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Based on observation, interview, and record review the facility failed to protect patient rights for a safe environment for 2 of 5 patients (#1 and 3) from a total sample of 10 patients, placing all current emergency department patients and future patients at risk for the loss of their rights.

Findings include:

1. The facility failed to provide adequate supervision for 2 of 5 patients (#1 and 3) requiring safety observations resulting in Patient #1 (who required a guardian) and Patient #3 having sexual intercourse in the unit bathroom while there were no staff present on the locked unit, resulting in the potential for less than optimal outcomes for all patients. (See A-144).

Based on observation, interview and record review the facility failed to provide adequate supervision for 2 of 5 patients (#1 and 3), reviewed in the emergency department, from a total sampled of 10 patients, requiring safety observations resulting in Patient #1 (who required a guardian) and Patient #3 having sexual intercourse in the unit bathroom while there were no staff present on the locked unit, resulting in the potential for less than optimal outcomes for all patients. Findings include:

Review of Patient #1's medical record on 10/05/2022 at 1445, revealed she was an 18-year-old female who presented to the emergency department (ED) via police. Review of Patient #1's face sheet indicated she had a legal guardian at the time of her admission to the facility. Per the ED provider note dated 7/22/2022 at 2356, Patient #1's chief complaint was altered mental status, was brought in by police from her group home after multiple attempts to kill herself, locked herself in a bathroom for 15-20 minutes, and had homicidal ideations. She was evaluated by behavioral health team who recommended inpatient placement and cert was filed. Review of ED provider notes dated 7/26/2022 at 0641 indicated Patient #1 was brought to the ED after she assaulted another member of her group home with a fork, expressed HI (homicidal ideations). Patient had superficial cuts on arms secondary to self-harm. The note also indicated Patient #1 was had sexual intercourse with another patient in the department. Potential safety issues/precautions: Psychiatric precautions. Provider note dated 7/29/2022 at 2059 indicated testing initiated per patient and guardian request. Review of Forensic Nurse Examiner (FNE) note dated 07/26/2022 at 0930 indicated Patient #1 stated she and Patient #3 had consensual sex. Patient #1 reported she was upset because Patient #3 didn't tell her he had HIV (Human Immunodeficiency Virus). Patient #1 refused to be examined by the FNE and stated she did not have any needs from the FNE at that time.

Review of Patient #3's face sheet on 10/04/2022 at 1510 indicated he was a 41-year-old male who presented to the ED on 7/22/2022 with a chief complaint of being sent by community mental health for medical clearance for inpatient psychiatric placement and had been petitioned by the state. ED Provider note on 7/22/2022 at 2138 indicated Patient #3 had a history of Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and HIV (Human immunodeficiency virus) infection. He had a court order as well as petition from his mother. Review of physician orders for Patient #3 revealed an order dated 7/22/2022 at 2137 for "Sitter at Bedside". The order was discontinued at discharge on 07/28/2022 at 0614. ED Tech note dated 7/25/2022 at 1914 indicated it was brought to his (ED Tech) attention from two separate patients, that while transporting a patient off the unit, Patient #3 and another patient on the unit used the back restroom to engage in sexual acts with each other. Per nurse note dated 07/25/2022 at 1942, Patient #3 and female patient had a sexual encounter on the unit. Female patient confirmed that vaginal intercourse occurred.

On 10/04/2022 at 1555, review of facility Department of Public Safety incident report dated 7/25/2022 at 1915 revealed the following timeline: Camera review showed the following on the ED E Station Open Side Desk:
1858:34 Patient #3 seen entering the bathroom
1858:46 Patient #1 seen entering the bathroom
1859:01 Patient #1 exited the bathroom
1900:25 Patient #1 re-entered bathroom
1905:04 ED Tech checked on bathroom
1905:21 Patient #3 exited bathroom
1905:46 ED tech checked on bathroom again
1910:59 Patient #1 exited bathroom

Review of the report indicated that security officer interviewed Patient #3 who stated he had sexual intercourse with Patient #1 in the bathroom. Staff knocked on the door and Patient #1 stated she was fine. Patient #3 stated he exited the bathroom after that.

During a tour of the ED on 10/04/2022 at 1145, Station E was observed to be a locked unit with 6 rooms. There was an open area observed in the back of the unit with recliner chairs, a television and a bathroom. The open area was not visible from the nursing station. During the tour, Staff K, stated Station E was a locked behavioral health station.

In an interview on 10/04/2022 at 1130, Staff C stated on 7/22/2022 the nurse and ED (Emergency Department) tech left the unit to transport a patient to another station. While they were gone is when Patient #1 and Patient #3 had sexual intercourse in the bathroom of Station E in the ED (a locked unit within the emergency department). When queried as to how many clinical staff were on at the time of the incident, Staff C stated one nurse and one tech. When asked how many staff were with the patients while the nurse and tech transported the patient to another unit, Staff C stated just the security staff member.

In an interview on 10/05/2022 at 1110, Staff N stated he and the RN (Registered Nurse) escorted a patient off the unit to another station. When they returned a patient came to him and stated "they are back there" gesturing to the open area of the unit. Staff N stated he went to the back bathroom, knocked, asked if everything was okay and a female stated yes. Staff N said he left the area when another patient stated, "they are back there doing something they shouldn't be doing." He went back to same bathroom where he observed Patient #1 pulling her pants up. A male in the open area gestured oral sex when asked if he knew what happened. Patient #3 came to him after the incident and was emotional. Staff N stated he observed both patients in the open area later and told Patient #3 to go to his room.

In an interview on 10/05/2022 at 1125, Staff O, stated he and the tech transferred a patient to another unit. When they got back, the tech went to the common area where a patient reported to him that Patient #1 and Patient #3 were in the bathroom. The tech went to the bathroom, knocked and asked if everything was okay. Patient #1 said yes. Another patient then told the tech the patients were having sex. Staff O stated he talked to Patient #1 who said they had sex in the bathroom, and she was bleeding a little. Staff O stated he reported the incident to risk, the doctor, administration. Staff O said when he and the tech transferred the patient to another unit, there was no nursing staff on the unit.

In an interview with Staff X (Sexual Assault Nurse Examiner) on 10/05/2022 at 1135, she stated she met with patient #3 who was alert and oriented and able to describe consensual sex. She was really concerned she was going to catch HIV and seeking help with her overactive sexual behaviors. Staff X stated Patient #3 denied any need for exam.

In an interview on 10/05/2022 at 1055, Staff M he stated he was involved in the root cause analysis (RCA) for the incident. The recommendations identified from the RCA were to secure and lock the back bathroom door and clarify the rounding times of staff, which was every 30 minutes.

In an interview on 10/05/2022 at 1240, Staff C stated the nurse and tech should not have left the unit.

On 10/04/2022 at 1500 and on 10/05/2022 at 0840, and at 1100, the surveyor requested a facility policy pertaining to bedside sitters. The facility did not provide a policy.