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CENTER FOR BEHAVIORAL MEDICINE 1000 E 24TH STREET KANSAS CITY, MO 64108 Sept. 25, 2013
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and policy review, the facility failed to ensure three patients (#5, #8 and #16) of five patients reviewed who currently exhibited, were alleged to be involved in, or had a history of sexual inappropriateness and/or sexual assault were supervised by hospital staff at an increased level to ensure that other patients were protected from those patients' behaviors. This had the potential to affect all patients in the facility. The facility census was 65.
Findings included:
1. Record review of the facility's policy titled, "Observation Levels" revised 09/12, showed direction that facility staff, at any time, may request the physician to order a special (custom or individualized) observation level based on identified risks the patient clinically presents, and that the custom observation level may be written for a specified time frame up to 30 days.
Record review of the facility's policy titled, "Observation Levels and Safety Management" revised 06/12, showed that a registered nurse (RN) may implement increased observation levels for patients at risk in an emergency situation.
Record review of the facility's policy titled, "Implementation of the Nursing Plan of Care" dated 08/12, showed RNs were to develop interventions that included:
- Strategies to assist patient's achieve expected outcomes;
- Implementation strategies for the interventions; and
- Ongoing verbal and written communication of the patient's response and progress towards the expected outcomes.

Record review of the facility's policy titled, "Comprehensive Treatment Plan (CTP) - Development and Documentation" dated 02/13, showed:
- Treatment planning was a dynamic process that provided the foundation for the active treatment of all patients.
- A treatment plan form titled, Critical Intervention Assessment and Plan, was used by an RN to complete an assessment and develop a plan to prevent an adverse event, or it was used as a post-event process to prevent the event from occurring again.
- The plan included factors that contributed to the event, warning signs and interventions to use (to prevent a future event).

2. Record review of Patient #8's medical record showed the following:
- The patient was admitted on [DATE] and the "Inventory of Problems" (patient behaviors that may result in poor patient outcome) included a history of sexual activity where sexual activity was not allowed.
- A Social Worker assessment dated [DATE] showed that the patient had become pregnant two times while she was hospitalized in psychiatric facilities.
- A treatment plan dated 05/14/13 included objectives that the patient will follow hospital rules of not allowing for sexual conduct with others, that the patient will maintain arms length when interacting with male patients, and that the patient will follow staff's redirection to change clothes if wearing low cut shirts.
- A "Critical Interventions Assessment and Plan" dated 08/06/13 at 4:00 PM, indicated that the patient was found naked on the bathroom floor and had allowed a male patient, Patient #26, to come into her room and have sex with her because, "I want to have sex with him". The patient was placed on one-to-one monitoring and moved to another hallway within the unit.
- A physician's order on 08/07/13 at 4:10 PM (24 hours later), discontinued the one-to-one observation of the patient "per patient request" and because the male patient had been moved to another unit.

The patient's observation frequency was returned to standard 15 minute nursing rounds, the same monitoring level in which the patient was able to engage in sexual activity with another patient.

3. During an interview on 09/24/13 at 2:35 PM, Staff W, Social Worker, stated that Patient #8 was always sexually preoccupied and was known to not follow the unit rules for not having sex in the hospital. After Patient #8 had sex with Patient #26, she was placed on one-to-one monitoring until Patient #26 was moved off of the unit, then she returned to standard 15 minute nursing rounds.

4. During an interview on 09/24/13 at 10:45 AM, Staff G, 3C Unit Manager, stated that "about a month ago", the charge nurse informed staff that Patient #8 and Patient #26 "would need to be watched" for inappropriate sexual behaviors together, but "we didn't think (Patient #26) was interested" in Patient #8. Later that day, Patient #8 was found naked in her room after having sex with Patient #26.

During an interview on 09/25/13 at 9:40 AM, Staff G stated that the facility used to monitor patients with a sexual precaution observation level and a continuous observation level, but realized that it was the same as one-to-one, "so we don't do it anymore".

5. During an interview on 09/24/13 at 3:10 PM, Staff X, 3C Charge Nurse, stated that the facility has "sexual precautions" (increased monitoring for sexual inappropriateness) that can be used when patients exhibit the potential for inappropriate sexual activity or have previously engaged in sexual activity, but it was not initiated for Patient #8.

6. Further review of Patient #8's medical record showed the following:
- A Physician's Progress Note dated 09/16/13 at 9:47 AM, indicated that the patient stated she did not feel safe, requested a transfer to another unit and threatened to harm herself, so the patient was placed on one-to-one observation for safety.
- A Social Worker Progress Note dated 09/16/13 at 10:30 AM, indicated that the patient made a phone call to her family member and stated, "Two boys touched my vagina", that the males had performed oral sex on her and that one of the males made her perform oral sex on him.
- An Observation Flowsheet indicated that the patient remained on one-on-one observation from 09/16/13 at 10:00 AM until 09/19/13 at 4:15 PM.
- A physician's order on 09/19/13 at 4:35 PM, discontinued the one-to-one observation of the patient.

The patient's observation frequency was returned to standard 15 minute nursing rounds, the same monitoring level in which the patient alleged that she was involved in inappropriate sexual activity with two male patients.

7. During an interview on 09/25/13 at 10:00 AM, Patient #8 stated the following:
- She had sex with Patient #26 on two different occasions while she was on the unit.
- Staff were not aware that she had sex with Patient #26 until she reported it to them.
- She had kissed and performed oral sex "a time or two" with another patient.

8. During an interview on 09/24/13 at 9:20 AM, Patient #14 stated that he had previously witnessed three male patients "fingering" (inserting their fingers inside of the female's vagina) Patient #8 while they were standing in a common patient area of the unit. Patient #14 stated that even though hospital staff made 15 minute observation rounds, patients were able to engage in sexual activity, including sexual intercourse, and admitted that he had previously engaged in sexual intercourse with a female patient in his room without staff's knowledge.

9. Record review of current Patient #16's medical record showed the following:
- A physician's order dated 09/17/13 at 5:15 PM for an "Administrative Transfer" to Unit 3D.
- A transfer admission note documented that the patient was accused of raping another patient (Patient #8) on 3C.
- A Nursing Weekly Summary for 09/15/13 through 09/21/13 documented that the patient was transferred to Unit 3C after raping another patient (Patient #8).

There was no indication in the record that the patient was placed on an individualized or increased observation level after he was accused of rape.

10. During an interview on 09/25/13 at 11:32 AM, Staff EE, Nurse Manager of Unit 3D, stated that Patient #16 was not placed on special observation precautions (observations made at 15 minute intervals with documentation that included the condition and behavior of the patient) after he was accused of raping Patient #8 because he was calm and cooperative, he was adamant that he did not rape the patient, and because the patient (Patient #8) was known to make accusations that historically were found to be false.
11. Record review of Patient #5's medical record showed the following:
- The medical psychiatric evaluation dated 07/26/13, showed he had an extensive arrest history, including sexual assault and forcible rape, and he was registered as a sexual offender.
- The nursing admission assessment dated [DATE], showed risk factors for sexual assault.
- The social work evaluation, dated 07/29/13, showed he had a history of sexual assault and forcible rape. The social worker recommended sexual precautions. No sexual precautions were ordered.
- The CTP dated 08/01/13, failed to show goals, objectives and/or interventions in relation to his history of sexual assault and the level of supervision he required to protect patients in the environment. The CTP also failed to show the integration of the nursing admission assessment and care plan.
- Within five days of admission the physician discontinued special 15 minute checks and placed the patient on standard 15 minute nursing rounds (observations made at 15 minute intervals with documentation that included the location of the patient, but not the condition and behavior of the patient), the same as all patients.
- Progress notes from 08/21/13 to 09/20/13 showed sexual preoccupation of patient on numerous occasions by making sexually inappropriate comments, gestures, and threats towards patients and staff. Examples of documentation included: "You should stay home because you make me have thoughts about you", he could not be an (sexual) offender if women opened up their legs, he described the breasts of a staff member, and he threatened to get a staff member fired if she did not give him a big hug sexually.

12. During an interview on 09/24/13 at 10:15 AM, Staff S, Licensed Clinical Social Worker (LCSW), stated that Patient #5 displayed flirtatious behavior during the admission interview.

13. During an interview on 09/24/13 at 11:05 AM, Staff T, RN, stated that he had concerns that Patient #5 was flirtatious, propositioning, and had incorporated a staff member into a delusion of them being husband and wife. No increased observation levels were initiated (after the physician discontinued the special 15 minute checks five days after admission.)

14. During an interview on 09/24/13 at 9:00 AM, Staff R, RN, stated that:
- All patients have regular 15 minute nursing rounds, with notation of patient's location.
- Most patients are placed on special 15 minute checks when admitted for a limited period of time. The condition and behavior of patient were recorded at 15 minute intervals for these checks.
- Usually one-to-one assignments were made until the patient was no longer considered a danger.
- They use to have arm's reach, close observation, and line of sight but they were eliminated about two years ago; sexual precautions were eliminated about one year ago.
- Revised interventions were expected to be initiated when patients displayed inappropriate sexual behaviors.
- Patient #5 had a desire and delusion of him being husband and wife with a staff member and that should have triggered revised treatment interventions.

15. During an interview on 09/25/13 at 9:30 AM, Staff BB, Psychiatric Technician, stated that female patients had discussed their concerns about Patient #5's sexually inappropriate behaviors and she was concerned about the effect his behavior had on female patients. One patient report included that he had inappropriately touched her near her breast.

16. During an interview on 09/25/13 at 10:40 AM, Staff FF, Psychiatric Technician, stated that:
- She recalled two patients who reported that Patient #5 made inappropriate sexual comments towards them.
- One patient told her that she didn't feel comfortable around him because he had always said sexual things around her.
- She was not given any direction in shift report about individualized interventions for him (Patient #5.) She was not given direction to increase observation of the patient and was not told what to do.

17. During an interview on 09/25/13 at 11:45 AM, Patient #24 stated that:
- She was concerned about Patient #5's behavior, that on one occasion he tried to fondle her and wanted to see her breasts.
- She was concerned that her room was in the men's hallway, and male patients walked by her room all the time.
- She was concerned that her roommate attracted male patients to her room by leaving the door open and changing her clothes without closing the door.
- She was concerned that male patients potentially had access to her room and she did not think staff would hear her if she called for help.

18. Observation on 09/25/13 at 12:25 PM, showed Patient #24's room was not visible from inside the nurses' station.

19. During an interview on 09/23/13 at 3:45 PM, Staff E, RN, Charge Nurse, stated that no patients were on any special precautions. Staff E stated that all patients get (are observed on ) general 15 minute nursing rounds.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, and policy review the facility failed to develop individualized care plans that included protective interventions and safety measures for two (#5 and #16) of five patients who exhibited or were accused of sexually inappropriate behaviors and/or sexual assault. This had the potential to affect all patients. The facility census was 65.

Findings included:

1. Record review of the facility's policy titled, "Implementation of the Nursing Plan of Care" dated 08/12, showed that:
- A registered nurse (RN) developed an initial nursing treatment plan following the patient's admission assessment process.
- The RN incorporated the initial nursing treatment plan into the comprehensive treatment plan (CTP) once developed by the multidisciplinary team.
- RNs made revisions to the treatment plan as problems/needs were identified with goals, objectives and interventions.
- Interventions included how the intervention would be coordinated between shifts to ensure continuity of care.

Review of the facility's policy titled, "Comprehensive Treatment Plan - Development and Documentation" revised 09/12, showed that each discipline presented findings from their assessment during the first treatment plan meeting, and the nursing care plan was incorporated into the CTP. Treatment plan revisions also occurred when unexpected events during treatment occur, including inappropriate sexual behavior.

2. Record review of Patient #5's medical record showed the following:
- A psychiatric evaluation dated 07/26/13, documented that the patient was admitted to the facility on [DATE] with an extensive arrest history including sexual assault and he was registered as a sexual offender.
- A nursing admission assessment dated [DATE], showed that he had risk factors for violence, assault, and sexual assault.
-The nursing initial treatment plan showed a problem of dangerous behavior towards others, a goal to demonstrate control of behavior by not assaulting others, and multiple interventions to meet goal. The nursing initial treatment plan was not incorporated into the CTP.
- A social work evaluation dated 07/29/13, showed the patient had current violation of probation, and past legal issues for sexual assault and forcible rape. The social worker recommended sexual precautions and this was not addressed in the CTP.
- The CTP dated 08/01/13, failed to show goals, objectives and/or interventions in relation to his extensive history of sexual assault and to include the level of supervision he required to protect other patients from potential harm. The CTP also failed to show the integration of the initial nursing care plan that addressed his risk factors for sexual assault.
- Progress notes dated 08/21/13 through 09/20/13, showed the patient made numerous sexual gestures and inappropriate comments to patients and staff which included, "you should stay home because you make me have thoughts about you", that all the women here wanted him, and that he could not be a sex offender if a woman opens up her legs.
- The CTP review dated 09/13/13, showed no revision to the goals, objectives, and/or interventions to address patient's sexually inappropriate behaviors.

3. During an interview on 09/24/13 at 2:35 PM, Staff U, RN, stated that she attended the treatment team meeting for Patient #5 on 08/01/13, but she was unaware that his risk factors for sexual assault included in the nursing admission assessment and initial nursing care plan were not integrated into the CTP.

4. During an interview on 09/24/13 at 11:05 AM, Staff T, RN, stated that he had concerns that Patient #5 was flirtatious, propositioning, and had incorporated a staff member into his delusion of being husband and wife. He stated that the CTP did not address the patient's sexual preoccupation and it probably should have.

5. During an interview on 09/24/13 at 9:00 AM, Staff R, RN, stated that it was expected that a revision was made to the CTP when patients displayed inappropriate sexual behaviors. The inappropriate sexual behaviors Patient #5 displayed should have triggered revised treatment interventions.

6. During an interview on 09/25/13 at 10:40 AM, Staff FF, Psychiatric Technician, stated that two patients reported that Patient #5 made inappropriate sexual comments towards them and that she reported it to staff. She was not told what to do during shift change reports.

7. During an interview on 09/25/13 at 10:00 AM, Staff D, Chief Operating Officer, stated that Patient #5's sexual history and behaviors should have been part of the CTP.

8. Record review on 09/25/13 of current Patient #16's medical record showed the following:
-A physician's order dated 09/17/13 at 5:15 PM for an "Administrative Transfer" to Unit 3D;
-A transfer admission note dated 09/17/13 documented that that patient was accused of raping another patient on 3C.
-The CTP was not revised to show goals, objectives, or interventions to protect the patients in the environment after Patient #16 was accused of rape.
9. During an interview on 09/24/13 at 3:20 PM, Staff F, LCSW, Unit Program Director, stated that:
- She coordinated the development and revision to patient treatment plans.
- She was not aware of Patient #5's ongoing sexually inappropriate behaviors.
- She verified that Patient #5's treatment plan did not include his history of sexual assault and the sexual behaviors reported by staff and patients since admission.
- She stated that Patient #16's CTP's was not revised after he was accused of raping another patient.