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Based on interview with facility staff and review of documents the facility failed to protect the rights of two patients to be free from all forms of abuse or harassment. Review of facility documentation revealed two patients (Patient E and Patient F) reported that they had engaged in sexual activity with one another during their hospitalization. Both of the patients were admitted to the hospital under involuntary holds, determined by the courts, for mentally disordered persons, who are a danger to themselves or others or gravely disabled. The facility failed to ensure the two mentally impaired patients were protected from all forms of abuse and potential harm.

Findings:

On 2/8/12 review of the QAPI (quality assessment and performance improvement) minutes for 11/23/11 revealed two patients reported that they had engaged in sexual activity while inpatients in the facility on 10/17/11. The facility policy titled " Sexual Contacts between PHF (psychiatric health facility) In-Patients " describes the procedure which was followed in investigating the incident. The facility's procedure was followed and it was determined, as stated in the following month's QAPI meeting minutes, that the patients had said the sexual activity was "consensual."

However, review on 2/8/12 of the patient records from the time of the incident revealed one of the participants (Patient E) had been admitted to the facility under California Penal Code 1370 (a mentally incompetent defendant) and the other (Patient F) was being held in the facility under California Welfare and Institutions Code 5250 (having a mental disorder or impairment by chronic alcoholism, a danger to others, or to himself or herself, or gravely disabled). The fact of their involuntary admission to the facility on such grounds would argue against their action being considered to be consensual. Such impaired individuals could lack proper judgment for their actions and their involvement in sexual activities after being committed to a locked psychiatric facility while mentally unstable could be viewed as abuse.

Based on review of documents the facility failed to ensure that the use of restraints was in accordance with the order of a physician for two of four patient records reviewed. Two of four patient records reviewed revealed the use of physical restraints was implemented without an order (Patient B and Patient C).

Findings:

Review of the record of Patient B on 2/8/12 revealed the statement " She was then physically escorted to her room " on the Seclusion or Seclusion & Restraint and/or Emergency Medication Form dated 10/5/11 at 18:00 (6:00 p.m.). Review of the physician order for that event revealed it was " place patient in locked seclusion only " . There was no order for the use of physical restraints.

Review of the record for Patient C on 2/8/12 revealed the physician order on 10/24/11 at 15:15 (3:15 p.m.) was " place patient in locked seclusion only. " However, on the seclusion and restraint record for that incident it stated " contained & escorted to locked seclusion x4 staff " in the behavior section and " contained x4 staff " in the preventative measures section. The only restraint listed on the physician order page of the Seclusion or Seclusion & Restraint and/or Emergency Medication Form is for mechanical restraint.

Review of the policy titled " Restraint and Seclusion " on 2/8/12 revealed it defined physical restraint but there was no procedure for its use. While both chemical and mechanical restraint had procedures to follow for their use.

Based on interview with facility staff and review of documents the facility failed to ensure that there was documentation of appropriate training of all individuals involved in the implementation of restraint or seclusion. Four of four patient records revealed the use of Sheriff ' s Officers (SO) in managing patients. (Patients A,B,C and D)

Findings:

Review of the medical records of patients A, B, C, and D on 2/8/12 revealed Sheriff ' s Officers (SO) had been involved in the use of restraints and in the placement of patients in seclusion. The record of Patient A documented take downs of the patient by SO on 10/30/11 in the interdisciplinary progress notes (IPN) and in the required monitoring tool on 10/31/11. The records of Patients B, C, and D document SO were called for assistance in placing the patients in seclusion and/or restraints. On 9/15/11 the record of Patient B stated " SO were called for assistance placed in seclusion " in the IPN. The record for Patient C on 10/24/11 stated " sheriffs were called to assist with client " and " place in seclusion room at 0230 by sheriff ' s " in the IPN. Again on 10/26/11 the IPN for Patient C stated " SO were called for assistance placed in seclusion. " The Seclusion or Seclusion & Restraint and/or Emergency Medication Form from 10/25/11 in the record of Patient C stated " seclusion, redirect by Sheriff. " The IPN for Patient D on 9/16/11 stated " 2 SO called in for assistance. "

In an interview at 11:00 a.m. on 1/27/12 the Program Manager stated law enforcement was used to restrain patients only for emergency medications and for custody patients. She also stated there was no log of calls for assistance from SO or log of their presence in the facility. In an interview on 2/8/12 at 10:20 a.m. the Program Manager stated there was no documentation of training of the SO in the safe implementation of seclusion or restraints. Review of the facility policy titled " Guards on the Psychiatric Health Facility " on 1/27/12 showed it mentions " hands-on " by the guard to subdue the patient, but there is no reference to any training of the guard.