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Based on a review of medical records, interviews with staff, and a review of the complaint log, it was determined the governing body failed to provide a safe environment for six (6) out of 12 (P#6, P#7, P#8 , P#9, P#10, P#12) patients sampled.

Cross reference A-0144 as it relates to the Governing Body being knowable of incidents involving sexual contact, but not providing proper oversight of the care of patients.

Based on a review of medical records, interviews with staff, and a review of the complaint log, it was determined the governing body failed to provide a safe environment for six (6) out of 12 (P#2, P#6, P#7, P#8 , P#9, P#10, P#12) patients sampled.

Cross reference A-0144 as it relates to the Governing Body's failure to provide safe and adequate care of patients.

Based on a review of medical records, interviews with staff, a review of incident reports, observations made during tours of the facility, and a review of policy and procedures, it was determined that the facility failed to protect the rights and provide care in a safe setting for six (6) out of 12 ( P#6, P#7, P#8 , P#9, P#10, P#12) patients sampled.

Cross reference A-0144 as it relates to the facility's failure to protect Patients' Rights to privacy, care in a safe setting, and a care setting free from abuse and harassment. .

Based on a review of medical records, interviews with staff, a review of incident reports, observations made during tours of the facility, and a review of policy and procedures, it was determined that the facility failed to protect the rights and provide care in a safe setting for six (6) out of 12 (P#6, P#7, P#8 , P#9, P#10, P#12) patients sampled.

Cross reference A-0144 as it relates to the facility's failure to protect a Patient's Rights privacy and safety.

Based on medical record review, incident reports, police reports, facility documents, staff and patient interviews, observations, and facility policies, it was determined that facility failed to protect a patient's right to care provided in a safe environment for six (6) out of 12 (P#6, P#7, P#8 , P#9, P#10, P#12) sampled.

Findings include:

A medical record review revealed that P#6 was admitted to the facility on 10/16/21 at 5:12 p.m. A review of a Psychiatry Progress Note on 10/23/21 at 10:45 a.m. revealed that P#6 had increased depression due to P#12 trying to sexually assault P#6. P#12 asked P#6 to suck his penis and forced himself on her in the Quiet Room. P#6 said P#12 pulled her pants down and fingered P#6 in the buttocks and vagina. The progress note revealed that since the incident, P#6 had been self-harming and was having crying spells. Review of the nurse Progress Notes revealed that on 10/23/21 at 11:30 a.m. a report was received from the nurse practitioner (NP) that P#6 was involved in an incident in which she was sexually assaulted by another male patient. Review of a Medical Progress note on 10/23/21 at 12:00 p.m., revealed that the provider was notified by the nursing staff that P#6 said she was sexually assaulted by a patient the previous evening and the morning of 10/23/21. Review of Progress Notes on 10/23/21 at 12:10 p.m., revealed there was a meeting with P#6, the RN, and the NP to obtain information regarding the allegations of sexual assault against P#6 by a male patient. P#6 reported that P#12 had been "cat-calling" her then coaxed her into the Quiet Room where P#12 kissed P#6 and placed his finger into P#6's vagina and rectum. The Progress Notes further revealed that P#12 forced P#6 to suck his penis. P#6 said that she was coerced by way of strangulation. The Progress Notes revealed that P#6 reported the incident happened during "phone time," around 9:00 p.m. on 10/22/21, as well as another incident on 10/23/21 at approximately 7:30 a.m. P#6 said that she had noted some vaginal bleeding described as "spotting," the prior evening and had confirmed through mid-morning. P#6 denied any further bleeding at the time of the Progress Notes on 10/23/21 at 12:10 p.m. The Progress Notes further revealed that the NP had ordered a SANE (Sexual Assault Nurse Examiner) evaluation to be performed.

A review of Progress Notes on 10/23/21 at 4:15 p.m. revealed the case was discussed with the facility Risk Management to provide an update. The police department was contacted on 10/23/21 at 5:05 p.m. to request an officer to perform an investigation and initiate a police report on the incident. On 10/23/21 at 6:25 p.m., an officer was present and stated a supervisor would perform the police investigation due to the nature of the situation. A review of the Practitioner Order Sheet on 10/23/21 at 9:45 p.m. revealed that P#6 would be transported to an area abuse shelter and would return to the facility after an examination. Review of a Practitioner Order Sheet on 10/24/21 at 10:25 a.m., revealed that P#6 would be moved to a seclusion room due to insecurities from the alleged assault. Review of a Nursing Reassessment progress note on 10/24/21 at 8:20 p.m., revealed P#6 was sitting in front of the nurses' station isolated from the group. P#6 reported anxiety and depression related to the "situation that happened," and "Post-Traumatic Stress Disorder (PTSD)." The Progress Note said P#6 had an order to sleep in the seclusion room because the patient did not feel safe.

A review of the SANE examination report for P#6 on 10/24/21 at 1:00 a.m., revealed there were abrasions on the cervix and labia minora (small inner folds of the external opening of the vagina).

During a telephone interview with the Sexual Assault Nurse Examiner (SANE) on 11/8/21 at 3:05 p.m., the SANE said the injuries found during the examination were consistent with the story told by P#6.

A review of Incident Report Forms revealed that there were three Incident Report Forms completed for P#6 on 10/23/21 at 7:30 a.m., 12:19 p.m., and 11:45 p.m. that involved a patient-to-patient boundary/sexual allegation. The sections of the Incident Report form for interventions, other notifications, supervisor review, and incident level were left blank. The incident reports failed to indicate that the police, child services, or the parent/guardian (case manager) were notified.

A review of the Intake Assessment revealed P#12 was admitted to the facility voluntarily on 10/20/21 at 3:15 a.m. Review of a Nursing Assessment on 10/20/21 at 3:41 a.m. revealed that impulsivity, anger, agitation, and low frustration tolerance were checked on the assessment form under depressive/affective symptoms; sexual impulsivity was not checked. Review of the physician ' s orders for P#12 on 10/20/21 at 2:38 p.m. revealed that P#12 was placed on every 5-minute observations. Review of Nurse Progress Notes on 10/21/21 at 12:05 p.m. revealed that P#12 was placed on Sexual Acting Out (SAO) precautions by the NP when the BHA's returned from recreational therapy and reported that P#12 was saying inappropriate sexual comments to female peers. Review of progress notes on 10/23/21 at 11:30 a.m., revealed a report was received from the NP that P#12 was involved in an incident with another patient. A female patient reported P#12 allegedly coaxed the female patient into the Quiet Room where P#12 kissed and touched the patient inappropriately and made the female patient perform sexual acts without consent. P#12 was questioned about the incident and denied having any sexual or inappropriate touching of any female patients. Review of Progress Notes on 10/24/21 at 11 a.m. revealed the guardian for P#12 was at the facility to sign P#12 out Against Medical Advice due to allegations of sexual improprieties his entire stay, except 10/24/21 due to P#12 being on 1:1 observation. Review of the Patient Observation Sheets revealed that P#12 was being observed every 15 minutes from 10/20/21 until 10/22/21. The Patient Observation Sheets revealed that P#12 was on SAO precautions beginning on 10/21/21 until discharge. The Observation Sheets further revealed that P#12 was on every 5-minute observations on 10/23/21 from 9:05 a.m. until 4:35 p.m. One-to-one observations began 10/23/21 until discharge. On 11/5/21 at 10:54 a.m. in the Conference Room, the Director of Nursing (DON) verified that the order for every 5-minute observations for P#12 on 10/20/21 at 2:38 p.m. had been missed by the nursing staff.

A medical record review revealed that P#7 was admitted to the facility on 8/24/21 at 1:45 pm for Major Depressive Disorder with severe psychosis. A review of P#7 ' s intake assessment on 8/24/21 at 1:20 pm revealed that P#7 had a medical history of sexual abuse and neglect. Review of the nursing reassessments from 8/24/21 to 9/2/21 failed to reveal that P#7 had any sexually inappropriate behavior.

A review of an Incident Report form for P#7 revealed that the report was submitted on 9/4/21 at 5:30 p.m. after DFACS reported to the charge nurse while "Risk" was on the unit during a phone call. P#7 had reported to the foster parent of being raped by a male patient. The incident had occurred at night on 8/29/21 at an unknown time. The incident report form indicated that P#7 was on suicide precautions at the time of the incident. The police involvement, risk manager follow-up notes, interventions or treatment given, nursing assessment, physician notified, notifications as applicable, incident report form reviewed by supervisor, and incident level sections of the Incident Report form were left blank. The Risk Manager (RM) (BB) signed the form but did not indicate the date or time the form was reviewed

A review of P#8 ' s medical record revealed that P#8 was admitted to the facility on 8/27/21 at 11:08 pm for Major Depressive Disorder with severe psychosis. The Intake Assessment revealed that P#8 had a medical history of sexual abuse/neglect. Further review of P#8's nursing reassessment revealed that on 9/6/21, P#8 was noted to have had sexually inappropriate behavior. A review of P#8 ' s progress notes from 8/30/21 to 9/6/21 revealed that on 9/6/21 at 8:10 p.m., P#8 was observed kissing and hugging another patient. P#8 was separated and reminded of the rules on the unit. Further review of the progress notes revealed that P#8 said he did not care, and he had sexual inappropriate behavior earlier, on the weekend. P#8 was advised about his sexual inappropriateness. A review of P#8 ' s patient observation record from 8/28/21 to 9/7/21 revealed that P#8 was on every 15-minute observations and suicide precautions. Further review of the patient observation record on 9/6/21 failed to reveal that P#8 was placed on Sexual Acting Out (SAO) precautions. A review of P#8 ' s record further revealed a written statement by P#8 explaining how he had a sexual activity with another patient at the facility in P#8's room. A review of P#8 ' s admission order dated 8/27/21 at 11:46 pm failed to reveal that P#8 was placed on any level of observation. Further review of the order revealed that P#8 was on suicide precautions.

A review of patient #9 and #10 medical records revealed that P#10 was a female patient admitted to the facility on 9/23/21, and P#9 was a male patient admitted on 9/17/21. On 9/25/21 at 7:30 p.m. P#9 was found in P#10 ' s room undressing her and about to engage in sexual intercourse. Staff intervened quickly and stopped them. P#10 was very upset and stated they had sex three times the day before. Both patients were supposed to be physically located every fifteen minutes (Q15). Nursing assessments did not reflect the sexual activity. P#9 did not have any nursing assessment on record for 9/25/21; P#9 was transferred to the Hero Unit on 9/25/21, after the sexual encounter. On 9/30/21, P#9 was found in another female patient's room lying down on her bed. The unit nurse talked to P#9 about his behavior.

A review of an Incident Report Form for P#10 revealed the form was completed on 9/25/21 at 6:30 p.m. The incident occurred on 9/25/21 at approximately 9:20 p.m. on the adult unit. The other party involved was P#9. The facts of the incident were that a behavior health assistant (BHA) was making rounds when P#10 was found in the male patient's room attempting to undress. The patients were separated. The BHA reported to the charge nurse. The House Supervisor notified the provider that P#10 was psychotic and claimed they had sex on the previous shift. The male patient was moved to another unit. Interventions checked on the Incident Report Form included the staff separated patients. The nursing assessment portion of the form revealed P#10 denied current/recent pain and no physical evidence of discomfort noted. The nurse signed the form on 9/25/21 at 9:30 a.m. The facility supervisor was notified on 9/25/21 at 9:25 a.m. The form was signed and received by the RM BB on 9/27/21. No incident level was indicated. The "precautions at the time" section was left blank. There was no police involvement noted. An Incident Report Form for P#9 was not provided to the surveyors.




A review of Quality Council Committee meeting minutes from January 2021 to October 2021 revealed the Quality Committee met on 1/27/21, 2/24/21, and 5/28/21. Nursing supervisors were out of nursing ratio. On 6/28/21, the quality committee discussed an increase in the number of incident reports for May and June. An incident of boundary violation involving patient and staff was reported, and the employee was terminated. On 7/22/21, the committee meeting minutes revealed that there was an incident of patient-to-patient boundary violation. The report revealed that a female patient was found in male ' s room pulling her pants up. On 9/30/21, the committee minutes revealed a case of patient-to-patient body exposure, and a case of patient-to-patient sexual intercourse. The facility substantiated both incidences. The committee minutes failed to reveal actions taken or a plan to prevent boundary violations in the future.

A review of the Complaint/Grievance Log for August 2021 to October 2021 revealed the following complaints/grievances that were substantiated by the facility:

October 2021: verbal abuse, patient-to-patient assault, and sexual assault (10/23/21).
September 2021: Abuse by staff, two separate complaints.
August 2021: Sexual harassment and emotional abuse, patient-to-patient, 8/23/21. Abuse from the night staff, 8/26/21.

A review of facility staff and census sheets revealed the following:

9/24/21, Adult unit day: 20 patients, two nurses, three BHAs.
9/24/21, Adult unit night: 20 patients, two nurse, two BHAs.
9/25/21, Adult unit day: 21 patients, two nurses, one BHA.
9/25/21, Adult unit night: 21 patients, one nurse, three BHAs.
10/22/21, Adolescent unit day: 21 patients, two nurses, four BHAs. One BHA is listed twice on day shift, and one nurse is also listed on the night shift, which would equal one nurse and three BHAs on the day shift.
10/22/21, Adolescent unit night: 21 patients, two nurses, one overlap nurse, two BHAs.
10/23/21, Adolescent unit day: 18 patients, one nurse, one overlap nurse, two BHAs, one overlap BHA.
10/23/21, Adolescent unit night: 18 patients, one nurse, one overlap nurse, one BHA, one overlap BHA. One patient was on 1:1 monitoring for Sexual Acting Out (P#12).


Review of the Incident Log for August 2021 through October 15, 2021, revealed the following:

August 2021; there were five incidents that involved patient to patient misconduct/body exposure.

August 2021; there were two incidents that involved patient to staff misconduct/body exposure.

August 2021: there was one incident that involved sexual intercourse on 8/29/2, between P#7 and P#8. There was not a separate incident listed for P#8.

September 2021: there were five incidents that involved patient to patient misconduct/body exposure. The report on 9/25/21 involved P#10 and P#9. There was an incident report for P#10 but not a separate incident listed for P#9.

September 2021: there was one incident that involved patient to staff misconduct/body exposure.

There were no sexual misconduct related incidents listed on the log in October 2021. The incident reports for P#6 were provided in a separate folder. The log was completed through 10/15/21.

A tour of the Hero (Veteran's) Unit and the Adolescent Units took place on 11/1/21 at 3:20 p.m. with the Director of Risk Management (BB). It was observed that there were 21 patients, 2 Behavioral Health Associates (BHA), and one charge nurse on the Hero Unit at the time of the tour. The tour continued to the Adolescent Unit, which had 16 patients, 3 BHA's and 2 nurses. The adolescents were in groups at the time of the tour. The Adolescent Unit had a centrally located nurses ' station with two sections. The inner section had a doorway and large glass window separating it from the outer nurses ' station. There was a desk and computer near the window of the inner nurses ' station with a view of the two dayrooms across a hall. There were posters on the window to the left of the computer that blocked the view of half the hallway where the patient rooms were located and the Quiet Room. The Quiet Room was approximately 10 x10, with an opening and no door. The front two corners of the Quiet Room were dark and not visible from outside the Quiet Room. The Quiet Room was on the left side of the nurses' station and across the hall from the two dayrooms. The outer nurses' station had a long desktop with a workspace and chair in the center of the desktop. The Quiet Room was not visible from the center of the outer nurses' station. It was observed that there were no video cameras, security officers, or surveillance mirrors observed on any of the units.

A tour of the Adult Unit took place on 11/1/21 at 3:30 p.m. with the Director of Admissions. It was observed that the unit was mixed, male and female. The Director of Admissions stated most of the substance abuse patients were housed on the adult unit. The census on the unit was 13 patients with one nurse and 2 behavioral health assistants (BHA)

A tour of the Adult North unit was conducted with the Director of Nursing (DON) on 11/1/21 at 3:30 p.m. There were 17 patients and five staff on the Adult North unit. The staff included three BHA, one Registered Nurse (RN) and one Licensed Practical Nurse (LPN).


An additional tour of the Adolescent unit took place on 11/3/21 at 1:00 a.m. with the House Supervisor (HS) DD. At the time of the tour, there was one RN, one medication nurse, and two BHAs. One BHA was monitoring a patient 1:1. The census was 19.


During a telephone interview with RN EE on 11/2/21 at 10:28 a.m., RN EE recalled there was an incident where someone walked in on two patients having sex in their room around the beginning of October. RN EE said she was not on the unit the night the incident occurred. RN EE said the male patient was moved to another unit and "did it again." RN EE further stated the male patient ended up on the HERO unit. RN EE said she could not remember the name of the patient. RN EE said there was always someone at the nurses' station on the adult unit keeping the nurses busy. One BHA would be on the adult unit with 32 patients, paperwork, trash, and other duties. The BHA would sit at the end of the hall, but the incident with the patients having sex must have happened when the BHA was doing paperwork. RN EE said the medication nurse would sometimes go into the medication room and shut the door. When there was only one BHA on the unit, the BHA would start on one end of the hallway and work around to the other hallway with the patient monitoring sheets. By the time the monitoring sheets were completed, it was already time to do the monitoring again. If there was a smoke break, the patients who did not smoke were left on the unit with one nurse at the nurses' station. RN EE said it would have been easy for a patient to sneak into another patient's room during smoke break, and the smoke breaks were timed. The patients would keep the nurses busy asking for things, like they were doing it on purpose. The facility did not have precautions to prevent patients from sneaking into rooms. RN EE stated the females and males on the adult unit were not separated, except for in the bedrooms, and it was the same on the Adolescent unit. RN EE said it would be easy to try to slip off when there were one or two BHA's on the unit. RN EE confirmed the Adolescent unit had a young guy penetrate and finger a girl about a week ago. RN EE stated the Adolescent unit had been having two nurses and two BHA's. RN EE said most of the issue was a lack of staff, and the facility was always short of staff. The previous night, there were three admissions back-to-back, which kept the nurses tied up in rooms with patients and took everybody off the floor. RN EE said when staff called out, the facility would move somebody to the unit that was lacking. If a patient was on 1:1 monitoring, there would not be additional staff available. At times, there would be one BHA to 19 patients.

An interview took place with RN OO on 11/3/21 at 12:30 a.m. on the HERO unit. RN OO said there were a lot of staffing issues, and there were times an LPN was left on the unit in charge. RN OO said there had been unsafe situations and no security at the facility. When patients were acting out, BHA's were put in situations to restrain the patients, and BHA's had gotten injured; one BHA on another unit had been injured badly. RN OO said some of the nurses would stay behind the counter when situations occurred. RN OO said the environment in general did not feel safe. RN OO said there were times there were 20 patients with one RN and one BHA. RN OO stated the medication nurse would be required to do paperwork on other units, which would leave RN OO as the only nurse. RN OO stated that a few days prior to the survey, the facility had told the staff that the Department was coming because of an alleged rape on the Adolescent unit, and staffing was increased due to preparations for the Department.

During a telephone interview with BHA FF on 11/3/21 at 10:41 a.m., BHA FF stated when he was doing vital signs on a female patient in the HERO unit, the female patient told BHA FF that P#9 was found lying in her bed.

An interview took place with the Risk Management Director (RM) (BB) on 11/5/21 at 8:50 a.m., RM BB confirmed that P#10 was found undressed in P#9 ' s room. RM BB confirmed that sexual intercourse happened between P#7 and P#8.
A review of facility ' s policy titled "Patient Rights", revised 7/2021, revealed patients have the right to be protected by the facility from neglect, physical, verbal, and emotional abuse, and from all forms of misappropriation and/or exploitation.

A review of the "Assessment and Reassessment" policy, revised 10/21, revealed all patients admitted to the hospital would receive a thorough assessment and evaluation. The nursing assessment would include, but not be limited to, a mental status assessment of thought disorder, social interactions, and special precautions. Patients would be reassessed as necessary for changes in their condition.

A review of "Incident Reporting - Risk Management Program" policy, last reviewed 1/21, revealed the incident report enabled the facility to manage risk, increase safety, and improve the quality of health care provided in the facility through risk control intervention and monitoring the effectiveness of the interventions and corrective action plan. Any staff member who witnessed, discovered, or had direct knowledge of an incident would have completed an incident report before the end of the shift/workday. The supervisor would have reviewed the incident report for legibility, completion, signature, and date. The supervisor would have notified the Risk Manager of a serious incident, as well as taken the lead in investigating non-serious incidents. The incident report would have been routed to the facility Risk Manager within 24 hours of the incident. Level I (Tragic) incidents included sexual intercourse (penetration), abuse by staff, and neglect by staff. Sexual misconduct, which included oral sex and digital penetration were considered Level II (Serious) incidents. Staff to patient boundary violations were also Level II incidents. Genital exposure and kissing were Level III (non-serious) incidents. Part of reporting the incident included describing the actions taken to mitigate damages and/or prevent further loss. Every incident reported required that the interventions be identified.

A review of the "Observations, Patient" policy, approved on 4/2020, revealed that to maintain patient safety, the facility staff would make and document routine safety rounds on patients in accordance with the level of observation ordered by the practitioner and/or initiated by the RN. The psychiatric practitioner would order one of three levels of observation at the time of admission and as the patient ' s condition warranted a change: every 15 minutes, every 5 minutes, or one-to-one. The psychiatric practitioner would also order precaution levels of observation for suicide, assault, elopement, seizure, fall, or Sexual Acting Out (SAO). All patients were monitored at minimum once in every 15-minute block of time. If a patient ' s behavior was unpredictable and there was potential risk for harm to self and others, yet behavior was not at the point requiring constant 1:1 observation, the patient would be monitored at minimum once in every 5-minutes. One to one (1:1) observation was the highest level of observation and was reserved for patients who were so unpredictable that without a dedicated staff member, there was a risk of the patient harming self or others.

A review of the "Sexual Acting Out" policy #CTS-119, last revised July 2021, revealed it was the policy of the facility to provide guidelines for the observation of patients with a known history of sexual perpetration, and/or those patients who had a high probability of demonstrating such behavior. Patients determined to be a danger to other patients due to being a sexual perpetrator would be placed on special observation status. The patient would be placed on a restricted privilege status per physician ' s order and per recommendation of each Treatment Team member. A physician ' s order was to be renewed every 24 hours to indicate Sexual Acting Out precautions. Sexual Acting Out precautions must have continued for as long as the patient was in the hospital. The Treatment Team was to review the "SAO precautions" order weekly. The patient on SAO would be escorted to the dining room and scheduled activities in the facility. All personnel caring for the patient on SAO were to be sufficiently informed of the patient ' s status. Patients on SAO precautions would be observed every fifteen minutes and/or through constant observations. In the event of serious intent and overt attempt/act, the patient would be put on constant observation status or 1:1 precaution.

A review of "Staffing Plan" policy # LD-105, last reviewed 7/21, revealed the unit would be staffed with an adequate number of RNs, LPNs and MHTs/PCTs to maintain a therapeutic milieu and a safe environment.

A review of Medical Staff Bylaws, approved May 2021, revealed the responsibilities of the medical staff were to account to the governing board for the patient care processes and outcomes rendered by all practitioners authorized to practice in the facility. Review of Medical Executive Committee (MEC) meeting minutes from January 2021 to September 2021 revealed the MEC met monthly. Nursing services were discussed in terms of infection control but failed to address patient safety as related to boundary violations or sexual aggression.

Based on a review of medical records, interviews with staff, a review of incident reports, observations made during tours of the facility, and a review of policy and procedures, it was determined that the facility failed to protect the rights and provide care in a safe setting for six (6) out of 12 (P#6, P#7, P#8 , P#9, P#10, P#12) patients sampled.

Cross reference A-0144 as it relates to the facility's failure to protect a Patient's Right to care in a setting free of abuse and harassment.

Based on a review of medical records, a review of the facility's incident report log, a review of the Quality Council Committee meeting minutes, and a review of policy and procedures, it was determined the facility failed to maintain a quality and performance improvement plan addressing the identified needs of patients' sexual interactions. At the time of survey, the facility's census was 76 patients.

Cross reference A-0144 as it relates to the facility's failure to implement and maintain a performance improvement program that reflects the complexity of the hospital's departments and services.

Based on a review of medical records, a review of the facility's incident report log, a review of the Quality Council Committee meeting minutes, and a review of policy and procedures, it was determined the facility failed to maintain a quality and performance improvement plan addressing the identified needs of patients' sexual interactions. At the time of survey the census at the facility was 76 patients.

Cross reference A-0144 as it relates to the facility's failure to track adverse events (sexual encounters) and implement preventative actions and mechanism that include feedback and learning throughout the hospital.

Based on a review of medical records, interviews with staff, a review of the facility's staffing records, and observations made during the facility tour, it was determined the facility failed to provide adequate staffing. At the time of survey, the facility census was 76 patients.

Cross reference A-0144 as it relates the facility's failure to provide adequate staffing and Registered Nurse (RN) supervision.

Based on a review of medical records, interviews with staff, a review of the facility's staffing records, and observations made during the facility tour, it was determined the facility failed to provide adequate staffing. At the time of survey, the facility census was 76 patients.


Cross reference A-0144 as it relates to the facility not having proper staffing to provide care in a safe setting to patients.

Based on interviews with staff, a review of the facility's staffing records, and observations made during the facility tour, it was determined the facility failed to provide adequate Registered Nurse (RN) supervision for patients. At the time of survey, the facility census was 76 patients.

Cross reference A-0144 as it relates to the facility's failure to ensure a registered nurse (RN) supervision of nursing care for all patients on a nursing unit.

Based on observation, staff and patient interviews, policies and facility's housekeeping lead action plan. It was determined that the facility failed to ensure that the hospital environment is maintained in a clean and safe manner. At the time of survey the facility census was 76 patients.

Findings included:

During a tour of the Adult Unit South on 11/1/21 at 3:30 p.m. along with the Director of Admission (DOA) TT, it was noticed the unit was mixed and DOA TT indicated they placed most of the substance abuse patients on this unit. The unit had seven bedrooms and fourteen beds, and one group room. Every room had two beds. There were thirteen patients on the unit, two Mental Health Techs (MHT), and one Charge Nurse. During the tour with the Director of Admission, the patients' bedroom floors were noted to be very dusty, the window bases and the baseboards were dirty and dusty as well. Some rooms had missing baseboards. The toilet seats were also noted to be dirty. In one bedroom, we noted the window curtain was maintained in place with a zip tie. The hallways were not swept and sticky as well as the laundry room.

During a tour of the Psychiatric Intensive Care Unit (PICU) on 11/1/21 at 4:00 p.m. along with DOA TT, it was indicated the unit had fifteen rooms, fifteen beds, and one seclusion room. At the time of the tour, there were fourteen patients, two MHTs, one Registered Nurse, and one LPN. There was a bathroom located next to the seclusion room. The bedrooms floor was dirty and sticky, we both noticed all the bedroom's windows were dusty and filthy. There were missing baseboard pieces in most of the bedrooms. The toilet seats in both bathrooms and the shower were very dirty and filthy. We both noticed the dining room's floor was filthy and sticky, the tables were as filthy as the floor itself. The group room was dusty, the floor was dirty.

A tour of the facility's Adult and the Adult north unit was conducted with the Director of Nursing (DON) CC on 11/1/21 at 3:30 p.m. There were 17 patients and five staff on the adult north unit. The staff included three behavioral health assistants (BHA), one registered nurse (RN), and one licensed practical nurse (LPN). There were nine rooms on the unit with one nursing station and a group room. The patient's bathroom appeared to have a brown stain. A further observation of the adult unit revealed there were 25 patients, three RN's and BHA's on the unit. There was an activity room, a dining room, and a group room on the unit. The unit appeared clean.

A tour of the Hero (Veteran's) Unit and the Adolescent Units took place on 11/1/21 at 3:20 p.m. with the Director of Risk Management (DRM) BB. It was observed that there were 21 patients, 2 Behavioral Health Techs, and one charge nurse on the Hero Unit at the time of the tour. A therapist was also on the unit at the time of the tour. The patients were in the hallway, patient rooms, and day rooms. Approximately 10 patients were in a dayroom watching television and were visible through a large window. A BHA was making rounds with the monitoring sheets. The BHA said all patients were every 15-minute monitoring, and there was no 1:1 monitored patient. Patient Advocate information was posted with the previous patient advocate photo and contact information, which had not been updated. Patient Rights and grievance contact information were posted on the wall near the nurses' station with contact information for the DRM BB. The tour further revealed that the Adolescent Unit had 16 patients, 3 BHA's, and 2 nurses. The adolescents were in groups at the time of the tour, and there were no patients observed in the patient rooms. The patient rooms were locked. It was observed that the patient rooms and common areas for both units appeared clean and ligature-free. There was a small amount of mold along the rims of the shower stalls.

An additional tour of the Hero unit on 11/3/21 at 1:00 a.m. with the House Supervisor revealed the nutrition room floor was sticky and had a black substance smeared in multiple places. The cabinet doors in the nutrition room were dirty. The dining room floor on the Hero unit was dirty. It was further observed that the main dining room floor on the first floor was dirty. Small pieces of paper were observed on the floors throughout the facility.

An interview took place with the patient (P) #10 on 11/1/21 at 4:50 p.m. on the HERO unit. P#10 said the laundry room and kitchen were very nasty, and nobody picked up trash or dusted. P#10 said the housekeeper would wet the floor and use a little dust mop for the bathroom once per week. The housekeeper did not use a bucket and mop, and P#10 said the floors had not been mopped the entire 32 days P#10 had been on the unit. P#10 further said patients would sweep the dayroom floor and clean the tables after every meal. Tech may have wiped the tables with a sanitizing cloth. P#10 further said the patients would change their linen every three days, and P#10's roommate took out the trash the morning of 11/1/21.

An observation of housekeeping took place on 11/2/21 at 7:30 a.m. with the housekeeper (HK) NN. HK NN said the housekeepers would normally observe to see which areas of the facility were the worst and would target those areas. HK NN said there was a shortage of housekeepers, which made it difficult to clean the entire facility. It was observed that HK NN entered a patient's room and cleaned the toilet and sink with spray cleaner and a cloth. The inside of the toilet was cleaned with a cleanser and a scrub brush, and the outside of the toilet was wiped clean with a cloth. The housekeeper proceeded to spray the floor of the bathroom, including the shower floor, with Pine-sol. The housekeeper then mopped the floor with a flat synthetic mop, like a dust mop. It was observed that the housekeeper emptied the trash in the bathroom and swept the floor of the patient's room. HK NN said deep cleaning was on Monday, Wednesday, and Friday, and included deeper cleaning of the showers and the room vents. HK NN said the floors are mopped with buckets maybe once per week.

A statement was made by the Director of Risk Management (RM) BB on 11/2/21 at 3:28 p.m. in the Conference Room. RM BB said the facility will let patients change sheets and make their beds. RM BB said she was not aware of a shortage of sheets. RM BB said most of the patients were changing their sheets because acuity was a little lower.
An interview took place on 11/3/21 at 12:30 a.m. on the HERO unit. RN OO said there had been no housekeeping on the HERO unit for months. RN OO said the BHA would clean up, and patients would change their sheets. RN OO said there were times the linen would have to be rewashed at the facility. RN OO said the floor on the HERO unit was not cleaned when the cleaning service was at the facility on 11/2/21.

An interview with the Mg. Environmental Safety (MS) OO and Director Housekeeping (DH) MM took place in the conference room on 11/3/21 at 2:28 p.m. MS OO explained that its responsibility is to oversee, guide, and support several facilities under their corporation in matters related to environmental services. DH MM said that he is that housekeeping is done in-house by the facility staff. DH MM explained that the facility has a manual that entails the step-by-step responsibility of housekeeping. DH MM said the housekeeping staff is responsible for cleaning the facility and does not allow patients to touch equipment for safety reasons. DH MM explained that the facility had currently purchased stiff hard brushes, mold, and mildew removals for staff, and he had instructed housekeeping staff whenever they see stains, they have to remove them immediately. DH MM said they are required to have seven employees and four housekeepers including a supervisor who had to work every day. DH MM explained that patients are offered fresh linen every three days and whenever they made a request. DH MM said there is clean linen on every unit and central storage. DH MM explained that he was not aware of his staff declining any patient a request to have their soiled linen changed. DH MM said that when the patient is discharged their linens are rolled up, placed on a soiled cart, and taken to be collected by the contracting agency. DH MM said the facility does not currently have a housekeeping log for cleaning, but the supervisor is expected to do spot checks behind the housekeepers. DH MM acknowledged there are opportunities for improvement regarding keeping the facility clean and believed some areas were not cleaned as they should be however DH MM explained that they have been short-staffed in the last two weeks but they have been able to hire more housekeepers and there will be an improvement moving forward. DH MM explained that the facility leadership had developed an action plan since the end of September on improving housekeeping and cleanliness within the facility. DH MM further explained that the facility contacted a cleaning company for deep cleaning and air vent cleaning. DH MM explained that the housekeeping supervisor (HS) PP was placed on a plan of a written warning and corrective action on 10/28/21 and submitted an action plan. DH MM further explained that he had also been written up for not providing adequate oversight. DH MM explained that the housekeeping staff currently don't undergo annual training, but they plan to implement a training program in the future. DH MM explained that moving forward there will be a lot of improvement in housekeeping.

A review of the facility's policy titled "Environmental Services" review date 3/2016 revealed that it is the policy of the facility to provide clean linen to all required areas and to protect the integrity of the linen while transporting and replenishing. Further review of the policy revealed that the floor must be completely free of dirt and must be dry. The environmental services will spray buff floors regularly to maintain floors.
A review of the facility's policy titled "Contact Precautions" review date 1/11/21 revealed that the routine cleaning and disinfection of patient care area may be increased in frequency if needed when there is a patient with an MDRO infection present. Terminal cleaning of the patient's room will be done per housekeeping upon the patient's discharge. All linen and towels should be replaced.
A review of the facility's policy titled "Handling of wastes, sharps and linen" last revised on 1/1/21 revealed that dirty linen is placed in a soiled linen cart lined with a heavy-duty bag. Linen bags must be tied or secured before being placed in the department designated area.

A review of the facility's housekeeping manual titled "Housekeeping management program" revealed that the following had to be done daily at the treatment rooms:
1. Spot clean walls, doors, door facings, columns, and other building surfaces. Use a cloth and germicidal detergent solution from a spray bottle.
2. Dust sills, ledges, and other horizontal building and furniture surfaces to remove obvious soil. Use a disposable cloth dampened with germicidal detergent solution.
3. Dust mop floors. Use a floor dusting tool with a treated, disposable dust mop headcover.
4. Damp-mop non carpeted floors.
II. Dining areas:
1. Dust mop non carpeted floors with a treated dust mop
2. Damp-mop non carpeted floors.
3. Remove stains from the carpet.
A review of the facility's document titled "Housekeeping Lead Action Plan" revealed that on 10/8/21 HS PP signed a lead action plan that included providing daily feedback to all housekeepers while checking their assigned areas after completion.
A revealed the facility's document titled "Fundamental Patient's Rights and Responsibilities" revealed that the patient had the following rights:
1. A right to treatment in a safe and humane environment including personal privacy, dignity, respect, and safety without discrimination based on race, creed, color, gender, sexual orientation, age, religion, social or economic background, education, or national origin.
2. A right to be free from any form of abuse and neglect; including verbal, physical, psychological, sexual, and emotional abuse or harassment.
3. A right to report concerns related to care, treatment, services, and patient safety issues.

Based on observations, staff and patient interviews, policies, and procedures. It was determined that the facility failed to ensure that patients admitted to the hospital are living in a safe environment. At the time of survey the facility census was 76 patients.

Findings included:

During a tour of the Adult Unit South on 11/1/21 at 3:30 p.m. with the Director of Admission (DOA) TT, it was noticed the unit was mixed and DOA TT indicated they placed most of the substance abuse patients on this unit. The unit had seven bedrooms and fourteen beds, and one group room. Every room had two beds. There were thirteen patients on the unit, two Mental Health Techs (MHT), and one Charge Nurse. During the tour with the Director of Admission, the patients' bedroom floors were noted to be very dusty, the window bases and the baseboards were dirty and dusty as well. Some rooms had missing baseboards. The toilet seats were also noted to be dirty. In one bedroom the window curtain was maintained in place with a zip tie. The hallways were not swept and sticky including the laundry room.

During a tour of the Psychiatric Intensive Care Unit (PICU) on 11/1/21 at 4:00 p.m. along with DOA TT, it was observed the unit had 15 rooms, 15 beds, and one seclusion room. At the time of the tour, there were 14 patients, two MHTs, one Registered Nurse, and one LPN. There was a bathroom located next to the seclusion room. The bedroom floor was dirty and sticky, all bedroom windows were observed to have dust. There were missing baseboard pieces in the bedrooms. The toilet seats in both bathrooms and the shower were noted to be unclean. The dining room floor was sticky, the tables were as noted to be unclean as the floor. The group room was observed to have dust and the floor was dirty.

A tour of the facility's Adult and the Adult north unit was conducted with the Director of Nursing (DON) CC on 11/1/21 at 3:30 p.m. There were 17 patients and five staff on the adult north unit. The staff included three behavioral health assistants (BHA), one registered nurse (RN), and one licensed practical nurse (LPN). There were nine rooms on the unit with one nursing station and a group room. The patient's bathroom was noted to have a visible brown stain.

A tour of the Hero unit on 11/3/21 at 1:00 a.m. with the House Supervisor revealed the nutrition room floor was sticky and had a black substance smeared in multiple places. The cabinet doors in the nutrition room were dirty. The dining room floor on the Hero unit was dirty. It was further observed that the main dining room floor on the first floor was dirty. Small pieces of paper were observed on the floors throughout the facility.

An interview took place with the patient (P) #10 on 11/1/21 at 4:50 p.m. on the HERO unit. P#10 stated the laundry room and kitchen were very nasty, and nobody picked up trash or dusted. P#10 said the housekeeper would wet the floor and use a little dust mop for the bathroom once per week. The housekeeper did not use a bucket and mop. P#10 stated the floors had not been mopped the entire 32 days P#10 had been on the unit. P#10 further said patients would sweep the dayroom floor and clean the tables after every meal. Tech may have wiped the tables with a sanitizing cloth. P#10 stated the patients would change their linen every three days, and P#10's roommate took out the trash the morning of 11/1/21.

An observation of housekeeping took place on 11/2/21 at 7:30 a.m. with the housekeeper (HK) NN. HK NN said the housekeepers would normally observe to see which areas of the facility were the worst and would target those areas. HK NN said there was a shortage of housekeepers, which made it difficult to clean the entire facility. It was observed that HK NN entered a patient's room and cleaned the toilet and sink with spray cleaner and a cloth. The inside of the toilet was cleaned with a cleanser and a scrub brush, and the outside of the toilet was wiped clean with a cloth. The housekeeper proceeded to spray the floor of the bathroom, including the shower floor, with Pine-sol. The housekeeper then mopped the floor with a flat synthetic mop, like a dust mop. It was observed that the housekeeper emptied the trash in the bathroom and swept the floor of the patient's room. HK NN said deep cleaning was on Monday, Wednesday, and Friday, and included deeper cleaning of the showers and the room vents. HK NN said the floors are mopped with buckets maybe once per week.




A statement was made by the Director of Risk Management (RM) BB on 11/2/21 at 3:28 p.m. in the Conference Room. RM BB said the facility will let patients change sheets and make their beds. RM BB said she was not aware of a shortage of sheets. RM BB said most of the patients were changing their sheets because acuity was a little lower.

An interview took place on 11/3/21 at 12:30 a.m. on the HERO unit. RN OO said there had been no housekeeping on the HERO unit for months. RN OO said the BHA would clean up, and patients would change their sheets. RN OO said there were times the linen would have to be rewashed at the facility. RN OO said the floor on the HERO unit was not cleaned when the cleaning service was at the facility on 11/2/21.

An interview with the Mg. Environmental Safety (MS) OO and Director Housekeeping (DH) MM took place in the conference room on 11/3/21 at 2:28 p.m. MS OO explained that its responsibility is to oversee, guide, and support several facilities under their corporation in matters related to environmental services. DH MM said that he is that housekeeping is done in-house by the facility staff. DH MM explained that the facility has a manual that entails the step-by-step responsibility of housekeeping. DH MM said the housekeeping staff is responsible for cleaning the facility and does not allow patients to touch equipment for safety reasons. DH MM explained that the facility had currently purchased stiff hard brushes, mold, and mildew removals for staff, and he had instructed housekeeping staff whenever they see stains, they must remove them immediately. DH MM said they are required to have seven employees and four housekeepers including a supervisor who had to work every day. DH MM explained that patients are offered fresh linen every three days and whenever they made a request. DH MM said there is clean linen on every unit and central storage. DH MM explained that he was not aware of his staff declining any patient a request to have their soiled linen changed. DH MM said that when the patient is discharged their linens are rolled up, placed on a soiled cart, and taken to be collected by the contracting agency. DH MM said the facility does not currently have a housekeeping log for cleaning, but the supervisor is expected to do spot checks behind the housekeepers. DH MM acknowledged there are opportunities for improvement regarding keeping the facility clean and believed some areas were not cleaned as they should be however DH MM explained that they have been short-staffed in the last two weeks, but they have been able to hire more housekeepers and there will be an improvement moving forward. DH MM explained that the facility leadership had developed an action plan since the end of September on improving housekeeping and cleanliness within the facility. DH MM further explained that the facility contacted a cleaning company for deep cleaning and air vent cleaning. DH MM explained that the housekeeping supervisor (HS) PP was placed on a plan of a written warning and corrective action on 10/28/21 and submitted an action plan. DH MM further explained that he had also been written up for not providing adequate oversight. DH MM explained that the housekeeping staff currently don't undergo annual training, but they plan to implement a training program in the future. DH MM explained that moving forward there will be a lot of improvement in housekeeping.

A review of the facility's policy titled "Environmental Services" review date 3/2016 revealed that it is the policy of the facility to provide clean linen to all required areas and to protect the integrity of the linen while transporting and replenishing. Further review of the policy revealed that the floor must be completely free of dirt and must be dry. The environmental services will spray buff floors regularly to maintain floors.

A review of the facility's policy titled "Contact Precautions" review date 1/11/21 revealed that the routine cleaning and disinfection of patient care area may be increased in frequency if needed when there is a patient with an MDRO infection present. Terminal cleaning of the patient's room will be done per housekeeping upon the patient's discharge. All linen and towels should be replaced.

A review of the facility's policy titled "Handling of wastes, sharps and linen" last revised on 1/1/21 revealed that dirty linen is placed in a soiled linen cart lined with a heavy-duty bag. Linen bags must be tied or secured before being placed in the department designated area.

A review of the facility's housekeeping manual titled "Housekeeping management program" revealed that the following had to be done daily at the treatment rooms:
1. Spot clean walls, doors, door facings, columns, and other building surfaces. Use a cloth and germicidal detergent solution from a spray bottle.
2. Dust sills, ledges, and other horizontal building and furniture surfaces to remove obvious soil. Use a disposable cloth dampened with germicidal detergent solution.
3. Dust mop floors. Use a floor dusting tool with a treated, disposable dust mop headcover.
4. Damp-mop non carpeted floors.
II. Dining areas:
1. Dust mop non carpeted floors with a treated dust mop
2. Damp-mop non carpeted floors.
3. Remove stains from the carpet.

A review of the facility's document titled "Housekeeping Lead Action Plan" revealed that on 10/8/21 HS PP signed a lead action plan that included providing daily feedback to all housekeepers while checking their assigned areas after completion.

A review of the facility's document titled "Fundamental Patient's Rights and Responsibilities" revealed that the patient had the following rights:
1. A right to treatment in a safe and humane environment including personal privacy, dignity, respect, and safety without discrimination based on race, creed, color, gender, sexual orientation, age, religion, social or economic background, education, or national origin.
2. A right to be free from any form of abuse and neglect; including verbal, physical, psychological, sexual, and emotional abuse or harassment.
3. A right to report concerns related to care, treatment, services, and patient safety issues.