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Based on observation, record review and interview, the hospital failed to provide care in a safe setting as evidenced by failing to provide appropriate patient observation and monitoring for 2 (#1, #2) of 3 (#1, #2, #3) sampled patients reviewed who were at risk for sexual abuse.
Findings:

Review of LDH self-reports revealed:
On 05/24/2024 at 1:00pm, Patient #2 was overheard by S3Educator saying to Patient #1, "Don't make me tell them what you made me do last night." Patients #1 and #2 allegedly engaged in sexual behaviors in the bathroom of room a on the night of 05/23/2024 at 9:59p.m. Patient #2 reported that "we were doing nasty stuff" and Patient #2 denied that anything happened at all. Video of the alleged event was reviewed by the administrative staff and the following timeline was established:
21:59 - Patient #2 and Patient #1 are in their room getting ready for bed when Patient #1 gets up and closes the door to room a completely.
22:05 - Patient #2 gets up and opens the door and looks down the hallway. Patient #1 closes the door and both patients enter the bathroom together.
22:16 - Bathroom light is turned off and then back on.
22:25:38 - Patient #2 comes out of the bathroom.
22:25:51 - Patient #1 comes out of the bathroom.
22:26 - Patients open the door and both patients exit towards the dayroom.
22:27:45 - Both patients return to room a and sit on the floor with the light on to play cards.
22:30:28 - S2MHT enters the room and instructs the patients to get in their respective beds and to go to sleep. No further incident is witnessed on video.

On 06/10/2024 at 10:30am, the above video was reviewed with S1Director of Compliance, which confirmed the above observations. During observation of the video, it was noted that the door to room a that opens into the hallway was closed from 21:59-22:30 (31 minutes), and no staff member entered the room during that period of time. S1Director of Compliance confirmed that the boys were not able to be observed with the door closed. S1Director of Compliance confirmed that the bedroom doors should always be left open when patients are in their rooms.

Review of the medical record for Patient #1 revealed an order on 05/18/2024 for observation levels every 15 minutes. Review of the medical record for Patient#2 revealed an order on 05/23/2024 for observation levels every 15 minutes.

Review of the documentation on the observation logs for Patient #1 and Patient #2 revealed they were to be monitored with documentation of location, activity and behavior every 15 minutes. The logs during the time period 05/23/2024 21:59-22:30, completed by S2MHT, showed that Patient #1 was in the room asleep in his bed during this time and Patient #2 was in the room and calm.

On 06/10/2024 at 10:30 a.m, interview with S1Director of Compliance confirmed that Patients #1 and #2 were not observed and monitored every 15 minutes as ordered, when the above alleged incident occurred.

Based on observation, record review and interview, the hospital failed to maintain an accurate medical record for 2 (#1, #2) of 3 (#1, #2, #3) sampled patients who had orders for observation levels every 15 minutes.
Findings:

Review of LDH self-reports revealed:
On 05/24/2024 at 1:00pm, Patient #2 was overheard by S3Educator saying to Patient #1, "Don't make me tell them what you made me do last night." Patients #1 and #2 allegedly engaged in sexual behaviors in the bathroom of room a on the night of 05/23/2024 at 9:59p,m. Patient #2 reported that "we were doing nasty stuff" and Patient #2 denied that anything happened at all. Video of the alleged event was reviewed by the administrative staff and the following timeline was established:
21:59 - Patient #2 and Patient #1 are in their room getting ready for bed when Patient #1 gets up and closes the door to room a completely.
22:05 - Patient #2 gets up and opens the door and looks down the hallway. Patient #1 closes the door and both patients enter the bathroom together.
22:16 - Bathroom light is turned off and then back on.
22:25:38 - Patient #2 comes out of the bathroom.
22:25:51 - Patient #1 comes out of the bathroom.
22:26 - Patients open the door and both patients exit towards the dayroom.
22:27:45 - Both patients return to room a and sit on the floor with the light on to play cards.
22:30:28 - S2MHT enters the room and instructs the patients to get in their respective beds and to go to sleep. No further incident is witnessed on video.

On 06/10/2024 at 10:30am, the above video was reviewed with S1Director of Compliance, which confirmed the above observations. During observation, it was noted that the door to room a that opens into the hallway was closed from 21:59-22:30 (31 minutes), and no staff member entered the room during that period of time. S1Director of Compliance confirmed that the boys were not able to be observed with the door closed. S1Director of Compliance confirmed that the bedroom doors should always be left open when patients are in their rooms.

Review of the medical record for Patient #1 revealed an order on 05/18/2024 for observation levels every 15 minutes. Review of the medical record for Patient#2 revealed an order on 05/23/2024 for observation levels every 15 minutes.

Review of the documentation on the observation logs for Patient #1 and Patient #2 revealed they were to be monitored with documentation of location, activity and behavior every 15 minutes. The logs during the time period 05/23/2024 21:59-22:30, completed by S2MHT, showed that Patient #1 was in the room asleep in his bed during this time and Patient #2 was in the room and calm.

On 06/10/2024 at 10:30 a.m., interview with S1Director of Compliance confirmed that the documentation did not accurately show the activity of Patient #1 and Patient #2.