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Based on medical record review, review of hospital policy, observation and staff interviews, the hospital's administrative staff failed to ensure that nursing staff appropriately supervised patients receiving services from the inpatient pediatric behavioral health (BH) units (see A0144).

The cumulative effect of this deficient practice resulted in the opportunity for inappropriate sexual contact between two inpatient adolescent patients and the hospital's inability to ensure the nursing staff provided safe and appropriate care in accordance with the hospital's policies and acceptable standards of practice. The hospital's administrative staff identified a total capacity potential of 15 patients for the inpatient pediatric behavioral health unit at the time of the investigation.

Based on medical record review, behavioral health (BH) security video review, staff interviews, and observation, the hospital's administrative staff failed to ensure that nursing staff on the inpatient pediatric BH unit appropriately supervised 2 of 10 patients reviewed (Patient #4, and Patient #7).

The effects of the failures and deficient practice resulted in the hospital staff's inability to ensure that patients received care in a safe setting resulting in allegations of Patient #4 having inappropriate sexual contact with Patient #7 on the evening of 7/26/24 through the early morning on 7/27/24.

Findings include:

1. Review of the policy, titled Psychiatric Nursing Precaution/Observation, dated 11/2023, revealed patients were to be observed every 15 minutes, twenty-four hours a day. For sexually acting out behaviors, the policy directed staff to ensure the patients were not left alone with other patients..."May be placed on dayroom restriction or 1:1 at RN discretion for increased monitoring and or safety."

2. During an interview on 8/21/24 at 3:49 PM, PNA Q recalled Patient #4 would avoid Patient #7. PNA Q stated, (prior to the incident that occurred on the night of 7/26/24 and the early morning of 7/27/24), "(Patient #7) was saying (Patient #4) was obsessed with (Patient #7) and (Patient #4) would say it wasn't true...we gave them verbal warnings, and if it continued, we would separate them. I did observe (Patient #7) inappropriately touching (Patient #4's) shoulder or trying to hug (Patient #4) and (Patient #4) would push Patient #7) away and tell staff."

3. During an interview on 8/21/24 at 1:15 PM, RN N recalled caring for Patient #7 on the evening of 7/26/24. RN N recalled Patient #4 and Patient #7 were sitting together earlier in the evening in the day area and had their hands on each other's legs. RN N stated, "I told them to move apart or they would be at separate tables. They moved apart and started whispering... I told them to stop or they would go to their rooms."

4. The hospital nursing staff were aware of the inappropriate physical contact between Patient #7 and Patient #4, but failed to evaluate, assess or counsel the patients about their inappropriate behaviors to keep the behaviors from escalating. The medical records for Patient #7 and Patient #4 lacked any documentation regarding the incidents of inappropriate contact between Patient #4 and Patient #7 prior to the incident that occurred on the night of 7/26/24 and the early morning of 7/27/24.

5. Review of Patient #7's medical record revealed:

a. On 7/6/24 at 6:43 PM, Patient #7 was admitted to the inpatient pediatric BH unit.

b. On 7/27/24 at 10:38 PM, RN F documentation revealed "At approximately 1:35 PM (Patient #7) was sitting in the day room with another peer, and reported that (Patient #4) came into (Patient #7's) room last night, and kissed (Patient #7), grabbed their hand to (touch Patient #4 in a sexual manner). (Patient #7) reported that they told (Patient #4) to stop and (Patient #4) choked (Patient #7). (Patient #7) reported they told the other peer because they feel more comfortable talking the peer. (Patient #7) expressed they were raped before, and this incident triggered them, so they didn't report it to staff. While talking to the (Patient #7) they saw the staff outside of (Patient #4's) room, and stated "what is (Patient #4) saying?" "(Patent #4) is going to tell them that I did something to (Patient #4), and I didn't"... (Patient #7) was able to write a report about what happened last night (between the night of 7/26/24 and the morning of 7/27/24). 6:00 PM, Staff O Rape Victim Advocate did a report (met) with the (Patient #7) in private...The patient (Patient #4) is on 1:1 observation per Staff D, Hospital Operations Manager (HOM). (Patient #7's) mother called and was notified of the incident ... (Patient #7's) mother is requesting that 1:1 female staff only, no males due to (Patient #7's) prior history of sexual assault. No further behavioral concerns reported or noted."

c. On 7/28/24 at 1:44 PM RN V documented Patient #7 discharged from the hospital.

6. Review of BH unit security video footage by the survey team on 8/16/24 at 2:30 PM revealed the following:

a. On 7/26/24 at 10:22 PM, Patient #4 entered the open door-way into Patient #7's room, shut Patient #7's door, remained in Patient #7's room for approximately 3 minutes, Patient #4 exited the room at 10:25 PM, left Patient #7's door partially open and walked 40 steps (equivalent to approximately 40 feet) back to his room. There were 2 staff visible in the nurses station (enclosed area with walls of glass on the top half) at the end of the hallway (approximately 7 feet from Patient #4's room and approximately 47 feet from Patient #7's room) during this time (the video angle was too far away to determine the identities of the staff).

b. On 7/26/24 at 11:00 PM, Patient #4 talked with nursing staff at the entry way to the nurses station, went to the doorway of his room, looked back periodically at the nurses station as he walked down the hallway and entered Patient #7's room at 11:01 PM, shut Patient #7's door, remained in Patient #7's room for approximately 1 minute, and then Patient #4 exited the room at 11:02 PM, shut Patient #7's door and returned to his room. There were 2 staff visible in the nurses station during this time.

c. On 7/27/24 at 12:06 AM, Patient #4 opened the door of his room, stood at his doorway for 30 seconds facing the nurses station, then walked down the hallway, opened the door to Patient #7's room and entered, shut the door, remained in Patient #7's room for approximately 12 minutes, Patient #4 exited the room at 12:18 AM and shut Patient #7's door, walked down to the hallway and returned to his room. One staff exited the nurses station immediately after Patient #4 returned to his room, but walked in the opposite direction of the camera view (unable to determine the identify of the staff).

d. On 7/27/24 at 6:04 AM, Patient #4 opened the door of his room, stood at his doorway for 20 seconds facing the nurses station, walked down the hallway, entered the partially opened door into Patient #7's room, Patient #4 shut Patient #7's door, remained in Patient #7's room for approximately 8 minutes, and then Patient #4 exited the room at 6:12 AM and returned to his room. During this same time frame on 7/27/24 at 6:08 AM, while Patient #4 was in Patient #7's room, PNA P walked down the hallway directly to Patient #7's room. PNA P opened Patient #7's door partially (approximately 18 inches) moved her head forward slightly while looking in the direction of the open doorway and shut the door within 2 seconds of opening the door. PNA P did not enter Patient #7's room or put her head in the room through the open doorway. PNA P then unlocked and entered the laundry room which was located across the hallway from Patient #7's room (approximately 6 to 7 feet from Patient #7's room). The laundry room door had a small quarter glass window, approximately 6 inches in width and 2 feet in length. PNA P remained in the laundry room for approximately 1 minute, exited, looked through the window into the room directly next to the laundry room and then returned to the nurses station. PNA P did not go into or look in the direction of Patient #4's room. As PNA P got close to the nurses station, Patient #4 could be seen peeking out the partially opened door of Patient #7's room and looking toward the direction of the nurses station just prior to exiting the room.

PNA P failed to notice Patient #4 was in Patient #7's room and failed to notice that Patient #4 was not in his own room.

7. During an interview on 8/21/24 at 9:05 AM, RN F explained Patient #7 told them Patient #4 had come into Patient #7's room last night (between the night of 7/26/24 and the early morning of 7/27/24) and used Patient #7's hand to touch Patient #4 in a sexual manner. RN F reported Patient #4 told them they went to Patient #7's room because Patient #7 said they had a gift for Patient #4. RN F explained Patient #4 reported no staff was around when they went to Patient #7's room.

8. During an interview on 8/21/24 at 3:49 PM, PNA Q recalled Patient #7 reported to them (on 7/27/24) Patient #4 had come to their room and kissed them without their consent. PNA Q recalled Patient #4 told them they went to Patient #7's room because Patient #7 said they had something to give them but when they went to Patient #7's room they said they didn't have anything for them and Patient #7 kissed Patient #4. PNA Q reported Patient #4 said they pushed Patient #7 away and ran out and cried.

9. Review of the BH pediatric unit census on the evening of 7/26/24 to the end of the night shift at 7:30 AM on 7/27/24 revealed a census of 4 patients.

10. Review of the BH unit staffing schedule/assignment sheet revealed the following:

a. Four staff (RN N, PNA P, PNA AA, PNA BB) on duty during the evening shift (7:00 PM - 11:30
PM) on 7/26/24.

b. Four staff (RN J, PNA P, PNA AA, PNA BB ) on duty during the night shift (11:00 PM - 7:30 AM)
on 7/26 - 7/27/24.

c. RN N worked 3:00 PM to 11:30 PM on 7/26/24 and was responsible for supervision and providing patient care to Patient #4 and Patient #7.

d. RN J worked 11:00 PM to 7:30 AM on 7/26/24 and 7/27/24. RN J was responsible for supervision and providing patient care to Patient #4 and Patient #7.

e. PNA P worked 7:00 PM to 7:30 AM on 7/26/24 to 7/27/24. PNA P was responsible for laundry and performing 15-minute checks on all patients, including Patient #4 and Patient #7 from 9:30 PM to 1:30 AM (when video footage revealed Patient #4 entered Patient #7's room 3 times) and 5:30 AM to 7:30 AM (when video footage revealed Patient #4 entered Patient #7's room 1 time).

11. During an interview on 8/21/24 at 3:17 PM, PNA P could not recall if they worked the evening shift of 7/26/24 through 7/27/24 7:30 AM. PNA P reported they worked the adult BH unit, but had been floated to the pediatric BH unit. PNA P explained when they perform 15-minute checks, the typical routine was to open the door and visualize the patient to make sure they were in the correct room. PNA P did not recall how long the patients would have been unsupervised while PNA P did laundry.

12. Review of documentation of 15-minute checks, "titled Rounding Sheets" by the hospital, revealed:

a. RN N performed 15-minute checks on all patients from 7:00 PM to 9:30 PM on 7/26/24.

b. RN J performed 15-minute patient checks on all patients from 3:45 AM to 5:00 AM on 7/27/24.

c. Various nursing staff, including PNA P, completed 15-minute checks every hour on the hour and every 15 minutes throughout the hour without any variation in the 15-minute check pattern on all patients from 10:15 PM on 7/26/24 to 6:30 AM on 7/27/24.

13. During an interview on 8/21/24 at 1:15 PM, RN N reported staff they walked completely into the patient's room to ensure the safety of the patient. RN N could not recall if they completed any of the 15-minute patient checks during the evening of 7/26/24.

14. During an interview on 8/21/24 at 10:06 AM, RN J explained when PNAs were busy or needed to take a break, RN J would perform their 15-minute checks for them. RN J recalled Patient #7 was sleeping in their room all night 7/26/24 to 7/27/24 when RN J performed 15-minute checks. RN J explained for 15-minute checks they opened the patient door, saw the patient breathing and then went to the next room. RN J denied they ever saw Patient #4 enter Patient #7's room.

15. On 8/20/24 at 9:05 AM, during an interview, the Interim Nurse Manager for the pediatric BH unit explained, that prior to the start of the onsite survey, the hospital increased the number of PNAs from 2 to 3 on night shift on 7/29/24. One of the 3 PNAs was assigned hall monitoring duties. The Manager also explained on 7/29/24 they verbally "trained staff to alter night 15-minute check patterns, throw in an extra round during the 15-minute checks, and PNAs go into the room to observe the patient and count respirations". The Manager explained there was not a new policy on these changes and they were waiting for the new 15-minute check forms to be approved by administration.

16. On 8/19/24 at 9:00 PM, observation conducted on the inpatient pediatric BH unit including reviewing the staffing matrix, revealed, in addition to varied 15-minute checks, one staff member sat and monitored the hallway to ensure patients were not entering another patient's room.

17. Prior to the end of the survey, hospital administration failed to provide evidence of staff education on the changes to the 15-minute check policy "alter patterns, throw in an extra round during the 15-minute checks, PNAs to go into the patients' rooms to observe the patient and count respirations, and one staff to monitor the hall at all times on the night shift" prior to the start of the complaint investigation survey on 8/15/24.

There was no evidence that hospital staff attempted to take the necessary action to separate or provide ongoing supervision for Patient #4 and Patient #7 after witnessed inappropriate touches prior to the incidents that occurred on 7/26/24 and 7/27/24. Hospital nursing staff failed to appropriately supervise patients on 7/26/24 from 10:22 PM to 7/27/24 at 12:18 AM and on 7/27/24 from 6:04 AM to 6:18 AM. PNA P had laundry responsibilities in addition to the 15-minute patient checks resulting in patients being left unsupervised for an unknown period of time and allegations were made of Patient #4 having sexual acting out behaviors with Patient #7. Nursing staff failed to protect the right of the patients to receive care in a safe setting.

Based on medical record review, review of hospital policy, observation and staff interviews, the hospital's administrative staff failed to ensure there nursing staff appropriately supervised patients to meet their safety needs while receiving services from the inpatient pediatric behavioral health (BH) unit (see A0395).

The cumulative effect of this deficient practice resulted in the hospital's inability to ensure an RN supervised and evaluated the nursing care on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy. The hospital's administrative staff identified a total capacity potential of 15 patients on the inpatient adult behavioral health unit at the time of the investigation.

Based on medical record review, behavioral health (BH) security video review, staff interviews, and observation, the hospital' s administrative staff failed to ensure that RN supervised and evaluated nursing care in accordance with accepted standards of nursing practice and hospital policy. This inaction culminated in an allegation of sexual activity involving Patient #4 and Patient #7 on the evening of 7/26/24 through the early morning on 7/27/24.

Findings include:

1. Review of the policy, titled Psychiatric Nursing Precaution/Observation, dated 11/2023, revealed patients were to be observed every 15 minutes, twenty-four hours a day. For sexually acting out behaviors, the policy directed staff to ensure the patients were not left alone with other patients..."May be placed on dayroom restriction or 1:1 at RN discretion for increased monitoring and or safety."

2. During an interview on 8/21/24 at 3:49 PM, PNA Q recalled Patient #4 would avoid Patient #7. PNA Q stated, (prior to the incident that occurred on the night of 7/26/24 and the early morning of 7/27/24), "(Patient #7) was saying (Patient #4) was obsessed with (Patient #7) and (Patient #4) would say it wasn't true...we gave them verbal warnings, and if it continued, we would separate them. I did observe (Patient #7) inappropriately touching (Patient #4's) shoulder or trying to hug (Patient #4) and (Patient #4) would push Patient #7) away and tell staff."

3. During an interview on 8/21/24 at 1:15 PM, RN N recalled caring for Patient #7 on the evening of 7/26/24. RN N recalled Patient #4 and Patient #7 were sitting together earlier in the evening in the day area and had their hands on each other's legs. RN N stated, "I told them to move apart or they would be at separate tables. They moved apart and started whispering... I told them to stop or they would go to their rooms."

4. The hospital nursing staff were aware of the inappropriate physical contact between Patient #7 and Patient #4, but failed to evaluate, assess or counsel the patients about their inappropriate behaviors to keep the behaviors from escalating. The medical records for Patient #7 and Patient #4 lacked any documentation regarding the incidents of inappropriate contact between Patient #4 and Patient #7 prior to the incident that occurred on the night of 7/26/24 and the early morning of 7/27/24.

5. Review of Patient #7's medical record revealed:

a. On 7/6/24 at 6:43 PM, Patient #7 was admitted to the inpatient pediatric BH unit.

b. On 7/27/24 at 10:38 PM, RN F documentation revealed "At approximately 1:35 PM (Patient #7) was sitting in the day room with another peer, and reported that (Patient #4) came into (Patient #7's) room last night, and kissed (Patient #7), grabbed their hand to (touch Patient #4 in a sexual manner). (Patient #7) reported that they told (Patient #4) to stop and (Patient #4) choked (Patient #7). (Patient #7) reported they told the other peer because they feel more comfortable talking the peer. (Patient #7) expressed they were raped before, and this incident triggered them, so they didn't report it to staff. While talking to the (Patient #7) they saw the staff outside of (Patient #4's) room, and stated "what is (Patient #4) saying?" "(Patent #4) is going to tell them that I did something to (Patient #4), and I didn't"... (Patient #7) was able to write a report about what happened last night (between the night of 7/26/24 and the morning of 7/27/24). 6:00 PM, Staff O Rape Victim Advocate did a report (met) with the (Patient #7) in private...The patient (Patient #4) is on 1:1 observation per Staff D, Hospital Operations Manager (HOM). (Patient #7's) mother called and was notified of the incident ... (Patient #7's) mother is requesting that 1:1 female staff only, no males due to (Patient #7's) prior history of sexual assault. No further behavioral concerns reported or noted."

c. On 7/28/24 at 1:44 PM RN V documented Patient #7 discharged from the hospital.

6. Review of BH unit security video footage by the survey team on 8/16/24 at 2:30 PM revealed the following:

a. On 7/26/24 at 10:22 PM, Patient #4 entered the open door-way into Patient #7's room, shut Patient #7's door, remained in Patient #7's room for approximately 3 minutes, Patient #4 exited the room at 10:25 PM, left Patient #7's door partially open and walked 40 steps (equivalent to approximately 40 feet) back to his room. There were 2 staff visible in the nurses station (enclosed area with walls of glass on the top half) at the end of the hallway (approximately 7 feet from Patient #4's room and approximately 47 feet from Patient #7's room) during this time (the video angle was too far away to determine the identities of the staff).

b. On 7/26/24 at 11:00 PM, Patient #4 talked with nursing staff at the entry way to the nurses station, went to the doorway of his room, looked back periodically at the nurses station as he walked down the hallway and entered Patient #7's room at 11:01 PM, shut Patient #7's door, remained in Patient #7's room for approximately 1 minute, and then Patient #4 exited the room at 11:02 PM, shut Patient #7's door and returned to his room. There were 2 staff visible in the nurses station during this time.

c. On 7/27/24 at 12:06 AM, Patient #4 opened the door of his room, stood at his doorway for 30 seconds facing the nurses station, then walked down the hallway, opened the door to Patient #7's room and entered, shut the door, remained in Patient #7's room for approximately 12 minutes, Patient #4 exited the room at 12:18 AM and shut Patient #7's door, walked down to the hallway and returned to his room. One staff exited the nurses station immediately after Patient #4 returned to his room, but walked in the opposite direction of the camera view (unable to determine the identify of the staff).

d. On 7/27/24 at 6:04 AM, Patient #4 opened the door of his room, stood at his doorway for 20 seconds facing the nurses station, walked down the hallway, entered the partially opened door into Patient #7's room, Patient #4 shut Patient #7's door, remained in Patient #7's room for approximately 8 minutes, and then Patient #4 exited the room at 6:12 AM and returned to his room. During this same time frame on 7/27/24 at 6:08 AM, while Patient #4 was in Patient #7's room, PNA P walked down the hallway directly to Patient #7's room. PNA P opened Patient #7's door partially (approximately 18 inches) moved her head forward slightly while looking in the direction of the open doorway and shut the door within 2 seconds of opening the door. PNA P did not enter Patient #7's room or put her head in the room through the open doorway. PNA P then unlocked and entered the laundry room which was located across the hallway from Patient #7's room (approximately 6 to 7 feet from Patient #7's room). The laundry room door had a small quarter glass window, approximately 6 inches in width and 2 feet in length. PNA P remained in the laundry room for approximately 1 minute, exited, looked through the window into the room directly next to the laundry room and then returned to the nurses station. PNA P did not go into or look in the direction of Patient #4's room. As PNA P got close to the nurses station, Patient #4 could be seen peeking out the partially opened door of Patient #7's room and looking toward the direction of the nurses station just prior to exiting the room.

PNA P failed to notice Patient #4 was in Patient #7's room and failed to notice that Patient #4 was not in his own room.

7. During an interview on 8/21/24 at 9:05 AM, RN F explained Patient #7 told them Patient #4 had come into Patient #7's room last night (between the night of 7/26/24 and the early morning of 7/27/24) and used Patient #7's hand to touch Patient #4 in a sexual manner. RN F reported Patient #4 told them they went to Patient #7's room because Patient #7 said they had a gift for Patient #4. RN F explained Patient #4 reported no staff was around when they went to Patient #7's room.

8. During an interview on 8/21/24 at 3:49 PM, PNA Q recalled Patient #7 reported to them (on 7/27/24) Patient #4 had come to their room and kissed them without their consent. PNA Q recalled Patient #4 told them they went to Patient #7's room because Patient #7 said they had something to give them but when they went to Patient #7's room they said they didn't have anything for them and Patient #7 kissed Patient #4. PNA Q reported Patient #4 said they pushed Patient #7 away and ran out and cried.

9. Review of the BH pediatric unit census on the evening of 7/26/24 to the end of the night shift at 7:30 AM on 7/27/24 revealed a census of 4 patients.

10. Review of the BH unit staffing schedule/assignment sheet revealed the following:

a. Four staff (RN N, PNA P, PNA AA, PNA BB) on duty during the evening shift (7:00 PM - 11:30
PM) on 7/26/24.

b. Four staff (RN J, PNA P, PNA AA, PNA BB ) on duty during the night shift (11:00 PM - 7:30 AM)
on 7/26 - 7/27/24.

c. RN N worked 3:00 PM to 11:30 PM on 7/26/24 and was responsible for supervision and providing patient care to Patient #4 and Patient #7.

d. RN J worked 11:00 PM to 7:30 AM on 7/26/24 and 7/27/24. RN J was responsible for supervision and providing patient care to Patient #4 and Patient #7.

e. PNA P worked 7:00 PM to 7:30 AM on 7/26/24 to 7/27/24. PNA P was responsible for laundry and performing 15-minute checks on all patients, including Patient #4 and Patient #7 from 9:30 PM to 1:30 AM (when video footage revealed Patient #4 entered Patient #7's room 3 times) and 5:30 AM to 7:30 AM (when video footage revealed Patient #4 entered Patient #7's room 1 time).

11. During an interview on 8/21/24 at 3:17 PM, PNA P could not recall if they worked the evening shift of 7/26/24 through 7/27/24 7:30 AM. PNA P reported they worked the adult BH unit, but had been floated to the pediatric BH unit. PNA P explained when they perform 15-minute checks, the typical routine was to open the door and visualize the patient to make sure they were in the correct room. PNA P did not recall how long the patients would have been unsupervised while PNA P did laundry.

12. Review of documentation of 15-minute checks, "titled Rounding Sheets" by the hospital, revealed:

a. RN N performed 15-minute checks on all patients from 7:00 PM to 9:30 PM on 7/26/24.

b. RN J performed 15-minute patient checks on all patients from 3:45 AM to 5:00 AM on 7/27/24.

c. Various nursing staff, including PNA P, completed 15-minute checks every hour on the hour and every 15 minutes throughout the hour without any variation in the 15-minute check pattern on all patients from 10:15 PM on 7/26/24 to 6:30 AM on 7/27/24.

13. During an interview on 8/21/24 at 1:15 PM, RN N reported staff they walked completely into the patient's room to ensure the safety of the patient. RN N could not recall if they completed any of the 15-minute patient checks during the evening of 7/26/24.

14. During an interview on 8/21/24 at 10:06 AM, RN J explained when PNAs were busy or needed to take a break, RN J would perform their 15-minute checks for them. RN J recalled Patient #7 was sleeping in their room all night 7/26/24 to 7/27/24 when RN J performed 15-minute checks. RN J explained for 15-minute checks they opened the patient door, saw the patient breathing and then went to the next room. RN J denied they ever saw Patient #4 enter Patient #7's room.

15. On 8/20/24 at 9:05 AM, during an interview, the Interim Nurse Manager for the pediatric BH unit explained, that prior to the start of the onsite survey, the hospital increased the number of PNAs from 2 to 3 on night shift on 7/29/24. One of the 3 PNAs was assigned hall monitoring duties. The Manager also explained on 7/29/24 they verbally "trained staff to alter night 15-minute check patterns, throw in an extra round during the 15-minute checks, and PNAs go into the room to observe the patient and count respirations". The Manager explained there was not a new policy on these changes and they were waiting for the new 15-minute check forms to be approved by administration.

16. On 8/19/24 at 9:00 PM, observation conducted on the inpatient pediatric BH unit including reviewing the staffing matrix, revealed, in addition to varied 15-minute checks, one staff member sat and monitored the hallway to ensure patients were not entering another patient's room.

17. Prior to the end of the survey, hospital administration failed to provide evidence of staff education on the changes to the 15-minute check policy "alter patterns, throw in an extra round during the 15-minute checks, PNAs to go into the patients' rooms to observe the patient and count respirations, and one staff to monitor the hall at all times on the night shift" prior to the start of the complaint investigation survey on 8/15/24.
There was no evidence that hospital staff attempted to take the necessary action to separate or provide ongoing supervision for Patient #4 and Patient #7 after witnessed inappropriate touches prior to the incidents that occurred on 7/26/24 and 7/27/24. Hospital nursing staff failed to appropriately supervise patients on 7/26/24 from 10:22 PM to 7/27/24 at 12:18 AM and on 7/27/24 from 6:04 AM to 6:18 AM. PNA P had laundry responsibilities in addition to the 15-minute patient checks resulting in patients being left unsupervised for an unknown period of time and allegations were made of Patient #4 having sexual acting out behaviors with Patient #7.