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Based on observation, interviews, and record review, the hospital failed to provide a safe care environment for two (Patient #2 and Patient #3) out of nine female patients on the hospital's Unit 1 on 08/01/12 when a male patient (Patient #5) on minimal staff observation entered the female patient room, exposed himself, and asked for sexual favors.

Findings included:

Patient #5's Coding Summary Form noted an admission date of 07/27/12 and a discharge date of 08/08/12. Admitting diagnoses included Schizoaffective Disorder, Homicidal Ideation, and History of Physical Abuse.

Physician admission orders dated 07/27/12 at 9:45 PM reflected sexually acting out precautions for Patient #5 as a "perpetrator." The level of observation was not specified.

The Psychiatric Evaluation dated and signed by Hospital Personnel #12 on 07/28/12 reflected Patient #5 had been discharged from a different psychiatric treatment facility the previous day where he "did apparently rub his body against a female staff ...which apparently hasten[ed] his discharge."

Nursing progress notes dated 08/01/12 at 6:55 PM reflected Patient # 5 made "hypersexual comments" and had "poor impulse and coping skills." According to nursing documentation dated 08/01/12 at 11:30 PM Patient #5 became "extremely agitated and sexually acting out, walking naked out on the hallway. "Nursing staff documented to "continue to monitor [Patient #5] q 15 minutes (every 15 minutes) for safety and comfort." Ten minutes later, on 08/01/12 at 11:40 PM, Patient #5 "was found" without clothes in another patient room.

Patient #5 remained on fifteen minute checks for another fourteen hours and 25 minutes until a physician order was written to place Patient #5 on a one-to-one staff observation level on 08/02/12 at 2:05 PM. Hospital Personnel #4 stated during an interview on 10/11/12 at 4:15 PM that "they (the nurses) should have called earlier."

According to the case management notes dated 08/02/12, Hospital Personnel #13 noted that Patient #2 was "upset and worried about her safety ..."

Record review of the hospital's Unit I census report dated 08/01/12 reflected a male patient (Patient #5) resided in Room 6 while two female patients (Patient #2 and Patient #3) occupied Room 4. Seven other female patients resided on Unit 1 that night.

According to observations on Unit I on 10/11/12 at 11:03 AM, Room 6 was located immediately next to Room 4 with approximately four and one half feet distance between the entry doors. An approximately 66 foot long hallway separated the rooms from the glass windowed nurses' station.

Hospital Personnel #7 stated on 10/11/12 at 1:45 PM that he was aware that Patient #5 "should have been on 1 to 1 [observational status]."

Hospital Policy #1200.201 dated 07/20/12 noted that the fifteen minute observation level was the "minimum level of observation for all patients."

Based on observation, interviews and record reviews, the hospital's registered nursing staff failed to supervise and evaluate the nursing care for three out of three patients (Patient #2, Patient #3, and Patient #5) on the hospital's Unit 1 on 08/01/12 when Patient #5 went into the female patients' room, exposed himself, and asked for sexual favors. This failure could have effected seven other female patients residing on Unit 1 on the night of 08/01/12.

Findings included:

Patient #5's Coding Summary Form noted an admission date of 07/27/12 and a discharge date of 08/08/12. Admitting diagnoses included Schizoaffective Disorder, Homicidal Ideation, and History of Physical Abuse.

Physician admission orders dated 07/27/12 at 9:45 PM reflected sexually acting out precautions for Patient #5 as a "perpetrator." The level of observation was not specified.

The Psychiatric Evaluation dated and signed by Hospital Personnel #12 on 07/28/12 reflected Patient #5 had been discharged from a different psychiatric treatment facility the previous day where he "did apparently rub his body against a female staff ...which apparently hasten[ed] his discharge."

Nursing progress notes dated 08/01/12 at 6:55 PM reflected Patient # 5 made "hypersexual comments" and had "poor impulse and coping skills." According to nursing documentation dated 08/01/12 at 11:30 PM Patient #5 became "extremely agitated and sexually acting out, walking naked out on the hallway. "Nursing staff documented to "continue to monitor [Patient #5] q 15 minutes (every 15 minutes) for safety and comfort." Ten minutes later, on 08/01/12 at 11:40 PM, Patient #5 "was found" without clothes in another patient room.

Patient #5 remained on fifteen minute checks for another fourteen hours and 25 minutes until a physician order was written to place Patient #5 on a one-to-one staff observation level on 08/02/12 at 2:05 PM. Hospital Personnel #4 stated during an interview on 10/11/12 at 4:15 PM that "they (the nurses) should have called earlier."

According to the case management notes dated 08/02/12, Hospital Personnel #13 noted that Patient #2 was "upset and worried about her safety ..."

Record review of the hospital's Unit I census report dated 08/01/12 reflected a male patient (Patient #5) resided in Room 6 while two female patients (Patient #2 and Patient #3) occupied Room 4. Seven other female patients resided on Unit 1 that night.

According to observations on Unit I on 10/11/12 at 11:03 AM, Room 6 was located immediately next to Room 4 with approximately four and one half feet distance between the entry doors. An approximately 66 foot long hallway separated the rooms from the glass windowed nurses' station.

Hospital Personnel #7 stated on 10/11/12 at 1:45 PM that he was aware that Patient #5 "should have been on 1 to 1 [observational status]."

Hospital Policy #1200.201 dated 07/20/12 noted that the fifteen minute observation level was the "minimum level of observation for all patients."