HospitalInspections.org

Based on review of documentation and interview, it was determined that patients at Cedar Crest Hospital were not always supervised adequately.

Findings were:

Facility policy entitled "Observation" described the various levels of patient observation:
* "Q 15 minute checks: The unit staff observes the patient a minimum of every 15 minutes and documents the observation in the Patient Observation Monitoring Form.
* Q 5-minute observation: The unit staff observes the patient a minimum of every 5 minutes and documents the observation in the Patient Observation Monitoring Form.
* Line of Sight (LOS): The unit staff will provide constant visual observation of the patient at all times. The unit staff may perform line-of-sight observations within a group of patients or milieu group activities. The assigned staff member documents the observation every 15 minutes on the Patient Observation Monitoring Form.
* 1:1: One (1) unit staff will provide constant visual observation and remain within arms-length of the patient. This continuous direct visual observation will continue even when patients shower, change clothes, use the bathroom, and while sleeping."

Facility policy entitled "Sexually Acting Out Precautions" stated in part "Cedar Crest maintains safety for all patients. Sexually Acting Out Precautions (SAOP) are ordered by the admitting physician, attending psychologist or Nurse Practitioner during admission or at any time during hospitalization when the patient's behavior is considered to be at risk of sexually acting out ...General Guidelines in Preventing Sexually Acting Out:
1. Program rules include safe boundaries.
2. No touching others.
3. Only one patient in the bedroom at a time during hygiene times.
a. At times, when a patient must go to his/her room while roommate is there due to illness or other circumstance, a staff member should monitor from outside the room or step the roommate out during that time, unless at bedtime.
4. Staff need to listen for conversations between patients that involve sexual connotation and intervene/redirect/document/alert RN as needed.
5. All bathroom doors are open when not in use.
6. Bedroom doors are closed and locked during day-time activities.
7. Patients are not to be undressed in their rooms. Clothes are changed in the bathroom only.
8. Patients are to be appropriately clothed when out of their room.
9. All attempts are made to room patients according to these rules: opposite sex patients are not placed in rooms with line of sight across hallways or with adjoining doors.
10. In the child and adolescent unit, patients with > 2 years' age difference should not room together.
11. Be aware of trigger behaviors (aggressive horseplay, teasing and lack of boundaries) as potential predecessors to sexually acting out.
12. Talk respectfully about sexuality, using correct terms for body parts. Provide correction/redirection to patients if suggestive, ambiguous words, slang or obscenities are utilized.
13. Emphasize that there are to be no secret games, stories, clubs or presents.
14. Discuss/report precautions/behaviors during shift to shift report and safety huddles."

On 1/24/19, Patient # 1 was placed on Q-5 minute checks and SAOP (sexually acting out precautions). On 1/26/19 during a documented disturbance in the activity room, Patient # 1 (11-year-old) and Patient # 3 (13-year-old) shared a consensual sexual encounter.

In an interview with the Director of Risk Management and Performance Improvement on 5/14/19, it was acknowledged that since Patient # 1 was already on SAOP precautions and Q-5 minute checks, a more heightened observation would have been appropriate.