HospitalInspections.org

Based on policy review, document review, medical record review and interview, the facility failed to ensure care was provided in a safe setting for 2 of 8 (Patient #3 and #4) sampled patients reviewed.

The findings included:

1. Review of the facility's "Alleged Sexual Behavior" policy (3/2025) revealed, " ...PROTOCOL FOR ALLEGED SEXUAL BEHAVIOR ...Nurse Immediate Actions, Response and Notifications ...Immediately separate patients ...Staff member to stay with patients until patients can be separated ...Place patients on increased level of observation (Q10, Q5, 1:1) [every 10 minutes, every 5 minutes, one on one] and SAO [sexual acting out] precautions (obtain orders) per assessment and physician order ..."

2. Review of the facility's Incident Report for August and September 2025 revealed on 8/26/2025 Patient #3 and Patient #4 were documented as "Sexual Allegations".

3. Medical record review for Patient #3 revealed an admission date of 8/23/2025 with diagnoses which included Post Traumatic Stress Disorder and Adjustment Disorder. Initial evaluation on 8/23/2025 revealed no history of sexually acting out behaviors.

Review of a nurse's note dated 8/26/2025 at 7:25 PM revealed a patient reported to the nurse that earlier in the day, around shower time, Patient #3 and Patient #4 were in the dayroom together without staff present. Patient #3 performed sexual acts on Patient #4.

Review of a nurse's note dated 8/26/2025 at 9:16 PM revealed Patient #3 "...remains on q15 [every 15 minutes] observation..." Type of precaution was documented as suicide and self-harm precautions.

Review of patient observation records for 8/26/25 revealed Patient #3 was on q15 minute observations through midnight on 8/26/2025. Precautions were documented as suicide and self-harm precautions.

Review of patient observation records for 8/27/2025 revealed Patient #3 was on q15 minute observations and suicide and self-harm precautions until 12:40 PM. At 12:40 PM, Patient #3 was changed to q10 minute observations and sexual acting out precautions (SAO) were initiated.

The facility failed to increase Patient #3's level of observation and failed to initiate sexual acting out precautions in a timely manner upon obtaining knowledge of a sexual incident between Patient #3 and Patient #4 on 8/26/2025. Observation level increase and SAO precautions were not implemented until the following day, 8/27/2025.

4. Medical record review for Patient #4 revealed an admission date of 8/10/2025 with diagnoses which included Major Depressive Disorder and Disruptive Mood Dysregulation. Initial evaluation on 8/9/2025 revealed no history of sexually acting out behaviors.

Review of a nurse's note dated 8/26/2025 at 7:25 PM revealed a patient reported to the nurse that earlier in the day, around shower time, Patient #4 and Patient #3 were in the dayroom together without staff present. Patient #3 performed sexual acts on Patient #4.

Review of patient observation records for 8/26/2025 revealed Patient #4 was on q15 minute observations through midnight on 8/26/2025. Precautions were documented as homicide precautions and auditory hallucination precautions.

Review of patient observation records for 8/27/2025 revealed Patient #4 was on q15 minute observations and homicide and auditory hallucination precautions until 11:15 AM, when Patient #4 was discharged home from the facility.

The facility failed to increase Patient #4's level of observation and failed to initiate sexual acting out precautions upon obtaining knowledge of a sexual incident between Patient #4 and Patient #3 on 8/26/2025.

In an interview on 10/7/2025 at 11:39 AM, the facility's Quality Director verified Patient #4's observation levels and precautions were not increased after knowledge was obtained about SAO behavior. The Quality Director verified Patient #3's observation level and precautions were increased the day after knowledge was obtained about SAO behavior.