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Based on record review and interview, the hospital failed to ensure the medical staff was accountable to governing body for the quality of care provided to patients. This deficient practice is evidenced by the medical director failing to ensure the hospital investigated a patient on patient sexual abuse allegation for 1 (#5) of 5 sampled patients.

Findings:

Review of the hospital's policy titled Suspected Child, Adult, disabled Person or Elderly Abuse/Neglect/Exploitation, Reference Number 2034, revealed in part:
Patient/residents have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation. It is the policy of this hospital to protect patient/residents from real or perceived abuse, neglect or exploitation from anyone, including staff members, students, volunteers, other patient/residents, visitors or family members.
Management of Suspected Abuse/Neglect:
Cases of sexual assault, physical abuse or neglect will be given priority and will be investigated thoroughly.

Review of Patient #2's medical record revealed he had been admitted to the hospital on 10/13/16 at 5:53 p.m. with an admitting diagnosis of aggression. His history of present illness was listed as: The patient is a 27 year old Caucasian male who has intellectual deficiency who was admitted from his group home after he was exhibiting increased agitation and violent behavior towards staff. The patient was also hyper-sexual.

Review of Patient #2's medical record revealed a Multidisciplinary Note by S4RN dated 10/14/16 at 2:30 p.m.: This nurse came back from lunch and was informed that during my lunch break this patient's roommate (Patient #5) came out screaming and stated that this patient had gotten on top of him and started humping him and feeling on him. S5LPN informed this nurse that patient's roommate was placed in another room. This patient was placed on 1:1 monitoring for safety at this time. Further review of Patient #2's medical record revealed no documented evidence of an investigation of the alleged abuse by any staff member.

Review of Patient #5's medical record revealed no documentation of the alleged sexual abuse by Patient #2 on 10/14/16.

Review of the hospital's incident reports for 2016 revealed none had been written for the alleged sexual abuse of Patient #5 by Patient #2 on 10/14/16.

In an interview on 11/29/16 at 10:42 a.m. with S22Psychiatrist, he said he was the medical director of the hospital. He said Patient #2 tried to get into bed with another patient and he was placed 1:1 and the roommate was moved. He said that was all he knew about the incident.

In an interview on 11/30/16 at 7:35 a.m. with S4RN, she said she was working on 10/14/16 when Patient #5 alleged Patient #2 had been sexually inappropriate with him. She said when she returned from lunch S5LPN had told her Patient #5 came out of his room screaming and said Patient #2 got on top of him and started feeling on him and humping him. S4RN said she did not do an incident report. She said Patient #2 was profoundly mentally retarded, difficult to assess and not very verbal. She said the staff did not investigate the alleged incident but they should have.

In an interview on 11/30/16 at 10:30 a.m. with S1AsstAdm, she verified Patient #5 had no documentation in his medical record of the alleged sexual abuse from Patient #2 on 10/14/16. She also verified the hospital had not investigated the allegation.

Based on record review and interview, the hospital failed to ensure the patient or their representative had the right to make informed decisions regarding their care. This deficient practice is evidenced by the hospital's failure to notify a patient's representative of a change in the patient's condition for 1 (#2) of 5 total sampled patient records reviewed.

Findings:

Review of the medical record for Patient #2 revealed he was admitted on 10/13/16 with diagnosis which included Impulse Control Disorder, Mental Retardation and Cerebral Palsy.

Review of the document in Patient #2's medical record titled Authorization to Release and Disclose Patient Healthcare Information dated 10/14/16 revealed Patient #2's healthcare information was to be released to Social Services Company "A" (Company that coordinates care for adults with developmental disabilities).

Review of a progress note for Patient #2 dated 10/23/16 revealed the following entry: Staff reports that patient did not sleep well for the last 2 nights. Continued to complain of stomach pain. Staff reports there is some question of a recent abdominal injury.

Review of a multidisciplinary note for Patient #2 revealed an entry on 10/14/16 at 2:30 p.m. by S4RN: This nurse came back from lunch and was informed that during my lunch break this patient's roommate came out screaming and stated that this patient had gotten on top of him and started humping him and feeling on him. S5LPN informed this nurse that patients roommate was placed in another room. This patient was placed on 1:1 monitoring for safety at this time.

Review of a CT scan result for Patient #2 revealed the scan had been done on 10/23/16 at 11:51 a.m. and interpreted on 10/23/16 at 12:34 p.m. The reason for study was listed as "Abdominal pain; Patient kicked in abdomen".

Review of a Multidisciplinary Note for Patient #2 dated 10/22/16 at 8:40 p.m. revealed he had a seizure and had been sent to a local emergency department.

Review of Patient #2's medical record revealed no documented evidence Social Services Company "A" had been notified of the incidents mentioned above.

In an interview on 11/28/16 at 12:35 p.m. with Program Director Social Services Company "A", she said she was not notified of Patient #2 having a CT scan or sexual misconduct with another patient until after he had been discharged from the hospital. She also said she visited Patient #2 every day.

In an interview on 11/29/16 at 1:48 p.m. with S2DON, she said the representative from Social Services Company "A" should have been notified of Patient #2's sexual abuse allegation, the patient being sent to the hospital for a seizure, and the patient receiving a CT scan of the abdomen. S2DON verified there was no documentation in Patient #2's medical record that a representative from Company "A" had been notified of any of the incidents. S2DON also said the hospital did not have any policies about notifying responsible parties about a patient's change in condition.

Based on record review and interview, the facility failed to ensure patients had the right to be free from all forms of abuse. This deficient practice is evidenced by failing to investigate an allegation of sexual abuse of a patient (#5) by another patient (#2).

Findings:

Review of the hospital's policy titled Suspected Child, Adult, disabled Person or Elderly Abuse/Neglect/Exploitation, Reference Number 2034, revealed in part:
Patient/residents have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation. It is the policy of this hospital to protect patient/residents from real or perceived abuse, neglect or exploitation from anyone, including staff members, students, volunteers, other patient/residents, visitors or family members.
Management of Suspected Abuse/Neglect:
Cases of sexual assault, physical abuse or neglect will be given priority and will be investigated thoroughly.

Review of Patient #2's medical record revealed he had been admitted to the hospital on 10/13/16 at 5:53 p.m. with an admitting diagnosis of aggression. His history of present illness was listed as: The patient is a 27 year old Caucasian male who has intellectual deficiency who was admitted from his group home after he was exhibiting increased agitation and violent behavior towards staff. The patient was also hyper-sexual.

Review of Patient #2's medical record revealed a Multidisciplinary Note by S4RN dated 10/14/16 at 2:30 p.m.: This nurse came back from lunch and was informed that during my lunch break this patient's roommate (Patient #5) came out screaming and stated that this patient had gotten on top of him and started humping him and feeling on him. S5LPN informed this nurse that patient's roommate was placed in another room. This patient was placed on 1:1 monitoring for safety at this time. Further review of Patient #2 ' s medical record revealed no documented evidence of an investigation of the alleged abuse by any staff member.

Review of Patient #5's medical record revealed no documentation of the alleged sexual abuse by Patient #2 on 10/14/16.

Review of the hospital's incident reports for 2016 revealed none had been written for the alleged sexual abuse of Patient #5 by Patient #2 on 10/14/16.

In an interview on 11/30/16 at 7:35 a.m. with S4RN, she said she was working on 10/14/16 when Patient #5 alleged Patient #2 had been sexually inappropriate with him. She said when she returned from lunch S5LPN had told her Patient #5 came out of his room screaming and said Patient #2 got on top of him and started feeling on him and humping him. S4RN said she did not do an incident report. She said Patient #2 was profoundly mentally retarded, difficult to assess and not very verbal. She said the staff did not investigate the alleged incident but they should have.

In an interview on 11/30/16 at 10:30 a.m. with S1AsstAdm, she verified Patient #5 had no documentation in his medical record of the alleged sexual abuse from Patient #2 on 10/14/16. She also verified the hospital had not investigated the allegation.

Based on policy review, record review and interview, the hospital failed to ensure the use of restraint or seclusion was in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient for 2 (#4, #5) of 5 sampled patients.

Findings:

Review of the hospital policy titled Seclusion and Restraint Use, Reference Number: 1000, revealed in part:
Therapeutic Holding is holding a patient in a manner that restricts the patient's movement against the patient's will. Therapeutic Holding is considered a restraint.
Restraints are used upon the written or verbal order of a physician.
Seclusion is used upon the written or verbal order of a physician.

Patient #4
Review of an incident report dated 7/14/16 at 1:15 p.m. revealed Patient #4 had become threatening towards staff, argumentative and then began attacking a staff member. Multiple staff members had to physically hold patient down to prevent patient him from harming staff.

Review of an incident report dated 7/14/16 at 1:45 p.m. revealed Patient #4 had thrown a chair at staff, in turn made a hole in the wall. The patient was then escorted to seclusion for staff safety.

Review of seclusion documentation for Patient #4 dated 7/14/16 revealed he had been placed into seclusion at 1:45 p.m. and released at 2:30 p.m.

Review of the medical record revealed no physician's order on 7/14/16 for physically restraining Patient #4 or placing Patient #4 into locked seclusion.

In an interview on 11/29/16 at 4:45 p.m. with S2DON, she verified there was no physician's order to place Patient #5 in restraints or seclusion. S2DON also said she did not know that a therapeutic hold was considered a restraint.

Patient #5
Review of a Multidisciplinary Note for Patient #5 written by nursing staff dated 10/9/16 at 4:20 p.m. revealed in part: When he was being redirected by the nurse he began to curse her and turned around real quick as if he was going to hit her so he was taken down. Tolerated injection well. Further review of Patient #5's medical record revealed there was no physician's order for the physical hold to administer medications.

In an interview on 11/30/16 at 10:00 a.m. with S2DON, she verified Patient #5 did not have a physician's order for a therapeutic hold to administer medications.

Based on record review and interview, the hospital failed to ensure all direct care staff received and remained current in training based on the use of nonphysical intervention skills for 13 (S6LPN, S7LPN, S8MHT, S9LPN, S10MHT, S11LPN, S12LPN, S13RN, S14RN, S15RN, S16RN, S17LPN, S18MHT) current staff members.

Findings:

Review of a document provided by the hospital as a list of current staff members and their nonphysical intervention skills training revealed 13 staff members had no documented training (S6LPN, S7LPN, S8MHT, S9LPN, S10MHT, S11LPN, S12LPN, S13RN, S14RN, S15RN, S16RN, S17LPN, S18MHT).

In an interview on 11/30/16 at 10:50 a.m. with S2DON, she verified the hospital had no documented evidence the above mentioned staff members had current nonphysical intervention skill training.

Based on observation, record review and interview, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This deficient practice is evidenced by failing to ensure mental health technicians supervised patients with increased levels of observation as ordered for 1 (#1) of 5 sampled patients and 1 (#R1) random patient.

Findings:

Review of the hospital policy titled Suicidal Precautions/Close Observations, Reference Number: 1001, revealed line of sight is defined as keeping the patient within view of staff at all times.

Patient #R1
Observation on 11/30/16 at 9:45 a.m. revealed S3MHT was designated to keep Patient #R1 in her line of sight at all times. Observation revealed Patient #R1 was in the day room with no staff observing her in their line of sight. S3MHT was observed down a hallway performing 15 minute rounds on other patients.

In an interview on 11/30/16 at 9:45 a.m. with S3MHT, she verified she was responsible for watching Patient #R1 in her line of sight at all times. S3MHT also verified she could not presently see Patient #R1 from the hallway.

In an interview on 11/30/16 at 10:00 a.m. with S2DON, she said Patient #R1 was ordered to be within the line of sight of an assigned staff member at all times since her admission on 11/28/16 because she had suicidal ideations and not had not yet been examined by a psychiatrist. S2DON verified the staff member responsible for maintaining line of sight on Patient #R5 should have had her in their vision at all times.

Patient #1
Review of the Daily Nursing Assessment for Patient #1 dated 11/21/16 at 8:00 a.m. revealed she could be hypersexual towards male peers and had to be frequently redirected.

Review of the Daily Nursing Assessment for Patient #1 dated 11/22/16 at 8:00 a.m. revealed she was hypersexual and has inappropriate behaviors.

Review of Multidisciplinary notes for Patient #1 dated 11/22/16 at 4:05 p.m. revealed she was documented as being very hypersexual towards male peers. Further review revealed she was documented as constantly redirected for inappropriate gestures and behaviors and that she had attempted to walk into day room with no shirt or bra.

Review of the Daily Nursing Assessment for Patient #1 dated 11/23/16 at 11:00 p.m. revealed she was hypersexual towards a male patient and dressed inappropriately. Further review revealed she was documented as sexually flirting with a specific male patient.

Review of Observation sheets revealed Patient #1 was observed 1:1 or line of sight on 11/27/16 from 7:00 p.m. until 11/26/16 at 6:45 a.m. in room "A" by S19MHT. Further review revealed she also documented performing 15 minute observations during the same time period on Patient #R2 in room "B" during the same time period. Observation on 11/29/16 revealed Room "A" and Room "B" could not be viewed from one location simultaneously.

Review of Observation sheets revealed Patient #1 was observed 1:1 or line of sight on 11/22/16 from 7:00 p.m. until 11/26/16 at 6:45 a.m. in Room " A " by S20MHT. Further review revealed during the same time period he also documented performing 15 minute observations on Patient #R3 in Room "C", Patient #R4 in Room "D", Patient #R5 in Room "E", and Patient #R6 in Room "F" during the same time period. Observation on 11/29/16 revealed Rooms "C", "D", 'E', and "F' were on a different hall than the patient on direct line of sight in Room "A" and could not have been viewed simultaneously.

In an interview on 11/28/16 at 4:35 p.m. with S21RN, she agreed at night when the patients were in their rooms the MHT's could not be monitoring patients on direct line of sight while monitoring patients in other rooms and other hallways every 15 minutes.

Based on record review and interview, the hospital failed to ensure the nursing staff developed, and kept current individualized and comprehensive nursing care plans for each patient for 3 (#1, #2, #3) of 5 sampled patients.

Findings:

Review of the hospital policy titled Multidisciplinary Treatment Plan (MTP), Reference Number: 7006, revealed in part:
3. The MTP is to be reviewed daily by the RN/LPN and review noted in nurses notes.
5. At any time during the care of the patient/resident, when a new problem is identified, it will be written on the MTP list with goals and interventions developed on the MTP by the members of the treatment team.

Patient #1
Review of the Daily Nursing Assessment for Patient #1 dated 11/20/16 at 11:00 p.m. revealed she was sexual and flirted with specific male peer.

Review of the Daily Nursing Assessment for Patient #1 dated 11/21/16 at 8:00 a.m. revealed she could be hypersexual towards male peers and had to be frequently redirected.

Review of the Daily Nursing Assessment for Patient #1 dated 11/22/16 at 8:00 a.m. revealed she was hypersexual and had inappropriate behaviors.

Review of Multidisciplinary notes for Patient #1 dated 11/22/16 at 4:05 p.m. revealed she was documented as being very hypersexual towards male peers. Patient constantly redirected for inappropriate gestures and behaviors and attempted to walk into day room with no shirt or bra.

Review of the Daily Nursing Assessment for Patient #1 dated 11/23/16 at 11:00 p.m. revealed she was hypersexual towards a male patient, dressed inappropriately and was sexually flirting with a specific male patient.

Review of Patient #1's treatment Plan revealed no problem had been identified for sexual inappropriateness.

In an interview on 11/28/16 at 4:35 p.m. with S21RN, she agreed Patient #1's treatment plan should have been updated to include her sexually inappropriate behaviors.


Patient #2
Review of a 1:1 observation record (no date) revealed Patient #2 woke up at 1:00 a.m. crying of stomach pains and Patient #2 didn't go to sleep. Further review revealed he cried about his stomach hurting badly.

Review of a 1:1 observation record 10/19/16 said Patient #2 had been going back and forth to the restroom complaining about a stomach ache.

Review of the Patient #2's medication administration record revealed he had received Phenergan on 10/22/16 for nausea at 4:30 a.m. on 10/22/16.

Review of a progress note dated 10/23/16 at 2:30 p.m. revealed the following: Patient #2 was still complaining of abdominal pain, variable locations. CT of abdomen without abnormalities. Abdominal pain now with complaints of epigastric pain. Staff reports possible injury from peer to abdominal area- possibly some response to GI cocktail given in ER. Will increase treatment for GERD, Gastritis and monitor.

Review of the Multidisciplinary Treatment Plans for Patient #2 revealed he had no problems identified and interventions listed for his repeated complaints of stomach pains.

In an interview on 11/29/16 at 1:48 p.m. with S2DON, she verified Patient #2 did not have his stomach pains care planned but should have.


Patient #3
Review of Patient #3's Daily Nursing assessment dated 10/20/16 revealed she was documented as having been sexually inappropriate with female peers and grabbing female peers inappropriately

Review of Patient #3's Multidisciplinary Treatment Plan revealed it had not been updated to include the problem and interventions for sexually inappropriate behaviors.

In an interview on 11/29/16 at 1:48 p.m. with S2DON, she verified Patient #3 should have had her sexually inappropriate behaviors identified on her Multidisciplinary Treatment Plan as a problem.

Based on record review and interview, the hospital failed to ensure an accurate system was in place to ensure medical records were promptly completed within 30 days of discharge.

Findings:

Review of the hospital policy titled Delinquent Medical Records, Reference Number: 4081, revealed in part:
It is the policy of the Medical Records Department to notify a practitioner of suspension when he/she has delinquent medical records. Should the medical record remain incomplete on the 15th day after a patient discharge, the Medical Records Department will notify the physician, via certified mail, that his/her admitting, consultative and surgical privileges have been suspended until his/her medical records have been completed.

Review of Patient #2's medical record on 11/30/16 revealed a verbal order that had not been authenticated by S22Psychiatrist dated 10/23/16.

Review of Patient #4's medical record on 11/30/16 revealed Seclusion order that had never been authenticated by S22Psychiatrist dated 7/14/16.

Review of Patient #5's medical record on 11/30/16 revealed a verbal order that had never been authenticated by S23NP dated 10/12/16 and another by S24NP dated 10/8/16.

In an interview on 11/29/16 at 2:20 p.m. withS25MedicalRecords, she said she was over the medical records at the hospital. She said she had no delinquent records over 30 days (did not identify the 3 delinquencies mentioned above). She said she only checked the medical records for delinquencies from S22Psychiatrist and his two practitioners. She said she did not look for missing signatures or delinquencies from the medical practitioners. She verified physician's not cosigning verbal orders would make a chart delinquent. S25MedicalRecords said she had been told to only check the charts for S22Psychiatrist and she had been doing it that way for 10 years. When asked if she could give me an accurate number of delinquent medical records involving practitioners other than the medical director, she said no because she had not been counting them. She also said she had never suspended any physician's although their policy stated to suspend after 15 days delinquent.

Based on record reviews and interviews, the hospital failed to ensure all authentications of verbal orders had been dated and timed for 3 (#2, #3, #5) of 5 sampled patients.

Findings:

Patient #2
Review of Patient #2's physician's orders revealed telephone orders dated 10/14/16 at 2:30 p.m., 10/15/16 at 4:35 p.m. and 9:00 p.m., 10/17/16 at 11:30 a.m., 10/22/16 at 11:30 a.m. and 4:00 p.m. and 10/25/16 at 5:30 a.m. The telephone orders had been authenticated by the ordering practitioner but the signatures had not been dated or timed.

Patient #3
Review of Patient #3's physician's orders revealed verbal orders had been written on 10/19/16 at 3:45 p.m., 10/20/16 at 11:10 a.m., 10/21/16 at 3:15 p.m., and 10/24/16 at 9:00 p.m. Further review revealed the orders had been authenticated by the ordering practitioner but the signatures had not been dated or timed.

Patient #5
Review of Patient #5's physician's orders revealed a verbal order that had been written on 10/1/16 at 7:30 p.m. had been authenticated by the ordering practitioner but the signature had not been timed or dated.

In an interview on 11/29/16 at 2:20 p.m. with S25MedicalRecords , she said authentications of verbal orders should have been timed and dated.

Based on record review and interview, the hospital failed to ensure all information necessary to monitor the patient's condition and other necessary information was included in the patient's medical record. This deficient practice was evidenced by failure to include a patient's allegation of being sexually abused by another patient in his medical record for 1 (#5) of 5 sampled patients.

Findings:

Review of Patient #2's medical record revealed a Multidisciplinary Note with an entry on 10/14/16 at 2:30 p.m. by S4RN: This nurse came back from lunch and was informed that during my lunch break this patient's roommate (Patient #5) came out screaming and stated that this patient had gotten on top of him and started humping him and feeling on him. S5LPN informed this nurse that patient's roommate was placed in another room. This patient was placed on 1:1 monitoring for safety at this time.

Review of Patient #5's medical record revealed no documentation of the alleged sexual abuse by Patient #2 on 10/14/16.

In an interview on 11/30/16 at 10:05 a.m. with S1AsstAdm, she verified there was no documentation in Patient #5's medical record of the alleged sexual abuse by Patient #2 on 10/14/16 but there should have been.