The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

TIMBERLAWN MENTAL HEALTH SYSTEM 4600 SAMUELL BLVD DALLAS, TX Oct. 19, 2017
VIOLATION: GOVERNING BODY Tag No: A0043
Based on record review and interview, the hospital failed to ensure that an effective governing body was responsible for the conduct of the hospital. On 10/09/17, a female adolescent patient had made an emotional disclosure about a male patient's presence in her room that resulted in an unwanted sexual encounter the night before. Hospital administration investigated the incident and was unaware of the male patient's order for staff to observe patient for potential sexual agression until surveyor inquiry during the onsite survey.

Cross refer: 482.12 (e)
VIOLATION: NURSING SERVICES Tag No: A0385
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**




Based on interview and record review, the hospital failed to have an organized nursing service.

Nursing failed to reassess and evaluate two of two female patients (Patients #1 and #2) after emotional disclosure of experiencing and/or observing sexually inappropriate behavior by their unit peers. Patient #1, a [AGE] year old female made an outcry on 10/09/17 that Patient #3, a [AGE] year old male, entered her room and had a sexual encounter with her on the evening of 10/08/17. Patient #1 was not assessed/evaluated by the nurse after her outcry. Patient #2 made an outcry that she was having flashbacks of past sexual abuse after seeing peers being sexually inappropriate. No further nurse assessment/evaluation was found after the original outcry was made.

Cross refer: A0395



Nursing failed to update and address physical and/or emotional needs of six of six patients' care plans (Patients #1, #2, #3, #24, #25, and #15) for their mental and physical well-being.

1) Patient #1's past history of sexual abuse with interventions/goals,

2) Patient #2's flashback from past sexual abuse cause by visualizing peers engage in sexually inappropriate behavior,

3) Patient #3's SAO-P (sexually acting out-perpetrator) precautions,

4) Patient #24's SAO-P precautions,

5) Patient #25's inability to safely digest milk and dairy products without stomach ache,

6) Patient #15's lactose intolerance that caused nausea, vomiting, rash, and diarrhea.

Cross refer: A0396
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to ensure 2 of 2 patients (Patient #1 and Patient #2) were reassessed and/or evaluated by a Registered Nurse.


1) Patient #1, a [AGE] year old female, made and outcry on 10/09/17 that Patient #3, a [AGE] year old male, entered her room and had a sexual encounter with her on the evening of 10/08/17. Patient #1 made the outcry after Patient #3 was discharged . Patient #1 was not assessed/evaluated by the nurse after her outcry.


2) Patient #2 made an outcry that she was having flashbacks of past sexual abuse after seeing peers being sexually inappropriate. No further nurse assessment/evaluation was found after the original outcry was made.


Findings included:


Review of the hospital Policy titled, "Assessment and Reassessment of Patients" with a review date of 03/2017 reflected, "The Registered Nurse will assess each patient at a minimum every shift and more often as deemed necessary...assessment will include the patient's mental and physical status...findings will be documented...more frequent assessments of patients may be needed when the patient is having a physical problem, change of condition...RN will assess the patient and document findings in a progress note..."

The Texas Board of Nursing (2017) noted "Professional nursing involves the observation, assessment, intervention, evaluation, rehabilitation, care and counsel, or health teachings of a person who is ill, injured, infirm, or experiencing a change in normal health processes..." (http://www.bon.texas.gov/practice_scope_of_practice_rn.asp).


1) Patient #1's Preadmission Evaluation/Management....(Psychiatric Diagnostic Evaluation with Medical Services) dated 10/05/17, timed at 1515, reflected, "Per intake...[AGE] year old was discharged from...two weeks ago...parents found a noose made out of a belt and shoe strings under her pillow...cut her wrists with a sharp rock...fixated and obsessed with suicide, writes suicidal poetry and reads negative entries about herself...past psychiatric history...sexually abused by biological mother's former husband who is presently incarcerated for molesting and abusing...patient...precautions suicide...level of observation Q15 minutes..."


The 10/09/17 (6A-6P) daily nursing flow sheet, timed at 0800, reflected, "Patient is alert/oriented times 4...patient is calm and compliant with medications and shift assessment...denies suicidal and homicidal thoughts...hallucinations and pain...no issues or distress noted at this time."


The Multidisciplinary Progress Note dated 10/09/17 at 1910 reflected Dr...was notified of "sexual allegations." "...Hospital was contacted for an MOT (Memorandum of Transfer) and police..." Officers arrived at approximately 2000 to speak to the patient. Nursing informed the patient's...that the patient was about to be transferred to... Hospital and to meet Police there. Patient #1's...told nursing that he refused to allow the patient to return to (Timberlawn) after the assessment at...Hospital. The patient was discharged against medical advice (AMA)...(cont) multidisciplinary progress note timed at 2100 reflected, "This nurse met with police officer who was leaving to meet...at hospital and explained physicians orders and...response...patient was transported via...transport...alert/oriented times 4...at 2245 staff member called facility...refused to sign, discharge paperwork...was released by hospital to parent's custody." No nursing assessment of the patient was documented after Patient #1's outcry.


The Multidisciplinary Progress Note dated 10/13/17 (late entry) for Monday 10/09/17 at approximately 1730 reflected, "Patient came to (Personnel #5) during dinner and reported that patient (Patient #3) came into my room and touched me...then he started kissing me...I told him to stop but then he got on top of me and continued to kiss me ...would not stop kissing me and kept telling me "you know you want it" he then took his pants off and then he took my pants off and my panties then patient got back on top of me and started kissing me more...then he stuck his thing in me, then took it out and stuck it in again and we had sex...anything else you want to report...no, but do you think I'm pregnant...I don't know but I'm going to make sure the nurses know your concerns and that you are safe and checked out...patient said ok, thank you." No patient assessment was found for Patient #1.


On 10/18/17, at 1151, Personnel #6 was interviewed by telephone. Personnel #6 was asked to review Patient #1's medical record. Personnel #6 was asked to review the multidisciplinary note dated 10/13/17, late entry for 10/09/17 and the nursing note dated 10/09/17, timed at 1912 to 2245. Personnel #6 verified a nursing note which addressed the nursing assessment of the patient after her outcry could not be found.



2) Patient #2's Precaution Notification Alert dated 10/05/17 reflected, "Precaution indicators...suicidal ideation's with multiple plans...sexual victimization...indicators history of rape...history of cutting..."

The Psychiatric Evaluation dated 10/05/17 timed at 1009 reflected, "Depressed, suicidal, cutting...patient is also dealing with rape by ex-boyfriend in 2016..."

The RN Admission assessment dated [DATE] timed at 0220 reflected, "States she has been suicidal and hopeless...states she has been sexually abused several times by family and close friends...states she really has been suppressing her feelings and now she feels she cannot go on anymore...."

The Psychosocial Assessment-Adolescent dated 10/06/17, timed at 1050, reflected, "[AGE] year old female...reports suicidal ideation has been there for about three months...reports thoughts of slitting throat or shooting self...in December 2016 patient reports rape by boyfriend...reports molestation by cousin...when patient was 7..."

The 10/07/17 Multidisciplinary Progress Note, timed at 2300, reflected, "Reports increased anxiety 10/10 and increased past flash backs after I saw some kids sexually acting out...brought back memories about my sexual abuse experience...spent time providing emotional support...almost 30 minutes to calm down..." No further documentation or assessment was found in the medical record which addressed the flash backs the patient suffered related to past sexual abuse.

On 10/18/17 at 1130 Personnel #6 was interviewed by telephone. Personnel #6 was asked to review Patient #2's medical record. The 10/07/17 nursing note was reviewed by Personnel #6. Personnel #6 verified no follow-up assessment and/or further interventions were provided for the patient after she disclosed having flashbacks after witnessing peers being sexually inappropriate.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**




Based on interview and record review, the hospital failed to ensure 6 of 6 patients' (Patients #1, #2 #3, #24, #25, #15) care plan was updated and/or addressed

1) Patient #1's past history of sexual abuse with interventions/goals,

2) Patient #2's flashback from past sexual abuse cause by visualizing peers engage in sexually inappropriate behavior,

3) Patient #3's SAO-P (sexually acting out-perpetrator) precautions,

4) Patient #24's SAO-P precautions,

5) Patient #25's inability to safely digest milk and dairy products without stomach ache,

6) Patient #15's lactose intolerance that caused nausea, vomiting, rash, and diarrhea.


Findings included:


1) Patient #1's Preadmission Evaluation/Management (Psychiatric Diagnostic Evaluation with Medical Services) dated 10/05/17, timed at 1515, reflected, "Per intake...[AGE] year old was discharged from...two weeks ago...parents found a noose made out of a belt and shoe strings under her pillow...cut her wrists with a sharp rock...fixated and obsessed with suicide, writes suicidal poetry and reads negative entries about herself...past psychiatric history...sexually abused by biological mother's former husband who is presently incarcerated for molesting and abusing...patient...precautions suicide..."

The Intake assessment dated [DATE] timed at 1230 reflected, "Father report's patient believes she is a Lesbian...and in love with best friend (female)..."

The 10/05/17 Initial Nursing Treatment Plan dated 10/05/17 timed at 1735 revealed, identified active problem, "SI (suicidal ideation's) plan to hang herself or slit her throat, cut wrists...identified problem danger to self, self-injurious..." No problem was identified which addressed patient's sexual abuse history and sexual identity concerns.

The Interdisciplinary Master Treatment Plan dated 10/07/17 reflected, "Master problem list...depression, suicidal ideation's, self-harm..."

The Psychosocial Assessment Adolescent dated 10/07/17 timed at 0800 reflected, "Patient wrote suicide note...attempted to hang herself and cut herself once admitted ...patient had a period of normality between 10-[AGE] years old...sexually abused by step dad, physically abused by step mom."

On 10/18/17 at 1151 Personnel #6 was interviewed by telephone. Personnel #6 was asked to review Patient #1's medical record. Personnel #6 verified the medical record did not address the patient's history of sexual victimization. Personnel #6 reviewed the initial and master treatment plan. Personnel #6 verified the documents had no documentation which identified the patients past sexual/physical abuse and sexual identity concerns.


2) Patient #2's Precaution Notification Alert dated 10/05/17 reflected, "Precaution indicators...suicidal ideation's with multiple plans...sexual victimization...indicators history of rape...history of cutting..."

The Psychiatric Evaluation dated 10/05/17 timed at 1009 reflected, "Depressed, suicidal, cutting...patient is also dealing with rape by ex-boyfriend in 2016..."

The RN Admission assessment dated [DATE] timed at 0220 reflected, "States she has been suicidal and hopeless...states she has been sexually abused several times by family and close friends...states she really has been suppressing her feelings and now she feels she cannot go on anymore...."

The 10/06/17 Initial Treatment Plan timed at 0220 reflected, "Suicidal Ideation, Depression..." The document which includes interventions and goals did not address patient's recent rape/molestation.

The 10/07/17 Multidisciplinary Progress Note timed at 2300 reflected, "Reports increased anxiety 10/10 and increased past flash backs after I saw some kids sexually acting out...brought back memories about my sexual abuse experience...spent time providing emotional support...almost 30 minutes to calm down...10/08/17 at 0005...patient in bed...respiration even and unlabored..." No further documentation or assessment was found in the medical record which addressed the flash backs the patient suffered related to past sexual abuse. No interventions and/or goals were found in the medical record.

The Interdisciplinary Master Treatment Plan dated 10/07/17 reflected, "Psychiatric Problem...Unstable Mood, Danger to Self, Major Depressive Disorder..." The interventions and goals did not address the patients' recent rape/molestation and/or recent event which involved flashbacks from seeing peers be sexually inappropriate.

On 10/18/17 at 1130 Personnel #6 was interviewed by telephone. Personnel #6 was asked to review Patient #2's medical record. Personnel #6 verified the treatment plan did not address the flashbacks Patient #2 had after witnessing peers being sexually inappropriate. The care plan, treatment plan was not updated and did not address the event and/or provide interventions and goals to address flashbacks of being raped/molested.



3) Patient #3's Physician's Certificate of Medical Examination for Mental Illness dated 10/02/17 reflected, "The patient slashed his mom's tires, threatened to kill himself by cutting his wrists then threatened to kill his mom and siblings...depressed and irritable mood, suicidal and homicidal ideation's, poor insight and judgement."

The Physician's Orders dated 10/07/17 timed at 2245 reflected, "Place patient on SAO-P (sexually acting out-perpetrator)..."

The Interdisciplinary Master Treatment Plan dated 10/05/17 reflected, "Unstable mood, suicidal ideation and homicidal ideation..." No update which included interventions, goals was found regarding the sexually acting out precautions Patient #3 was placed on 10/07/17.

On 10/18/17 at 1206 Personnel #6 was interviewed by telephone. Personnel #6 was asked to review Patient #3's medical record. Personnel #6 verified the patient was placed on sexually acting out precautions on 10/07/17 at 2245. Personnel #6 verified the care plan/treatment plan did not address the sexually acting out precautions ordered.



4) Patient #24's Physician Psychiatric Evaluation dated 10/08/17 at 1500 reflected the patient's psychiatric diagnoses that included Major Depressive Disorder, Severe, with Psychosis.

Physician's Orders dated 10/13/17 at 1435 reflected the patient was placed on SAO-P.

Multidisciplinary Progress Notes dated 10/13/17, untimed, unsigned, unauthenticated, reflected "the therapist was informed during a family session with another patient that...[Patient #24] entered her room one night and that he might have kissed her or something..."

Personnel #7 was interviewed on 10/18/17 at 0817. Personnel #7 was asked to review the patient's care plan and stated the SAO-P precautions were not on Patient #24's treatment plan. Patient #24 was placed on SAO-P after a female patient reported that Patient #24 had entered her room and "kissed her or something."


5) Patient #25 was observed by the surveyor on the hospital's adolescent unit day room on 10/18/17, at 0711. Patient #25 told the surveyor that her stomach hurt "every time" she drank milk or ate cheese. Patient #25 stated she had told a nurse about her stomach pain after eating cheese and "we eat a lot of cheese here."

Personnel #24 stated on 10/18/17, at 0715 that Patient #25 "hasn't said anything." Personnel #24 informed Patient #25 that changes in the patient's dietary regimen were made at that time.

Patient #25's Nutrition Consult dated 10/12/17 at 1200 reflected the patient had "...stomach ache...[secondary to] eating lots of cheese..." Recommendations included for the "registered dietician to follow up per treatment team consultation prn [as needed]."

Patient #25's Interdisciplinary Master Treatment Plan dated 10/14/17 did not address Patient #25's milk or milk product intolerance without gastrointestinal discomfort.



6) Patient #15's Intake assessment dated [DATE] at 1932 reflected the patient's allergies included lactose intolerance.

Patient #15's Physician MOT (Memorandum of Transfer) Orders dated 10/07/17 at 2030 reflected Patient #15 had "no known drug or food allergies."

RN Admission assessment dated [DATE] at 2045 reflected the patient was lactose intolerant and reacted with "nausea, vomiting, rash, and diarrhea."

Patient #15's Master Treatment Plan Updated dated 10/15/17 did not reflect the patient's lactose intolerance. The document did not reflect a nurse signature.

Personnel #6 acknowledged the above findings during an interview on 10/18/17 at approximately 1130.
VIOLATION: CONTRACTED SERVICES Tag No: A0083
The hospital's governing body failed to ensure that services provided on the hospital's adolescent unit meet the health and safety of patients. Male Patient #3 was allowed to stay in a room approximately five steps across the hallway to a female patient's room. On 10/07/17, a physician ordered Patient #3 to be observed for potential sexual aggression. Approximately 24 hours later, Patient #3 was left unsupervised by staff and entered Patient #1's room. The next day, Patient #1 was sent to a medical hospital for emergent examination due to sexual assault . Clinical and administrative staff were unaware of the physician's order for sexual acting out behavior observation for Patient #3 until surveyor enquired about it during the onsite survey.


Findings included:


Patient #3's Physician's Certificate of Medical Examination for Mental Illness dated 10/02/17 reflected, "The patient slashed his mom's tires, threatened to kill himself by cutting his wrists then threatened to kill his mom and siblings...depressed and irritable mood, suicidal and homicidal ideation's, poor insight and judgment."


Patient #3's Physician's Orders dated 10/07/17, timed at 2245, reflected, "Place patient on SAO-P [sexual acting out- perpetrator] precautions..."


Patient #3's Patient Observation Checklist dated 10/07/17, 10/08/17, and 10/09/17 did not reflect the patient was on sexual acting put precautions.


Patient #3's Nursing Note dated 10/07/17 did not reflect any documentation by nursing as to why the patient was placed on sexual acting out precautions per physician orders dated 10/07/17.


Patient #1's Multidisciplinary Progress Note dated 10/13/17 (late entry) for Monday 10/09/17 at approximately 1730 reflected Patient #1 came to Personnel #5 during dinner and reported that "...[Patient #3] came into my room and touched me...then he started kissing me...I told him to stop but then he got on top of me and continued to kiss me...would not stop kissing me and kept telling me 'you know you want it'... he then took his pants off and then he took my pants off and my panties then patient got back on top of me and started kissing me more...then he stuck his thing in me, then took it out and stuck it in again and we had sex...do you think I'm pregnant...?"


Patient #1's 10/09/17 physician orders, timed at 2015, reflected to transfer the patient to pediatric emergency care for evaluation.


Personnel #3 stated during an interview on 10/13/17 at 1320 that the incident had been investigated by management staff. Personnel #3 was asked by the surveyor whether Patient #3 had been on sexual acting out precautions. Personnel #3 denied knowledge of it.


During an interview on 10/13/17 at approximately 1430, Personnel #1 denied awareness of Patient #3's precautionary observation status for sexual acting out.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, record review, and interview, the hospital failed to protect the rights of each patient and failed to provide a safe environment for 13 out of 13 patients (Patients # 1, #2, #3, #4, #6, #7, #9, #10, #11, #13, #15, and #17, and #18).


1) On 10/08/17, at a time when patients had to be asleep in their rooms according to the unit schedule, staff failed to supervise Patient #3, a male, who had unrestricted access to a female Patient #1's room, close-by. Patient #3 entered Patient #1's room and stayed for about six minutes before returning to the hallway. Approximately 20 hours later, Patient #1 disclosed unwarranted sexual encounter with Patient #3. Patient #1was emergently sent for a SANE (Sexual Assault Nurse Examiner) examination at a medical hospital. Until the surveyor's inquiry during the survey, clinical and administrative staff were unaware that Patient #3 had been placed on special precautionary observation level for potential sexual aggression approximately 24 hours prior to the incident.


2) Twelve out of thirteen patients on the hospital's adolescent unit (Patients # 1, #2, #4, #6, #7, #9, #10, #11, #13, #15, #17, and #18) were left without documentation of their location and behavior for more than 45 minutes on 10/09/17. The patients were on suicide precautions, had active suicidal and/or sexually inappropriate thoughts and/or behavior, and/or were noted with poor insight and judgment.


3) At the time of survey, none of the night-shift assigned mental health technicians had evidenced training to address age specific and developmental needs of the hospital's adolescent population.


Cross refer: A0144
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on observation, interview, and record review, the hospital failed to ensure that a safe environment was provided for 13 of 13 patients (Patients # 1, #2, #3, #4, #6, #7, #9, #10, #11, #13, #15, #17, and #18).


1) Patient #3, a male, was placed on SAO-P (sexually acting out- perpetrator) precautions on 10/07/17 per physician's order. Neither clinical nor administrative staff was aware that Patient #3 was placed on special precautions for staff to observe the patient's potential sexual aggressive behavior. Without staff observation, Patient #3 entered a female patient's (Patient #1's) room, unrestricted, on the evening of 10/08/17, at a time when staff documented that the patients were in the day room and/or dining area. Patient #3 remained in Patient #1's room for about six minutes. Approximately 20 hours later, and after Patient #3's discharge, Patient #1 reported an unwarranted sexual encounter with Patient #3 to staff. Patient #1 was sent for emergency evaluation for sexual assault at a medical hospital.


2) Twelve out of thirteen adolescent patients on suicide precautions (Patients #1, #2, #4, #6, #7, #9, #10, #11, #13, #15, #17, and #18) were left without staff documentation of the patients' location and behavior for more than 45 minutes on 10/09/17. The patients had a history of suicide attempt(s) prior to admission, active suicidal ideation, depression, sexually inappropriate behavior during the course of hospitalization , and/or were noted with poor insight and judgment.


3) None of the six mental health technicians (MHTs) assigned to work the night shift on the adolescent unit had evidenced training and demonstrated competence to target the specific developmental needs of the adolescent patient population.


Findings included:


1) Patient #3's Physician's Certificate of Medical Examination for Mental Illness dated 10/02/17 reflected, "The patient slashed his mom's tires, threatened to kill himself by cutting his wrists then threatened to kill his mom and siblings...depressed and irritable mood, suicidal and homicidal ideation's, poor insight and judgement."

Patient #3's Physician's MOT Orders and Preliminary Plan of Care dated 10/02/17, timed at 1100, reflected, "Precautions...assaultive, suicide...level of observation...Q15 minutes."

Patient #3's Physician's Orders dated 10/07/17, timed at 2245, reflected, placed the patient on SAO-P (sexual acting out-perpetrator) precautions.

Patient #3's Observation Checklist dated 10/07/17, 10/08/17, and 10/09/17 reflected Patient #3 was on 15-minute observation checks for suicide and assault. The documents did not reflect special observations for sexual acting out behavior. The checklist dated 10/08/17, at 2230 and 2245, reflected Patient #3 ate in the dining room.


Personnel #3 was interviewed on 10/13/17, at 1320, and stated Personnel #12 was in charge of supervising the patients. Personnel #12's documentation "did not match what we saw on camera ...[Personnel #12] falsified the documents."


On 10/18/17, at 1151, Personnel #6 was interviewed. Personnel #6 acknowledged that Patient #3 was not in the dining room at the time of the alleged sexual encounter incident.



Patient #1's Preadmission Evaluation/Management (Psychiatric Diagnostic Evaluation with Medical Services) dated 10/05/17, timed at 1515, reflected, " ...parents found a noose made out of a belt and shoe strings under her pillow...cut her wrists with a sharp rock...fixated and obsessed with suicide, writes suicidal poetry, and reads negative entries about herself...past psychiatric history...sexually abused by biological mother's former husband who is presently incarcerated for molesting and abusing...patient...precautions suicide...level of observation Q15 minutes..."


Patient #1's Registered Nurse (RN) Admission assessment dated [DATE], timed at 2045, reflected the patient was not sexually active. It noted the "...[AGE] year old presents for anxiety and depression...consistently stated her intention to commit suicide by hanging..."

Patient #1's Psychosocial Assessment Adolescent dated 10/07/17, timed at 0800, reflected, "Patient wrote suicide note...attempted to hang herself and cut herself once admitted ...patient had a period of normality between 10-[AGE] years old...sexually abused by step dad, physically abused by step mom."

Patient #1's Observation Checklist dated 10/08/17 reflected, "Q15 minute checks...(no precautions listed)...2230 and 2245 patient interacting socially in the day area."

On 10/18/17, at 1151, Personnel #6 was interviewed. Personnel #6 was asked to review Patient #1's observation record for 10/08/17. Personnel #6 stated based on the video footage the patient was in her room between 2230 to 2245 during the time of the alleged sexual encounter and verified the document incorrectly documented the patient was in in the day area interacting.


The Multidisciplinary Progress Note dated 10/13/17 reflected Patient #1 approached Personnel #5 on 10/09/17 at about 1730 and reported that "...(Patient #3) came into my room and touched me...then he started kissing me...I told him to stop but then he got on top of me and continued to kiss me...would not stop kissing me and kept telling me 'you know you want it'...he then took his pants off and then he took my pants off and my panties... got back on top of me and started kissing me more...then he stuck his thing in me, then took it out and stuck it in again and we had sex...do you think I'm pregnant...?"


Patient #1's Multidisciplinary Progress Note dated 10/09/17 at 1910 reflected the patient's physician was notified of " ...sexual allegations...[emergency care hospital] was contacted for an MOT (Memorandum of Transfer) and police. Officers arrived at approximately 2000 to speak to the patient. Nursing informed the patient's [family member] that the patient was about to be transferred to ...[emergency care hospital] and to meet Police there ....this nurse met with police officer ...patient was transported via ...[emergency medical services] ..."

Patient #1's physician orders dated 10/09/17, timed at 2015, reflected an order to transfer " ... patient to... [pediatric emergency care] for evaluation...at 2030...discharge patient AMA (against medical advice)."

Patient #1's (Pediatric Emergency Care) Emergency Department Provider Note dated 10/09/17 at 2334 reflected the patient had been admitted for "...concern for sexual assault prior to arrival...complains of lower abdominal and pelvic pain..." The notes timed at 0153 (on 10/10/17) reflected "...forensic examination completed..."

Patient #1's (Pediatric Emergency Care) Child Life Specialist Progress Note dated 10/10/17, at 0220, reflected Patient #1 received a SANE (Sexual Assault Nurse Examiner) examination.


On 10/13/17, at 1245, Personnel #5 was interviewed. Personnel #5 stated that on Monday, 10/09/17, at dinner time, Patient #1 told him that "one of the boys ...[Patient #3]" came into her room and touched her. Patient #1 told Patient #3 "no" and "stop" and "pushed him off" but Patient #3 " ...continued to kiss me ...just kept kissing me ...touching me ...got up and pulled his pants down, pulled my jeans off and my panties, took his thing and stuck it in me, pulled it out, and stuck it back in, and we had sex." Personnel #5 stated that Patient #1 became very emotional at that time and asked Personnel #5 whether she was pregnant. Personnel #5 stated he told Patient #1 that "the nurses will keep you safe from here on." Patient #1's and Patient #3's rooms were approximately five to ten feet apart; the alleged incident happened on Sunday, 10/08/17 between 2230 and 2245. Personnel #5 stated he informed the nurses and administration of the reported incident. At the time of alleged incident, Patient #1's roommate, Patient #2, was not in her room although all patients had to be in their rooms with lights out as of 2200. Personnel #5 was asked by the surveyor whether Patient #3 was on precautions for sexual acting out behavior and stated he did not know. Personnel #5 stated he reviewed unit surveillance video footage and "we saw Patient #3 go into a female room at about 1040 [2240] and leave about 1043 [2243]."


Personnel #1 stated during an interview on 10/13/17, at 1345, that Personnel #12, assigned to supervise 16 patients "was not where she was supposed to be ... the [unit] nurses acknowledged that they did not know where...[Personnel #12] was..." Personnel #1 acknowledged that Patient #1's room was in the same hallway and close to Patient #3's room.

During an interview on 10/13/17, at 1430, Personnel #1 denied awareness of Patient #3's order to be observed for sexual perpetrator behavior,


Personnel #6 was interviewed by telephone on 10/17/17, at 1134. Personnel #6 stated Personnel #12, assigned to supervise the patients, had "left the unit."


Personnel #8 was interviewed by telephone on 10/17/17, at 1222, and denied awareness of any incident but the unit was "usually short-handed." Personnel #8 stated that on Sunday, 10/09/17, the unit was staffed with one MHT "...and we should have had two...the patients were rambunctious...the other RN (Registered Nurse) tried to wrangle them...we can't make them go to their rooms." Personnel #8 stated she was not aware that Personnel #12 had left the unit and "...sometimes I did not see...[Personnel #12] but we have faith that the techs take care of the patients...it was a disorganized place...I guess, I was charge nurse ..." Personnel #8 denied awareness that Patient #3 had been on sexual acting out (SAO) observational status on 10/08/17.

Observations on the hospital's adolescent patient unit on 10/18/17, at 0600, reflected one MHT, Personnel #21, supervised nine patients. Three rooms occupied with male patients on SAO precautions were not immediately visible to Personnel #21 while conducting room checks at an angled-off patient hallway.


During an interview on 10/18/17, at 0630, Personnel #22 acknowledged the above observation and stated that nurses were expected to observe the milieu but it was "not realistic that the nurse always watches the patients when the tech [MHT] makes rounds."




2) Patient #1's Preadmission Evaluation/Management Timberlawn Mental Health System (Psychiatric Diagnostic Evaluation with Medical Services) dated 10/05/17, timed at 1515, reflected the patient had been admitted for suicidal ideation. Patient #1's level of observation was every 15 minute checks. Patient #1's observation checklist dated 10/09/17 reflected the patient was on every 15 minute observations for suicide precautions. There was no evidence of staff documentation regarding the patient's behavior and location for 1715, 1730, and 1745. The patient observation check list was left incomplete for that time.


Patient #2's Physician's MOT (Memorandum of Transfer) Orders and Preliminary Plan of Care dated 10/05/17, timed at 1000, reflected the patient was on suicide precautions and staff was to observe her every 15 minutes. Patient #2's Observation Checklist dated 10/09/17 reflected, "Observation status 15 minute checks ...precautions suicide ..." The observation rounds document was left incomplete for 1715, 1730, and 1745.


Patient #4's Physician MOT Orders dated 10/08/17, at 0119, reflected the patient was on detox and suicide precautions and was to be observed every 15 minutes. Prior to admission, Patient #4 reported he did not want to live any longer and wanted to commit suicide. The patient had used marijuana, Xanax, and "some other pill" within 24 hours prior to admission. Patient #4's Observation Checklist dated 10/09/17 reflected Patient #4's suicide precautions. The observation rounds document was left blank for 1715, 1730, and 1745.


Patient #6's Physician MOT Orders dated 09/30/17, timed at 0032, reflected admitting diagnoses that included Mood (Affective) Disorder. The patient was placed on suicide precautions to be staff observed every 15 minutes. Physician Orders dated 10/05/17 at 1235 reflected the patient was placed on "Sexual Acting Out" precautions. Physician Progress Note dated 10/06/17, at 0830, reflected Patient #6 displayed symptoms of sexual inappropriate behavior. Patient #6's Observation Checklist dated 10/09/17 reflected the patient's precaution status for suicide and sexual acting out. The patient's behavior and location were supposed to be documented every 15 minutes. The observation rounds document was left blank for 1715, 1730, and 1745.


Patient #7's Physician's Preadmission Examination orders dated 10/05/17, at 1618, reflected admitting diagnoses that included Major Depressive Disorder. Patient #7 was placed on 15-minute observation for suicide precaution. Physician Progress Note dated 10/09/17, at 1420, reflected the patient was sad, withdrawn, and had increased depressive symptoms. Patient #7's Observation Checklist dated 10/09/17 reflected the patient's suicide precautionary status. The observation rounds document was left blank for 1715, 1730, and 1745.


Patient #9's Physician MOT Orders dated 09/24/17, timed at 0921, reflected the patient was admitted with diagnoses including Major Depressive Disorder. He was placed on suicide precautions. Physician Orders dated 10/05/17, at 1400, required staff to observe the patient for sexual acting out behavior. Physician Progress Note dated 10/07/17, at 1159, reflected Patient #9's statement that his "depression meds [medications] are not working ...still expressing thoughts to harm self." Patient #9's Observation Checklist dated 10/09/17 reflected the patient's precaution status for suicide and sexual acting out behavior. The observation rounds document was left blank for 1715, 1730, and 1745.


Patient #10's Physician MOT Orders dated 10/04/17 at 1525 reflected the patient's admitting diagnoses that included Major Depressive Disorder. The patient was placed on 15-minute staff observations for suicide precautions. Physician Progress Notes dated 10/09/17, at 1219, reflected the patient was anxious. His judgement and insight were "poor." Patient #10's Observation Checklist dated 10/09/17 reflected the patient's precaution status for suicide. The observation rounds document was left blank for 1715, 1730, and 1745.


Patient #11's Physician MOT Orders dated 10/05/17 at 2244 reflected the patient was admitted with diagnoses that included Major Depressive Disorder. He was placed on 15-minute observational staff rounds for suicide. Physician Progress Note dated 10/07/17, at 1056, reflected Patient #11 had suicidal ideation, was depressed, sad, flat, worried, and was noted to have poor judgement and insight. The Daily Nursing Flow Sheet dated 10/08/17, at 2015, reflected the patient was isolative and did not interact with other patients. Patient #11's Observation Checklist dated 10/09/17 reflected the patient's precaution status for suicide. The observation rounds document was left blank for 1715, 1730, and 1745.



Patient #13 was hospital admitted on [DATE], at 1922, according to the patient's Physician MOT Orders. Admitting diagnoses included Major Depressive Disorder. Physician Progress Note dated 10/07/17, at 1055, reflected the patient was sad, flat, and depressed. Her judgement and insight were physician noted to be "poor." Observation Checklist dated 10/09/17 reflected the patient's precaution status for suicide. Daily Nursing Flow Sheet dated 10/09/17, at 1750, reflected the patient was discharged . There was no documented evidence that staff observed the patient's behavior and location during the last 30 minutes prior to her discharge. The observation rounds document was left blank for 1715, 1730, and 1745. The rounds check timed at 1800 noted the patient's discharge.


Patient #15" Physician MOT Orders dated 10/07/17 at 1510 reflected the patient was admitted with Major Depressive Disorder. He was placed on suicide precautions with 15-minute staff observation rounds. Patient #15's Intake assessment dated [DATE] at 1932 reflected the patient witnessed violence and experienced family loss. He had been using hallucinogens, stimulants including cocaine and crystal meth, marijuana, alcohol, and opiates for up to three years prior to his admission. Patient #15 had attempted to commit suicide "numerous" times since the age of 13, and methods included overdosing, suffocation, eating plastic or glass, slashing of throat, hanging, and access to firearms. Physician Progress Note dated 10/09/17 at 1429 reflected the patient was hearing voices and had suicidal ideation. He was noted to be anxious, and with poor judgement and insight. Patient #15's Observation Checklist dated 10/09/17 reflected the patient's precaution status for suicide. The observation rounds document was left blank for 1715, 1730, and 1745.


Patient #17's Physician MOT Orders dated 10/05/17 at 0347 reflected she was admitted with diagnoses that included Major Depressive Disorder. Patient #17 was placed on suicide precautions with 15-minute staff observation rounds. Patient #17's Observation Checklist dated 10/09/17 reflected the patient's precaution status for suicide. The observation rounds document was left blank for 1715, 1730, and 1745.


Patient #18's Physician's MOT Orders dated 10/07/17 at 0527 reflected admitting diagnoses that included Major Depressive Disorder. The patient was placed on detox and suicide precautions with 15-minute staff observation rounds. Daily Nursing Flow Sheet dated 10/08/17 at 1205 reflected the patient did not have any medical problems. Daily Nursing Flow Sheet dated 10/08/17 at 1945 reflected the patient had "superficial and deep cuts over lower and upper extremities." Physician Progress Note dated 10/09/17 at 1430 reflected the patient minimized her symptoms ...still says she is not depressed despite significant self-harm ..." Patient #18's Observation Checklist dated 10/09/17 reflected the patient's precaution status for suicide. The observation rounds document was left blank for 1715, 1730, and 1745.


On 10/18/17 at 1151 Personnel #6 was interviewed by telephone. Personnel #6 further reviewed the 10/09/17 observation record and verified the 1715, 1730 and 1745 rounds were not completed and left blank for Patients # 2 and #4.


Personnel #15 acknowledged the above findings on 10/19/17 at approximately 1130.

The policy titled Patient Observation/Level of Observation dated 03/2017 reflected "level of observation will consist of monitoring every 15 minutes...patients on fifteen minute checks can expect to be checked a minimum of every fifteen minutes to maintain safety...behavior codes will be completed on all patients at each check... to ensure patient safety, as well as, to provide a process for observing and documenting patient location and behavior...visually observe patients when behind closed doors by...knocking on bedroom and bathroom doors...announce that they are stepping into the room for rounds...open the door and visually observe the safety of the patient......notify Charge Nurse/Nursing Supervisor/Team Leader before leaving an area...hand off the Patient Observation Rounds forms to person responsible for completing observations in your absence..."



3) Personnel #21 interviewed on the hospital's adolescent unit on 10/18/17, at 0600, and stated the night shift was staffed with one nurse and one MHT. Personnel #21 stated he/she had started to work the adolescent unit "last week" and denied age specific training for the adolescent unit.


Personnel #16 was asked by the surveyor to review Personnel #21's employee file during an interview on 10/18/17, at 1020. Personnel #16 denied that Personnel #21 had received training and demonstrated competence that target the specific developmental needs of the adolescent patient population.


Personnel #16 reviewed five additional employee files (Personnel #11, #17, #18, #10, and #19) during an interview on 10/19/17, at 1005. Personnel #16 stated the MHTs were assigned to work night shift on the adolescent unit. Personnel #16 denied that that the MHTs had training and demonstrated competence that targeted the specific developmental needs of the adolescent patient population