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Based on interview and record review, the facility failed to ensure the facility's policies and procedures were implemented when:

1. After being sexually inappropriate with staff, Patient 5 was not placed on a 1:1. This failure resulted in Patient 4 being choked and sexually assaulted by Patient 5 (0398);

Based on interview and record review, the facility failed to implement their "Precautions and Observations of Patients," and "Patient to Patient Assault" policies and ensure Patient 4 was protected from abuse/assault per the facility's written policies and procedures.

This failure resulted in Patient 4 being harmed when choked and sexually assaulted by Patient 5.

Findings:

On October 12, 2023, at 10:45 a.m., an interview with the Director of Performance Improvement and Risk Management (DPIRM) was conducted. The DPIRM stated, on October 4, 2023, at approximately 12:40 p.m., Patient 5 was found in Patient 4's room on top of her. Patient 5 was choking Patient 4, and both did not have any clothing on, below the waist. She stated Patient 4 was transferred to an outside hospital for an exam, and Patient 5 was taken into police custody.

A record review was conducted on October 12, 2023, 1 p.m., with the DPIRM. Patient 4's medical record indicated Patient 4 was admitted October 3, 2023, at 1:39 p.m., on a 5150 (involuntary 72-hour psychiatric hospitalization with a mental health disorder who may be a threat to self or others) hold with a psychiatric diagnosis of schizophrenia. Patient 4's record indicated her observation level was Q15 (monitored every 15 minutes). DPIRM stated all patients are evaluated when they initially arrive and are placed on observation every 15 minutes, every 5 minutes or 1:1 (one staff to be with one patient at all times).

The facility document titled, "PSYCHIATRIC EVALUATION," dated October 3, 2023, indicated, "...female [Patient 4]who presents to [name of facility] on a 5150 for DTO [danger to others], after threatening her mother and throwing items at her..."

The facility document titled, "PROGRESS NOTE," dated October 4, 2023, at 5:54 p.m., indicated, "...patient [Patient 4] is found isolating in her room, remaining in bed..."

The facility document titled, "PROGRESS NOTES," dated October 4, 2023, at 12:45 p.m., indicated, "...I heard someone screaming, walked towards the noise and [Patient 4's name] was running towards me saying please help me, the other pt [patient] attacked me. I check the pt there was some marks at her neck and cut on her left hand...when BHA [Behavior Health Associate] doing rounds found him over the pt try to have sex with her..."

The facility document titled, "MEDICAL PROGRESS NOTE," dated October 4, 2023, at 1:07 p.m., indicated, "...called by nurse as pt got assaulted by another pt per pt the other pt came to the room pulled his pants down and asked her to pull her pants down and came on top of her and pressed on her neck pt states no penetration sexually but not sure. She said it was about a minute before someone came to the room...R/O [rule out] vaginal injury...sent to ER [Emergency Room] now..."

The facility document titled, "PRACTIONER ORDER SHEET," dated October 4, 2023, at 1:07 p.m., indicated, "...send to ER [emergency room] to r/o vaginal injury..."

The facility document titled, "PROGRESS NOTES," dated October 4, 2023, at 2 p.m., indicated, "...pt was tearful. She was withdrawn as well...observed a cut on pt's wrist and what appeared to be red marks on pt's L [left] side of neck..."

The facility document titled, "PROGRESS NOTES," dated October 4, 2023, at 5 p.m., indicated, "...Around 12:45 [p.m.] patient was found on the floor as she was being held down and choked by [Patient 5]..."

The facility document titled, "MEDICAL PROGRESS NOTE," dated October 5, 2023, at 1:55 p.m., indicated, "...eye has redness on left eye..."

The facility document titled, "MEDICATION ADMINISTRATION RECORD," dated October 5, 2023, at 5:50 p.m., indicated, "...plan B [emergency contraceptive, a backup method to other birth control] 1x [one time] dose now...unprotected sex..."

An interview and concurrent record review of Patient 5's chart was conducted on October 12, 2023, at 1:30 p.m. with the DPIRM. Patient 5's chart indicated Patient 5 was admitted September 29, 2023, at 5 p.m., on a 5150 hold with a psychiatric diagnosis of major depressive disorder. The DPIRM stated Patient 5 had an altercation with a male staff (BHA1) in the morning. Patient 5 was then given an emergency IM (intramuscular injection) medication for his aggression. Patient 5 then followed a female staff (BHA 2) into a patient room and grabbed her butt.

The facility document titled, "PSYCHIATRIC EVALUATION," dated September 30, 2023, indicated, "...on a 5150 hold for SI [suicidal ideation] attempt after drinking bleach..."

The facility document titled, "PROGRESS NOTES," dated October 4, 2023, at 8:30 a.m., indicated, "...pt became agitated and paranoid yelling, attack staff member..."

The facility document titled, "PRACTIONER ORDER SHEET," dated October 4, 2023, at 8:41 a.m., indicated, "...Haldol 10 mg [mg-unit of measurement] IM x 1 time now...Diphenhydramine 50 mg IM 1 time now...Physical assault on staff..."

The facility document titled, "...PROGRESS NOTES," dated October 4, 2023, indicated, "...patient assaulted 2 staff members this morning...He grabbed 1 staff member by the throat...He later inappropriately touched another staff member in a sexual manner...he made clear that he was physically desiring to touch the staff member...place patient on one-to-one observation due to being a danger to others..."

The facility document titled, "PRACTIONER ORDER SHEET," dated October 4, 2023, at 10:15 p.m., indicated "...increase Risperdal to 4 mg PO [by mouth] BID [twice a day] psychosis...Place patient on 1:1 observation during the day, q5 [every 5] min [minutes] after 2100 [9 p.m.]...DTO; assaulting others..." Per DPIRM, there was no documented evidence patient was placed on a 1:1 as ordered by physician.

The facility document titled, "PRACTIONER ORDER SHEET," dated October 4, 2023, at 12:45 p.m., indicated, "...please place on 1:1 observation at all times now...DTO, sexually assaultive behavior..." Per DPIRM, this second order was placed by another physician after the assault.

The facility document titled, " PROGRESS NOTES," dated October 4, 2023, at 12:55 p.m., indicated, "...Around 12:45 a BHA [BHA 3] was rounding on patients and BHA [3] yelled "get off of her...I ran to room [number of room] and patient [Patient 5] was standing over Patient 4 with his pants down and Patient 4 was laying on the floor...Per BHA [3] report before I walked in the room, patient was on top of Patient 4 and was choking her..."

The facility document titled, "Progress Notes," dated October 4, 2023, at 5 p.m., indicated, "...patient was placed in seclusion per providers orders around 1330 [1:30 p.m.] for sexually assaultive behavior towards another female patient in which he removed female patient's pants and laid on top of her while holding her down by her neck...patient was released from seclusion when he was released to Riverside Police department around 1620 [4:20 p.m.] for custody..."

On October 12, 2023, at 3:02 p.m., an interview was conducted with BHA 3. He stated, while doing rounds after lunch, he could not locate Patient 5. He looked in the lunchroom, day room, then proceeded to look for him down the hallway. He stated he started looking in patients' rooms and noticed that Patient 4's room door was slightly closed. He stated he entered Patient 4's room and observed Patient 5 on top of Patient 4 on the floor between the two beds. BHA 3 stated both Patient 4 and Patient 5 did not have any pants or underwear on at this time. BHA 3 stated if Patient 5 would have been placed on 1:1 monitoring as ordered, this incident would not have happened. BHA 3 stated if Patient 5 would have been placed on a 1:1, the unit would have been short one BHA because 1:1 BHAs are extra and do not count in the staffing.

The document titled, "ACUITY AND STAFFING: (NAME OF UNIT)," dated October 4, 2023, day shift and the document titled "Staffing Grid with Acuity Totals," was reviewed with DPIRM. The DPIRM stated unit staffing is based on patient acuity. The acuity and staffing document indicated there were 24 patients on the unit. The document further indicated the patient acuity for Unit A was 51 with one patient on a 1:1 (Patient 3), dropping the acuity total to 48 as the 1:1 patient acuity is not counted for staffing. Per the staffing grid, the unit should have two RNs, one LVN, and two BHAs, with one extra BHA for the 1:1.

The document titled, "Wednesday, October 4, 2023 (name of unit) was reviewed. The document indicated the unit had two RNs, one LVN and three BHAs. One of the three BHAs was assigned to a 1:1 for Patient 3. Per DPIRM the unit did not have enough BHAs to place Patient 2 on a 1:1.

On October 12, 2023, at 3:45 p.m. an interview was conducted with Registered Nurse (RN) 1. RN 1 stated Patient 5 hit a male staff (BHA 1) in the morning. RN 1 stated she administered an emergency IM medication to Patient 5. She stated Patient 5 later followed a female staff, (BHA 2), and grabbed her butt. She stated Patient 5 had an order to be placed on a 1:1 at 10:15 a.m., but RN 1 was not aware because she was in the medication room. She stated the floor nurse, a charge nurse (CN) or a house supervisor (HS) can place an aggressive patient on a 1:1 while calling the physician for the verbal order. She stated the unit would have needed another BHA to be assigned to Patient 5. She stated when a patient needs to be on a 1:1 they should be placed on a 1:1 right away.

On October 12, 2023, at 4:13 p.m. an interview with the Director of Clinical Services (DCS) was conducted. She stated when a physician writes an order for a patient to be placed on a 1:1, it should be acted upon immediately. She stated it should be a massive communication between floor nurses, charge nurse, and house supervisor. DCS stated the HS was aware of the order and there was a delay in placing Patient 2 on a 1:1. DCS stated the CN or HS could have relieved staff on Unit A so Patient 5 could have been placed on a 1:1.

On October 16, 2023, at 1:13 p.m. an interview was conducted with BHA 2. BHA 2 stated Patient 5 hit a male staff (BHA 1) the morning of October 4, 2023. She stated a while later when she was rounding on patients, Patient 5 followed her into a patient's room and proceeded to grab her butt. BHA 2 stated she informed nursing staff about the butt grab, but nothing was done to Patient 5. BHA 2 stated she informed Nurse Practitioner (NP) when she came in about Patient 5 grabbing her butt. BHA 2 stated the NP assessed Patient 5 right away and wrote an order for Patient 5 to be placed on a 1:1. BHA 2 stated NP told her, BHA 1, the RNs, and the Charge Nurse, about the order. BHA 2 stated during meetings, they have been told that the HS can help when they are short, but she didn't. She stated this incident could have been avoided if someone would have helped on the unit and placed Patient 5 on a 1:1 monitoring.

On October 16, 2023, at 2:02 p.m. an interview with Social Worker (SW) 1 was conducted. SW 1 stated once the order is placed, the HS or CN is notified and then it is their responsibility to place a patient on 1:1. SW 1 stated this incident would not have occurred if the order would have been followed.

On October 16, 2023, at 2:43 p.m., an interview with Social Worker (SW) 2 was conducted. SW 2 stated the HS is responsible for assigning a BHA to a patient who needs to be on a 1:1. SW 2 stated the HS had requested another BHA to come in, but that staff was not scheduled to come in until 2 p.m. SW 2 stated a charge nurse, or the HS could have helped on the floor so that a male BHA could have been assigned to Patient 5 until that BHA came in at 2 p.m.

On October 16, 2023, at 3 p.m., an interview with BHA 1 was conducted. BHA 1 stated they were on the floor on a 1:1 with a different patient. BHA 1 stated Patient 5 became aggressive the morning of October 4th and punched him. BHA 1 stated staff gave Patient 5 an injected medication after the aggression. BHA stated after the injection medication, BHA 2 told him that Patient 5 had grabbed her butt. BHA 1 stated he spoke to the NP and was told that NP had placed an order for Patient 5 to have a 1:1 sitter. BHA 1 stated the unit did not have enough BHAs to place Patient 5 on a sitter and that another BHA would have to have come in.

On October 16, 2023, at 4 p.m., an interview with the NP was conducted. She stated she was informed of Patient 5's inappropriate behavior when she came onto the unit. She stated she met with Patient 5 and decided he needed to be placed on a 1:1 for predatory behavior. She stated she let unit nurses know of the need for a 1:1. NP stated that an hour later she noticed Patient 5 was still not on a 1:1. She stated she spoke to the HS to clarify that Patient 5 needed to be on a 1:1. She stated the HS told her she was working on it, currently did not have the staff to complete the order but was working on it. NP stated the HS knows the hospitals resources and therefore could have made changes to have Patient 5 monitored. NP stated if Patient 5 had been placed on a 1:1 this incident would have not occurred.

A review of the facility policy and procedure titled, "PRECAUTIONS AND OBSERVATIONS OF PATIENTS," dated April 2023, indicated, "...provide a safe and secure environment for patients during their hospitalization. Levels of observation can be initiated by nursing staff and are accompanied by a physician order when a patient may be considered to be at increased risk for harm to self, others...sexual acting out...Clinical staff should assess the patient's risk factors...the licensed nurse or physician should determine the level of risk associated with each new admission and throughout their hospitalization on the basis of past behavior, present situation and current mental status...an order for the appropriate level of observation and precautions should be documented in the physician's order section of the medical record, and the Rounds Sheets should be initiated by the charge nurse or designee...Initiation of precautions should be documented in the physician orders specifying date, time and level of observation...A licensed nurse or designee should ensure that all patient orders for special precautions are recorded and posted...registered nurse should address the status of the patient on special precautions in the progress notes...for the level of observation and precaution initiated...during the course of treatment, any qualified mental health/medical professional...may determine that intensified patient supervision is warranted and clinically necessary..."

A review of the facility policy and procedure titled, "Patient to Patient Assault," revised April 2023, indictaed, "...Purpose...to provide a safe and secure enviroment for all patients and staff..."

Based on interview and record review, the facility failed to implement their "Precautions and Observations of Patients," and "Patient to Patient Assault" policies and ensure Patient 4 was protected from abuse/assault per the facility's written policies and procedures.

This failure resulted in Patient 4 being harmed when choked and sexually assaulted by Patient 5.

Findings:

On October 12, 2023, at 10:45 a.m., an interview with the Director of Performance Improvement and Risk Management (DPIRM) was conducted. The DPIRM stated, on October 4, 2023, at approximately 12:40 p.m., Patient 5 was found in Patient 4's room on top of her. Patient 5 was choking Patient 4, and both did not have any clothing on, below the waist. She stated Patient 4 was transferred to an outside hospital for an exam, and Patient 5 was taken into police custody.

A record review was conducted on October 12, 2023, 1 p.m., with the DPIRM. Patient 4's medical record indicated Patient 4 was admitted October 3, 2023, at 1:39 p.m., on a 5150 (involuntary 72-hour psychiatric hospitalization with a mental health disorder who may be a threat to self or others) hold with a psychiatric diagnosis of schizophrenia. Patient 4's record indicated her observation level was Q15 (monitored every 15 minutes). DPIRM stated all patients are evaluated when they initially arrive and are placed on observation every 15 minutes, every 5 minutes or 1:1 (one staff to be with one patient at all times).

The facility document titled, "PSYCHIATRIC EVALUATION," dated October 3, 2023, indicated, "...female [Patient 4]who presents to [name of facility] on a 5150 for DTO [danger to others], after threatening her mother and throwing items at her..."

The facility document titled, "PROGRESS NOTE," dated October 4, 2023, at 5:54 p.m., indicated, "...patient [Patient 4] is found isolating in her room, remaining in bed..."

The facility document titled, "PROGRESS NOTES," dated October 4, 2023, at 12:45 p.m., indicated, "...I heard someone screaming, walked towards the noise and [Patient 4's name] was running towards me saying please help me, the other pt [patient] attacked me. I check the pt there was some marks at her neck and cut on her left hand...when BHA [Behavior Health Associate] doing rounds found him over the pt try to have sex with her..."

The facility document titled, "MEDICAL PROGRESS NOTE," dated October 4, 2023, at 1:07 p.m., indicated, "...called by nurse as pt got assaulted by another pt per pt the other pt came to the room pulled his pants down and asked her to pull her pants down and came on top of her and pressed on her neck pt states no penetration sexually but not sure. She said it was about a minute before someone came to the room...R/O [rule out] vaginal injury...sent to ER [Emergency Room] now..."

The facility document titled, "PRACTIONER ORDER SHEET," dated October 4, 2023, at 1:07 p.m., indicated, "...send to ER [emergency room] to r/o vaginal injury..."

The facility document titled, "PROGRESS NOTES," dated October 4, 2023, at 2 p.m., indicated, "...pt was tearful. She was withdrawn as well...observed a cut on pt's wrist and what appeared to be red marks on pt's L [left] side of neck..."

The facility document titled, "PROGRESS NOTES," dated October 4, 2023, at 5 p.m., indicated, "...Around 12:45 [p.m.] patient was found on the floor as she was being held down and choked by [Patient 5]..."

The facility document titled, "MEDICAL PROGRESS NOTE," dated October 5, 2023, at 1:55 p.m., indicated, "...eye has redness on left eye..."

The facility document titled, "MEDICATION ADMINISTRATION RECORD," dated October 5, 2023, at 5:50 p.m., indicated, "...plan B [emergency contraceptive, a backup method to other birth control] 1x [one time] dose now...unprotected sex..."

An interview and concurrent record review of Patient 5's chart was conducted on October 12, 2023, at 1:30 p.m. with the DPIRM. Patient 5's chart indicated Patient 5 was admitted September 29, 2023, at 5 p.m., on a 5150 hold with a psychiatric diagnosis of major depressive disorder. The DPIRM stated Patient 5 had an altercation with a male staff (BHA1) in the morning. Patient 5 was then given an emergency IM (intramuscular injection) medication for his aggression. Patient 5 then followed a female staff (BHA 2) into a patient room and grabbed her butt.

The facility document titled, "PSYCHIATRIC EVALUATION," dated September 30, 2023, indicated, "...on a 5150 hold for SI [suicidal ideation] attempt after drinking bleach..."

The facility document titled, "PROGRESS NOTES," dated October 4, 2023, at 8:30 a.m., indicated, "...pt became agitated and paranoid yelling, attack staff member..."

The facility document titled, "PRACTIONER ORDER SHEET," dated October 4, 2023, at 8:41 a.m., indicated, "...Haldol 10 mg [mg-unit of measurement] IM x 1 time now...Diphenhydramine 50 mg IM 1 time now...Physical assault on staff..."

The facility document titled, "...PROGRESS NOTES," dated October 4, 2023, indicated, "...patient assaulted 2 staff members this morning...He grabbed 1 staff member by the throat...He later inappropriately touched another staff member in a sexual manner...he made clear that he was physically desiring to touch the staff member...place patient on one-to-one observation due to being a danger to others..."

The facility document titled, "PRACTIONER ORDER SHEET," dated October 4, 2023, at 10:15 p.m., indicated "...increase Risperdal to 4 mg PO [by mouth] BID [twice a day] psychosis...Place patient on 1:1 observation during the day, q5 [every 5] min [minutes] after 2100 [9 p.m.]...DTO; assaulting others..." Per DPIRM, there was no documented evidence patient was placed on a 1:1 as ordered by physician.

The facility document titled, "PRACTIONER ORDER SHEET," dated October 4, 2023, at 12:45 p.m., indicated, "...please place on 1:1 observation at all times now...DTO, sexually assaultive behavior..." Per DPIRM, this second order was placed by another physician after the assault.

The facility document titled, " PROGRESS NOTES," dated October 4, 2023, at 12:55 p.m., indicated, "...Around 12:45 a BHA [BHA 3] was rounding on patients and BHA [3] yelled "get off of her...I ran to room [number of room] and patient [Patient 5] was standing over Patient 4 with his pants down and Patient 4 was laying on the floor...Per BHA [3] report before I walked in the room, patient was on top of Patient 4 and was choking her..."

The facility document titled, "Progress Notes," dated October 4, 2023, at 5 p.m., indicated, "...patient was placed in seclusion per providers orders around 1330 [1:30 p.m.] for sexually assaultive behavior towards another female patient in which he removed female patient's pants and laid on top of her while holding her down by her neck...patient was released from seclusion when he was released to Riverside Police department around 1620 [4:20 p.m.] for custody..."

On October 12, 2023, at 3:02 p.m., an interview was conducted with BHA 3. He stated, while doing rounds after lunch, he could not locate Patient 5. He looked in the lunchroom, day room, then proceeded to look for him down the hallway. He stated he started looking in patients' rooms and noticed that Patient 4's room door was slightly closed. He stated he entered Patient 4's room and observed Patient 5 on top of Patient 4 on the floor between the two beds. BHA 3 stated both Patient 4 and Patient 5 did not have any pants or underwear on at this time. BHA 3 stated if Patient 5 would have been placed on 1:1 monitoring as ordered, this incident would not have happened. BHA 3 stated if Patient 5 would have been placed on a 1:1, the unit would have been short one BHA because 1:1 BHAs are extra and do not count in the staffing.

The document titled, "ACUITY AND STAFFING: (NAME OF UNIT)," dated October 4, 2023, day shift and the document titled "Staffing Grid with Acuity Totals," was reviewed with DPIRM. The DPIRM stated unit staffing is based on patient acuity. The acuity and staffing document indicated there were 24 patients on the unit. The document further indicated the patient acuity for Unit A was 51 with one patient on a 1:1 (Patient 3), dropping the acuity total to 48 as the 1:1 patient acuity is not counted for staffing. Per the staffing grid, the unit should have two RNs, one LVN, and two BHAs, with one extra BHA for the 1:1.

The document titled, "Wednesday, October 4, 2023 (name of unit) was reviewed. The document indicated the unit had two RNs, one LVN and three BHAs. One of the three BHAs was assigned to a 1:1 for Patient 3. Per DPIRM the unit did not have enough BHAs to place Patient 2 on a 1:1.

On October 12, 2023, at 3:45 p.m. an interview was conducted with Registered Nurse (RN) 1. RN 1 stated Patient 5 hit a male staff (BHA 1) in the morning. RN 1 stated she administered an emergency IM medication to Patient 5. She stated Patient 5 later followed a female staff, (BHA 2), and grabbed her butt. She stated Patient 5 had an order to be placed on a 1:1 at 10:15 a.m., but RN 1 was not aware because she was in the medication room. She stated the floor nurse, a charge nurse (CN) or a house supervisor (HS) can place an aggressive patient on a 1:1 while calling the physician for the verbal order. She stated the unit would have needed another BHA to be assigned to Patient 5. She stated when a patient needs to be on a 1:1 they should be placed on a 1:1 right away.

On October 12, 2023, at 4:13 p.m. an interview with the Director of Clinical Services (DCS) was conducted. She stated when a physician writes an order for a patient to be placed on a 1:1, it should be acted upon immediately. She stated it should be a massive communication between floor nurses, charge nurse, and house supervisor. DCS stated the HS was aware of the order and there was a delay in placing Patient 2 on a 1:1. DCS stated the CN or HS could have relieved staff on Unit A so Patient 5 could have been placed on a 1:1.

On October 16, 2023, at 1:13 p.m. an interview was conducted with BHA 2. BHA 2 stated Patient 5 hit a male staff (BHA 1) the morning of October 4, 2023. She stated a while later when she was rounding on patients, Patient 5 followed her into a patient's room and proceeded to grab her butt. BHA 2 stated she informed nursing staff about the butt grab, but nothing was done to Patient 5. BHA 2 stated she informed Nurse Practitioner (NP) when she came in about Patient 5 grabbing her butt. BHA 2 stated the NP assessed Patient 5 right away and wrote an order for Patient 5 to be placed on a 1:1. BHA 2 stated NP told her, BHA 1, the RNs, and the Charge Nurse, about the order. BHA 2 stated during meetings, they have been told that the HS can help when they are short, but she didn't. She stated this incident could have been avoided if someone would have helped on the unit and placed Patient 5 on a 1:1 monitoring.

On October 16, 2023, at 2:02 p.m. an interview with Social Worker (SW) 1 was conducted. SW 1 stated once the order is placed, the HS or CN is notified and then it is their responsibility to place a patient on 1:1. SW 1 stated this incident would not have occurred if the order would have been followed.

On October 16, 2023, at 2:43 p.m., an interview with Social Worker (SW) 2 was conducted. SW 2 stated the HS is responsible for assigning a BHA to a patient who needs to be on a 1:1. SW 2 stated the HS had requested another BHA to come in, but that staff was not scheduled to come in until 2 p.m. SW 2 stated a charge nurse, or the HS could have helped on the floor so that a male BHA could have been assigned to Patient 5 until that BHA came in at 2 p.m.

On October 16, 2023, at 3 p.m., an interview with BHA 1 was conducted. BHA 1 stated they were on the floor on a 1:1 with a different patient. BHA 1 stated Patient 5 became aggressive the morning of October 4th and punched him. BHA 1 stated staff gave Patient 5 an injected medication after the aggression. BHA stated after the injection medication, BHA 2 told him that Patient 5 had grabbed her butt. BHA 1 stated he spoke to the NP and was told that NP had placed an order for Patient 5 to have a 1:1 sitter. BHA 1 stated the unit did not have enough BHAs to place Patient 5 on a sitter and that another BHA would have to have come in.

On October 16, 2023, at 4 p.m., an interview with the NP was conducted. She stated she was informed of Patient 5's inappropriate behavior when she came onto the unit. She stated she met with Patient 5 and decided he needed to be placed on a 1:1 for predatory behavior. She stated she let unit nurses know of the need for a 1:1. NP stated that an hour later she noticed Patient 5 was still not on a 1:1. She stated she spoke to the HS to clarify that Patient 5 needed to be on a 1:1. She stated the HS told her she was working on it, currently did not have the staff to complete the order but was working on it. NP stated the HS knows the hospitals resources and therefore could have made changes to have Patient 5 monitored. NP stated if Patient 5 had been placed on a 1:1 this incident would have not occurred.

A review of the facility policy and procedure titled, "PRECAUTIONS AND OBSERVATIONS OF PATIENTS," dated April 2023, indicated, "...provide a safe and secure environment for patients during their hospitalization. Levels of observation can be initiated by nursing staff and are accompanied by a physician order when a patient may be considered to be at increased risk for harm to self, others...sexual acting out...Clinical staff should assess the patient's risk factors...the licensed nurse or physician should determine the level of risk associated with each new admission and throughout their hospitalization on the basis of past behavior, present situation and current mental status...an order for the appropriate level of observation and precautions should be documented in the physician's order section of the medical record, and the Rounds Sheets should be initiated by the charge nurse or designee...Initiation of precautions should be documented in the physician orders specifying date, time and level of observation...A licensed nurse or designee should ensure that all patient orders for special precautions are recorded and posted...registered nurse should address the status of the patient on special precautions in the progress notes...for the level of observation and precaution initiated...during the course of treatment, any qualified mental health/medical professional...may determine that intensified patient supervision is warranted and clinically necessary..."

A review of the facility policy and procedure titled, "Patient to Patient Assault," revised April 2023, indictaed, "...Purpose...to provide a safe and secure enviroment for all patients and staff..."