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Based on document review and interview, the facility failed to report incident to appropriate regulatory agencies in 2 of 2 incidents (involving Pt1, Pt2, Pt3 and Pt4) and the facility failed to investigate 1 of 2 incidents involving sexual aggression (involving Pt3 and Pt4).

Findings include:

1. Review of policy titled: Recognizing and Reporting Suspected Abuse/Neglect/Exploitation, reviewed 08/2017 indicates "This hospital mandates that, under the guidance of applicable laws, any healthcare worker having reasonable cause to believe that any person is in the state of abuse, exploitation or neglect shall report the information to the appropriate regulatory agency". "...Cases of suspected sexual assault, physical abuse or neglect will be give priority and will be investigated thoroughly...In many instances, the healthcare provider may suspect the possibility of a inflicted injury before the physician. Careful assessment and documentation of physical findings can help provide the data that are believed to confirm diagnosis. Examination of all patients will be done promptly and in privacy...All cases of suspected abuse/neglect". must be reported to authorities. A person (including employee, volunteer or other person) associated with the hospital, who reasonably believes or who knows of information that would reasonably cause a person to believe that the physical or mental health or welfare of a patient of the hospital, who is receiving medical services, has been, is or will be adversely affected by abuse or neglect by any person shall, as soon as possible, report the information supporting the belief to the Indiana State department of Health and Department of Mental Health & Addiction, or the appropriate healthcare regulatory agency, by telephone, in writing or by personal visit".

2. Review of policy titled: Incident Reports, revised 03/2017, indicated an incident report should be completed immediately following the incident and should reflect documentation that a head-to-toe assessment completed, any injuries, attending physician notified within 1 hour and the family/significant other notified. The report is then forwarded to the Director of Nursing who will complete the next working day.

3. Review of Pt1's MR admitted 04/12/18 for sexualized behaviors. Patient oriented to person. On 04/14/18 the Nursing Daily Assessment notes indicate that patient "trying to get male to feel her chest and between her legs"; patient was "assisted and educated not to act like that and back to her chair and observed by staff". On 04/14/18 at 7:20 pm nursing note indicates "Patient was in room 111 with male peer. It was reported to writer that they were touching/fondling each other. Brought out of room, redirected to different areas of the milieu; staff staying in close proximity of this patient. Family and management notified." Management notified at 7:30 pm and family at 7:45 pm. At 8:00 pm MD1 notified of situation and order received for 1:1 coverage for 24 hours. Lack of documentation of examination or reporting to appropriate agency.

4. Review of Pt2's MR admitted 04/07/18 for aggression and exit-seeking behaviors. Nursing Daily Assessment notes dated 04/14/18 indicates patient oriented to person and place but thought process is confused at 5:00 am. The same was noted on 04/15/18 at 4:15 am. Nurse documented on 04/14/18 at 7:28 pm that it was reported to her that Pt2 and another patient were engaged in inappropriate activity; "writer did not observe". Lack of documentation of examination or reporting to appropriate agency.

5. Review of Pt3's MR admitted on 05/20/18 for sexual aggression. Nursing Daily Assessment notes dated 06/04/18 lacked documentation of participation in sexual aggression; oriented to person, but confused in thought process. On 06/05/18, MD2, Psychiatric Medical Director, documented on Provider Progress Note that patient found in room in bed with another patient without pants or underwear on; other patient in similar state of undress.
Lack of documentation of examination or reporting to appopriate agency.

6. Review of Pt4's MR admitted on 05/24/18 for aggressive and exit-seeking behavior. Nursing Daily Assessment notes dated 06/05/18 indicate peer to peer contact in room; redirected to separation. Lack of documentation for nursing note on 06/04/18. On 06/05/18 at 1:00 pm, the Provider Progress Note MD2 documented patient found in another patient's bed; both were not clothed from the waist down. Pt4 was unable to answer any questions when asked directly; examined by the FNP (Family Nurse Practitioner) and "no injury noted". Lack of documentation of reporting to appropriate agency.

7. Interview on 06/19/18 at 10:00 am with P50, Director of Nursing, P54, Director of Operations and MD1 confirmed serious incident report process as: incident occurs, MD called, family/legal representative called, Director of Nursing reviews, sends information to the P57, Regional Director of Nursing who is responsible for notifying any government/regulatory agency of incident.

8. Interview on 06/19/18 at 10:20 am with P54 confirmed video of incident kept for 2 weeks; confirmed P54 called P57 and asked if P57 called government/regulatory agency to report incidents; P57 said no.

9. Interview with P50 on 06/19/18 at approximately 10:45 am, confirmed that the incident on 06/04/18 involving Pt3 and Pt4 was not investigated or documented on the Incident Report.

Based on document review and interview, the facility failed to provide nursing staff to meet the needs of the patient in 1 out of 10 patient's medical records reviewed (Pt1).

Findings include:

1. Review of policy titled: Patient Acuity and Staffing Guide, revised 06/2018, indicated that, under Core Coverage, the minimum staffing levels may be adjusted up or down based on patient acuity, staff skill levels and patient care activities. There is a Patient Acuity Scoring Tool to be filled out daily.

2. Interview on 06/19/18 at 1:50 pm with P50 confirmed that patient care staffing minimum was 3 nurses and 3 CNAs. Also confirmed at time of sexual aggression incident on 04/14/18, with a census of 22, there were 2 nurses and 3 CNAs scheduled but P50 unable to locate daily schedule where Supervisor would write-in staff who were asked to come or sent home early. Unable to verify if any staff where called in to complete the physician's order of 1:1 monitoring on 04/14/18.

3. No further documentation given before exit.

Based on document review and interview, the registered nurse failed to ensure the physician order written in the medical record (MR) was followed for one (1) of ten (10) patient MR's reviewed. (Patient # 5)

Findings include:

1. Review of MR for patient # 5 indicated the following:
A. The patient was a 78 y/o (year/old) admitted to H # 1 (Psychiatric Hospital) hospital on 04/26/2018 with the following diagnoses: schizoaffective disorder, borderline personality disorder, diabetes mellitus, and obesity.
B. On 05/08/2018 at approximately 2:00 pm, P # 55 (Chief Medical Officer-CMO) wrote an order for "Mepilex to L (left) heel-change daily and PRN" for (open wound).
C. Review of the MAR (Medication Administration Record) indicated the dressing change was entered on the MAR on 05/08/2018, but was lacking documentation of dressing changes being completed as ordered on patient # 5's L heel from 05/08/2018 (when the dressing was ordered) until the patient's discharge on 05/14/2018.

2. On 06/20/2018 at approximately 3:20 pm an interview with administrative staff member P # 50 (Director of Nursing-DON), and administrative staff member P # 54 (Director of Operations-DOO), confirmed that patient # 5's MR lacked the daily wound dressing change documentation to the patient's L heel which had been ordered by the physician.

Based on document review and interview, the facility failed to ensure the nursing staff followed the policy and procedure related to developing and updating the patients treatment plan/plan of care (POC) for one (1) of ten (10) patient medical records (MR's) reviewed. (Patient # 5)

Findings include:

1. Review of the hospital policy titled, "TREATMENT PLAN", issued date 05/2016, indicated that every patient "shall have an individualized comprehensive Master Treatment Plan". The "needs", strengths, preferences and goals of the patient are "identified based on screening and assessment", and are "used in the plan for care, treatment or services". Every patient's treatment plan shall "identify patient goals" and associated objectives and "interventions necessary to meet the identified goals". Goals and objectives will be "reevaluated" and, as necessary, "revised based on changes in the patient's condition", problems, needs and responses to care, treatment and services. The treatment plan shall contain "specific interventions". Patient's that receive a "new diagnoses, regarding physical health care needs", will be addressed in the next scheduled treatment team meeting. This policy was last revised on 04/2018.

2. Review of the hospital policy titled, "PATIENT RIGHTS AND RESPONSIBILITIES", issued date 05/2016, indicated "a current individualized treatment plan that addresses" the patient's needs. An individualized treatment plan "will be specific and identify appropriate and adequate services, as available, either directly or by referral". This policy was last revised on 08/2017.

3. Review of MR for patient # 5 indicated the following:
A. The patient was a 78 y/o (year/old) admitted to H # 1 (Psychiatric Hospital) hospital on 04/26/2018 with the following diagnoses: schizoaffective disorder, borderline personality disorder, diabetes mellitus, and obesity.
B. The initial ADMISSION SKIN ASSESSMENT form was completed on 04/27/2018 at approximately 9:00 pm, indicated the patient to have a five (5) cm (centimeter) by five (5) cm site with a "dry skin callous on the R (right) heel". The box for "heels" was marked checked which the directions on the form indicated "check each pressure point that is clear of redness or lesions". The MR lacked a treatment plan/plan of care and interventions related to the patient's skin integrity concern.

4. On 06/20/2018 at approximately 3:20 pm with administrative staff member P # 50 (Director of Nursing-DON), and administrative staff member P # 54 (Director of Operations-DOO), confirmed that patient # 5's MR was lacking documentation related to a treatment plan/plan of care for skin integrity concerns upon admission, and lacked updating throughout the patient's hospital stay.

Based on observation and interview, the facility failed to provide the safety and well-being of patients are assured by having slippery floors throughout the whole hospital.

Findings include:

1. Review of policy titled: Patient Safety Plan, reviewed 08/2017, indicated the definition of Patient Safety was freedom from accidental injury while receiving healthcare services. The definition of a Patient Safety Event was any identified defect, error, medical accident, near miss, sentinel event or procedural event.

2. Upon arrival at facility, this surveyor noticed the floors to be slippery throughout the facility. Surveyor could slide rubber soled shoes across floor without much effort.

3. Interview with P51, Administrator and MD1 on 06/18/18 at 2:45 pm, confirmed that floors were slippery.

4. Interview on 06/19/18 at 2:00 pm with P51, confirmed humidifier to be rented from HVAC (heating, ventilation and air conditioning) company and placed 06/19/18. Completed before exit.