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Based on record reviews, observation, and interviews, it was determined the Condition of Participation ("CoP") for Nursing Services was not met as evidenced by the hospital's failure to ensure nursing services and interventions were provided after the display of hypersexual behaviors for one (1) of three (3) patients (Patient #3) and physician ordered checks were completed for three (3) of three (3) patients (Patient #1, #2, and #3). This failure resulted in three minor patients, who were either on five (5) minute checks or fifteen (15) minute checks, being able to congregate in a patients room for approximately two (2) hours without being detected by staff and having sexual intercourse. This situation constituted immediate jeopardy ("IJ"). Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment, or death as a result of a provider's noncompliance with one or more health and safety requirements.

Finding:

Standard: §482.23(b)(3) RN Supervision of Nursing Care also known as A-0395 - Based on the record reviews, observation, and interviews, the hospital failed to ensure nursing services and interventions were provided after the display of hypersexual behaviors for one (1) of three (3) patients (Patient #3) and physician ordered checks were completed for three (3) of three (3) patients (Patient #1, #2, and #3). This failure resulted in three minor patients, who were either on five (5) minute checks or fifteen (15) minute checks, being able to congregate in a patients room for approximately two (2) hours without being detected by staff and having sexual intercourse. This situation constituted immediate jeopardy ("IJ"). Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment, or death as a result of a provider's noncompliance with one or more health and safety requirements. See A-0395 for details.

Please see A-0000 Initial Comments for details related to the IJ template, removal plan, and abatement of the IJ.

The cumulative effect of this deficient practice resulted in noncompliance with this Condition of Participation.

Based on the record reviews, observation, and interviews, the hospital failed to ensure nursing services and interventions were provided after the display of hypersexual behaviors for one (1) of three (3) patients (Patient #3) and physician ordered checks were completed for three (3) of three (3) patients (Patient #1, #2, and #3). This failure resulted in three minor patients, who were either on five (5) minute checks or fifteen (15) minute checks, being able to congregate in a bedroom for approximately two (2) hours without being detected by staff and having sexual intercourse. This situation constituted immediate jeopardy ("IJ"). Immediate jeopardy is defined as a situation in which a recipient of care has suffered or is likely to suffer serious injury, harm, impairment, or death as a result of a provider's noncompliance with one or more health and safety requirements.

Findings:

On 4/6/2021, the Division of Licensing and Certification was made aware of the following incident: At approximately 1:00 AM on 4/2/21 three minor patients on the 1NW [One North West] adolescent unit at Spring Harbor Hospital engaged in sexual intercourse in a bedroom. It was acknowledged by the three patients, when they were individually interviewed, that they had all willingly engaged in sexual intercourse in a bedroom.

The hospital's "Levels of Observation/Freedom of Movement" ("FOM") policy, last revised 4/2018, indicated: "Patients are assigned a level of observation and freedom of movement based on their clinical presentation. Patients are monitored for safety according to their prescribed level of observation ... Further, "15 Minute Checks: Every 15 minutes a staff member will conduct checks and document the patient's location. 5 Minute Checks: When prescribed the staff member will conduct checks every 5 minutes and document the patient's location on the designated observation form. Five-minute checks may be used if the level of acuity requires a more frequent and intensive level of observation than 15-minute checks. The nurse in charge is responsible for assigning nursing staff to monitor patients' levels of observations. The staff person assigned to checks, visual observation, and constant observation (1:1) is documented on the daily Assignment Sheet for each shift (day, evening, and night). The Nurse in Charge is responsible for communicating changes in levels of observation and/or FOM at the time the change occurs and during change of shift report..."

Patient #1's medical record was reviewed and indicated the following:

- On 3/26/2021 at 5:00 PM, Patient #1, was admitted to Spring Harbor Hospital, for his/her fifth admission, for chronic post-traumatic stress disorder, increased depression, and thoughts of suicide.

- On 4/1/2021 at 10:28 PM, RN #8 documented in the patient's medical record, "... Some poor boundaries with peers observed; pt [patient] and roommate get along well though partake in rough-housing-esque bx [behavior] and required redirection throughout the day".

Patient #2's medical record was reviewed and indicated the following:

- On 3/23/2021 at 2:15 PM, Patient #2 was seen at Mid Coast Hospital Emergency Room for suicidal and homicidal ideation one day after being discharged from Spring Harbor Hospital ("SHH") after a five day stay. The medical record from Mid Coast Hospital revealed the following on 3/25/2021: The guardian explained that while Patient #2 was admitted to SHH recently, that Patient #2 had inappropriate boundaries with a another patient on the unit. While in the Emergency Department, he/she was preoccupied with missing and wanting to call his/her "friends" who are still currently admitted to SHH. The crisis team recommended an inpatient level of care due to concerns of suicidal ideation, sexualized behavior, and impulsivity. They also discussed a plan for the Licensed Clinical Social Worker to get a referral for a psychosexual evaluation. The family was afraid to have him/her return home at present due to unsafe and sexualized behaviors. The medical record revealed that Patient #2 had a long history of psychiatric problems including sexually assaulting a student on the school bus, attacking his/her family member, inappropriate behavior over social media, and cutting of his/her wrist most recently at SHH. Between 3/24/2021 through 3/29/2021, an active bed search was conducted to find inpatient placement for Patient #2.

- On 3/29/2021 at 3:00 PM, Patient #2 was admitted to Spring Harbor Hospital, for his/her third admission, for chronic post-traumatic stress disorder, adjustment disorder with mixed disturbance of emotions and conduct, oppositional defiant disorder, and generalized epilepsy. Nurse Practitioner ("NP") #1 signed an order, dated 3/29/2021 at 3:32 PM, stating that the patient's level of observation was fifteen (15) minute checks. At 4:01 PM, NP #1 wrote in the history and physical, that a referral had been made for a psychosexual evaluation.

- On 3/30/2021 at 8:34 AM, the Licensed Clinical Professional Counselor wrote in the "Psychosocial Assessment" that Patient #2 presented for psychiatric hospitalization three weeks ago after a behavioral outburst at home following an event where he/she was bullying peers online and expressing sexually inappropriate content.

- On 3/31/2021 at 8:57 AM, Physician #1 signed an order which increased the patient's level of observation to five (5) minute checks due to a seizure that he/she had on 3/30/2021.

- On 3/31/2021 at 5:21 PM, Registered Nurse ("RN") #5 documented in the patient's medical record, "[Patient #2] required ample redirection for inappropriate sexualized comments to staff and peers. [He/She] was oppositional with redirection and continued to make comments. [He/She] was redirected after picking up peer in hallway and eventually put them down".

- On 4/1/2021 at 2:28 AM, RN #4 documented in the patient's medical record that another patient with poor boundaries was going over to Patient #2's doorway

- On 4/1/2021 at 11:04 AM, RN #1 documented in the patient's medical record that the Patient #2 was visible in milieu, attended groups, was interacting with peers; some redirection was required for poor boundaries/inappropriate conversation with his/her roommate and another peer of the opposite gender; he/she responded to re-direction; he/she stated an increase in his/her depression and suicidal thoughts; and the patient stated "I tried to kill myself ... my suicidal thoughts were a 9/10". The Provider and Charge Nurse was notified; the Provider assessed the patient on unit; and frequent re-direction was required in relation to his/her interactions with patient in another room.

Patient #3's medical record was reviewed and indicated the following:

- On 3/31/2021 at 2:30 PM, Patient #3 was admitted to SHH following a suicide attempt. At 3:38 PM, Physician Assistant #3 signed an order, stating that the patient's level of observation was fifteen (15) minute checks.

- On 4/1/2021 at 6:00 AM, the Overnight House Nurse Supervisor documented in the SHH House Supervisor Report that Patient #3 was "Disrobing and walking into hall in underwear".

- On 4/1/2021 11:05 PM, RN #2 documented in the patient's medical record, "The patient needed a lot of prompts to stay in [his/her] room at bedtime...". RN #1 stated, "[Patient #3] admitted to unit with this staff member at 3:00 PM... Re-direction required by staff for inappropriate/sexualized comments. Went to room at 9:00 PM per staff request - came out into doorway multiple times inappropriately dressed [in undergarments] and required staff to sit outside of doorway in order to settle into room...".

There was no evidence found in Patient #3's medical record that indicated the patient was reassessed and new interventions were put into place and implemented after the patient displayed inappropriate sexualized comments and was inappropriately dressed in the hallway or in the doorway of his/her room.

On 4/12/2021, three (3) surveyors reviewed the completed "Level of Observation" sheets for Patient #1, Patient #2, and Patient #3 for 4/1/2021 and 4/2/2021. The review revealed all the checks for all three (3) patients had been completed, which included the assurance of the three (3) R's: resting, relaxed, and respirations.

On 4/13/2021 at 3:00 AM, a surveyor was onsite at the hospital to observe checks being completed. The surveyor observed Psychiatric Technician #1 walking the hall, stepping into the bedrooms. The time spent checking the patients was minimal; he opened the door, sometimes taking one step into the doorway, and then exited the bedroom pulling the bedroom door behind him. The door was touching the doorjamb but was not fully closed so that it was latched shut. The estimated time spent opening the door through closing the door was at most, ten (10) seconds. Psychiatric Technician #1 stated, "I heard, through secondhand information, that the story had changed several times, but had not heard directly from management the results of any investigation. [Patient #2] was on five (5) minute checks at the time of the alleged event..." He indicated that his coworker, was on checks when the alleged event actually occurred. He also stated, "I don't think it [the alleged event] happened".

On 4/12/2021 at 1:22 PM, the Patient Relations Coordinator was interviewed. He stated, "I learned about the event from a call/page at 10:40 AM [on 4/2/2021] from RN Manager that we had an allegation of sexual conduct. The RN Manager began the investigation and then she called me, and I came in to investigate. I met with all three (3) patients and I did substantiate the event...and the interviews revealed that the boys had intercourse with the female separately...I also learned that the staff did not do checks".

On 4/12/2021 at 2:52 PM, the Chief Nursing Officer ("CNO") was interviewed. She stated, "We do not have a policy on patients visiting in each other's rooms". When the CNO was asked directly about whether or not patients are allowed in other rooms...she declined to answer, stating, "You should talk to the Nurse Manager".

On 4/12/2021 at 2:58 PM, the Northwest Nurse Manager was interviewed. She stated, "Patients are not allowed in each other's rooms...There is supposed to be a staff member in the hallway, in practice. If a patient is going into another patient's rooms...we would monitor. For checks, staff use the 3 R's : resting, relaxed and respirations...we have to stand in the doorway or enter the room, depending on the patient. We need to hear or visualize. If they don't see it, they get a second person for help. The Root Cause Analysis ("RCA") for the event has revealed that the hallway practice was not being done in the overnight...As soon as we are aware that patients have been caught in other patient's rooms, we would do something. We wouldn't have known anything before this event to help prevent this situation".

On 4/13/2021 at 12:45 PM, the Director of Quality and Safety was interviewed. He stated, "The RCA revealed that observations of respirations may not have taken place. Nobody was there to witness event, but we presume, based off of the interviews...that observations were not completed".

On 4/13/2021 at 1:30 PM, Patient #2, who was still at the hospital, was interviewed. Patient #2 stated the following: he/she and Patient #1 had sex with Patient #3 in a bedroom; they made decoys for the beds in each of their bedrooms; the door to the bedroom was opened; and the staff peeked in, but the mattress was blocked by a desk and they could not be seen.

On 4/13/2021 at 2:55 PM, Patient #3, who had been discharged from the hospital, was interviewed via telephone. Patient #3 stated the following: he/she did not remember having sexual intercourse with Patient #2; he/she admitted to having sex with Patient #1; it had started as a joke and they both Patient #1 and Patient #2 wanted to do it; he/she didn't want to have sex with Patient #1 but Patient #1 kept asking and he/she told Patient #1; he/she remembers Patient #2 going down on him/her; he/she was in the bedroom with the other two patients for more than an hour and a half; he/she remembers staff coming in, but they just laid still until the staff left; the staff person who was doing the checks that night wasn't doing a check, she was just cracking the door and closing it; and it was not long enough to go in the room and check on them.

On 4/13/2021 at 4:21 PM, Patient #1, who had been discharged from the hospital, was interviewed via telephone. Patient #1 stated Patient #3 held up a big piece of paper that was seen by him/her and Patient #2; this was around 9:30 PM to 10:00 PM; the paper asked if we wanted to have sex; both of us said sure; we all agreed upon it; we talked and told each other we would give each other from 11:00 PM to 3:30 AM; we took showers around 10:30 PM; he/she made decoys for everybody; we snuck over to Patient #3's room, but the roommate was there, so we went to another bedroom; he/she had sex with Patient #3; he/she waited in the bathroom while Patient #2 had sex with Patient #3; he/she came out of the bathroom and he/she and Patient #3 just stayed in the bed and cuddled and talked; he/she didn't know how the staff didn't notice; they were not super hidden; and they were low to the ground on one of the beds and the desk was there. He/she guessed where staff would be - one staff was on the phone, one was on the computer, and the other two staff were in the sitting area and couldn't see us; He/She and Patient #2 distracted the staff and Patient #3 went back to his/her room. In addition, Patient #1 stated "they always just peek in and leave when doing checks".

On 4/13/2021 at 5:07 PM, RN #1 was interviewed. She stated, "What I told [1 Northwest Nurse Manager] my concern that evening, which was related to increasing a patient's observation with Patient #2. He/She was on 5 minute checks for seizures. I had a long talk with [Patient #2's] physician that he/she had suicidal ideation...I had communicated all of the information before I left for the evening. I talked to Psychiatric Technician #3, so she was aware that [Patient #2] was on 5-minute checks before for seizures, but that he/she now was having increased suicidal ideation. I spoke to the Charge Nurse and RN #2...I made sure everyone was aware that [Patient #2] was having increased suicidal ideation...My concern was that I had been very clear that we needed to keep a close eye on [Patient #2], and he/she should've been having someone watch him closer. I talked with [1 Northwest Nurse Manager] with boundary concerns specifically to these three (3) kids, that we are being extra cautious...everyone was aware of these issues. We looked into changing the rooms, but we were told it wouldn't work...on the evening of the 31st and 1st, I was concerned about those kids...[Patient #3] had been seen undressing in [his/her] doorway. When that happened, we tried to move [him/her] closer to the nurses' station. A room was being emptied the next day but nothing could be changed before then...I left at 11:30 PM [on 4/1/2021], I was pacing back and forth at the end of the hallway to monitor their rooms...it definitely didn't happen until after I left. I thought they were asleep".

On 4/14/2021 at approximately 8:30 AM, the Nurse Manager was interviewed. She stated the following: she was at the hospital at 11:00 PM that night; there was a shift report that explained all of the concerns regarding inappropriate boundaries, but she/she could not recall the details; Patient #2 was on five (5) minute checks for suicidal ideation; we are more mindful of kids that are on five (5) minute checks; the staff were getting up and going to the door; and you need to visualize the patient, whether they are sleeping and verify respirations. She confirmed that Patient #1 and #2 came to the desk around 1:00 AM and after we knew they were awake, she had staff focus more on that area of the hallway.

On 4/14/2021 at 12:15 PM, RN #2 was interviewed. He stated, he was aware of the event; when he came into work on Thursday night 4/1/20210 he had noted that Patient #3 had run into another bedroom during the night (approximately after 9:00 PM, maybe 9:30 PM to 10:00 PM); he did give prompts to the minors to stay in their own rooms; RN #1 and other staff talked about the observation of Patient #3 running into another bedroom; there was a discussion about room changes; and RN #1 was bringing the issue up to the Nurse Manager and other staff.

On 4/16/2021 at 12:10 PM, the 1 Northwest Nurse Manager was interviewed. She stated, "In regard to information shared at the team huddle on the morning of 4/1/2021, I have subsequently learned that there was a discussion in regard to [Patient #3], but I do not recall what was said...".

Based on the above, Patient #3 displayed inappropriate sexualized comments and behaviors and there was no evidence that a reassessment was conducted or new interventions implemented. Patient #2 was on five (5) minute checks and Patient #1 and #3 were on fifteen (15) minute checks which were not completed per protocols, the patients were able to congregate in a bedroom for approximately two (2) hours without being detected by staff conducting the required observations, and Patient #1 and Patient #3 had sexual intercourse without being detected and Patient #2 and Patient #3 had sexual intercourse without being detected.

On 4/15/2021 at 2:30 PM, the above findings were confirmed with the President of SHH.

Please see A-0000 Initial Comments for details related to the IJ template, removal plan, and abatement of the IJ.