HospitalInspections.org

Based on observation, interview, and record review, the facility failed to provide services necessary to protect 2 of 2 patients (Patient #1 and Patient #2). This was evidenced by the facility's failure to ensure that observation rounds were conducted every 15 minutes during the early morning of 2/18/2025. During this timeframe, Patient #1 and Patient #2 leveled allegations that sexual misconduct had transpired between them.

Findings were:

Review of policy 17820416 - Levels of Observation and Precaution Levels, last reviewed 03/2025, showed: All patients will be routinely observed in compliance with physician orders and prescribed protocols ... Staff will observe patient and document on the Patient Observation Record every 15 minutes.

Review of the Accountability Flow Sheet (Patient Observation Record) for Patient #1 on the Children's Unit showed the following entries documenting the date and time, and staff member making the entry.
2/17/2025 - 11:31 PM, 1:02 AM = 31 minutes. Staff Q (MHT)
2/18/2025 - 2:46 AM, 3:11 AM = 25 minutes. Staff Q (MHT)
2/18/2025 - 6:17 AM, 6:41 AM = 29 minutes. Staff Q (MHT)
2/18/2025 - 6:43 PM, 7:13 PM = 30 minutes. Staff O (MHT)

Review of the Accountability Flow Sheet (Patient Observation Record) for Patient #2 on the Children's Unit showed the following entries documenting the date and time, and staff member making the entry.
2/18/2025 - 2:46 AM, 3:11 AM = 25 minutes. Staff Q (MHT)
2/18/2025 - 4:01 AM, 4:29 AM = 28 minutes. Staff Q (MHT)
2/18/2025 - 5:48 AM, 6:16 AM = 28 minutes. Staff Q (MHT)
2/18/2025 - 6:43 PM, 7:13 PM = 30 minutes. Staff O (MHT)
2/18/2025 - 11:46 PM, 12:19 AM = 33 minutes. Staff Q (MHT)

Patient #1.
Review of the Psychiatric Evaluation by Staff J (MD) dated 2/13/2025 at 9:41 AM showed Patient #1 was a 9-year-old male admitted from a residential treatment facility for mood issues, anger, homicidal thoughts, and suicidal thoughts with a plan to stab himself.

Review of Nursing Note by Staff G (RN) dated 2/18/2025 at 8:02 PM showed that Patient #1 reported sexual contact between himself and Patient #2 during the night.

Patient #2.
Review of the Psychiatric Evaluation by Staff X (MD) dated 2/19/2025 at 1:12 AM showed Patient #2 was a 9-year-old male admitted with anger and aggression and homicidal thoughts.

Review of Nursing Note by Staff G (RN) dated 2/18/2025 at 7:24 PM showed that Patient #2 reported sexual contact between himself and Patient #1 during the night.