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Based on interview, record review, and policy review, it was determined the facility failed to have an effective Governing Body in place to successfully manage the facility. Record review and interview with the Medical Director (MD) revealed the Governing Body failed to: ensure Patient #2 and Patient #3 were free from abuse, provide increased supervision for Patient #2 and Patient #3, document observed inappropriate behaviors in the Progress Notes between Patient #2, and Patient #3, ensure patient rights had not been violated for Patient #2 and Patient #3, ensure ordered medications were administered to Patient #3 and failed to ensure labwork had been completed for Patient #3.

The findings include:

Review of the document titled, "Bylaws of the Board of Governors," dated and signed, on 04/01/2020, by the Chair of the Board, stated; Article IV, Purpose of the Hospital- The Board shall be accountable for the safety and quality of care, treatment, and services of the Hospital... Article V stated, The principle duties and responsibilities of the Board shall be to: 4.) Ensure continuous quality improvement through monitoring of professional services provided by the Medical Staff, allied health professionals and other health care providers who provide services at the Hospital.

Review of Patient #2's clinical record revealed the facility admitted the patient, on 06/04/2021, with diagnoses that included Psychosis and Catatonia.

Review of Patient #3's closed record revealed the facility admitted the patient, on 06/09/2021, with diagnoses that included Human Immunodeficiency Virus (HIV), Psychosis, Delusions, and Hallucinations related to Methamphetamine withdrawals.

Record review revealed on, 06/09/2021, Patient #2 was found by Mental Health Technician (MHT #2) in Patient #3's room, and both patients had been lying in his/her bed, fully clothed.

Review of the facility's investigation, completed by the Risk Manager on 06/14/2021, revealed the facility's video footage confirmed Patient #2 and Patient #3 had engaged in sexual intercourse in Patient #3's shower.

Further record review revealed on, 06/09/2021, Patient #3's medication order for Symtuza (anti-viral medication) had not been administered, was not in the facility, or available for administration to Patient #3 during the patient's stay at the hospital. Interviews with Psychiatrist #1, the Medical Physician, RN #1, RN #2, RN #5, and RN #8 revealed staff had not notified the physician that Patient #3 had not received his/her doses of the prescribed medication.

Record review revealed, on 06/14/2021, Patient #2 was assessed to be an AWOL (unauthorized leave) risk, exited his/her unit and entered Patient #3's unit.

Record review revealed, on 06/14/2021, after a potential HIV exposure, Patient #3 had labs ordered; however, the facility was unaware of the status of the labs due to lack of documentation.

Interviews with the Risk Manager (RM), Registered Nurse (RN) #1, and MHT #2, revealed the facility failed to thoroughly investigate the incident which had occurred between Patient #2 and Patient #3 on 06/13/2021.

Interview with the RM, and House Supervisor #1 revealed the facility failed to report the incident which had occurred on 06/13/2021, between Patient #2 and Patient #3 to the State Survey Agency in a timely manner.

Interview with Registered Nurse #8, after Patient #2 had entered Patient #3's unit, revealed Patient #3 had become agitated, threw furniture, and had to be de-escalated by staff, demanding to leave the facility.


Refer to A-0395, A-0405, A-0144, A-0145, and A-1655.

Based on interview, record review, and review of the facility's policy, it was determined the facility's Governing Body failed to ensure quality of care was provided for two (2) of ten (10) sampled patients (Patient #2 and Patient #3) as evidenced by the facility's failure to:

1. Ensure patients were free from abuse for two (2) of ten (10) sampled patients (Patient #2 and Patient #3)
2. Ensure adequate supervision for two (2) of ten (10) sampled patients, despite sexually acting out (SAO) precautions in place (Patient #2 and Patient #3).
3. Ensure Patient #2 was provided a safe environment with increased supervision to prevent the patient from AWOL, away without leave.
4. Ensure patient behaviors had been documented in the patients' clinical records for two (2) of ten (10) sampled patients (Patient #2 and Patient #3)
5 Ensure administration of an anti-viral medication, as prescribed by the physician, for one (1) of ten (10) sampled patients (Patient #3).
6. Ensure labs had been completed as ordered for one (1) of ten (10) sampled patients (Patient #3).

The findings include:

Review of the facility's policy titled, "Abuse/Neglect Reporting," revised 02/2020, revealed the facility identified, prevented, protected victims of abuse, and the process for reporting abuse. According to the policy, the facility assessed patients during the intake process to identify a history of abuse/neglect and a psychosocial assessment was performed by a counselor to determine a more detailed current/history of abuse or traumatic experiences. The policy revealed neglect was careless or purposeful omission of an incident, which required care for the patient to be given proper attention such as lack of physical care. Further review revealed behavioral indicators of sexual abuse included sexual promiscuity and poor peer relationships. Additional review of the policy revealed staff reported allegations of abuse to the House Supervisor and Physician; obtained applicable orders, document all actions in the medical record; the Director of Risk Management (DRM), Director of Nursing (DON), Chief Executive Officer (CEO), and Chief Operating Officer (COO).

Review of the facility's policy titled, "Sexual Acting Out (SAO) Precautions," reviewed 01/2018, revealed staff had been educated on prevention and early identification of sexually acting out behaviors. The intake admission assessment evaluated for a history of sexually acting out behaviors in the past six (6) months; history of sexual aggression as a child; history of sexual abuse; psychosis with sexual preoccupation; and, displayed poor physical boundaries. SAO Precautions could include but were not limited to interventions such as blocking the second bed to keep the room private, placement of patient in a room close to the nurse's station, every fifteen (15) minute observations, and instructed the patient on appropriate physical boundaries. Additional review revealed the patient would remain on the precautions until the physician deemed them no longer necessary and an assessment would be conducted every twenty-four (24) hours with documentation in the Progress Notes. The policy stated staff would monitor and document in the clinical record sexually inappropriate physical or verbal behaviors, poor boundaries, lingering close to bedroom/bathroom, and/or sexually provocative behaviors. The policy revealed staff would monitor for and immediately notify the nurse or nursing supervisor of the observed behaviors, and the nursing supervisor would notify the Director of Risk Management (DRM) to initiate an investigation. Further review revealed patients were educated about appropriate physical boundaries and could have a six (6) foot physical restriction initiated, or no contact with a patient.

Review of the facility's policy titled, "Documentation Requirements," dated 05/2020, revealed the purpose of the policy was to provide continuity and quality care by communication of the patient's progress and assessments through documentation, and it was the policy of the facility for clinical staff to document the patient's progress and response to treatment goals and objectives in the medical records. Further review revealed staff were to 1.) Documents facts and observations that described the patient's progress throughout the course of treatment.; 6.) Document in the medical record that reflected and correlated with the patient's high risk behaviors, including sexual aggression, and sexual victimization; and, 7.) Document in the medical record the patient's refusal and reasons to participate in treatment.

Review of the facility's policy titled, "Patient Safety Events," reviewed 02/2018, revealed the facility monitored, addressed, and assessed causal factors related to safety events. The policy revealed a patient safety event was a condition that could have resulted or did result in harm from a system breakdown, equipment failure, or human error. It further revealed permanent harm was a type of impairment not present on admission and severe temporary harm was a critical life threatening event which resulted in the requirement of a higher level of care but no permanent harm. The policy further revealed safety events included those that resulted in a hazardous condition, a close call, no harm, an event with some harm noted, and a sentinel event that resulted in serious harm.

Review of the facility's policy titled, "Key Control," reviewed 01/2019, revealed the purpose of the building's security system with locked doors was to provide safety and security to staff, patients, and visitors.

Review of the facility's policy titled, "Room Assignments," reviewed 10/2019, revealed the facility determined room assignments that took into account the patient's diagnoses; physical, mental, and cognitive status which could result in compromise to the patient's ability to respond. Further review revealed reasons for a room transfer could result from disruptive behavior, impaired cognitive status, or physical disruption which could affect the other patients. The policy revealed room transfers would be reviewed by the Nurse Manager, House Supervisor, or the Physician.

Review of the document titled, "Bylaws of the Board of Governors of (the facility's name)", dated and signed on 04/01/2020 by the Chair of the Board, stated; Article IV, Purpose of the Hospital- The Board shall be accountable for the safety and quality of care, treatment, and services of the Hospital... Article V stated, The principle duties and responsibilities of the Board shall be to: 4.) Ensure continuous quality improvement through monitoring of professional services provided by the Medical Staff, allied health professionals and other health care providers who provide services at the Hospital.

Review of the facility's policy titled, "Patient Rights and Responsibilities," reviewed 05/2020, revealed the hospital provided care in a respectful, safe, unbiased, timely, therapeutic, and in a comprehensive manner. Further policy review revealed the hospital informed the patient of his/her responsibilities during the admission process which included treating staff and other patients' belongings and environment with respect, following patient policies and procedures; involvement of family or legally authorized person in decisions regarding treatment; and communicating with staff regarding personal, emotional, and environmental concerns which could affect the patient's treatment. The policy review further revealed the Intake Coordinator provided information related to the Patient's Bill of Rights, at the time of admission to the patient or legal guardian, which included services offered by the facility with their costs, process for conditional release or discharge, visitation rights, and grievance procedures.

Review of the Symtuza website (https://www/) revealed- "Advise patients to take SYMTUZA with food every day on a regular dosing schedule, as missed doses can result in development of resistance. Inform patients not to alter the dose of SYMTUZA or discontinue therapy with SYMTUZA without consulting their physician."

1. Review of Patient #2's Nursing Daily Progress Notes, dated 06/09/2021, revealed Patient #2 had been discovered by staff, during the routine fifteen (15) minute observation rounds, in the bed with Patient #3.

Continued review of the Progress Note revealed, on 06/13/2021, Patient #2 had been discovered in Patient #3's shower. The facility assessed Patient #2 to have a flat affect and illogical and disorganized thought processes.

Review of the Licensed Practitioner Progress Notes, completed by Psychiatrist #2, dated 06/09/2021 through 06/15/2021, described Patient #2's thought processes as slow, paranoid, and delayed in response to conversation.

Review of Patient #2's Physician's Orders, dated 06/10/2021, revealed Sexually Acting Out (SAO) Precautions had been initiated following an inappropriate sexual interaction with Patient #3 on 06/09/2021.

Review of the Master Treatment Plan, dated 06/10/2021, revealed Patient #2 was assessed to be the aggressor when he/she had been discovered in Patient #3's bed.

Review of Patient #2's Physician's Orders, dated 06/14/2021, revealed the following orders: Human Immunodeficiency Virus (HIV) lab testing, Urine for Chlamydia, Trichomonas, and Gonorrhea; a pregnancy test, and a Hepatitis Panel. Further review of the order revealed a Post Exposure Protocol that included Plan B for pregnancy prevention, and Truvada and Doletegravir for the HIV exposure. On 06/20/2021, the orders included a single dose of Metronidazole tablet for treatment of Trichomoniasis, a sexually transmitted disease (STD).

Review of the Medical Physician's Consultation Note, dated 06/14/2021, for Patient #2, revealed a complaint had been identified in regards to sexual activity with a another patient, (Patient #3), who was HIV positive. Further review of the note revealed Patient #2 remained psychotic and had difficulty understanding the implications of the sexual activity even though it was consensual.

The Surveyor attempted to contact Patient #3 via telephone, on 06/22/2021 at 12:00 PM and, on 06/23/2020 at 10:59 AM, but was unable to contact the patient for an interview.

Interview with Patient #2, on 06/23/2021 at 10:45 AM, revealed he/she had sexual intercourse with Patient #3 on 06/13/2021 in the shower before staff came in and told him/her to get dressed and exit the room.

Interview with Registered Nurse (RN) #1, on 06/23/2021 at 11:14 AM, revealed there had been an observed pattern of inappropriate behaviors between Patient #2, and Patient #3. He stated after Patient #3 was admitted to the Psychiatric Intensive Care Unit (PICU), on 06/09/2021, Patient #2 had focused on him/her. The RN revealed, after Patient #2 was discovered by staff, in the bed with Patient #3, Patient #2 also had a number of attempts that same night to get back into Patient #3's room. RN #1 stated he had informed the Charge Nurse (he could not recall the Charge Nurse's identity) during his shift, of the patient's inappropriate behavior. Continued interview with RN #1 revealed the goal of his actions was to create a safe environment for the patients, and to prevent any violence. RN #1 stated a couple of days later, an MHT (RN #1 could not recall the MHT's name who separated the patients) separated Patient #2 from Patient #3, after he/she observed Patient #3's head laying in Patient #2's lap. RN #1 stated it was a constant struggle for staff to redirect and separate the two (2) patients. He also stated he did not report the head in the lap incident to anyone.

Interview with House Supervisor #3, on 06/23/2021 at 12:42 PM, revealed she did not know she was required to call the DRM, DON, and CEO in regards to the incident that occurred, on 06/13/2021, between Patient #2 and Patient #3 when the patients had been discovered in the shower together. She stated notification had been sent to the Risk Manager via e-mail. However, looking back, the House Supervisor stated she now realized that a phone call notification should have been made to the Risk Manager.

Interview with MHT #2, on 06/24/2021 at 10:36 AM, revealed he had instructed Patient #2 and Patient #3, that they were at the hospital for mental health treatment and were not to have a relationship or anything physical with another patient.

Interview with the Director of Risk Management (DRM), on 06/24/2021 at 12:57 PM, revealed her responsibility included notification of incidents that could possibly result in litigation. She stated she was not aware Patient #3 was HIV positive until after the incident on 06/13/2021. The DRM stated during the investigation and review of the video footage, it had been determined that sexual intercourse between Patient #2 and Patient #3 on 06/13/2021, had occurred. She stated during the interview process, Patient #2 and Patient #3 had admitted to having sexual intercourse.

Interview with the Interim Director of Nursing (DON), on 06/25/2021 at 9:10 AM, revealed she had heard in passing that Patient #2 had been sitting on Patient #3's bed. She stated she was not told of any additional inappropriate behaviors, but the two (2) patients should have been separated on different units before the incident on 06/13/2021.

Interview with the Unit Manager, on 06/25/2021 at 12:56 PM, revealed she did not recall being asked by anyone to look into possibly moving either Patient #2 or Patient #3 to another unit after they had been observed in bed together on 06/09/2021.

Interview with House Supervisor #1, on 06/25/2021 at 2:56 PM, revealed her role was to ensure staff and patient safety in the facility. She stated she had been informed Patient #2 had entered Patient #3's room one night, but was easily redirected out of the room. Further interview revealed she had sent an e-mail to the Unit Manager to determine if Patient #3 would be appropriate to move to another unit; however, she stated she did not get a response from the Unit Manager. She stated she had not been aware Patient #3 was HIV positive and she would have taken the responsibility to separate the patients after the observation of touching behaviors.

Interview with the Director or Nursing (DON), on 07/01/2021 at 12:33 PM, revealed the staff were responsible to provide a safe environment for the patients in the facility.

Interview with the Chief Executive Officer (CEO), on 07/01/2021 at 2:19 PM, revealed the staff were responsible to identify, report, and intervene with potential or abuse allegations.

2. Review of the High Risk Notification Alert Assessment for Patient #2, dated 06/04/2021, revealed no documented evidence of a history of sexually acting out behaviors.

Review of Patient #2's Nursing Daily Progress Notes, dated 06/09/2021, revealed during the routine fifteen (15) minute observation rounds, Patient #2 had been discovered by staff, fully clothed, in bed with Patient #3. Continued review revealed, on 06/10/2021, Patient #2 had been observed going into Patient #3's room and, on 06/13/2021, staff observed Patient #2 in Patient #3's shower. Patient #2 had been assessed to have a flat affect and illogical and disorganized thought processes.

Review of the Admission Registered Nurse Note/Plan, dated 06/09/2021, revealed Patient #3 had a history of sexually acting out behaviors (SAO) both as a victim and as a perpetrator.

Review of Patient #2's Nursing Daily Progress Notes, dated 06/09/2021, revealed Patient #2 had been discovered by staff during the routine fifteen (15) minute observation rounds, fully clothed and in the bed with Patient #3. Review of the Daily Progress Notes, dated 06/10/2021, described that Patient #2 had been observed to walk into a peer's room. Continued review of the Note, dated 06/10/2021, revealed no documented evidence of any observed inappropriate behaviors.

Review of Patient #3's Master Treatment Plan (MTP), initiated on 06/09/2021, revealed Patient #3 had a history of SAO behaviors as both a victim, and perpetrator. Patient #3's history of SAO had been identified as a "Maintenance Problem," which is a problem that was stable or controlled, and which was not considered an active problem, therefore, the MTP did not include interventions.

Review of Patient #2's Master Treatment Plan (MTP), dated 06/10/2021, revealed an identified and current problem with SAO. Continued review of the MTP revealed interventions and goals were in place.

Review of the Nursing Daily Progress Notes, dated 06/13/2021, revealed Patient #2 and Patient #3 were discovered unclothed and in Patient #3's shower on 06/13/2021.

Attempted to contact Patient #3 via telephone, on 06/22/2021 at 12:00 PM and on 06/23/2020 at 10:59 AM, but was unable to contact the patient for interview.

Interview with RN #1, on 06/23/2021 at 11:14 AM, revealed there was a pattern of inappropriate behaviors between Patient #2 and Patient #3. He stated when Patient #3 was admitted to the facility, on 06/09/2021, Patient #2 was focused on him/her. The RN stated after Patient #2 was discovered in Patient #3's bed, on 06/09/2021, he/she continued to make a number of attempts to get back into Patient #3's room. Continued interview with RN #1 revealed a couple of days later, he had entered the television room and observed a MHT (he was not able to recall the name of the MHT) separating Patient #2 from Patient #3 after the MHA observed Patient #3's head laying in Patient #2's lap. RN #1 stated he had informed the House Supervisor of the patients' behaviors during his shift, on 06/09/2021. He further stated the Registered Nurses and MHT's had to continually redirect and separate the two (2) patients. RN #1 revealed it was the responsibility of the Registered Nurses to document behaviors in the Nursing Daily Progress Notes, as well as a Regular Progress Note. He stated he should have documented the head in the lap observation in both of the patients' medical records. RN #1 stated Registered Nurses' documentation of behaviors helped with communication among the MHT's, other Registered Nurses, the Advanced Practice Registered Nurse, the Psychiatrist, the RM, Medical Director, and the Chief Executive Officer.

Interview with MHT #1, on 06/24/2021 at 10:35 AM, revealed he was notified during report, on 06/10/2021, that Patient #2 and Patient #3 had been holding hands. He also stated he had observed Patient #3 giving Patient #2 a shoulder massage. The MHT stated that he had separated the patients, and instructed Patient #3 that his/her behavior was not acceptable. He stated he then informed the nurse.

Interview with the Interim Director of Nursing (IDON), on 06/25/2021 at 9:10 AM, revealed documentation of behaviors and staff interventions were important to determine if there was a pattern or progression of the behaviors.

Interview with the Director of Nursing (DON), on 07/01/2021 at 12:33 PM, revealed any unusual events/observations should be documented in detail in a progress note to communicate to staff so that they would understand the patient's condition and/or make treatment revisions.

Interview with the Chief Executive Officer (CEO), on 07/01/2021 at 2:19 PM, revealed the nurses were responsible for patient supervision by ensuring the fifteen (15) minute rounds performed by the MHT's were done correctly and on time. She stated the purpose of the rounding contributed to patient safety.

Interview with the Medical Director, on 07/01/2021 at 3:10 PM, revealed abnormal behaviors or events should be clearly documented for the Psychiatrist to review and make adjustments to a patient's treatment as required.

Interview with RN #7, on 07/02/2021 at 9:47 AM, revealed documentation of observed patient behaviors was an important communication technique among staff members and the patient's doctors.

Interview with RN #10, on 07/02/2021 at 1:11 PM, revealed documentation of behaviors was important to determine if the patient's behaviors were escalating so that staff could take the proper actions.

3. Review of Patient #2's Physician's Orders, dated 06/10/2021, revealed an order that included away without leave (AWOL/Elopement) precautions.

Review of Patient #2's Master Treatment Plan included interventions for Absent Without Leave (AWOL/Elopement) precautions had been initiated on 06/10/2021.

Review of Patient #2's Progress Notes revealed two (2) successful AWOL's from his/her unit, on 06/10/2021 and 06/14/2021. Patient #2 had also made several requests for discharge paperwork and inquired if he/she could go home.

Review of the Progress Note, dated 06/15/2021 at 11:30 AM, revealed the following documentation by RN #8; Patient #3 got angry, threw a chess board at the nurses' station, was verbally deescalated by staff, and stated that he/she wanted to leave the facility. Review of an additional Progress Note, dated 06/15/2021 at 12:00 PM, revealed Patient #3 had been assessed by the Certified Social Worker (CSW), prior to discharge, for his/her safety. Further review revealed of the Note revealed the patient told the CSW he/she just wanted to leave the facility.

Observations, on 06/23/2021 at 10:45 AM and 06/29/2021 at 2:30 PM, revealed all doors in the facility were secured with locks. Further observation of the doors to the two (2) adjacent adult psychiatric units, revealed signage posted which indicated patients were on the unit, that had been identified to be at risk for exiting the unit.

Observation of Patient #2, on 06/23/2021 at 10:45 AM, revealed he/she was dressed appropriately, walking in the hall, and made eye contact with the Surveyor.

Interview with Certified Social Worker (CSW) #1, on 06/23/2021 at 1:16 PM, revealed Patient #3 had been doing well with his/her treatment plan and had actively participated in his/her treatment with a positive attitude, until the day he/she was discovered in the shower with Patient #2. The CSW stated thereafter, Patient #3 just wanted to leave the facility. Continued interview with CSW #1 revealed there was a lack of awareness by staff in regards to Patient #3's HIV status and this status caused emotional stress for Patient #3.

Interview with RN #8, on 06/28/2021 at 2:23 PM, revealed it appeared that Patient #3 had gotten upset after Patient #2 entered his/her unit, on 06/14/2021. She stated Patient #3 wanted to go home on 06/14/2021 after he/she saw Patient #2 enter his/her new unit. RN #8 stated she had been able to calm Patient #3, and convinced him/her to stay until the following day in order to see the psychiatrist. She stated his/her behaviors, which included, throwing a chess board, confrontations with staff, and demands to leave the facility had started on the evening after he/see observed Patient #2 enter his/he unit. RN #8 stated she felt like Patient #3 had gotten upset by seeing Patient #2, after he/she had been moved to a different unit on 06/13/2021. She stated it could have appeared that Patient #2 was attempting to get to Patient #3, after he/she had been told of the HIV exposure.

Interview with the Unit Manager (UM), on 06/29/2021 at 2:52 PM, revealed staff were responsible to be aware of patients' locations, especially when they (staff) passed through locked doors. She stated staff were to ensure doors closed behind them in order to secure the patient's units and provide safety.

Interview with Registered Nurse (RN) #3, on 06/29/2021 at 3:38 PM, revealed, on 06/14/2021, Patient #2 had gone AWOL from an adjacent unit (PICU), and then the patient had entered into another unit (Adult Psychiatric Unit) behind her.

Interview with the Director of Risk Management (DRM), on 06/29/2021 at 4:10 PM, revealed Patient #3 did not want staff to tell Patient #2 of his/her HIV status until after he/she had been separated from Patient #2, and had moved to a separate unit. She stated Patient #3 told her that he/she would be treated differently once Patient #2 was informed of his/her HIV status. The DRM stated Patient #3 had been compliant and had participated in his/her treatment plan until 06/14/2021. She stated Patient #3 then demanded to leave the facility against medical advice. She stated the facility was responsible to keep the patients safe and provide a safe environment, but that was not the case when Patient #2 had entered Patient #3's unit.

Interview with the Chief Executive Officer (CEO), on 07/01/2021 at 2:19 PM, revealed staff was responsible to ensure door security whenever they passed through locked doors in order to ensure patients' safety.

4. Review of Patient #2's Physician's Orders, dated 06/10/2021, revealed Sexually Acting Out (SAO) Precautions were initiated following an inappropriate interaction with Patient #3 on 06/09/2021.

Review of the Master Treatment Plan, dated 06/10/2021, revealed Patient #2 had been identified as the aggressor of SAO behaviors when he/she was discovered by staff to be in the bed with Patient #3.

Continued record review revealed additional SAO behaviors were observed between Patient #2, and Patient #3 that included: hand holding, shoulder massaging, and laying a head in the other's lap. However, these behaviors had not been communicated with the Unit Manager.

Review of Patient #3's Nursing Daily Progress Notes, dated 06/13/2021, revealed Patient #2 and Patient #3 had been discovered in Patient #3's shower on 06/13/2021.

The Surveyor attempted to contact Patient #3 via telephone, on 06/22/2021 at 12:00 PM and, on 06/23/2020 at 10:59 AM, but was unable to contact the patient for interview.

Interview with Registered Nurse (RN) #1, on 06/23/2021 at 11:14 AM, revealed there was a pattern to the behaviors between Patient #2 and Patient #3. He stated when Patient #3 was admitted to the facility on 06/09/2021, Patient #2 focused on him/her. The RN stated after Patient #2 was discovered by RN #3 in bed with Patient #3, Patient #2 had also been observed by RN #1, a number of times, that same night, to attempt to get back into Patient #3's room. RN #1 stated he had informed the House Supervisor of the patients' inappropriate behaviors observed during his shift, on 06/09/2021. RN #1 stated he could not remember the identity of the MHT, but a couple of days later, he entered the television room as an MHT (whose identity he could not remember) was separating Patient #2 from Patient #3, after the MHT had observed Patient #3's head laying in Patient #2's lap. He stated staff continually had to redirect and separate the two (2) patients. RN #1 stated that staff should document patients' behaviors in the Nursing Daily Progress Notes and a regular Progress Note, for any concerns or events outside of the required shift charting. He stated he should have documented the head in the lap observation in order to communicate with other staff members so they could also be aware of the patients' behaviors.

Interview with MHT #1, on 06/24/2021 at 10:35 AM, revealed he had been notified during report, on 06/10/2021, that Patient #2 and Patient #3 had been holding hands. He stated he had observed Patient #3 giving Patient #2 a shoulder massage. MHT #1 stated he separated the patients, and instructed Patient #3 that shoulder massages between patients was not an acceptable behavior, and then he (MHT #1) notified the nurse.

Interview with the Interim Director of Nursing (IDON), on 06/25/2021 at 9:10 AM, revealed documentation of behaviors and of staff's intervention (s) was important in order to determine if a pattern or progression of the patient's behaviors existed.

Interview with the Director of Nursing (DON), on 07/01/2021 at 12:33 PM, revealed any unusual events or observations should be documented, in detail, in a Progress Note, in order to communicate with other staff so they could understand the patient's conditions, and/or make treatment plan revisions.

Interview with the Medical Director, on 07/01/2021 at 2:13 PM, revealed RN supervision and ongoing patient evaluations were required in order to provide safe patient care, and so adjustments in treatment could be made, as needed.

Interview with the Chief Executive Officer (CEO), on 07/01/2021 at 2:19 PM, revealed the nurses were responsible for supervision of the patients by ensuring the fifteen (15) minute rounds were done correctly and on time. She stated the purpose of rounds was to contribute to patient safety.

Interview with RN #7, on 07/02/2021 at 9:47 AM, revealed documentation of inappropriate behaviors observed by staff was an important communication technique used among staff members and the patients' doctors.

Interview with RN #10, on 07/02/2021 at 1:11 PM, revealed documentation of behaviors was important to determine if behaviors were escalating so staff could take the proper actions.

5. Review of the facility's policy titled, "Medication Variance," dated 05/2020, revealed, Policy- Errors in medication administration must be reported immediately to the prescribing physician-on-call, for action to be taken, and 4.) Categories of breakdown in the system that contribute to medication errors: Medication Unavailable- failure to administer dose as ordered because medication was not available on the nursing unit.

Closed clinical record review for Patient #3 revealed the document titled, "List of Current Medications at Time of Admission", dated 06/09/2021 at 8:39 PM, by Registered Nurse #1. Continued review of the clinical record revealed a telephone order had been given by Psychiatrist #1 for Symtuza (antiviral) one tablet (tab) daily- purpose: HIV positive. The document also revealed Patient #3 had been been taking the medication as regularly scheduled.

Review of the document, "Nursing Admission Checklist", dated 06/09/2021 at 11:10 PM, revealed the checklist had been verified by RN #1, who confirmed all orders for Patient #3 had been transcribed on the MAR, and verified that all the Medical Doctors' (MD) orders had been completed.

Review of the Medication Administration Record (MAR), for the entirety of Patient #3's stay at the facility, revealed no documented evidence that the medication, Symtuza, had been placed on Patient #3's MAR, or that the patient had received the medication, as ordered, by the psychiatrist.

Telephonic interview with Pharmacist #2, on 06/24/2021 at 3:12 PM, revealed the pharmacy had received the fax from the facility, on 06/10/2021 at 12:11 AM, in regards to Patient #3's Symtuza order. However, the pharmacist stated the pharmacy had documented in their notes that a telephonic dialogue had occurred between RN #1 and a pharmacy staff member. The pharmacist stated RN #1 had informed the pharmacy that Patient #3 had been admitted with his/her own supply of Symtuza. Therefore, the pharmacy did not send any Symtuza to the facility.

Telephonic interview with Patient #3's family member, on 06/24/2021 at 3:28 PM, who was listed on the patient's Authorization to Disclose Patient Information Form, signed and witnessed on 06/09/2021, revealed Family Member #1 had not received a telephone call from the facility requesting she bring the patient's Symtuza into the facility. Family Member #1 also stated that Patient #3 was homeless. However, he/she came to her house every morning to take his/her HIV medication.

Interview with House Supervisor #2, on 06/25/2021 at 10:28 AM, revealed whenever the facility admitted a patient who had been taking a prescribed, expensive medication at home, such as HIV medications, the facility would first ask the family to bring the medication (s) into the facility. She stated in her experiences at the facility, if a patient did not bring their expensive medications with them to the facility, and no one else, like a family member,would bring the medication to the facility, the patient, honestly, did not receive the medication. She stated if a medication was not available at the facility, or the facility was unable to obtain the medication from the patient's family, the doctor should always be notified. She stated if the medication was not listed on the facility's approved Formulary, then the pharmacy would not send the medication without the approval from the facility's administration. She also stated when a patient did not receive their prescribed medications, then the facility had failed the patient.

Interview with Psychiatrist #1, on 06/25/2021 at 8:45 AM, revealed he had not been made aware by the facility that Patient #3 had not received Symtuza as ordered. He stated his expectation of the facility was that all medication (s) would be administered the Nurses as ordered. He stated if he had

Based upon observation, interview, open and closed record review, and policy review, it was determined the facility failed to provide care in a safe setting and to protect and promote each patient's rights for two (2) of ten (10) sampled patients (Patient #2 and Patient #3).

The findings include:

Review of the clinical record revealed Patient #2 was exposed to the Human Immunodeficiency Virus (HIV) when he/she had sexual intercourse with Patient #3, on 06/13/2021. Furthermore, after Patient #3 moved to another unit following a sexual encounter with Patient #2, Patient #2, who was on AWOL (Absent Without Leave) precautions, exited his/her unit and entered into Patient #3's unit.

Review of Patient #2's clinical record revealed, on 06/09/2021, he/she had been discovered by staff to be in the bed with Patient #3, and was placed on Sexually Acting Out Precautions (SAO) on 06/10/2021.

Record review also revealed the facility failed to perform a thorough investigation after the incident between Patient #2 and Patient #3 occurred, and prior to the State Survey Agency entering the facility on 06/22/2021.

Review of Patient #3's closed clinical record revealed the facility had separated Patient #2 from Patient #3 by relocating Patient # 3 to another unit. However, on 06/14/2021, Patient #2 went AWOL, and entered Patient #3's unit (unit moved to). From then on, Patient #3 displayed aggression and voiced his/her intent to leave the facility.

Interviews with Mental Health Technician (MHT) #1, MHT #2, MHT #3, Registered Nurse (RN) #1, Unit Manager, House Supervisor #1, House Supervisor #3, Director of Risk Management (DRM), Psychiatrist #1, Psychiatrist #2, and the Chief Executive Officer (CEO) revealed there had been a failure in the system to document and report inappropriate behaviors that had been observed between Patient #2 and Patient #3 from 06/10/2021 through 06/12/2021. Continued interviews, with these staff, revealed the facility had not reported an incident of sexual intercourse between Patient #2 and Patient #3 to the State Survey Agency in a timely manner.


(Refer to A-144, A-145, A-0395, A-0405 , and A-1655)

Based on observation, interview, record review, and review of the facility's policies, it was determined, the facility failed to ensure a safe environment for two (2) of ten (10) sampled patients (Patient #2 and Patient #3).

1. On 06/09/2021, Patient #2 was discovered by staff to be in the bed with Patient #3. Further record review revealed Patient #3, who was Human Immunodeficiency Virus Positive (HIV +) had sexual intercourse in the shower with Patient #2 on 06/13/2021.
2. Patient #2 exited his/her locked unit, on 06/14/2021, despite having been placed on absent without leave (AWOL) precautions, and entered Patient #3's unit.
3. After Patient #2 had gone AWOL, and entered Patient #3's unit, Patient #3 told staff he/she wanted to leave the facility.

The findings include:

Review of the facility's policy titled, "Patient Safety Events," reviewed 02/2018, revealed the facility monitored, addressed, and assessed causal factors related to safety events. The policy revealed a patient safety event was a condition that could have resulted or did result in harm from a system breakdown, equipment failure, or human error. It further revealed permanent harm was a type of impairment not present on admission and severe temporary harm was a critical life threatening event which resulted in the requirement of a higher level of care but no permanent harm. The policy further revealed safety events included those that resulted in a hazardous condition, a close call, no harm, an event with some harm noted, and a sentinel event that resulted in serious harm.

Review of the facility's policy titled,"Key Control," reviewed 01/2019, revealed the purpose of the building's security system with locked doors was to provide safety and security to staff, patients, and visitors.

Review of the facility's policy titled, "Room Assignments," reviewed 10/2019, revealed the facility determined room assignments that took into account the patient's diagnoses; physical, mental, and cognitive status which could result in compromise of the patient's ability to respond. Further review revealed reasons for a room transfer could result from disruptive behavior, impaired cognitive status, or physical disruption which could affect the other patients. The policy stated room transfers would be reviewed by the Nurse Manager, House Supervisor, or the Physician.

Review of the facility's policy titled, "Patient Rights and Responsibilities," reviewed 05/2020, revealed the hospital provided care in a respectful, safe, unbiased, timely, therapeutic, and comprehensive manner. Further policy review revealed the hospital informed the patient of his/her responsibilities during the admission process which included treating staff and other patients' belongings and environment with respect, following patient policies and procedures; involvement of family or legally authorized person in decisions regarding treatment; and communicating with staff regarding personal, emotional, and environmental concerns which could affect the patient's treatment. The policy review further revealed the Intake Coordinator provided information at the time of admission to the patient or legal guardian of the Patient Bill of Rights, which included services offered by the facility with their costs, process for conditional release or discharge, visitation rights, and grievance procedures.

1. Record review revealed the facility admitted Patient #2, on 06/04/2021, with diagnoses that included Severe Psychosis and Catatonia.

Closed record review revealed the facility admitted Patient #3, on 06/09/2021, with diagnoses that included Human Immunodeficiency Virus (HIV), Delusions and Hallucinations related to Methamphetamine use.

Review of Patient #2's clinical record revealed, on 06/09/2021, Registered Nurse (RN) #3 discovered Patient #2 in the bed with Patient #3.

Review of the incident report, dated 06/13/2021, at approximately 8:45 PM, revealed staff discovered Patient #2 and Patient #3 had taken a shower together. The video footage from Patient #3's room, which had been reviewed by the Director of Risk Management (DRM), the Unit Manager (UM), and House Supervisor #1, determined sexual intercourse had taken place on 06/13/2021.

Review of Patient #2's Daily Progress Notes, dated 06/13/2021, revealed Patient #2 had entered Patient #3's room while Patient #3 had been showering. Staff discovered the patients had taken a shower together.

Interview with Registered Nurse #1, on 06/23/2021 at 11:17 AM, revealed after the 06/09/2021 incident, he had observed other inappropriate behaviors between Patient #2 and Patient #3, and staff were constantly separating the two (2) patients. He stated Patient #2 had been focused on Patient #3, and Patient #2 was quick and stealthy with his/her behaviors. RN #1 stated the SAO (Sexual Acting Out) Precautions, ordered on 06/10/2021, included the standard fifteen (15) minute observation rounds and increased staff awareness of SAO behaviors.

Interview with the Director of Risk Management (DRM), on 06/23/2021 at 3:00 PM, revealed if facility staff had been aware of the SAO behaviors between Patient #2 and Patient #3, prior to 06/13/2021, the patients should have been separated. She stated she was not aware Patient #3 was HIV positive until after the incident on 06/13/2021.

Interview with MHT (Mental Health Technician) #2, on 06/24/2021 at 10:36 AM, revealed he was aware Patient #2 was discovered in Patient #3's bed the week prior and the patients should have been separated at that time. He stated during his fifteen (15) minute observation rounds on 06/13/2021, he was not able to locate Patient #2, who was then discovered in Patient #3's shower.

Interview with RN #3, on 06/24/2021 at 12:21 PM, revealed, on 06/09/2021, during fifteen (15) minute observation rounds (while working in the MHT role), she discovered Patient #2 lying fully clothed in Patient #3's bed.

Interview with the DRM, on 06/24/2021 at 12:57 PM, revealed during the morning Flash Meeting, on 06/10/2021, the Unit Manager stated she would look into the concerns regarding Patient #2's behavior.

Interview with the Unit Manager, on 06/25/2021 at 12:56 PM, revealed she did not recall communication regarding separating Patient #2 and Patient #3. The Unit Manager further stated the facility had discussed the incident in a Morning Flash Meeting, but no definite decisions were made.

Interview with House Supervisor #1, on 06/25/2021 at 2:56 PM, revealed she had sent an email to the Unit Manager and the DRM on 06/09/2021 with the suggestion of moving one of the patients to a different unit. She stated the following day, Patient #2 and Patient #3 remained on the same unit and she had not heard back from the Unit Manager.

Interview with the Director of Nursing (DON), on 07/01/2021 at 12:33 PM, revealed that SAO precautions should be communicated with staff in order to prevent behaviors, provide redirection to patients, and to make more frequent rounds and observation of the patient that had been ordered SAO.

Interview with the Chief Executive Officer (CEO), on 07/01/2021 at 2:19 PM, revealed monitoring for SAO behaviors as well as communication of these behaviors amongst the facility staff allowed the facility to ensure patient safety.

2. Observation of Patient #2, on 06/29/2021 at 2:30 PM, revealed the patient was calm and did not attempt to exit the unit.

Observations in the facility, on 06/29/2021 at 10:45 AM and 06/23/2021 at 2:30 PM, revealed all doors in the facility were secured with locks and facility staff possessed keys to the doors. Observation of the doors to the two (2) adjacent adult psychiatric units revealed signs posted that identified a patient was at a high risk for exiting the unit.

Review of Patient #2's Progress Notes revealed two (2) successful attempts to exit from his/her the unit, on 06/10/2021 and 06/14/2021, with requests for discharge paperwork or the patient asked about going home daily.

Review of Patient #2's Physician's Orders, dated 06/10/2021, revealed an order that included AWOL precautions after an attempted exit from his/her unit.

Review of Patient #2's Master Treatment Plan, dated 06/10/2021, included interventions for Absent Without Leave (AWOL/Elopement) precautions.

Review of the facility's video footage, dated 06/14/2021 at 6:44 PM, revealed Patient #2 exited his/her unit and entered Patient #3's unit after following staff through the two (2) secured unit doors.

Interview with Patient #2, on 06/29/2021 at 2:30 PM, revealed he/she could not remember the day or incident when he/she exited the unit on 06/14/2021.

Interview with the Unit Manager (UM), on 06/29/2021 at 2:52 PM, revealed staff was responsible to be aware of patients' locations, especially when passing through locked doors. The UM stated staff were to make sure the doors closed behind them to secure the units and provide safety to the patients.

Interview with Registered Nurse (RN) #3, on 06/29/2021 at 3:38 PM, revealed she had entered the unit, on 06/14/2021, when Patient #2 had exited the adjacent unit and entered the unit behind her coming through the locked unit door.

Interview with the Chief Executive Officer (CEO), on 07/01/2021 at 2:19 PM, revealed staff were responsible for door security upon passing through locked doors to ensure patients' safety and that they were in the correct designated area.

3. Unable to observe Patient #3, as he/she had left the facility on 06/15/2021.

Review of RN #8's Nurse's Daily Progress Note, dated 06/15/2021 at 11:30 AM, revealed one day after Patient #3 had been moved to another unit, the patient became angry, threw a chess board at the nurses' station, had to be verbally deescalated by staff, and the patient insisted on leaving the facility immediately.

Review of a Progress Note revealed, on 06/15/2021 at 12:00 PM, the Certified Social Worker (CSW) assessed Patient #3 prior to his/her discharge for safety. Further review revealed the patient told the CSW that he/she just wanted to leave the facility, and denied being suicidal or homicidal.

Attempted to contact Patient #3 via telephone on 06/22/2021 at 12:00 PM and, on 06/23/2020 at 10:59 AM, but was unable to contact the patient for interview.

Interview with Certified Social Worker (CSW) #1, on 06/23/2021 at 1:16 PM, revealed Patient #3 had been doing well with his/her treatment and actively participated with a positive attitude until the day he/she was discovered in the shower with Patient #2. He stated thereafter, Patient #3 wanted to leave the facility. CSW #1 went stated Patient #3 felt he/she would be treated differently once his/her HIV status was revealed to Patient #2. He stated this caused emotional stress for Patient #3.

Interview with RN #8, on 06/28/2021 at 2:23 PM, revealed it appeared Patient #3 had been upset after Patient #2 entered his/her unit, on 06/14/2021. She stated Patient #3 wanted to go home on 06/14/2021 after he/she saw Patient #2 enter his/her new unit. RN #8 stated she was able to calm Patient #3, and convinced him/her to stay until the following day to see the psychiatrist. She stated his/her behaviors which included throwing a chess board, confrontations with staff, and demanding to leave, started the evening after he/she saw Patient #2 enter his/her unit. RN #8 stated she felt like Patient #3 had been upset by seeing Patient #2 after being moved, on 06/13/2021, to another unit. She stated it could have appeared Patient #2 had attempted to get to Patient #3 after being told of the HIV exposure.

Interview with the Director of Risk Management (DRM), on 06/29/2021 at 4:10 PM, revealed Patient #3 did not want staff to tell Patient #2 of his/her HIV status until after he/she had been moved to a separate unit. She stated Patient #3 told her he/she would be treated differently once Patient #2 was informed. The DRM stated Patient #3 had been compliant and had participated in his/her treatment program until 06/14/2021, when he/she wanted to leave the facility against medical advice (AMA). She stated the facility was responsible to keep the patients safe and provide a safe environment. However, that had not been the case when Patient #2 entered Patient #3's unit, after he/she moved on 06/13/2021.

Prior to exiting, on 07/02/2021, the facility submitted an Immediate Jeopardy (IJ) Removal Plan alleging the IJ was corrected on 07/01/2021. Review of the IJ Removal Plan and on-site validation determined the IJ was abated on 07/01/2021.

1. The Director of Risk Management reviewed the policy, "Sexually Acting Out" (SAO), on 06/23/2021, which did not require revision. Interview with the DRM, on 07/01/2021 at 3:30 PM, revealed she reviewed the SAO policy which she determined was appropriate and did not require revisions.

2. On 06/23/2021, the DRM began to provide education to all nursing staff concerning abuse and neglect reporting, boundary violations, and preventing SAO. Training included notification of the physician, reporting incidents immediately and to obtain orders for increased staff supervision, and additional interventions as needed. Review of the education roster for abuse and neglect reporting, boundary violations, and prevention of SAO, revealed current employees had been educated by 07/01/2021. Interviews with facility staff revealed they received education provided by the DRM on the topics of abuse/neglect reporting, boundary violations, and prevention of SAO.

3. The Staff Coordinator ensured staff received training prior to beginning of their shift. Review of the employee training roster revealed all staff currently working in the facility had received re-education on abuse reporting, boundary violations, and prevention of SAO incidents.

4. On 06/23/2021, the Chief Executive Officer (CEO), the Director of RM, ant the Director of Nursing (DON) reviewed the requirements regarding timely reporting of an abuse incident to the State Survey Agency (SSA).

5. The RM, and the DON attested the understanding of reporting expectations and requirements. Review of this information was verified and complete.

6. On, 07/01/2021, the DON and the Director of Clinical Services started education on appropriately updating Treatment Plans, as needed.

7. The CEO and DON ensured placement of Absence Without Leave (AWOL) signage on the appropriate units to ensure staff were aware of high risk exit seeking patients.

8. Interview with staff and Administration revealed the facility had recently provided re-education on Abuse, SAO Behaviors, and prevention.

Based on observation, interview, and record review, review of the facility's policies it was determined the facility failed to protect two (2) of ten (10) sampled patients from abuse (Patient #2 and Patient #3).

Patient #2 and Patient #3 had sexual intercourse, on 06/13/2021, and as a result, Patient #2 was exposed to the Human Immunodeficiency Virus (HIV). Prior to the incident, staff had observed sexually acting out behaviors (SAO) between Patient #2 and Patient #3, but failed to notify the Management, and failed to intervene appropriately per the facility's policy and procedure. Additionally, the facility failed to complete a thorough abuse investigation, and failed to report to the State Survey Agency timely. After the patients had a sexual encounter, on 06/13/2021, staff moved Patient #3 to another unit. Patient #2, who was on AWOL (Absent Without Leave) precautions, exited his/her unit, unsupervised and entered Patient #3's unit.

The findings include:

Review of the facility's policy titled, "Sexual Acting Out (SAO) Precautions," revised 01/2018, revealed staff had been educated for prevention and early identification of sexually acting out behaviors. Early identification was initiated on admission with the completion of an intake assessment for a history of sexually acting out behaviors in the past six months, history of sexual aggression as a child, history of sexual abuse, psychosis with sexual preoccupation, and if the patient displayed poor physical boundaries. Additional review revealed the patient would remain on the SAO precautions until the physician deemed the precautions were no longer necessary, to include, an assessment every twenty-four (24) hours with documentation in the Progress Notes. The policy revealed staff would immediately notify the nurse or nursing supervisor of the observed behaviors, and the nursing supervisor would notify the Director of Risk Management (DRM) to initiate an investigation. Further policy review revealed patients were educated about appropriate physical boundaries.

Review of the facility's policy titled,"Abuse/Neglect Reporting", revised 02/2020, revealed the facility identified, prevented, protected victims of abuse, and the process for reporting abuse. According to the policy, the facility assessed patients during the intake process to identify a history of abuse/neglect and a psychosocial assessment was performed by a counselor to determine a more detailed current/history of abuse or traumatic experiences. The policy revealed neglect was careless or purposeful omission of an incident, which required care for the patient to give proper attention such as lack of physical care. Further review revealed behavioral indicators of sexual abuse included sexual promiscuity and poor peer relationships. Additional review of the policy revealed staff reported allegations of abuse to the House Supervisor and Physician; obtained applicable orders, document all actions in the medical record; and report to the Director of Risk Management (DRM), Director of Nursing (DON), Chief Executive Officer (CEO), and Chief Operating Officer (COO).

Observation of Patient #2, on 06/23/2021 at 10:45 AM, revealed he/she was dressed appropriately and was walking in the hallway on his/her unit.

Per interview, on 06/23/2021 at 10:45 AM, Patient #2 stated he/she had sexual intercourse with Patient #3, on 06/13/2021, in the shower before staff came in and told him/her to get dressed and exit the room.

Observation and interview with Patient #3 was not possible as the patient had left the facility.

Review of Patient #2's clinical record revealed the hospital admitted Patient #2, on 06/04/2021, as an involuntary seventy-two (72) hour hold with diagnoses that included Severe Psychosis and Catatonia.

Review of the High Risk Notification Alert assessment completed, on 06/04/2021, revealed Patient #2 did not have a history of sexually acting out behaviors.

Review of the Licensed Practitioner Progress Notes documented by Psychiatrist #2's Advanced Practioner Registered Nurse (APRN), dated 06/09/2021, 06/10/2021, 06/11/2021, 06/12/2021, 06/13/2021, 06/14/2021, and 06/15/2021, described Patient #2's thought processes as slow, paranoid, and delayed in response to conversation.

Review of Patient #2's Nursing Daily Progress Notes, dated 06/09/2021, revealed Patient #2 had been discovered by staff, during the routine fifteen (15) minute observation rounds, to be laying in the bed with Patient #3.

Review of an additional Progress Note, revealed on 06/10/2021, Patient #2 exhibited poor boundary awareness and entered into Patient #3's room. Further review of the Progress Notes, dated 06/13/2021, revealed Patient #2 had been discovered in Patient #3's shower. Patient #2 had been assessed with a flat affect, and illogical and disorganized thought processes.

Review of Patient #2's Physician's Orders, dated 06/10/2021, revealed Sexually Acting Out (SAO) Precautions had been initiated following inappropriate interaction with another patient on 06/09/2021.

Review of Patient #2's Master Treatment Plan (MTP) included interventions to address SAO had been initiated on 06/10/2021.

Review of Patient #2's Medical Physician's Consultation Note, dated 06/14/2021, revealed a complaint had been identified as sexual activity with a patient who was HIV positive. The note also revealed Patient #2 remained psychotic and had difficulty understanding the implications of the sexual activity even though it was consensual.

Record review of Patient #3's closed record revealed the facility admitted the patient on 06/09/2021 with diagnoses that included Psychosis, Hallucinations, and Delusions related to Methamphetamine use.

Review of Patient #3's MTP, dated 06/09/2021, revealed a maintenance problem (a stable concern or medical issue) of SAO behaviors as a victim and perpetrator. The MTP did not have active interventions for the behaviors, as it was not identified as an active problem during the hospital stay.

Review of Patient #3's Nursing Daily Progress Notes, dated 06/13/2021, revealed facility staff observed Patient #3 in the shower with a another patient, both unclothed.

Unable to observe Patient #3 as he/she was discharged on 06/15/2021.

Attempted to contact Patient #3 via telephone on 06/22/2021 at 12:00 PM and, on 06/23/2020 at 10:59 AM for an interview.

Interview with Registered Nurse (RN) #1, on 06/23/2021 at 11:14 AM, revealed Patient #2, and Patient #3 had a pattern of poor boundaries. He stated when Patient #3 had been admitted, on 06/09/2021, Patient #2 had been focused on Patient #3. Continued interview with RN #1 revealed, on 06/09/2021, RN #3 found Patient #2 in in the bed with Patient #3. Further interview revealed Patient #2 had attempted a minimum of two (2) more times that night to get back into Patient #3's room; however, he and RN #3 had intervened. RN #1 stated he had informed the Charge Nurse, during his shift, about the patients' behaviors on 06/09/2021. The RN could not recall who the Charge Nurse's name. He stated the goal of his actions were to create a safe environment for the patients. Further interview with RN #1, revealed a few days following the 06/09/2021 incident, the Mental Health Technician (name unknown) had separated Patient #2 from Patient #3 after the MHT had observed Patient #3's head laying in Patient #2's lap. RN #1 stated it had been a constant struggle for staff to redirect and separate the two (2) patients. He stated he had not reported the head in the lap incident to anyone. Further interview with RN #1 revealed he had immediately separated the patients on 06/13/2021, when Patient #2 was discovered in Patient #3's shower. Following the incident, he informed House Supervisor #3, documented the incident in the Progress Notes, and completed an Incident Report. RN #1 stated upon interviewing the patients, Patient #2 would not talk to him and Patient #3 stated nothing happened between them. Continued interview revealed the Director of Risk Management (DRM) had not yet contacted him for an interview in regards to the incident. However, he stated he thought the DRM had gathered all the necessary information from House Supervisor #3, who was present at the time of the incident.

Interview with House Supervisor #3, on 06/23/2021 at 12:42 PM, revealed she had been unaware she was required to call the DRM, DON, and CEO in regards to the incident which occurred on 06/13/2021, when Patient #2 was found in Patient #3's shower. She stated notification of the incident had been sent to the Risk Manager via e-mail. However, after receiving re-education, she realized a phone call notification should have been made and notification should have been done immediately in order to ensure patient safety.

Interview with Mental Health Technician (MHT) #2, on 06/24/2021 at 10:36 AM, revealed he had previously observed Patient #3 to have his/her head on Patient #2's lap. Per interview, the MHT stated he instructed Patient #2 and Patient #3, that physical contact was prohibited because they were patients at the hospital. He further stated he had informed House Supervisor #3 about what he witnessed on 06/13/2021. However, he had not been interviewed by the Unit Manager or the DRM regarding the incident. MHT #2 stated he assumed he was not questioned about the incident because the DRM had gotten all the information from House Supervisor #3.

Interview with the DRM, on 06/24/2021 at 12:57 PM, revealed she had not interviewed the staff who were present on 06/13/2021, about the incident between Patient #2 and Patient #3 because her main concern at that time had focused on the safety of the patients, as well as, getting Patient #2's HIV exposure evaluated by the physician. Additionally, she stated upon review of the video footage of the unit's hallway, and Patient #3's room, as well as the information from House Supervisor #3, she had been able to determine the order of the events between the patients. The DRM stated she had attempted to contact RN #1, but he never returned her call. She stated her normal process, when investigating a patient incident was to interview staff present at the time of the incident.

Interview with the Interim Director of Nursing (IDON), on 06/25/2021 at 9:10 AM, revealed she had heard in passing of Patient #2 sitting on Patient #3's bed. She stated she had not been informed by staff of any additional inappropriate behaviors between Patient #2 and Patient #3. However, the two (2) patients should have been separated and put on different units before the incident on 06/13/2021.

Interview with House Supervisor #1, on 06/25/2021 at 2:56 PM, revealed her role was to ensure staff and patient safety in the facility. She stated she had been informed Patient #2 had entered Patient #3's room one night, but had been easily redirected out of the room. Further interview revealed she had sent an e-mail, on 06/09/2021, to the Unit Manager (UM) to determine if Patient #3 would be appropriate to move to another unit, but she did not get a response from the UM. She stated she had not been aware Patient #3 was HIV positive. Continued interview revealed if she had known, she would have taken the responsibility to separate the patients after staff had observed their sexually acting out behaviors.

Interview with the Unit Manager (UM), on 06/25/2021 at 12:56 PM, revealed she did not recall being asked by anyone, nor, did she recall having received communication via email from House Supervisor #1 to look into possibly moving either Patient #2 or Patient #3 to another unit.

Interview with RN #5, on 06/30/2021 at 11:05 AM, revealed staff ensured patient safety and prevention of behaviors/abuse via fifteen (15) minute observational rounds which included communication and timely reporting of issues to management.

Interview with the Director or Nursing (DON), on 07/01/2021 at 12:33 PM, revealed the staff was responsible to provide a safe environment for the patients in the facility. He stated his expectation of the fifteen (15) minute observational rounds was to assist with prevention of behaviors. The DON stated any observations by staff of potential abuse should be reported immediately to the House Supervisor. Documentation of the behaviors of the patients should be complete so that the physician and/or management were kept aware of concerns. The DON stated Patient #2 and Patient #3 should have been separated after the incident on 06/09/2021.

Interview with the Chief Executive Officer (CEO), on 07/01/2021 at 2:19 PM, revealed the staff were responsible to identify, report, and intervene with potential abuse allegations immediately.

Prior to exiting, on 07/02/2021, the facility submitted an Immediate Jeopardy (IJ) Removal Plan alleging the IJ was removed on 07/01/2021. Review of the IJ Removal Plan and on-site validation determined the IJ was removed on 07/01/2021.

1. The Director of Risk Management reviewed the policy, "Sexually Acting Out" (SAO), on 06/23/2021, which did not require revision. Review of the policy revealed it was appropriate, with no changes required.

2. On 06/23/2021, the Risk Manager (RM) began to provide education to all nursing staff concerning abuse and neglect reporting, boundary violations, and preventing SAO. Training included notification of the physician, reporting incidents immediately and to obtain orders for increased staff supervision, and additional interventions, as needed.

3. Beginning 06/23/2021, the Staff Coordinator ensured staff received training prior to beginning of their shift. Verification of the training roster revealed all staff currently working in the facility had received re-education on abuse reporting, boundary violations, and prevention of SAO incidents.

4. On 06/23/2021, the Chief Executive Officer (CEO), the Director of RM, and the Director of Nursing (DON) reviewed the requirements regarding timely reporting of abuse incident to the State Survey Agency (SSA).

5. The RM, and the DON attested the understanding of reporting expectations and requirements. Review of this information was verified and complete.

6. On, 07/01/2021, the DON and the Director of Clinical Services started education on appropriately updating Treatment Plans as needed.

7. The CEO and DON ensured placement of Absence Without Leave (AWOL) signage on the appropriate units to ensure staff were aware of high risk exit seeking patients.

8. Interview with staff and Administration revealed the facility had recently provided re-education on Abuse, SAO Behaviors, and prevention.

9. On 06/25/2021, the CEO, DON, the Director of Pharmacy, and the Medical Director discussed the process and expectations to obtain HIV medications, or other critical medications not on the facility's formulary when a patient did not have access to their home medications. If the medication was not available, the pharmacist would notify the physician for an alternative order, if the alternative order was not acceptable, then the pharmacy would send the medication as ordered. The Medication Policy was reviewed and revised by the DON.

10. Education was provided to staff regarding actions to take when medication was not available, refusals of medications, and physician notification when medications were not given as prescribed. Interviews with nursing staff revealed education had been provided regarding the administration of HIV, and critical medications.

11. Nursing Staff were provided education prior to the beginning of their shift. Review of the Training/Education Roster revealed staff had been provided education prior to working in the facility.

12. The CEO provided education to the Director of Pharmacy, and to the Medical Director on 06/30/2021 concerning the process and expectation for obtaining HIV and other critical medications. Interview with the Pharmacy, and the Medical Director revealed they were aware of the process to obtain HIV and other critical medications.

Based on interview, record review, review of the facility's policy and video footage, it was determined the facility failed to maintain an effective Quality Assessment and Performance Improvement Program (QAPI) that identified the facility's failure to report and document inappropriate patient behaviors, report timely, and thoroughly investigate abuse, and to ensure Physician's Orders were followed for two (2) of ten (10) sampled patients (Patient #2, and Patient #3).

The findings include:

Interview with the Director of Nursing (DON), on 07/01/2021 at 12:33 PM, the Chief Executive Officer (CEO), on 07/01/2021 at 2:17 PM, and the Chief Medical Director, on 07/01/2021 at 2:13 PM, revealed QAPI met quarterly and discussed any problems regarding staff, reviewed policies, monitored data regarding patient safety, and oversaw the nursing staff. Further interview revealed they had not been made aware of the present concerns related to Patient Safety, Abuse, Medication/Labs, or Nursing Services and Documentation.

Interview with the Chief Executive Officer (CEO), on 07/01/2021 at 2:19 PM, revealed the QAPI Committee also directed Performance Improvement Teams (PIT) which sought out solutions for an identified, specific problem. This PIT team met weekly and there were four (4) teams meeting "right now". The CEO stated the facility identified current issues and concerns in a Daily Flash Meeting, which was comprised of several members of the Management Team. She stated she had a daily template she used which addressed Staffing, Intakes, Incident Reports, Grievances, and any Environment of Care (EOC), Discharges, Patients on Special Observations, High Risk Precautions, and Blocked off Beds. She stated staff also e-mailed her concerns, and she did rounds at least daily, and talked with staff, and patients.

Review of Patient #2's clinical record revealed the facility admitted the patient on 06/04/2021, with diagnoses that included Psychosis and Catatonia.

Review of Patient #3's closed record revealed the facility admitted the patient, on 06/09/2021, with diagnoses that included Human Immunodeficiency Virus (HIV), psychosis, delusions, and hallucinations related to Methamphetamine withdrawals.

Further record review revealed, on 06/09/2021, Patient #3's medication order for Symtuza (anti-viral medication) had not been administered by the staff during his/her entire stay at the hospital. Interview with Psychiatrist #1, 06/25/2021 at 8:45 AM, Registered Nurse (RN) #1, on 06/28/2021 at 9:00 AM, and RN #5, on 06/30/2021 at 11:06 AM, along with clinical record review, revealed staff had not notified the physician that the patient had not received the ordered medication.

Per review of facility record, dated 06/09/2021, Patient #2 was found in bed with Patient #3. The facility's review documented staff interviews, the patients were fully clothed. Additionally, on 06/13/2021, per review of the facility's video footage, Patient #2 was observed entering Patient #3's room after his/her fifteen (15) minute check. Patient #2 and Patient #3 were observed to have sexual intercourse in his/her shower, per the staff's video footage review. The Mental Health Associate (MHA) found Patient #2 coming out of the shower and escorted him/her back to his/her room.

Record review revealed, on 06/14/2021, the facility assessed Patient #2 to be an AWOL risk; however, on 06/14/2021, the patient exited his/her unit, without staff knowledge, and entered Patient #3's unit. After this incident, Patient #3 became agitated, aggressive, and demanded to leave the facility.

Per record review, the facility obtained Physician's orders for Patient #3 to have labs drawn. However, there was no documented evidence the patient's labs were drawn, or if the patient refused to have his/her blood drawn.

Review of the, "QAPI 2020 Annual Report," revealed QAPI members met quarterly. Topics discussed during the 2020 year included, Sentinel Events, Fall Rates, Seclusion, Physical Hold Rate, Chemical Restraint Rate, Sexually Acting Out Behaviors, and Contraband Rate. The report also included Quality Safety Initiatives such as Suicide Risk Screening, Discharge Safety Plan, High Risk Visual Cue Upon admission, and Follow up Appointments.

Based on observation, interview, record review, and policy review, it was determined the facility failed to implement an effective Quality Assurance Performance Improvement Program (QAPI) to ensure patient safety for 2 (two) of ten (10) sampled patients (Patient #2 and Patient #3).

1.) Patient #2 was exposed to the Human Immunodeficiency Virus (HIV) upon sexual intercourse with Patient #3 on 06/13/2021.
2.) The physician had ordered Patient #3 an antiviral medication, Symtuza, upon admission. However, the medication was not transcribed to the Medication Administration Record (MAR) or obtained from the pharmacy or the patient's family to be administered, this resulted in the omission of five (5) days of treatment.
3.) After Patient #3 had been moved to another unit after a sexual encounter with Patient #2. Patient #2, who was on AWOL (Absent Without Leave) precautions, exited the unit and entered Patient #3's unit which caused Patient #3 to become upset, and voiced he/she wanted to leave the facility.
4.) Additionally, there was an absence of documentation related to Patient #3's refusal of laboratory work.

The findings include:

Review of the facility's policy titled, "Quality Assurance and Performance Improvement Plan" (QAPI), dated 05/17/2021, and signed by the Administrator, revealed the purpose of the program was based upon an integrated and collaborative approach to increase the probability of desired patient outcomes by assessing and improving those governance, clinical, and support processes that most affect patient outcomes. The plan was used as a guide to design, measure, assess and improve organizational performance; identify, minimize and prevent organizational risks and ensure delivery of safe patient care. Continued review of the policy revealed: Objectives- To enhance, maintain and continually improve the quality and safety of patient care, resolution of problems and on-going pursuit of opportunities to improve patient care and to provide a culture where care is delivered in a safe environment and quality of care is measured, monitored, and continuously improved. To promote safety and prevent untoward occurrences through systemic monitoring of environment to reduce facility and medical liability.

Review of the facility's policy titled, "Patient Safety Events," reviewed 02/2018, revealed the facility monitored, addressed, and assessed causal factors related to safety events. The policy revealed a patient safety event was a condition that could have resulted or did result in harm from a system breakdown, equipment failure, or human error. It further revealed permanent harm was a type of impairment not present on admission and severe temporary harm was a critical life threatening event which resulted in the requirement of a higher level of care but no permanent harm. The policy further revealed safety events included those that resulted in a hazardous condition, a close call, no harm, an event with some harm noted, and a sentinel event that resulted in serious harm.

1. Review of the clinical record revealed the facility admitted Patient #2, on 06/04/2021, as an involuntary seventy-two (72) hour hold with diagnoses that included Severe Psychosis and Catatonia.

Closed record review revealed the facility admitted Patient #3 on 06/09/2021 with diagnoses that included Human Immunodeficiency Virus (HIV), and Delusions and Hallucinations related to Methamphetamine use.

Review of Patient #2's Nursing Daily Progress Notes, dated 06/09/2021, revealed Patient #2, had been discovered by staff fully clothed and in the bed with Patient #3 during the routine fifteen (15) minute observation rounds. Additional review of the Progress Notes, dated 06/10/2021, revealed Patient #2 had been going into Patient #3's room with poor boundaries. Patient #2 had also been discovered in Patient #3's shower on 06/13/2021. The facility assessed Patient #2 to have a flat affect and illogical and disorganized thought processes.

Review of the Incident Report, dated 06/13/2021 at 9:05 PM and 06/14/2021 at 10:00 AM, revealed Patient #2, and Patient #3 had been found in Patient #3 shower. Both patients denied sexual contact. Patient #3 was transferred to another unit, and the physician was notified. Further review of the investigation revealed through interview, and review of camera footage, it had been determined that sexual intercourse between the two (2) patients had occurred.

Review of the Licensed Practitioner's Progress Notes, documented by Psychiatrist #2's Advanced Practice Registered Nurse (APRN), dated 06/09/2021 through 06/15/2021, described a daily assessment of Patient #2's thought processes as slow, paranoid, and delayed in response to conversation.

Review of Patient #2's Physician's Orders, dated 06/10/2021, revealed Sexually Acting Out (SAO) Precautions had been initiated following an inappropriate interaction with Patient #3 on 06/09/2021.

Review of Patient #2's Master Treatment Plan (MTP), dated 06/10/2021, revealed interventions were added to the MTP which identified Patient #2 as an aggressor for SAO behaviors after Patient #2 had been discovered in Patient #3's bed.

Review of Patient #2's lab results, reported on 06/18/2021, revealed a urine test for Trichomonas (a sexually transmitted disease) was positive for Patient #2.

Review of the Medical Physician's Consultation Note, dated 06/14/2021, revealed the reason for the physician's visit, had been identified because Patient #2 had been exposed to HIV during a sexual encounter with Patient #3. The Note also revealed Patient #2 remained psychotic and had difficulty understanding the implications of the exposure.

Record review revealed, on 06/13/2021, Patient #2 and Patient #3 had been discovered in Patient #3's shower, unclothed. Upon further review, the additional observed SAO behaviors of hand holding, shoulder massaging, and laying a head in the other patient's lap had not been documented in the medical record nor, communicated with the Unit Manager.

Review of the Progress Note, dated 06/15/2021 at 11:30 AM, revealed Patient #3 had gotten angry, threw a chess board at the nurses' station, had to be verbally deescalated by staff, and stated he/she wanted to leave the facility "now".

Review of a Progress Note, dated 06/15/2021 at 12:00 PM, revealed Patient #3 had been seen, and assessed by the Certified Social Worker (CSW) prior to discharge. Further review revealed the CSW evaluated the patient for safety. During the assessment, Patient #3 revealed to the CSW that he/she just wanted to leave the facility.

Interview with Patient #2, on 06/23/2021 at 10:45 AM, revealed he/she had sexual intercourse with Patient #3, on 06/13/2021, in the shower before staff came in and told him/her to get dressed.

State Survey Agency (SSA) attempted to contact Patient #3 via telephone, on 06/22/2021 at 12:00 PM, and on 06/23/2020 at 10:59 AM, but was unable to contact the patient for interview.

Interview with Registered Nurse (RN) #1, on 06/23/2021 at 11:14 AM, revealed there had been a pattern of sexually inappropriate behaviors between Patient #2 and Patient #3. He stated when Patient #3 was admitted on 06/09/2021, Patient #2 had became focused on Patient #3 and had been observed in Patient #3's room, in his/her bed. Per interview with RN #1, Patient #2 continued to go to Patient #3's room, even after being separated. Further interview revealed the Licensed Nurses and MHT's had to continually separate the patients as Patient #3 had also been observed to have his/her head in Patient #2's lap. RN #1 stated he did not document the patients' behaviors, but he should have.

Interview with House Supervisor #3, on 06/23/2021 at 12:42 PM, revealed her role was to ensure staff and patient safety in the facility. She stated she was informed Patient #2 had entered Patient #3's room one night but was easily redirected out of the room. Further interview revealed she had sent an email to the Unit Manager to determine if Patient #3 was appropriate to move to another unit; however, she had not gotten a response. She stated she was aware that Patient #3 was HIV positive. She stated, if she had known, she would have taken the responsibility to separate the patients after the observation of touching behaviors occurred.

Interview with Mental Health Technician (MHT) #2, on 06/24/2021 at 10:36 AM, revealed he had instructed Patient #2 and Patient #3, that they were at the hospital for mental health treatment, and they were not to have a relationship or anything physical with another patient.

Interview with the Director of Risk Management (DRM), on 06/24/2021 at 12:57 PM, revealed she was to be notified of incidents that could possibly result in litigation. She stated she had not been made aware Patient #3 was HIV positive until after the incident of sexual intercourse had occurred between Patient #2 and Patient #3 on 06/13/2021. The DRM stated during the investigation and review of the video footage from Patient #3's room, she observed sexual intercourse between Patient #2 and Patient #3 on 06/13/2021. She stated that interviews with Patient #2 and Patient #3 revealed they had sexual intercourse.

Interview with the Interim Director of Nursing (IDON), on 06/25/2021 at 9:10 AM, revealed she was responsible for ensuring the patients' safety. Per interview, the IDON stated she had heard about Patient #2 sitting on Patient #3's bed, but she had not been informed of any other inappropriate behaviors. Continued interview with the IDON revealed the patients should have been separated. The IDON stated communication by staff of inappropriate behaviors was important to determine a pattern in the patients' behaviors.

Interview with the Unit Manager, on 06/25/2021 at 12:56 PM, revealed she did not recall being asked to look into possibly moving either Patient #2 or Patient #3 to another unit after they they were found in bed together on 06/09/2021.

Interview with RN #10, on 07/02/2021 at 1:11 PM, revealed documentation of patient behaviors was important in order to determine if the behaviors were escalating so that staff could take the proper actions.

Interview with the facility's Medical Director (MD), on 07/01/2021 at 2:13 PM, revealed the Registered Nurse's responsibilities included supervision and evaluation of the patients to ensure a safe environment.

Interview with the Chief Executive Officer (CEO), on 07/01/2021 at 2:19 PM, revealed the nurses were responsible for supervision of the patients by ensuring safety rounds were performed. She stated the purpose of the observation rounds, conducted every fifteen (15) minutes, was to help to ensure the patients' safety.

2. Review of Patient #3's Physician's Orders, dated 06/09/2021, revealed an order for Symtuza (an antiviral medication to treat HIV) one (1) tablet daily and the order had been faxed to the pharmacy. Further review of the orders revealed the medication was not signed off by the nurse to indicate acknowledgement of the order.

Review of the Medication Administration Record (MAR), dated 06/10/2021 through 06/15/2021, revealed the medication Symtuza had not been transcribed to the MAR as ordered and the medication had not been administered.

Attempted to contact Patient #3 via telephone, on 06/22/2021 at 12:00 PM and on 06/23/2020 at 10:59 AM, but was unable to contact the patient for interview.

Telephonic interview with Patient #3's sister, on 06/22/2021 at 3:28 PM, revealed neither the patient nor hospital staff had contacted her about whether Patient #3 had been taking the physician ordered antiviral medication, or if she would bring the medication to the facility. She stated Patient #3 had been coming to her house daily to take the antiviral medication.

Interview with RN #2, on 06/25/2021 at 12:31 PM, revealed she had assumed Patient #3 had been noncompliant with his/her HIV medication because he/she had informed her that his/her family refused to bring the medication to the hospital.

Interview with the Unit Manager, on 06/25/2021 at 12:56 PM, revealed she had not been informed Patient #3 had not received his/her antiviral medication until the investigation was initiated by the State Survey Agency.

Interview with RN #1, on 06/28/2021 at 8:40 AM, revealed Patient #3 had told him, upon admission, that he/she had brought the HIV medications with him/her, and he then notified the pharmacy Patient #3 had brought his/her own supply of Symtuza with him/her. The RN stated the medication could not be located in the patient's belongings. He stated on 06/10/2021, he informed the oncoming RN, RN #2, to communicate with Patient #3 to see if his/her family could bring his/her own supply of Symtuza to the facility.

Interview with the DON, on 07/01/2021 at 12:33 PM, revealed he was responsible to ensure nursing staff were trained and provided care according to the job description. He further stated it was the facility's responsibility to obtain prescribed medications.

Interview with the Chief Executive Officer (CEO), on 07/01/2021 at 2:19 PM, revealed the facility was responsible to either obtain the prescribed medications from the patient's family, patient's pharmacy, or the hospital pharmacy. She stated it was not acceptable for patients not to receive their medication.

3. Observations on 06/29/2021 at 2:30 PM and 06/23/2021 at 10:45 AM revealed all doors in the facility were secured with locks, and keys were carried by facility staff. Continued observation of the doors to the two (2) adjacent adult psychiatric units revealed signs posted that identified patient(s) were at risk for exiting the unit.

Observation of Patient #2, on 06/29/2021 at 2:30 PM, revealed the patient was calm and not attempting to exit the unit.

Review of Patient #2's Progress Notes revealed two (2) successful elopements from the unit on 06/10/2021 and 06/14/2021. Patient #2 also made frequent requests to be discharged and to go home daily.

Review of Patient #2's Master Treatment Plan included interventions for Absent Without Leave (AWOL/Elopement) precautions initiated on 06/10/2021.

Review of Patient #2's Physician's Orders, dated 06/10/2021, revealed an order that included AWOL precautions.

Interview with the Director of Risk Management (DRM), on 06/24/2021 at 12:57 PM, revealed she was notified of incidents that could possibly result in litigation. She stated she was unaware Patient #3 was HIV positive until after the incident on 06/13/2021. The DRM stated during the investigation and review of the video footage it had been determined that, on 06/13/2021, Patient #2 and Patient #3 had sexual intercourse in Patient #3's shower. She also stated Patient #2 and Patient #3 admitted to having sexual intercourse.

Interview with RN #8, on 06/28/2021 at 2:23 PM, revealed it appeared Patient #3 had gotten upset after Patient #2 entered his/her unit on 06/14/2021. She stated Patient #3 wanted to go home, on 06/14/2021, after he/she had seen Patient #2 enter his/her new unit. RN #8 stated she was able to calm Patient #3, and convinced him/her to stay until the following day in order to be seen by the psychiatrist. She stated Patient #3's behaviors included- throwing a chess board, confrontation with staff, and a demand to leave the facility "now". RN #8 stated she felt like Patient #3 was upset after he/she observed Patient #2 enter his/her new unit. Continued interview with the RN revealed it could have appeared that Patient #2 was attempting to get on to Patient #3's unit so that he/she could get to Patient #3, after being informed of the HIV exposure.

Interview with Certified Social Worker (CSW) #1, on 06/23/2021 at 1:16 PM, revealed Patient #3 had been doing well with his/her treatment and had actively participated with a positive attitude until the day he/she was discovered in the shower with Patient #2. He stated thereafter, Patient #3 wanted to leave the facility. CSW #1 stated there was a lack of staff awareness in regards to the patient's HIV status, and it caused emotional stress for patient.

Interview with Patient #2, on 06/29/2021 at 2:30 PM, revealed he/she did not remember the incident nor, the day he/she exited his/her unit, and entered Patient #3's unit.

Interview with the Unit Manager (UM), on 06/29/2021 at 2:52 PM, revealed staff was responsible to be aware of patients' locations, especially when passing through locked doors. She stated staff were to make sure the doors closed behind them to secure the units and provide safety to the patients.

Interview with Registered Nurse (RN) #3, on 06/29/2021 at 3:38 PM, revealed she had entered the unit, on 06/14/2021, when Patient #2 exited the adjacent unit and entered her unit behind her coming through the locked unit door.

Interview with the Chief Executive Officer (CEO), on 07/01/2021 at 2:19 PM, revealed the QAPI Committee met monthly, and also directed Performance Improvement Teams (PIT) which seeks out solutions for an identified, specific problem. This PIT Team meets weekly and there were four (4) teams meeting "right now". She stated that the facility also had identified current issues and concerns during a "Daily Flash Meeting", which lasted around thirty minutes, and was comprised of several members of the Management Team. She stated she had a daily template she used which addressed Staffing, Intakes, Incident Reports, Grievances, and any Environment of Care (EOC) concerns, Discharges, Patients on Special Observations, High Risk Precautions, and Blocked off Beds. She stated staff could also e-mail her their concerns. Continued interview revealed she did rounds at least daily, and talked with staff, and patients. She stated she also worked at the facility on her on-call weekends.

Interview with the Medical Director (MD), on 07/01/2021 at 3:10 PM, revealed the QAPI Committee discussed overall function of the hospital, Quality of Care Improvement, Patient Satisfaction, and Patient Safety. He stated he could not recall any issues discussed related to Patient Safety or Quality of Care.

Additional interview with the DRM, on 07/01/2021 at 3:45 PM, revealed her job was to mitigate risks, and her role in PI was to report on facility incidents, discuss regulatory issues and facility compliance. She stated she also communicated with the Board of Governors.

Interview with the Performance Improvement Director (PI), on 07/02/2021 at 1:00 PM, revealed she oversees the PI Committee, which meets monthly. She stated she collected information from the Quality of Care Dashboard, reviewed Core Measures, as well as performed audits of the Medical Records. She also collected data from the chart audits, and core measures which were sent to Joint Commission, and the Centers for Medicare and Medicaid. The PI Director stated she also analyzed facility information and performed bench- marking against other facilities.

4. Closed clinical record review of Patient #3's Physician's Orders revealed the Medical Doctor (MD) had written an order, on 06/14/2021 at 3:40 PM, for a Human Immunodeficiency Virus (HIV) Viral Load, CD 4 Count, Hepatitis B Surface Antigen, and a Hepatitis C Viral Load.

Continued record review revealed no documented evidence that addressed why the resident's ordered labs had not been obtained by the phlebotomist.

Interview with the Infection Prevention Nurse (IP), on 06/24/2021 at 3:14 PM, revealed the House Medical Doctor, along with recommendations for Post-Exposure Prophylaxis (PEP), suggested the labs be ordered due to a patient's exposure to HIV. The IP Nurse stated she believed she had been told by staff that the labs had been refused by Patient #3. However, she stated the lab should have documented the refusal on the lab requisition.

Interview with Registered Nurse #6 (RN), on 06/29/2021 at 9:39 AM, revealed once lab orders had been placed in the computer by staff, and sent to the lab, a lab requisition would be generated, and the requisition would then be placed in a file which provided notification to the phlebotomist. Continued interview with RN #6 revealed if a lab requisition did not make it to the file, then the phlebotomist would not be aware of the order, and blood would not be drawn. He stated he did recall Patient #3 had refused the labs, as he/she had been very agitated that morning, along with making threats to leave the facility. He stated the lab would attempt to draw a patient's blood three times and then the phlebotomist would sign refused on the requisition form, and place the form in the patient's medical record. He stated he had not documented the refusal because the lab would document that information on the requisition once it had been placed back in the patient's chart.

Continued review of Patient #3's medical record revealed no documented evidence that a lab requisition had been generated, or placed in the resident's medical record.

Interview with RN #10, on 06/28/2021 at 3:07 PM, revealed she had ordered the labs for Patient #3 in the computer and recalled the IP had given her all the correct lab codes to use so she would know which code was needed. She stated she had printed out the lab requisition and placed it in the lab basket for the phlebotomist to draw the lab early in the morning the following day (06/15/2021).

Telephonic interview with the Corporate Compliance Officer of the facility's contracted laboratory (lab), on 06/29/2021 at 2:00 PM, revealed there was no record of Patient #3's labs in their system, and, an order entry would not occur without a specimen. The Corporate Compliance Office stated whenever a patient refused an ordered lab(s), the phlebotomist should inform the nurse.

Interview with the Chief Nursing Officer (CEO), on 07/01/2021 at 12:30 PM, revealed he expected the staff to ensure all ordered labs had been completed. However, if a patient refused to have a lab drawn, then staff should notify the provider, and document the refusal in the patient's medical record. She stated, at this point, the facility could not provide an answer on what happened with the labs for Patient #3. She stated the Quality Assessment Performance Improvement (QAPI) Committee met monthly and had completed audits on documentation which revealed concerns.

Prior to exiting, on 07/02/2021, the facility submitted an Immediate Jeopardy (IJ) Removal Plan alleging the IJ was corrected on 07/01/2021. Review of the IJ Removal Plan and on-site validation determined the IJ was abated on 07/01/2021.

1. Review of the facility's IJ Removal Plan, dated 07/01/2021, revealed on 06/23/2021, the Risk Manager reviewed the Sexually Acting Out (SAO) policy, and determined the policy did not require revision. Interview with the RM 07/01/2021 at 3:45 PM, revealed she had reviewed the SAO policy and procedure, and determined no revisions were required.

2 Training of staff occurred prior to working a shift in the facility. Review of the education roster revealed the staff working had received education on ensuring the safety of the patients. Interview with the CNO, on 04/01/2021 at 12:30 PM, revealed staff training began 06/25/2021.

3. The CEO and DON ensured posting of AWOL signage of the appropriate unit doors where high risk, exit seeking, patients resided. The signage was observed to be in place on the Psychiatric Intensive Care Unit (PICU).

4. Education was provided to staff regarding actions to take when medication was not available, refusals of medications, and physician notification when medications were not given as prescribed. Interviews with RN #9, on 07/02/2021 at 9:15 AM, and RN #7, on 07/02/2021 at 9:47 AM, revealed education had been provided regarding the administration of HIV, and critical medications.

5. The CEO provided education to the Director of Pharmacy, and to the Medical Director on 06/30/2021 concerning the process and expectation for obtaining HIV and other critical medications. Interview with the Pharmacist and the Medical Director, on 07/01/2021 at 2:13 PM, revealed they were aware of the process to obtain HIV and other critical medications.









42858

Based on interview, policy review, and record review, it was determined the facility failed to ensure patients were adequately supervised to provide a safe environment (Patients #2 and #3). Patient #2 and Patient #3 exhibited sexually acting out (SAO) behaviors. Registered Nurses failed to monitor, document, and communicate with other facility staff to address the behaviors which eventually led to sexual intercourse between Patient #2 and Patient #3. Furthermore, the nursing staff failed to ensure Patient #3 received his/her anti-viral medication, as ordered by the doctor, for the treatment of his/her HIV.

The findings include:

Review of Patient #2's clinical record revealed the facility admitted the patient on 06/04/2021 with diagnoses that included Psychosis and Catatonia.

Review of Patient #3's closed record revealed the facility admitted the patient, on 06/09/2021, with diagnoses that included Human Immunodeficiency Virus (HIV), Psychosis, Delusions, and Hallucinations related to Methamphetamine withdrawals. Further record review revealed Patient #3 had a Physician's Order for Symtuza (anti-viral medication) to treat his/her HIV. Interview and record review revealed the patient went without his/her medication during the entire length of his/her stay at the facility. (Refer to A-0405)

Interview with the Director of Risk Management (DRM) revealed upon review of the video footage on 06/13/2021, Patient #2 was observed entering Patient #3's room after his/her fifteen (15) minute check. She stated further video review revealed Patient #2 and Patient #3 were observed to have sexual intercourse in his/her shower. Interview with the DRM revealed she observed Patient #2 coming out of Patient #3's shower. Per interview and record review, the facility failed to provide oversight in the supervision and monitoring of the patients to provide a safe environment. Additionally, the facility failed to document the patient's previous behaviors related to "acting out sexually" and failed to document the patient's behaviors, which led to the patients having sexual contact in Patient #3's shower. (Refer to A-0115, A-0144, A-0145, A-0286, A-0385, A-0405, A-1620, and A-1655.

Record review revealed on 06/14/2021, Patient #2, whom the facility assessed to be an Absent Without Leave (AWOL) risk, exited his/her unit and entered Patient #3's unit, causing Patient #3 to become agitated, aggressive and demanded to leave the facility.

Per interviews with staff, the pharmacist, and the physicians, as well as closed and open record reviews, revealed the facility failed to ensure the patients were provided adequate supervision and monitoring to ensure the patients were provided a safe environment.

Refer to A-0395, and A-0405

Based on observation, interview, policy review, and record review, it was determined the facility failed to ensure adequate Registered Nurse (RN) supervision and evaluation of nursing care for two (2) of ten (10) sampled patients (Patient #2 and Patient #3).

The findings include:

Review of the facility's policy, Sexual Acting Out Precautions, revised 01/2018, revealed staff had been educated on prevention and early identification of sexually acting out behaviors. The policy revealed the RN would reassess and document in the progress notes sexually acting out behaviors.

Review of the clinical record revealed the facility admitted Patient #2, on 06/04/2021, as an involuntary seventy-two (72) hour hold with diagnoses that included Severe Psychosis and Catatonia.

Closed record review revealed the facility admitted Patient #3, on 06/09/2021, with diagnoses that included Human Immunodeficiency Virus (HIV), and Delusions and Hallucinations related to Methamphetamine use.

Review of Patient #2's Physician's Orders, dated 06/10/2021, revealed Sexually Acting Out (SAO) Precautions had been initiated following an inappropriate interaction with Patient #3 on 06/09/2021.

Review of Patient #2's Nursing Daily Progress Notes, dated 06/09/2021, revealed Patient #2 had been discovered by staff, during the routine fifteen (15) minute observation rounds, to be in the bed with Patient #3. Continued review of a Progress Note revealed, on 06/10/2021, Patient #2 was observed going into Patient #3's room. Further review revealed that, on 06/13/2021, Patient #2 was discovered by staff in Patient #3's shower. The facility assessed Patient #2 as having a flat affect and illogical and disorganized thought processes.

Review of the Licensed Practitioner Progress Notes, documented by Psychiatrist #2's Advanced Practice Registered Nurse (APRN), dated 06/09/2021 through 06/15/2021, described Patient #2's thought processes as slow, paranoid, and delayed in response to conversation.

Review of Patient #2's Master Treatment Plan, dated 06/10/2021, revealed Patient #2 had been identified as the aggressor for SAO behaviors when discovered in Patient #3's bed.

Review of Patient #3's Nursing Daily Progress Notes revealed, on 06/13/2021, Patient #2 and Patient #3 had been discovered together, in Patient #3's shower, unclothed. Further review of the Progress Notes, revealed no documentation regarding staff observations of the SAO behaviors of hand holding, shoulder massaging, and laying a head in another's lap, nor documentation of communication of the SAO behaviors to the Unit Manager, or the Risk Manager.

Observation of Patient #2, on 06/23/2021 at 10:45 AM, revealed he/she was dressed appropriately, and made eye contact.

Unable to observe Patient #3 as he/she was discharged from the facility on 06/15/2021.

Attempted to contact Patient #3 via telephone, on 06/22/2021 at 12:00 PM and, on 06/23/2021 at 10:59 AM, but was unable to contact patient for interview.

Interview with Patient #2, on 06/23/2021 at 10:45 AM, revealed he/she had sexual intercourse with Patient #3 on 06/13/2021 in the shower before staff came in and told him/her to get dressed and exit the room.

Interview with Mental Health Aide (MHA) #3, on 06/24/2021 at 10:09 AM, revealed he had notified the nurse (unknown) of his observation of inappropriate behaviors between Patient #2 and Patient #3.

Interview with Registered Nurse (RN) #1, on 06/23/2021 at 11:14 AM, revealed there had been a pattern of sexually inappropriate behaviors between Patient #2 and Patient #3. He stated after Patient #3 was admitted, on 06/09/2021, Patient #2 was focused on Patient #3. The RN stated after Patient #2 was discovered in Patient #3's bed, there were also a number of attempts, that same night, of Patient #2 trying to return to Patient #3's room. RN #1 stated he had informed the Charge Nurse (unknown) during his shift on 06/09/2021 about the patient's inappropriate behaviors. Further interview with RN #1 revealed he had observed a MHA (name unknown), who had separated Patient #2 from Patient #3 after he observed Patient #3's head laying in Patient #2's lap. RN #1 stated it was a constant struggle for staff to redirect and separate the two (2) patients. He stated he did not report the head in the lap incident to anyone.

Interview with RN #3, on 06/24/2021 at 12:21 PM, revealed she had worked as a MHT, on 06/09/2021, and she had observed Patient #2 lying in the bed with Patient #3. RN stated she notified RN #1 of her observation. RN #3 stated that on a different day, she had Patient #3 leave his/her room because staff could not convince Patient #2 to leave Patient #3's room. RN #3 stated she contacted the physician regarding Patient #2's behavior, and obtained a one time medication order.

Interview with the Unit Manager (UM), on 06/25/2021 at 12:56 PM, revealed she did not recall being asked to look into possibly moving either Patient #2 or Patient #3 to another unit after they were found clothed in bed together on 06/09/2021.

Interview with House Supervisor #3, on 06/23/2021 at 12:42 PM, revealed she did not know she was required to call the DRM, DON, and CEO regarding the incident on 06/13/2021 when Patient #2 and Patient #3 were discovered in the shower together. She stated she had sent notification via email to the Risk Manager. However, looking back, she realized a phone call notification should have been made.

Interview with House Supervisor #1, on 06/25/2021 at 2:56 PM, revealed her role was to ensure staff and patient safety in the facility. She stated she was informed Patient #2 had entered Patient #3's room one night, but was easily redirected out of the room. Further interview revealed she had sent an email to the Unit Manager to determine if Patient #3 would have been appropriate to move to another unit, but she did not get a response. She stated she was not aware Patient #3 was HIV positive. House Supervisor #1 stated if she had known, she would have taken the responsibility and separated them after the observation of touching behaviors.

Interview with the Director of Risk Management (DRM), on 06/24/2021 at 12:57 PM, revealed her responsibility included notification of incidents that could possibly result in litigation. She stated she was not aware of the additional behaviors exhibited by Patient #2, and Patient #3, that included hand holding, shoulder massage, and a head in the lap.

Interview with the Interim Director of Nursing (IDON), on 06/25/2021 at 9:10 AM, revealed she had heard in passing of Patient #2 sitting on Patient #3's bed. She also stated she had not been told of any additional inappropriate behaviors, but the two (2) patients should have been separated, and placed on different units before the incident occurred on 06/13/2021.

Interview with the Director or Nursing (DON), on 07/01/2021 at 12:33 PM, revealed the staff were responsible to observe for behaviors, a change in condition, or any concern that would require a change to the patient's treatment plan. He stated all patients were on fifteen minute (15) minute observations but, SAO precautions directed staff's awareness of patients' behaviors in order to redirect or provide interventions to prevent any unwanted occurrences.

Interview with the facility Medical's Director, on 07/01/2021 at 2:13 PM, revealed RN supervision and evaluation was necessary to provide safe care, with treatment modifications, as needed, under the care of the physician.

Interview with the Chief Executive Officer (CEO), on 07/01/2021 at 2:19 PM, revealed the nurses were responsible for supervision of the patients by ensuring the fifteen (15) minute rounds performed by the MHA's was completed correctly, on time and documented. She stated the purpose of rounding contributed to patient safety.

Prior to exiting, on 07/02/2021, the facility submitted an Immediate Jeopardy (IJ) Removal Plan alleging the IJ was removed on 07/01/2021. Review of the IJ Removal Plan and on-site validation determined the IJ was abated on 07/01/2021.

1. Review of the facility's IJ Removal Plan, dated 07/01/2021, revealed on 06/23/2021, the Risk Manager reviewed the Sexually Acting Out (SAO) policy, and determined the policy did not require revision. Interview with the RM revealed she had reviewed the SAO policy and procedure, and determined no revisions were required.

2. On 06/23/2021, the Risk Manager provided education on abuse, neglect reporting, boundary violations, and prevention of SAO incidents.

3. Training of staff occurred prior to working a shift in the facility. Review of the education roster revealed the staff working had received education.

4. The CEO and DON ensured posting of AWOL signage of the appropriate unit doors where high risk, exit seeking, patients resided. The signage was observed to be in place on the Psychiatric Intensive Care Unit (PICU).

5. Interview with the Risk Manager on 07/01/2021 at 3:45 PM, revealed training had been provided regarding SAO precautions, Abuse and Neglect Reporting, and boundary violations.

Based on interviews, closed record review, and policy review, and the Symtuza website, it was determined the facility failed to administer medication as ordered by the physician for one (1) of ten (10) sampled patients (Patient #3). Patient #3 did not receive his/her anti-viral as ordered.

The findings include:

Closed record review revealed the facility admitted Patient #3 on 06/09/2021 to the PICU (Psychiatric Intensive Care Unit) with the following diagnoses: Severe Psychosis, Hallucinations, Delusions related to Methamphetamine use, and Human Immunodeficiency Virus (HIV). The patient was discharged Against Medical Advice (AMA) on 06/15/2021.

Review of the facility's policy, titled, "Medication Variance," dated, 05/2020, stated Policy- Errors in medication administration must be reported immediately to the prescribing physician-on-call, for action to be taken. And 4.) Categories of breakdown in the system that contribute to medication errors: Medication Unavailable- failure to administer dose as ordered because medication was not available on the nursing unit.

Review of the Symtuza website ( https://www.symtuza.com/) revealed- "Advise patients to take SYMTUZA with food every day on a regular dosing schedule, as missed doses can result in development of resistance. Inform patients not to alter the dose of SYMTUZA or discontinue therapy with SYMTUZA without consulting their physician."

Closed clinical record review revealed the document titled, "List of Current Medications at Time of Admission," dated 06/09/2021 at 8:39 PM, by Registered Nurse #1 stated a telephone order had been given by Psychiatrist #1 for Symtuza (anti-viral) one tablet (tab) daily- purpose: HIV positive. The document also revealed Patient #3 had been been taking the medication as regularly scheduled.

Review of the document, "Nursing Admission Checklist," dated 06/09/2021 at 11:10 PM, revealed the checklist had been verified by RN #1 which confirmed all orders for Patient #3 had been transcribed on the MAR, and staff had ensured that all the Medical Doctors (MD) orders had been completed.

Review of the Medication Administration Record (MAR) for the entirety of Patient #3's stay at the facility revealed no documented evidence the medication Symtuza had been placed on Patient #3's MAR. Continued review revealed Patient #3 had not received the medication as ordered by the psychiatrist for the entirety of his/her inpatient stay at the facility.

Closed record review revealed, on 06/09/2021, Patient #3 signed and witnessed an Authorization to Disclose Patient Information to a family member.

Telephonic interview with Pharmacist #2, on 06/24/2021 at 3:12 PM, revealed the pharmacy had received the fax from the facility on 06/10/2021 at 12:11 AM in regards to Patient #3's Symtuza order. However, the pharmacist stated the pharmacy had documented in their notes that a telephonic dialogue had occurred between RN #1 and a pharmacy staff member. The pharmacist stated RN #1 had informed the pharmacy that Patient #3 had been admitted with his/her own supply of Symtuza; therefore, the pharmacy did not send any Symtuza to the facility.

Telephonic interview with Patient #3's family member, on 06/24/2021 at 3:28 PM, who was listed on the patient's Authorization to Disclose Patient Information, signed and witnessed on, 06/09/2021, revealed Family Member #1 had not received a telephone call from the facility or the patient requesting to bring the patient's Symtuza into the facility. The family member also revealed that Patient #3 was primarily homeless. However, he/she came to her house every morning to take his/her medication for HIV.

Interview with Psychiatrist #1, on 06/25/2021 at 8:45 AM, revealed he had not been made aware by the facility that Patient #3 had not received Symtuza as ordered. He stated his expectation of the facility was all medications should be administered by staff as ordered. Psychiatrist #1 stated if he had been made aware the Symtuza was not available to the patient, he would have consulted with the Medical Doctor for a possible alternative treatment.

Interview with House Supervisor #2, on 06/25/2021 at 10:28 AM, revealed whenever the facility admitted a patient who was taking prescribed, expensive medications at home, such as HIV medications, the facility would first ask the family to bring the medication (s) to the facility. She stated in her experiences at the facility, if a patient did not bring their expensive medications with them to the facility, and no one else, like a family member would bring the medication to the facility, the patient, honestly, did not receive the medication. She stated if a medication was not available at the facility, or the facility was unable to obtain the medication from the patient's family, the doctor should always be notified. The House Supervisor stated if the medication was not listed on the facility's approved Formulary, then the pharmacy would not send the medication without the approval from the facility's administration. She also stated when a patient did not receive their prescribed medications, then the facility had failed the patient.

Interview with RN #2, on 06/25/2021 at 11:30 AM, revealed she had been the oncoming nurse on 06/10/2021. She stated she had been made aware Patient #3 had been ordered Symtuza in shift report. RN #2 stated she had asked the patient several times to call his/her family and ask them if they would bring the medication into the facility. Continued interview revealed Patient #3 informed her that the family had refused to bring the medication to the facility, and at that point she assumed the patient was not compliant with the medication. RN #2 stated she had not called the family because a Release of Information had to be completed and signed by the patient and at that time Patient #3 was alert and oriented, but still was experiencing hallucinations. She stated she had not notified the physician in regards to the unavailability of the Symtuza. However, she was pretty sure she had notified the House Supervisor of the medication situation in regards to the Symtuza.

Interview with the Medical Physician (Doctor), on 06/25/2021 at 12:31 PM, revealed she had not been aware until "today", 06/25/2021, that Patient #3 had not received his/her HIV medications as ordered. She stated if she had been notified by the licensed nurses that the medication had not been sent to the facility, she would have called the pharmacy herself to ensure the patient received the medication as ordered. The Medical Physician stated there were HIV clinics that she could have reached out to in the community and sometimes they would send the medication to the facility.

Interview with Unit Manager #1, on 06/25/2021 at 1:03 PM, revealed staff had not made her aware Patient #3 had not received his/her Symtuza, as ordered by the physician. She stated staff should have made her aware of the situation with Patient #3's Symtuza. Unit Manager #1 stated that medications, not on the facility's formulary, would require approval by the Chief Executive Officer (CEO) in order for the pharmacy to send the medication to the facility.

Interview with RN #8, on 06/25/2021 at 2:41 PM, revealed staff was aware that Patient #3 had a Physician's Order to receive a HIV drug. She stated staff should have placed the medication order on the Medication Administration Record (MAR), and then the order should have been faxed to the pharmacy. She stated sometimes the pharmacy would fax or call the facility to inform them the medication was too expensive. RN #8 stated at that point, staff should notify either the doctor, or the house supervisor. She stated medications should be administered per the doctor's order because if the doctor ordered the medication, the patient needed it.

Telephonic interview with RN #1, on 06/28/2021 at 9:00 AM, revealed he had been Patient #3's nurse upon his/her admission on 06/09/2021. RN #1 stated, upon the patient's admission, he discovered the patient had not brought his/her Symtuza tablets with him/her; and, he faxed the order to the pharmacy. He stated he also asked the patient to call his/her family to see if they might be able to bring the Symtuza to the facility. RN #1 stated he had observed the patient on the telephone; however, he did not confirm with the patient that the patient's family would or would not bring the medication to the facility. He stated he had relayed this information to the oncoming nurse for follow-up. RN #1 stated he thought he had notified the pharmacy that the patient did not have the medication with him/her upon admission to the facility and Patient #3's family would bring the medication to the facility. Continued interview revealed he was aware the family had not brought the Symtuza to the facility, and at that point, it was a facility standard to notify the physician, the house doctor, and the psychiatrist. He stated that from his understanding, it was not a good thing for a patient to miss taking doses of an anti-viral medication. The nurse also stated medications should not be placed on the MAR if they were not available, because that would be considered a medication error.

Interview with RN #5, on 06/30/2021 at 11:06 AM, revealed she mainly worked dayshift in the PICU. She stated she was aware Patient #3 had not received the Symtuza as ordered by the physician. The RN stated if a patient could not bring their own medications, like HIV medications, to the facility with them, they generally did not receive the medication because of the expense of the medication. She stated staff should report this to the doctor. Further interview revealed she thought maybe Patient #3 did not have the medication at home. She stated she thought it was important for patients to receive their medication (s) as ordered, but if this was not possible, the doctor should be notified, and informed.

Interview with the Director of Nursing (DON), on 07/01/2021 at 12:33 PM, revealed he started his employment with the facility on 06/14/2021, and had extensive experience with psychiatric nursing. He stated when a high cost medication had been ordered by the doctor, the Nursing Supervisor should speak with the pharmacy, and the Nursing Supervisor had the authority to approve the medication. Further interview revealed then, the Nursing Supervisor would inform the Chief Executive Officer (CEO), the DON, the Chief Financial Officer (CFO), and the Unit Manager (UM), He stated all ordered medications should be placed on the patient's MAR, and the provider should be notified if/when a medication could not be administered as ordered.

Interview with the Chief Executive Officer (CEO), on 07/01/2021 at 2:17 PM, revealed at no time would the facility ever refuse to pay for expensive drugs as ordered by the physician. She stated the facility would not allow cost to be a reason that medications would not be given. The CEO stated the nurse manager was responsible and expected to dialog with the pharmacy when expensive medications were ordered by the doctor. Continued interview revealed if the patient could not bring their medications from home, the nurse manager could approve the medication. However, staff had not reported to anyone, including the doctors, or Administration that Patient #3's medication had not been ordered from the pharmacy, and had not been administered to Patient #3, as ordered. She stated since she had been the administrator at the facility, she was not aware of any Action Plans initiated in Quality Assurance Performance Improvement (QAPI) regarding medication administration.

Prior to exiting, on 07/02/2021, the facility submitted an Immediate Jeopardy (IJ) Removal Plan alleging the IJ was removed on 07/01/2021. Review of the IJ Removal Plan and on-site validation determined the IJ was abated on 07/01/2021.

1. On 06/25/2021, the CEO, DON, the Director of Pharmacy, and the Medical Director discussed the process and expectations to obtain HIV medications, or other critical medications not on the facility's formulary when a patient did not have access to their home medications. If medication was not available, the pharmacist would notify the physician for an alternative order, if the alternative order was not acceptable, then the pharmacy would send the medication as ordered. The Medication Policy was reviewed and revised by the DON.

2. Education was provided to staff regarding actions to take when medication was not available, refusals of medications, and physician notification when medications were not given as prescribed. Interviews with nursing staff revealed education had been provided regarding the administration of HIV, and critical medications.

3. Nursing Staff was provided education prior to the beginning of their shift. Review of Training/Education Roster revealed staff had been provided education prior to working in the facility.

4. The CEO provided education to the Director of Pharmacy, and to the Medical Director on 06/30/2021 concerning the process and expectation for obtaining HIV and other critical medications. Interview with the Pharmacy and the Medical Director, on 07/01/2021 at 2:13 PM, revealed they were aware of the process to obtain HIV and other critical medications.

Based on interview, policy review, and record review, it was determined the facility failed to ensure the clinical record provided a complete and accurate functional representation of the patient to indicate the facility was aware of the patient's status, with appropriate interventions in place, and the outcome of the interventions for two (2) of ten (10) sampled patients (Patient #2 and Patient #3).

The findings include:

Review of Patient #2's clinical record revealed the facility admitted him/her on 06/04/2021 with diagnoses that included Psychosis and Catatonia.

Further review revealed Patient #2 had been placed on Sexually Acting Out Precautions(SAO) on 06/10/2021.

Continued review of the clinical record revealed documentation on 06/13/2021 related to the patient's poor boundaries with another patient, and Patient #2 laying in the bed.

Closed record review revealed the facility admitted Patient #3 voluntarily on 06/09/2021 to the Psychiatric Intensive Care Unit (PICU) with the following diagnoses: Severe Psychosis, Hallucinations, Delusions related to Methamphetamine use and positive for Human Immunodeficiency Virus (HIV).

Interviews with Mental Health Technician (MHT) #1, on 06/24/2021 at 9:55 AM, MHT #3 on 06/24/2021 at 10:09 AM, and Registered Nurse (RN) #1, on 06/23/2021 at 11:17 AM, revealed the sexually acting out behaviors (SAO) exhibited by Patient #2 and Patient #3 included holding hands, shoulder rubbing, and head in the other's lap.

Review of Patient #2's and Patient #3's clinical records revealed not all observed inappropriate behaviors between the two (2) patients had not been documented by the Licensed Nurses. Additionally, there was an absence of documentation related to Patient #3's refusal of laboratory work.

Under Condition of Participation 482.61: Special Medical Record Requirements for Psychiatric Hospitals

Refer to Standard A-1655

Based on interview, open and closed record review, and policy review, it was determined the facility failed to record progress notes for two (2) of 10 (ten) sampled patients (Patient #2 and Patient #3).

1. Patient #2 and Patient #3 exhibited sexually acting out behaviors (SAO); however, staff failed to document the behaviors in the medical record.
2. Patient #3 had labs ordered; however, there was no documented evidence to reveal if the patient had the labs drawn.

The findings include:

Review of the facility's policy, Documentation Requirements, reviewed 05/2020, revealed the purpose of the document was to provide continuity and quality care by communication of patient's progress and assessment through documentation. It is the policy of the hospital for clinical staff to document the patient's progress and response to treatment goals and objectives in the medical record. 1.) Documents facts and observations that describe the patient's progress throughout the course of treatment; 6.) Documentation in the medical record reflects and correlates with patient symptoms/high risk behaviors including sexual aggression, sexual victimization...as well as precautions/observation level; and, 7.) Documents in the medical record, the patient's refusal and reasons to participate in treatment.

1. Review of Patient #2's Nursing Daily Progress Notes, dated 06/09/2021, revealed Patient #2 was discovered by staff, during the routine fifteen (15) minute observation rounds, lying in the bed with Patient #3. Continued Progress Note review, dated 06/10/2021, revealed Patient #2 was observed by staff to go into Patient #3's room. Further review revealed there were no additional Progress Note entries which described Patient #2's observed SAO behaviors.

Review of the Admission RN Note/Plan, dated 06/09/2021, revealed Patient #3 had a history of sexually acting out behaviors, both as a victim and as a perpetrator.

Review of Patient #3's Master Treatment Plan (MTP), initiated, on 06/09/2021, revealed staff had identified a history of SAO behaviors and had also identified the SAO as a maintenance problem. Further review revealed a maintenance problem was a problem that was stable or controlled which was not considered an active problem. Therefore, did not include interventions.

Review of Patient #2's Master Treatment Plan (MTP), dated 06/10/2021, revealed SAO was a current problem and Patient #2 had been identified as an aggressor.

Review of the Nursing Daily Progress Notes, dated 06/13/2021, revealed Patient #2 and Patient #3 were discovered in Patient #3's shower, unclothed. Upon further review, there was no documented evidence the additional SAO behaviors of hand holding, shoulder massaging, and laying a head in the other's lap, observed by staff, had not been documented in the patient's medical records.

Interview with Registered Nurse (RN) #1, on 06/23/2021 at 11:14 AM, revealed there had been an observed pattern of sexually inappropriate behaviors between Patient #2 and Patient #3. He stated when Patient #3 was admitted, on 06/09/2021, Patient #2 focused on Patient #3. The RN stated after Patient #2 was discovered in Patient #3's bed, there were also a number of attempts, that same night, by Patient #2 trying to return to Patient #3's room. RN #1 stated he informed the Charge Nurse (unknown) during his shift on 06/09/2021 about the patient's inappropriate behaviors. Further interview with RN #1 revealed he had observed a MHT (identity unknown), separate Patient #2 from Patient #3 after he had observed Patient #3's head laying in Patient #2's lap. RN #1 stated it was a constant struggle for staff to redirect and separate the two (2) patients. He stated he did not report the head in the lap incident to anyone.

Interview with Mental Health Technician (MHT) #1, on 06/24/2021 at 10:35 AM, revealed he had been notified during shift report, on 06/10/2021, that Patient #2 and Patient #3 had been observed holding hands. He also stated he had observed Patient #3 giving Patient #2 a shoulder massage. MHT #1 separated the patients, instructed Patient #3 he/she had displayed unacceptable behavior, and then he notified the nurse.

Interview with the Interim Director of Nursing (IDON), on 06/25/2021 at 9:10 AM, revealed documentation of behaviors and staff interventions was important to determine if there was a pattern or progression of the behaviors.

Interview with the Director of Nursing (DON), on 07/01/2021 at 12:33 PM, revealed any unusual events/observations should be documented, in detail, in the patient (s) chart and on a Progress Note so other staff could understand the patient's condition and/or make treatment revisions.

Interview with the Chief Executive Officer (CEO), on 07/01/2021 at 2:19 PM, revealed staff were expected to document the care provided to the patients, the description of daily patient routines, what did or did not occur, and actions the staff had taken.

Interview with the Medical Director, on 07/01/2021 at 3:10 PM, revealed staff were expected to clearly document patient care, patient behaviors, and patient events in the medical record, so the Psychiatrists could review and make adjustments to a patient's treatment, if required.

Interview with RN #7, on 07/02/2021 at 9:47 AM, revealed any observed inappropriate behaviors should be documented by the staff. She stated documentation provided communication among staff members and the patient's doctors.

Interview with Charge Nurse #1, on 07/02/2021 at 1:11 PM, revealed documentation of behaviors was important to determine if the behaviors were escalating so that staff could take the proper actions.

2. Closed record review revealed the facility admitted Patient #3 voluntarily on 06/09/2021 to the Psychiatric Intensive Care Unit (PICU) with the following diagnoses: Severe Psychosis, Hallucinations, Delusions related to Methamphetamine use and positive for Human Immunodeficiency Virus (HIV).

Review of the facility's policy titled, "Documentation Requirements," dated 05/2020, stated the purpose of the policy was to provide continuity and quality care by communication of patient's progress and assessment through documentation, and it was the policy of the facility for clinical staff to document the patient's progress and response to treatment goals and objectives in the medical records. 1. Documents facts and observations that describe the patient's progress throughout the course of treatment. 6. Documentation in the medical record reflects and correlates with patient high risk behaviors, including sexual aggression, and sexual victimization, and 7. Documents in the medical record the patient's refusal and reasons to participate in treatment.

Closed clinical record review of Patient #3 Physician's Orders revealed the Medical Doctor had written an order, on 06/14/2021 at 3:40 PM, for the following lab work: Human Immunodeficiency Virus Viral Load (HIV), CD 4 Count, Hepatitis B Surface Antigen, and a Hepatitis C Viral Load.

Review of Patient #3's medical record revealed no documented evidence that a lab requisition had been generated, or placed in his/her medical record. Continued record review revealed no documented evidence to address why or why not the ordered labs had not been drawn and sent to the lab.

Interview with the Infection Preventions (IP), on 06/24/2021 at 3:14 PM, revealed the House Medical Doctor ,along with the recommendations from the Post-Exposure Prophylaxis (PEP), had suggested labs be ordered, on 06/13/2021, due to Patient #2's exposure to HIV. The IP stated she believed she had been told by staff that the labs had been refused by Patient #3. However, the lab should have documented this as a refusal on the lab requisition.

Interview with RN #10, on 06/28/2021 at 3:07 PM, revealed she had ordered the labs for Patient #3 in the computer and recalled the IP had given her all the correct lab codes to use so she would know exactly which code was needed. She stated she printed out the lab requisition and placed it in the lab basket for the phlebotomist to draw the lab early in the morning the following day (06/15/2021).

Interview with Registered Nurse #6 (RN), on 06/29/2021 at 9:39 AM, revealed lab order (s) were placed in the computer by the staff, and then the order was sent to the lab. At this point, a lab requisition would be generated for facility use. RN #6 stated the requisition would then be placed in a file in to notify the phlebotomist of the order. Continued interview with RN #6 revealed if a lab requisition did not make it to "this file" then the patient's blood would not be drawn. He stated he did recall Patient #3 had refused the labs, as the patient had been very agitated, and making threats to leave the facility. RN #6 revealed the lab would attempt to draw a patient's blood a total of three times before the phlebotomist would sign refused on the requisition form and place the form into the patient's medical record. He stated he had not documented the refusal because the lab would document that information on the requisition form once the form had been placed back into the patient's chart.

Telephonic interview with the Corporate Compliance Officer at the facility's contracted Lab, on 06/29/2021 at 2:00 PM, revealed there was no record of Patient #3's labs in their system, and an order entry did not occur without a specimen. Further interview revealed when a patient refused ordered lab (s), the phlebotomist should inform the nurse.

Interview with the Chief Nursing Officer (CNO) on, 07/01/2021 at 12:30 PM, revealed he expected staff to ensure ordered labs were completed. However, if a patient refused to have a lab drawn, then staff should notify the provider, and document the refusal in the patient's medical record. He stated, at this point, the facility could not provide an answer on what happened with the labs for Patient #3.

Interview with the Chief Medical Director, on 07/01/2021 at 2:13 PM, revealed all pertinent documentation should be completed by the staff regarding the patient's care He stated staff should document in the patient's clinical record and this documentation should be clearly available to the physician. He stated the facility needed to work on their documentation.

Interview with the Chief Executive Officer (CEO), on 07/01/2021 at 2:17 PM, revealed staff should document all care, assessments, pertinent information, and notifications on the patients. She revealed if documentation was not entered into a note in the patient's chart, then it did not happen. She stated the Quality Assessment Performance Improvement (QAPI) Committee met monthly and had completed audits on documentation, which had revealed concerns.

Prior to exiting, on 07/02/2021, the facility submitted an Immediate Jeopardy (IJ) Removal Plan alleging the IJ was removed on 07/01/2021. Review of the IJ Removal Plan and on-site validation determined the IJ was abated on 07/01/2021.

1. On 06/30/2021, the Risk Manager (RM) and the Director of Nursing (DON) initiated staff education on documentation of behaviors, boundary violations, and Sexually Acting Out Behaviors (SAO) in the Progress Notes. Review of the staff education rosters revealed staff received education prior to working their shift in the facility.

2. The Staff Coordinator ensured staff received training prior to beginning of their shift. Review of the employee training roster revealed all staff currently working in the facility had received re-education on abuse reporting, boundary violations, and prevention of SAO incidents.

3. Interview with staff revealed the facility had provided education related to documentation.

4. Training of staff occurred prior to working a shift in the facility. Review of the education roster revealed the staff working had received education.













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