/2021 revealed, "...Restraint means the use of manual method, physical or mechanical device, material or equipment that immobilizes the ability of a patient to move his arms, legs, body, or head freely...Restraint may only be ordered by the attending physician or covering practitioner..."

14. Medical record review for Patient #2, a 25 year old female, revealed an admission date of 9/2/2022 with diagnoses which included Schizoaffective Disorder, Bipolar Type. Patient #2 was involuntarily admitted to the in-patient unit, with orders for Q5 minute observation, and precautions for high-risk suicide. Patient #2's chief complaint was, "I want to kill myself." Patient #2 reportedly attempted to commit suicide by cutting her wrist with metal pieces from a mask and sustained superficial scratches to left forearm. Patient #2 verbalized hearing voices telling her to kill herself. Review of the "Seclusion/Restraint Packet" Progress Note dated 9/3/2022 at 4:24 PM revealed, Patient #2 was acting out and spit on a nurse. The patient fell down and refused to get up. The tech and nurse carried Patient #2 to seclusion. The hospital was unable to provide an order for restraints for Patient #2. Another incident on 10/29/2022 revealed Patient #2 was upset and started acting out and trying to hurt herself, slammed door to her room and screaming. She refused to go to seclusion and began fighting/attempting to spit on staff. Patient #2 was again restrained by staff holding her arms and legs. There was no documentation of an order for restraints for Patient #2.

Refer to A-0395.

Based on review of Tennessee Rules and Regulations for Registered Nurses, policy review, medical record review and interview, failed to ensure nursing supervision to provide care in a safe setting for 7 of 9 (Patients #1, 2, 3, 4, 5, 6 and 7) patients sampled; nursing services failed to ensure supervision to maintain patient observation levels as prescribed by the physician's for 4 of 9 (Patients #1, 2, 3 and 5) sampled patients who were high-risk; failed to ensure nursing supervision to protect the patient from patient to patient abuse for Patients #1, 2, 3, 4, and 5; failed to ensure nursing supervision to protect patients from patient to patient physicial abuse for Patients #6 and 7; and failed to ensure nursing supervision to prevent residents from being restrained without a physician's order for Patient #2.

The findings included:

1. Review of "Rules of the Tennessee Board of Nursing Chapter 1000- 01, Rules and Regulations of Registered Nurses" revealed, "... 1000-01-.14(1)(b)7... Supervise others to whom nursing activities are delegated...." and "... 1000-01.14(1)(b)10... Demonstrate a respect for the dignity and rights of clients..."

2. Review of the hospital "PATIENT RIGHTS AND RESPONSIBILITIES" policy approved 12/2021 and reviewed 8/2022 revealed, "...Patients have the right to be protected...from neglect...from physical, verbal, and emotional abuse..."

3. Review of the hospital "OBSERVATIONS, PATIENT" policy approved 12/2021 and reviewed 8/2022 revealed, "...In order to maintain patient safety the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and/or confirmed with the DON [Director of Nursing]...PROCEDURE...The physician will order one of three levels of observation at time of admission and as the patient's condition warrants a change...1. 15 minute 2. Q [Every] 5 minute 3. One-to-one...The physician may also order a precaution level of observation for...1. Suicide 2. Assault 3. Elopement 4. Seizure 5. Fall 6. Sexual Acting Out...The nurse may not decrease the level of observation, i.e., change from 1:1 to Q5 minute without an order by the psychiatric practitioner...Documentation of Observations...Staff documents all levels of observation on each patient's observation form which becomes a part of the patient record. Each entry is to include the following...Level of observation...Precaution...Location...Behavior...Activity...Time...Staff initial signature... Documentation of the observation is to be completed once the patient has been observed...It is not permissible to complete in advance or to backfill time frames that were not completed in a timely manner...Q 5 Minute Observations (previously known as Line of Sight)...patient is placed on Q5 minute observation if their behavior is unpredictable and there is potential risk for harm to self or others...Patient is in visual range of assigned staff at all times...Nurse will assess patient minimum of every four hours in a progress note..."

4. Review of the hospital "PRECAUTIONS, SEXUAL ACTING OUT" policy approved 10/2022 revealed, "...provision of a safe, therapeutic environment of care includes the prevention of patient to patient sexual incidents. Patients shall not have sexual contact with one another...If the hospital determines that there has been an allegation of sexual familiarity (contact) between patients, an immediate investigation must take place..."

5. Review of the hospital "SMOKING POLICY" reviewed 1/2022 revealed, "...In accordance with Tenn. Code...patients aged twenty one (21) years of age or older are permitted to smoke in designated areas of the hospital..."

6. Medical record review for Patient #1, a 20 year old male, revealed an admission date of 10/28/2022 with diagnoses which included Schizoaffective Disorder, Bipolar Type and Asthma.

The Intake Assessment dated 10/28/2022 at 1:04 PM, revealed the patient presented to the hospital as a walk-in due to experiencing suicidal ideation with a plan to hang himself with a sheet. The patient reported hearing command voices telling him to kill himself and his brother. The voices told him to dump his brother in the river.

Review of the admission physician's order dated 10/28/2022 at 1:30 PM, revealed Patient #1 was voluntarily admitted to the in-patient unit, with orders for Q5 minute observation, and precautions for high-risk suicide.

The "HIGH RISK NOTIFICATION FORM" dated 10/28/2022 at 3:00 PM revealed, "...Level of Observation Ordered by Practitioner: Q5 min [minutes] [box checked]...Suicidal Ideation with plan to: to hang self with sheet [box checked]..."

A document provided at entrance conference revealed a facility incident that Patient #1 had intercourse with Patient #2 on 10/28/2022.

Review of the Admission Nursing Assessment dated 10/28/2022 at 3:00 PM revealed Patient #1's Chief Complaint was, "...I had suicidal thoughts, homicidal thoughts. I need to get back on my medicine. I can control myself without them but I need them..." Admission Suicide Risk Screening was reviewed by the Registered Nurse (RN) and the Overall Risk Level Score was noted as High.

Review of the "PATIENT OBSERVATIONS - 5 Minutes (1200-2355)" form dated 10/28/2022, revealed Behavioral Health Associate (BHA) #2 documented Patient #1 was outside smoking at 7:55 PM, 8:00 PM, and at 8:05 PM. On 10/28/20222 at 8:10 PM and 8:15 PM, BHA #2 documented Patient #1 was outside sitting/lying. The Q5 minutes observation form documented Patient #1 in his room at 8:35 PM. There were no behavioral observations documented on the Q5 minute observation forms for newly admitted Patient #1.

Review of the Nursing Reassessment dated 10/29/2022 at 8:16 AM revealed, "...New pt [patient]...is irritable. He wants to switch units b/c [because] his friends are over there. Outburst when told no..."

Review of the Psychiatric Evaluation dated 10/29/2022 at 11:50 AM revealed, Patient #1 was discharged from the hospital the prior month but had not taken his medications. The patient wanted to be restarted on his medications as he reported hearing voices that told him to harm others. The patient also believed that others were watching him and trying to harm him.

Review of the Facility Investigation Report dated 11/17/2022, revealed Patient #1 indicated that he and Patient #2 agreed to have sexual intercourse with each other when she came to his room.

In a telephone interview on 11/14/2022 at 11:56 AM, BHA #2 was asked about the Q5 minute observations on Patient #1. BHA #2 revealed he was depending on his co-worker to do the observations and his co-worker told him Patient #1 was in his room. The surveyor clarified with BHA #2 the Q5 minute observation record for Patient #1 showed him outside smoking at 7:55 PM, 8:00 PM, and 8:05 PM; and outside sitting/lying at 8:10 PM and 8:15 PM. BHA #2 was asked why the Q5 minute observation form reflected the patient was outside smoking even though his coworker said the patient was in his room. BHA #2 stated that information was "interesting"

In an interview in the conference room on 11/14/2022 at 12:15 PM, Risk Manager #2 verified, per video footage, Patient #2 entered his room at 8:06 PM.

Patient #1 was newly admitted to the unit on 10/28/2022 at 3:00 PM with a plan to hang self with a sheet. Patient #1 was placed on Q5 minute observations. By 8:06 PM, as documented by video footage and interview, Patient #1 was alone in the room and unaccounted for when Patient #2 entered Patient #1's room and they had intercourse. BHA #2 failed to conduct Q5 minute observations as ordered by the physician and falsified documentation in the medical record when he documented Patient #1 was outside smoking.

7. Medical record review for Patient #2, a 25 year old female, revealed an admission date of 9/2/2022 with diagnoses which included Schizoaffective Disorder, Bipolar Type. Patient #2 had recently been discharged from this hospital 9/1/2022.

Review of the Intake Assessment dated 9/2/2022 at 7:01 PM, revealed Patient #2 had a plan to starve herself while she was receiving in-patient services.

Review of the admission physician orders dated 9/2/2022 at 7:48 PM, revealed Patient #2 was involuntarily admitted to the in-patient unit, with orders for Q5 minute observation, and precautions for high-risk suicide.

Review of the Psychiatric Evaluation dated 9/3/2022 at 2:25 PM revealed, Patient #2's chief complaint was, "I want to kill myself." The evaluation revealed the patient was a rapid readmit with recent suicidal ideation with an attempt. Patient #2 reportedly attempted to commit suicide by cutting her wrist with metal pieces from a mask and sustained superficial scratches to left forearm. Patient #2 verbalized hearing voices telling her to kill herself.

Review of the "PATIENT OBSERVATIONS - 5 Minutes" forms dated 9/9/2022, revealed no behavioral observations were documented and the form was blank for 11:05 PM and 11:10 PM.

Review of the "PATIENT OBSERVATIONS - 5 Minutes" forms dated 9/10/2022, revealed no behavioral observations were documented and the form was blank for 11:35 PM and 11:40 PM.

Review of the "PATIENT OBSERVATIONS - 5 Minutes" forms dated 9/12/2022, revealed Patient #2 was "outside, smoking" from 1:05 PM until 3:30 PM.

Review of the "PATIENT OBSERVATIONS - 5 Minutes" forms dated 10/6/2022 beginning at 6:00 AM and Q5 minutes through 7:00 AM, revealed there were no observations of Patient #2 documented although staff initials were documented.

Review of the "PATIENT OBSERVATIONS" form dated 10/14/2022 and 10/15/2022 revealed Patient #2 was on 15-minute observations. There were no behavioral observations documented on the forms. There was no documentation of a physician's order to decrease Patient #2's level of observation to Q 15 minute.

The "NURSING REASSESSMENT" dated 10/16/2022 at 6:52 AM revealed, "...pt having suicidal thoughts...continue to monitor and provide support...pt currently on Q5..."

Review of the "PATIENT OBSERVATIONS" form dated 10/16/2022 and 10/17/2022 revealed Patient #2 was on 15-minute observations. There were no behavioral observations were documented on the forms. There was no documentation of a physician's order to decrease Patient #2's level of observation to Q 15-minute.

Review of the "PATIENT OBSERVATIONS - 5 Minutes" forms dated 10/27/2022 at 12:00 AM through 10/27/2022 at 11:55 PM, revealed no behavioral observations were documented on the forms. The form was blank from 11:05 PM through 11:55 PM.

The Progress Notes dated 10/27/2022 at 10:10 PM revealed, "... [Patient #2] Came to nurse's station. C/O [complains of] wanting to kill her self. She had a scratch on her inner right wrist area on her right arm. Started hitting head against wall...2215 [10:15 PM] Geodon [used for acute agitation] 20 mg [milligrams] IM [intramuscular]...given..."

A document provided at entrance conference revealed a facility incident where Patient #2 reported she had intercourse with Patient #1. According to the report both patients said it was consensual. Patient #2 went into Patient #1's room.

Review of the "PATIENT OBSERVATIONS - 5 Minutes (1200-2355)" form dated 10/28/22, revealed Behavioral Health Associate (BHA) #1 documented Patient #2 was outside smoking at 7:55 PM. The documentation of Patient #2's location, activity, and behavior on 10/28/22 at 8:00 PM, 8:05 PM, and 8:10 PM, was illegible. On 10/28/2022 at 8:15 PM, BHA #1 documented Patient #2 was outside sitting/lying. The Q5 minutes observation form documented Patient #2 was in her room at 8:20 PM.

Review of video recording of the East Hallway on 10/28/2022 at 8:13 PM, revealed Patient #2 knocked on Patient #1's door then entered his room. On 10/28/2022 at 8:18 PM, an unidentified male staff walked down the East Hallway but did not stop in the camera view. On 10/28/2022 at 8:22 PM, Patient #2 exited Patient #1's room. Patient #2 was in Patient #1's room for 9 minutes.

Review of a handwritten note by Patient #2 dated 10/28/2022 revealed, "...having a good day today...feeling stressed and frustrated...I had intercourse with [named Patient #1] tonight...I can't wait to do it again he is so masculine and sexy...I love him so much..."

The Facility determined a sexual boundary violation did occur between Patient #1 and Patient #2 on 10/28/2022 at approximately 8:13 PM. Patient #2 remained in Patient #1's room until 8:22 PM.

The "NURSING REASSESSMENT" dated 10/29/2022 at 8:20 AM revealed, "...exhibits attention seeking behavior. Frequent outburst..."

Review of a Progress Note dated 10/30/2022 revealed, "... at Med pass patient reported that she had sex with another patient...(10/29)...She reported that it occurred around 9:40 PM. However, when I spoke with [named Patient #1] he stated ...9:00 PM. He stated that the patient [Patient #2]...came into his [Patient #1] room and asked him to have sex and he said yes...She [Patient #2] asked if she should be placed on sexual precautions/1:1 due to incident...told the patient that she would not be placed on one to one due to her already being placed on Q5 minutes. Patient became upset after and started acting up trying to hurt herself and ran to her room and slammed the door and began screaming. She also began banging on things in her room patient...was given Geodon [antipsychotic to treat acute agitation] 30 minutes after receiving the shot patient continued to act out...had to be restrained by staff..."

The "NURSING REASSESSMENT" dated 10/30/2022 at 10:30 PM revealed, "...C/O not feeling good...much attention seeking..."

The "NURSING REASSESSMENT" dated 10/31/2022 at 8:40 PM revealed, "...To Rape Crisis/Police Facility for Evaluation...0115 [1:15 AM] Back on unit...0145 [1:45 AM] Tried to harm self [symbol for with] electrical outlet metal...0152 [1:52 AM] Placed in seclusion..."

The Psychiatry Progress Note dated 10/31/2022 at 2:00 PM revealed, "...Had a difficult weekend-alleged sexual encounter [symbol for with] another pt-Seclusion last night [secondary] aggression toward staff..."

The Progress Notes dated 11/2/2022 at 1:15 PM, revealed Patient #2 requested to leave Against Medical Advice (AMA). She was assessed and deemed competent enough to follow through with such request and it was approved.

Patient #2 was discharged on 11/3/2022 with diagnoses of Schizoaffective Disorder, Bipolar Type.

In an interview in the conference room on 11/14/2022 at 12:15 PM, Risk Manager #2 verified per video footage Patient #2 entered Patient #1's room at 8:06 PM.

Review of the Facility Investigation Report dated 11/17/2022, revealed [named] Police Department arrived at the facility on 10/31/2022 and took a statement from Patient #2 and then transported her to the crisis center.

Patient #2 reported she went to Patient #1's room where she kissed and made out with him took her clothes off and got on top of him then proceeded to have sex both vaginally and anally but didn't agree to.

BHA #2 reported that he relied on a coworker to conduct observations on the patient for him and that he was not aware that Patient #1 and Patient #2 had sexual intercourse on the night in question.

In a telephone interview on 11/28/2022 at 2:37 PM, Detective #1 and Detective #2 revealed they were investigating Patient #2's case. Detective #1 revealed they did not have the final report from the crisis center on Patient #2, but had been made aware she had a "tear on her vulva."

In a telephone interview on 12/8/2022 at 8:34 AM, Registered Nurse (RN) #1 was asked about Patient #2 and the reported sexual incident. RN #1 revealed Patient #2 went to the cafeteria and told the person in the café she had sex with Patient #1. Patient #2 told RN #1 it happened around medication pass when no one was paying attention.

Nursing services failed to provide observations as ordered by the physician for Patient #2 which allowed Patient #2 to enter Patient #1's room and have intercourse.

8. Medical record review revealed Patient #3, a 25-year-old female, was admitted to the hospital on 9/17/2022 with diagnoses which included Major Depressive Disorder, Recurrent Severe with Psychosis.

Review of the Intake Assessment dated 9/17/2022 at 11:36 AM, revealed the patient reported worsening suicidal ideations and thoughts of hopelessness and worthlessness about the future. Past diagnosis included intermittent explosive disorder, autism, and "mental retardation."

Review of the admission physician orders dated 9/17/2022 at 1:33 PM, revealed Patient #3 was involuntarily admitted to the in-patient unit, with orders for Q5 minute observation, and precautions for high-risk suicide.

Review of the "PSYCHIATRIC EVALUATION" dated 9/18/2022 at 10:00 AM, revealed the Chief Complaint of, "...I've been trying to kill myself..." Medical history of Fetal Alcohol Syndrome. Social History revealed the patient lived in a group home. Admitting diagnoses was changed to Schizoaffective Disorder and Depression.

The physicians order dated 9/19/2022 at 5:37 PM revealed, "...Q5 checks 1:1 initiated..."

The physicians order dated 9/20/2022 at 8:28 AM revealed, "...Transfer pt to East when bed comes available..."

Review of the "PATIENT OBSERVATIONS - 5 Minutes" forms dated 9/23/2022 revealed Patient #3 decreased from 1:1 observation to Q5 minute observations at 2:10 PM. There was no documentation of a physician's order to decrease Patient #3's level of observation.

Review of the "PATIENT OBSERVATIONS - 5 Minutes" forms dated 9/23/2022 beginning at 2:15 PM through 9/ 24/2022 at 11:55 PM, revealed no behavioral observations were documented on the forms.

Review of the "PATIENT OBSERVATIONS - 5 Minutes" form dated 9/24/2022 revealed Patient #3 was in her room and appeared asleep at 10:30 AM, 10:35 AM, 10:40 AM, and 10:45 AM.

The facility determined a sexual boundary violation occurred between Patient #3 and Patient #4. They were found to be alone in her room on 9/24/2022 from 10:37 AM to 10:41 AM with the door closed.

A document provided at entrance conference revealed a facility incident on 9/25/2022 that Patient #3 reported Patient #4 came into her room, made her take her clothes off, and attempted to have sex with her.

Review of the Patient Observation form dated 9/25/2022 starting at 12:00 AM, revealed Patient #3 was on every 15-minute checks. There was no documentation of a physician's order to decrease the level of observation for Patient #3.

The "NURSING REASSESSMENT" dated 9/25/2022 at 10:20 AM revealed, "...She has been cursing at staff and triggering the unit...destroying property and pulling plaster out of the wall...fighting other pts. PRN [as need medication] given..."

Review of the Patient Observation form dated 9/26/2022 starting at 12:00 AM, revealed Patient #3 was on Q5 minute observations. Patient #3 remained on Q5 minute observations until 9/28/2022 at 9:20 AM when she was placed on 1:1. There was no behavioral observations documented on the Q5 minute observation forms from 9/26/2022 - 9/28/2022.

The Psychiatry Progress Note dated 9/27/2022 at 1:15 PM revealed, "...Says another pt forced his sexual advances toward her..."

The physicians order dated 9/28/2022 at 9:20 AM revealed, "...Place PT on 1:1 observation..."

The physicians order dated 9/28/2022 at 10:20 AM, revealed the patient could be transported to the crisis center for evaluation.

Review of the Progress Notes dated 9/28/2022 at 11:00 AM, revealed a Detective from the local Police Department came on-site to talk with Patient #3 regarding her allegation against Patient #4. The Detective spoke with the Conservator who gave permission to transport the patient to the crisis center.

Review of the report from local Crisis Center #1 revealed, "...9/28/2022...The patient is a vulnerable adult...possible HIV exposure...the alleged assailant is a patient in the same facility as the victim...CDC [Centers for Disease Control] post assault protocol followed...History of Assault...PATIENT REPORTS, 'HIS NAME IS [Patient #4]...IN THE HALLWAY BY MY ROOM. HE TOLD ME TO KISS HIM FIRST. HE WAS TRYING TO TOUCH MY PRIVATE PART FIRST, (POINTS TO GENITAL AREA). IN MY ROOM, HE PULLED HIS PANTS OFF FIRST AND TOLD ME TO TOUCH IT (PENIS) AND I DID. HE TOLD ME TO SUCK HIS DICK. HE TOLD ME TO TAKE MY PANTS OFF. HE PUSHED, PUSHED, PUSHED TO MAKE THE BLOOD COME OUT (PENILE/VAGINAL PENETRATION). HIS DICK INSIDE MY MIDDLE PART. AFTER THAT, I WENT INTO THE BATHROOM AND WIPED BLOOD FROM BETWEEN MY LEGS'...Per history she is not sexually active...Exam...Genital...Vestibule is erythemic (redness) and irritated with reddish, bluish abrasion at 9 o'clock...blue stain utilized to visualize laceration from fossa navicularis to posterior fourchette, anterior to hymen. Scant bright red blood present after use of speculum...right inner knee, round bluish bruise, [symbol for approximately] 2 cm [centimeter] x [by] 2 cm...Left upper arm, irregularly shaped, yellowish, brownish bruising, [symbol for approximately] 4 cm x 6 cm..."

Review of a Witness Statement dated 9/28/2022 at 4:50 PM, revealed Risk Manager #1 spoke with the conservator regarding the "alleged reported incident on September 25, 2022." The Conservator told Risk Manger #1 the Patient had informed the family of "alleged forced sexual encounter with a patient."

Review of the "24 Hour Pharmacy Review ANTIMICROBIAL SURVEILLANCE PROGRAM" dated 9/28/2022 at 6:15 PM, revealed Patient #3 was ordered Doxycycline (antibiotic to treat bacterial infections) 100 mg bid (twice per day) x (times) 7 days, Flagyl (antibiotic to treat vaginal infections) 500 mg bid x 7 days, and Truvada (reduce the risk of HIV infections) 200/300 daily x 28 days. The diagnosis was Prophylaxis.

The physician's order dated 9/30/2022 at 3:40 PM, revealed to keep Patient #3 on 1:1 observations and discharge to group home.

Review of the "24 Hour Pharmacy Review ANTIMICROBIAL SURVEILLANCE PROGRAM" dated 10/1/2022 at 9:45 AM, revealed the Nurse Practitioner checked "There are signs of infection. Continue treatment as written."

Patient #3 was discharged on 10/3/2022.

Review of the Facility Investigation dated 10/4/2022 revealed Patient #3 reported to staff that she was sexually assaulted by a patient [Patient #4] on 9/26/2022 sometime before medication administration but after breakfast.

Review of an undated Witness Statement revealed, BHA #1 was sitting outside with the patients. BHA #1 overheard Patient #3 telling another patient about Patient #4 touching her inappropriately. Patient #3 stated Patient #4 came into her room and asked could he touch her private area and she touch his. BHA #1 reported to the house supervisor.

In a telephone interview on 11/28/2022 at 2:37 PM, Detective #1 was asked about Patient #1. Detective #1 revealed she was notified about the case 1 month after the incident because it was initially routed through the middle Tennessee area where the patient lived. Detective #1 revealed the Patient notified her family member of forced sexual contact with penetration and bleeding. Detective #1 revealed she received permission from the court appointed conservator to transport the patient to the crisis center. The exam showed she had a tear in her vulva per Detective #1.

In an interview in the conference room on 12/12/2022 at 11:01 AM, the Quality Improvement Director verified there were no physician orders to decrease the level of observation for Patient #3.

In a telephone interview on 12/14/2022 at 1:10 PM, BHA #1 verified her written witness statement but revealed she did not remember the date and time she made the statement. When asked about the demeanor of the patients, BHA #1 revealed she "didn't take it seriously, well I mean I did take it seriously..." because the other patient was talking and laughing, and Patient #3 was smiling. BHA #1 revealed she reported the incident to the House Supervisor. When asked if she was aware of any prior concerns between Patient #3 and Patient #4, BHA #1 revealed she was not aware of any concerns.

9. Medical record review for Patient #4, a 30 year old male, revealed an admission date of 9/23/2022 with diagnoses which included Schizoaffective Disorder, Bipolar Type.

The Intake Assessment dated 9/23/2022 at 2:22 AM revealed, Patient #4 reported on 9/22/2022 hearing auditory hallucinations with commands. Patient reported voices made him request to be shot by police.

Review of the admission physician orders dated 9/23/2022 at 3:20 AM, revealed Patient #4 was admitted to the in-patient unit, with orders for Q5 minute observation, and precautions for high-risk suicide.

The admission nursing assessment dated 9/23/2022 at 4:57 AM, revealed Patient #4's Chief Complaint was, "I got in a verbal and physical altercation at my group."

Review of the "PSYCHIATRIC EVALUATION" dated 9/23/2022 at 9:55 AM, revealed the Chief Complaint of, "I'm here to get reevaluated and reintegrated into the real world." Patient called police and asked them to shoot him. At the end of the evaluation, the psychiatrist revealed, "...PT punched himself in the face and stated, 'God told me to do that'..." Social History revealed the patient spent 4 years in prison for rape.

The "NURSING REASSESSMENT" dated 9/24/2022 at 9:00 AM revealed, Patient #4 paced the halls all day and responded to internal stimuli. His mood was anxious and labile, and he was compliant with medications.

A document provided at entrance conference revealed a facility incident on 9/25/2022, Patient #4 went into Patient #3's room, made her take her clothes off, and attempted to have sex with her.

Review of the "NURSING REASSESSMENT" dated 9/25/2022 at 12:00 PM revealed, Patient #4 paced the halls all day.

The "NURSING REASSESSMENT" dated 9/26/2022 at 8:48 AM, revealed Patient #4 was calm but guarded at times.

The "NURSING REASSESSMENT" dated 9/26/2022 at 8:00 PM, revealed Patient #4 spent much of his time in his room.

The Psychiatry Progress Note dated 9/27/2022 at 1:10 PM revealed, "...PT requires increased level of observation due to sexually inappropriate behavior..."

Review of a session note dated 9/27/2022 at 2:35 PM revealed, Patient #4 presented irritable and boastful. He initially was in denial about the sexual allegations but after "much encouragement" he validated his actions. Patient #4 stated, "why the fuck does it matter if I have sex if I'm a fucking adult."

The physicians order dated 9/27/2022 at 3:42 PM revealed, "...Make PT on 1:1 for sexually inappropriate behavior..."

Review of a Witness Statement dated 9/28/2022 at 9:45 AM revealed Patient #4 stated he was in the hallway talking with Patient #3. He revealed he kissed her on the shoulder, patted her on the butt, and she was smiling up at him. They went into her room and sat on the bed and he kissed her cheek. He revealed he took down his pants and took her pants off. He revealed they had consensual sex but he did not ejaculate due to "not feeling it" with her. He revealed he pulled his pants up and left the room.

The Psychiatry Progress Note dated 9/28/2022 at 2:00 PM revealed, "...Pt states that he did indeed have sexual intercourse with a female patient..."

Review of the physician's order dated 9/28/2022 at 6:30 PM, included laboratory orders for: Hepatitis B panel (HBV), Hepatitis C panel (HCV), HIV serum, Syphilis serum, urine chlamydia, and urine gonorrhea.

The Psychiatry Progress Note dated 9/29/2022 at 10:10 AM revealed, "...Asking to DC [discharge] AMA...continues to admit to sexual intercourse but insist it was consensual..."

Review of a session note dated 9/29/2022 at 11:30 AM revealed, Patient #4 met with therapist to discuss treatment plan for sexual misconduct. Patient refused to sign the treatment plan update as he became increasingly angry and irritated.

The Psychiatry Progress Note dated 10/3/2022 at 10:00 AM revealed, "...Irritable. Wants to come off 1:1. Was informed that this could not happen due to allegations of sexual misconduct..."

Review of a session note dated 10/4/2022 at 1:41 PM revealed, "...previous sex offender and has rape charges...accusations of sexual assault weeks ago while here inpatient...will remain 1:1...discharging to homeless shelter..."

The Psychiatry Progress Note dated 10/5/2022 at 1:15 PM revealed, "...'They told us charges of rape were dropped'...Pt remains on 1:1..."

The Psychiatry Progress Note dated 10/7/2022 at 1:15 PM revealed, "...Denies previous sexual allegation. Wants to know when he will be discharged..."

Review of the laboratory results dated as collected on 9/23/2022 and received on 9/30/2022 at 8:01 AM, revealed the gonorrhea and chlamydia sample were submitted in an improper collection device. A nurse initialed the report on 10/5/2022 at 3:30 PM. There was no documentation the hospital collected another sample for gonorrhea and chlamydia in the proper collection device.

Review of the laboratory results dated as collected on 9/29/2022 at 9:25 AM, revealed the HBV, BCV, and HIV serum test had been canceled.

Patient #4 was discharged on 10/26/2022 with diagnoses which included Schizoaffective Disorder, Bipolar Type.

In an interview in the conference room on 12/12/2022 at 11:03 AM, the Quality Improvement Director verified the gonorrhea and chlamydia sample were not recollected by the facility. The Director revealed training on laboratory procedures had been conducted with the nursing staff.

Nursing services's failure to ensure patient observations were performed in accordance with physician's orders allowed the Q5 minute observation procedure to enable the alleged sexual assault on Patient #3.

10. Medical record review for Patient #5, a 28 year old female, revealed an admission date of 10/5/2022 with diagnoses which included Schizoaffective Disorder, Bipolar Type and Intellectual Disability.

Review of the Intake Assessment dated 10/5/2022 at 3:45 AM, revealed Patient #5 presented to the hospital after being found outside her group home hitting herself in the face, causing bleeding, with paranoia, delusions, and audio hallucinations commanding her to kill herself.

Review of the admission physician orders dated 10/5/2022 at 3:15 AM, revealed Patient #5 was admitted to the in-patient unit, with orders for Q5 minute observation, and precautions for high-risk suicide.

Review of the Psychiatric Evaluation dated 10/5/2022 at 12:30 PM revealed, Patient #5's chief complaint was, "...I was hearing voices and felt like I was being spied on so I punched myself in the nose..." Social history revealed Patient #5 lived in a group home.

Review of the Patient Observation form dated 10/13/2022 starting at 12:00 AM, revealed Patient #5 was on every 15-minute checks. There was no documentation of a physician's order to decrease Patient #5's level of observation to Q15 minute.

A document provided at entrance conference revealed a facility incident on 10/15/2022 that Patient #5 reported Patient #2 touched her in her "privates."

There was no documentation of a Patient observation form for Patient #5 for 10/16/2022 and 10/17.2022.

The "NURSING REASSESSMENT" dated 10/17/2022 at 10:33 AM revealed, "...frequent outburst. Argument [symbol for with] another pt this morning..."

The physicians order dated 10/17/2022 at 12:45 PM, revealed Patient #5 was transferred to another unit in the hospital. There was no documentation of a physician's order to decrease the level of observation for Patient #5.

Review of the Patient Observation form dated 10/18/2022 at 12:00 AM through 11:45 PM, revealed Patient #5 was on every 15-minute checks. No behavioral observations were documented on the form. There was no documentation of a physician's order to decrease the level of observation for Patient #5.

Review of the Facility Investigation dated 11/8/2022, revealed on 10/17/2022 Patient #5 reported that on 10/15/2022, Patient #2 grabbed her between the legs in the activity room. Patient #2 denied the allegation but did report that she told Patient #5 that she was attracted to her, and then grabbed her hands and arms in a matter that was consistent with being arrested. During the investigation, it was revealed both patients got into a verbal exchange involving name calling but staff were not made aware of any incident regarding inappropriate touching. There was no video surveillance in the activity room.

In an interview in the conference room on 12/12/2022 at 11:02 AM, the Quality Improvement Director verified Patient #2 and Patient #5 were roommates on the date of the allegation.

Patient #5 had orders for Q5 minute observations on admission. Nursing services decreased the level of observation for Patient #5 to Q15 minute observations without a physic