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Based on interview and record review, the facility failed to ensure that each patient's rights were protected as evidenced by:

1. The facility failed to ensure one patient (Patient 1) was free from abuse. (Cross Reference A 145).

2. The facility failed to ensure four patients (Patients 1, 3, 4 and 5) were provided care in a safe environment. (Cross Reference A 144).

The cumulative effect of these systemic problems resulted in the facility's failure to meet statutorily mandated compliance with the Condition of Participation for Patient Rights.

Based on interview and record review, the facility failed to provide care in a safe setting for four patients (Patients 1, 3, 4 and 5) when:

1. The facility did not provide Patient 1 with supervision as ordered for patient safety;
2. Violence arising out of patients' riotous behavior made Patients 3, 4 and 5 feel fearful, anxious and unsafe.

These failures violated patients' right to safety in the care environment.

Findings:

1. During an interview on 11/4/16, at 11:15 a.m., the Chief Nursing Officer (CNO) stated the facility did not have enough staff to implement Patient 1's physician order for 1:1 supervision (e.g., a staff-to-patient ratio of 1:1, for patient supervision needs) at bedtime, on 10/30/16.

During an interview on 11/10/16, at 2:50 p.m., Unlicensed Staff E stated she was the only mental health worker scheduled to accept patient assignments on Patient 1's unit the evening of 10/30/16. Unlicensed Staff E stated the charge nurse did not assign her a 1:1 with Patient 1 that evening. Unlicensed Staff E stated that when she is the only worker scheduled, she is unable to perform 15-minute supervision checks every 15 minutes, on time, due to heavy workload requirements. Unlicensed Staff E confirmed finding Patient 2 in Patient 1's room during "safety checks" at the end of her shift. Unlicensed Staff E stated she did not realize Patient 1 required a 1:1 assignment during bedtime hours until the "[next shift] came on." Unlicensed Staff E "knew [Patient 2] shouldn't have been in another person's room" that evening.

During a review of the clinical record for Patient 1, the "Physician Orders," dated 10/28/16, indicated Patient 1's physician desired the facility to provide "1-1 supervision at night for bedtime."

The facility business document titled "Adolescent Unit Guidelines," no date, indicated a bedtime of " ... 9:00 p.m. (10 p.m. on the weekends) ... ."

During a review of the clinical record for Patient 2, the "Patient Observation Record," dated 10/30/16, indicated that during the evening shift Patient 2 posed a safety risk to other patients because Patient 2 exhibited sexual and violent behaviors.

The facility policy and procedure titled "Level of Observation," dated 5/1/13, indicated that a "Constant Observation 1:1" staff-to-patient assignment required staff to "maintain approximately one arms length away from the patient at all times," and to continue observations "even in the event of a patient showering, changing clothes or using the restroom."

2. During an interview on 11/9/16, at 11:06 a.m., the Chief Nursing Officer (CNO) stated an unusual incident occurred on 11/6/16 when patients on an adolescent unit "kicked and hit" staff. The CNO stated the police were called to the facility in response to the event.

During an interview on 11/15/16, at 10:00 a.m., Unlicensed Staff B confirmed the incident on the adolescent unit from 11/6/16. Unlicensed Staff B confirmed patients were violent toward staff and prevented staff trying to calm and make safe the care environment from doing their job. Unlicensed Staff B stated the incident required staff to place two patients in physical holds, as well as in seclusion. Unlicensed Staff B stated the incident frightened three patients, who were moved to another inpatient unit because they "didn't feel safe."

During a concurrent interview and record review of the "Daily Assignment" sheets for the adolescent units "500/Sierra" and "400," dated 11/6/16, on 11/16/16, at 10:40 a.m., Unit Manager C confirmed the facility moved three patients from the "500/Sierra" Unit to the "400" Sequoia Unit during the evening shift on 11/6/16 because the patients vocalized "fear and anxiety" from having witnessed the patients' behavior and facility response.

Based on interview and record review, the facility failed to ensure one patient (Patient 1) was free from abuse, when the facility did not prevent a second patient (Patient 2) from entering Patient 1's room during the evening shift on 10/30/16. This failure resulted in Patient 2 sexually assaulting Patient 1.

Findings:

During an interview on 11/4/16, at 9:53 a.m., the Director of Performance Improvement (DPI) stated that Patient 1 alleged on 10/31/16 that Patient 2 sexually assaulted the patient the evening before, on 10/30/16. The DPI stated Patient 2 "forced" Patient 2's self onto Patient 1 for sexual purposes. The DPI stated Patient 1 asked Patient 2 to stop, but Patient 2 did not. The DPI stated the facility's video surveillance system recorded activity in the facility's hallways at the time of the incident. The DPI stated the video surveillance captured Patient 2 entering and exiting Patient 1's room. The DPI stated the video recording indicated Patient 2 spent "40 minutes" inside Patient 1's bedroom.

During an interview on 11/4/16, at 11:15 a.m., the Chief Nursing Officer (CNO) stated Patient 1 was supposed to receive a "1:1" (e.g., a staff-to-patient ratio of 1:1, for patient supervision needs) at bedtime on the evening of 10/30/16. The CNO stated a 1:1 assignment at bedtime required staff to be "present, in arms reach" of the assigned patient after 9:00 p.m. The CNO stated the facility could not provide a 1:1 assignment for Patient 1 on the evening of the sexual assault because it "didn't have staff" to assume the role.

During an interview on 11/7/16, at 10:42 a.m., the DPI stated the facility's abuse policy and procedures were limited to abuse reporting. The DPI stated the facility retained no policy for training staff on abuse-related duties, or preventing abuse in the facility. The DPI stated staff were educated about necessary job duties related to abuse through a "quiz" and "handouts" provided during orientation.
During a concurrent interview and record review of video surveillance on 11/7/16, at 4:00 p.m., the Plant Operations Director (POD) stated the video surveillance recording showed Patient 2 entered Patient 1's bedroom at 10:40 p.m., on 10/30/16. The POD stated the recording showed two staff entered Patient 1's bedroom 38 minutes later, at 11:18 p.m. The POD stated the recording showed Patient 2 exited Patient 1's bedroom one minute after staff entered, or at 11:19 p.m.

During an interview on 11/9/16, at 2:34 p.m., Police Sergeant D stated a police investigation into the 10/30/16 incident between Patient 1 and Patient 2 substantiated that Patient 2 made sexual contact with Patient 1, with willful intent, by "digital penetration" of Patient 1's person.

The facility policy and procedure titled "Abuse Reporting" dated 7/24/13, indicated the facility had no formal system for preventing, identifying and investigating suspected abuse, training staff about their abuse-related duties, or screening staff for abuse indicators before hire.

Based on interview and record review, the facility failed to provide an organized nursing service for three patients (Patients 1, 8 and 9) as evidenced by:

1. The facility did not have a system to ensure a sufficient number of registered nurses and other qualified staff available to meet patients' acuity needs. (Cross Reference A 392).
2. The facility failed to ensure licensed staff kept current the multidisciplinary treatment plans. (Cross Reference A 396).
3. The facility failed to ensure qualified staff were assigned to observe patients while in the role as the "Hallway Monitor" staff person for the 300 Unit. (Cross Reference A 397).

The cumulative effect of these systemic problems resulted in the facility's failure to meet statutorily mandated compliance with the Condition of Participation for Nursing Services.

Based on interview and record review, the facility did not supervise one patient (Patient 1) as ordered for patient need, when it did not provide enough staff to implement Patient 1's order for 1:1 supervision, at bedtime, and perform safety checks every 15 minutes. These failures allowed another patient (Patient 2) to enter Patient 1's room, while unsupervised, and sexually assault Patient 1.

Findings:

During an interview on 11/4/16, at 11:15 a.m., the Chief Nursing Officer (CNO) stated the facility did not have enough staff to implement Patient 1's physician order for 1:1 supervision (e.g., a staff-to-patient ratio of 1:1, for patient supervision needs) at bedtime, on 10/30/16.

During a concurrent interview and record review of the facility's recorded video surveillance system, dated 10/30/16, on 11/7/16, at 4:00 p.m., the Plant Operations Director (POD) confirmed Patient 2 entered Patient 1's bedroom at 10:40 p.m. The POD also confirmed no staff member entered Patient 1's room from 10:40 p.m. until 11:18 p.m., or 38 minutes.

During a joint interview on 11/9/16, at 10:00 a.m., the CNO, Unit Nurse Manager C, Unit Nurse Manager F and Unlicensed Staff A were in attendance. Unit Nurse Managers C and F stated the facility did not increase the number of registered nursing staff on a unit if a patient's acuity needs required additional nursing services. Unit Nurse Manager F stated nurse managers used the a "staffing acuity form" provided by the facility to assess staffing numbers in relation to patient needs. Unit Nurse Manager F stated the form expressly limited a manager from assigning more than one registered nurse to a patient care unit. Unit Nurse Managers C and F stated that despite using the form, they have been unable to provide sufficient numbers of nursing staff to meet patients' clinical needs. Also, Unlicensed Staff A stated the facility used untrained staff in clinical areas on 11/4/16 to meet staffing needs.

During an interview on 11/10/16, at 2:50 p.m., Unlicensed Staff E stated she did not provide 1:1 supervision for Patient 1 during the evening shift on 10/30/16. Unlicensed Staff E stated she was the only mental health worker scheduled to accept patient assignments and the charge nurse did not assign her a 1:1 with Patient 1. Unlicensed Staff E stated that when she is the only mental health worker scheduled to a unit, she is unable to perform the 15-minute supervision checks every 15 minutes, on time, due to heavy workload requirements. Unlicensed Staff E recalled a heavy workload during her shift on 10/30/16. Also, Unlicensed Staff E recalled being pulled "multiple times" to another unit during the evening shift to "provide reassurance" to another, unassigned patient. Unlicensed Staff E stated she did not learn Patient 1 required a 1:1 assignment during bedtime hours until the "[night shift] came on." "I was confused!" Unlicensed Staff E confirmed finding Patient 2 in Patient 1's room during "safety checks" at the end of her shift that evening. Unlicensed Staff E "knew [Patient 2] shouldn't have been in another person's room."

During a review of the clinical record for Resident 1, the "Physician Orders," dated 10/28/16, indicated Patient 1 was ordered to be placed on "1-1 supervision at night for bedtime."

The facility business document titled "Adolescent Unit Guidelines," no date, indicated a bedtime of "... 9:00 p.m. (10 p.m. on the weekends) ... ."

The facility business record titled "Daily Assignment," dated 10/30/16 on the evening shift, indicated no staff were assigned to 1:1 supervision of Patient 1 at bedtime.

The facility policy and procedure titled "Level of Observation," dated 5/1/13, indicated that the "Constant Observation 1:1" staff-to-patient assignment required staff to "maintain approximately one arms length away from the patient at all times," and to continue close observations "even in the event of a patient showering, changing clothes or using the restroom."

The facility policy and procedure titled "Level of Observation," dated 5/1/13, indicated a "Routine Every 15-Minute Check" required staff to "observe and document patients' location and behavior every 15 minutes." The policy and procedure further indicated a 15-Minute Check was the facility's "minimum level of observation for all patients."

Based on interview and document review, the hospital failed to ensure licensed staff kept current the multidisciplinary treatment plan for a patient that required suicidal precautions, and to include individual interventions for suicidal precautions, for three of nine patients (Patients 8, 9 and 1). These failures could result in a delay in treatment and security for both the patient and others.

Findings:

1. Review of the Psychiatric Evaluation dated 10/27/16 indicated Patient 8 was admitted on 10/26/16 with diagnoses Major depressive disorder, recurrent, severe.

Review of Patient 8's Admission Orders dated 10/26/16 and timed at 6:15 p.m., indicated Patient 8's Observation Level: was checked for "Routine (Q [Every] 15 minutes checks)."
Note: Per the facility's policy and procedure titled "Level of Observation" effective date 5/1/2013, Level 3: routine every 15 minute check defined as "Staff will "check in" with patient periodically during waking hours to ascertain safety and well being."

Review of Patient 8's Physician's Orders (and Rationale when required) indicated on 10/31/16 at 9:45 a.m., the physician orders read "Please place patient on a 1:1. Expresses high level of suicidal ideation + urges to self harm. Stated doesn't feel safe alone."
Note: Per the facility's policy and procedure titled "Level of Observation" effective date 5/1/2013 Level 1: Constant Observation 1:1. Specified and dedicated staff member is assigned to the patient. Staff member will maintain approximately one arms length away from the patient at all times."

Review of Patient 8's master treatment/care plan indicated there were no updates to the initial problems/goals of the master treatment/care plan to reflect the physician's order for 1:1 monitoring. The treatment/care plan dated 10/26/16 indicated interventions that were provided to the patient - "Monitor patient as ordered by physician:" every 15 minutes was checked.

Review of Patient 1's master treatment/care plan indicated no update

2. Review of the Discharge Summary dated 11/4/16 indicated Patient 9 was admitted on 10/27/16 with diagnoses Major depressive disorder, recurrent, severe.

Review of Patient 9's Admission Orders dated 10/26/16 and timed at 11:30 p.m., indicated Patient 9's Observation Level: was checked for "Routine (Q [Every] 15 minutes checks)."
Note: Per the facility's policy and procedure titled "Level of Observation" effective date 5/1/2013 Level 3: routine every 15 minute check defined as "Staff will "check in" with patient periodically during waking hours to ascertain safety and well being."

Review of Patient 9's Physician's Orders (and Rationale when required) indicated on 10/27/16 at 10:16 a.m., and on 10/31/16 at 11:00 a.m., the physician orders read "1:1 for safety."
Note: Per the facility's policy and procedure titled "Level of Observation" effective date 5/1/2013, Level 1: Constant Observation 1:1. Specified and dedicated staff member is assigned to the patient. Staff member will maintain approximately one arms length away from the patient at all times."

Review of Patient 9's master treatment/care plan indicated there were no initial interventions or updates to the initial problems/goals of the master treatment/care plan to reflect the physician's orders for 1:1 monitoring.






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3. During a review of clinical record for Patient 1, the Face Sheet, no date, indicated Patient 1 was admitted to the facility on 10/27/16, secondary to the "single episode" of a "Major Depressive Disorder."

During review of the clinical record for Patient 1, the "Progress Notes," dated 10/27/16, indicated Patient 1 was found after bedtime in the patient's bedroom "with a pillow case and bed sheet wrapped around [the patient's] neck, trying to choke and kill" the patient's self.

During a review of the clinical record for Patient 1, the "Physician Orders," dated 10/28/16, indicated Patient 1 was ordered to be placed on "1-1 supervision at night for bedtime."

Review of Patient 1's master treatment/care plan indicated no update to reflect the 10/28/16 physician order for 1:1 supervision.

During an interview on 11/8/16 at 3:00 p.m., Chief Nursing Officer stated that a treatment plans of care should be updated when new physician orders are received, for the 1:1 monitoring to begin. The nurse needed to revise the care plan as needed.

On 11/9/16, review of the facility policy MULTIDISCIPLINARY TREATMENT PLANNING (MDTP), revised 12/11/13, indicated the purpose "to provide a process for implementation of comprehensive individualized treatment planning for every inpatient. The MDTP is reviewed and revised as needed...The plan shall be revised more frequently when the patient's status or acuity changes significantly (example if patient is secluded or restrained for very dangerous/violent behavior to self or others)...Each patient's MDTP is reviewed at least twice a week and more often as warranted. The Physician directs patient care planning."

Based on interview, and document review, the hospital failed to ensure qualified staff were assigned to observe patients while in the role as the "Hallway Monitor" staff person for the 300 Unit. This failure has the potential to place patients at risk whose special needs would not be met by unqualified staff.

Findings:

During an interview on 11/8/16 at 3:00 p.m., the Chief Nursing Officer (CNO), stated the hospital implemented at new "Hallway Monitor" position for the four units. The "Hallway Monitor" staff person was assigned around the clock seven days a week. She stated the hospital did not have a policy and procedure for this position that would describe duties for the assigned staff person. She stated she received the directive in an email from the administrative assistant on 11/2/16.

During a joint interview on 11/9/16, at 10:00 a.m., the CNO, Unit Nurse Manager C, Unit Nurse Manager F and Unlicensed Staff A were in attendance. Unlicensed Staff A stated the facility used untrained staff in clinical areas on 11/4/16 to meet the directive from administration to staff the "Hallway Monitor" position around the clock.

During a concurrent review of the Daily Staffing record with Unlicensed Staff A, dated 11/4/16, indicated Unlicensed Staff G was assigned as the "Hallway Monitor" on the PM shift from 3:00 p.m. - 5:30 p.m., the Cedar Unit or the 300 Unit.

During an interview on 11/9/16 at noon, Unlicensed Staff G, stated she was the "Hall Monitor" person assigned on 11/4/16 on the PM shift. She stated she was told to sit in a chair in the hallway and watch patients in the hallway. If she identified something out of the ordinary she was to report to floor staff. She stated she has not seen a job description for this role, she had not seen a policy/procedure outlining the duties for this role. She stated she has not had assault training and she was not a mental health worker. She worked in the business office and currently in health information management as a file clerk.

During a concurrent interview, and document review, Human Resource (HR) Director confirmed Unlicensed Staff G's qualifications. He stated he did not develop a job description for the "Hallway Monitor" position and was aware the hospital was assigning unlicensed staff as a "Hallway Monitor."