HospitalInspections.org

Based on interviews, the hospital failed to provide appropriate staff supervision, for two (Patient #1 and Patient #2) of ten patients sampled, which resulted in an inappropriate sexual encounter (inappropriate touching) between Patient #1 and Patient #2 in the hospital's self-regulation room, and thus a failure to provide care in a safe setting. Despite re-education that was disseminated by the Director of Nursing (DoN) and conducted by nursing leadership to the staff nurses and staff Mental Health Technicians (MHTs), the current staff understanding as it relates to staff supervision of patients in the self-regulation room (where the inappropriate sexual encounter occurred) continue to conflict with hospital policy.

Findings include:

The surveyor interviewed the DoN on 09/09/2025 at 5:25 P.M. The DoN stated that after this sexual encounter event occurred between Patient #1 and Patient #2, MHT #5 and MHT #6 (the MHT staff that were responsible for supervising Patient #1 and Patient #2 in the self-regulation room) were terminated and that the DoN determined there needed to be across the board re-education of hospital policies. The DoN stated that education was done building-wide as a refresher and the information was disseminated through staff huddles, and information posted throughout the units. The education included information regarding self-regulation room rules as well as how to appropriately complete observation safety check sheets.

Document review on 09/09/25 indicated that a flyer (one of the education tools disseminated to hospital staff) that the surveyor received from the DoN regarding self-regulation room rules specifically states, "One person at a time without staff."

The surveyor interviewed a Special Needs Unit (SNU) nurse on the SNU, Nurse #2 on 09/08/2025 at 3:45 P.M. Nurse #2 stated that if one patient is in the self-regulation room, then the one patient can be unattended.

The surveyor interviewed MHT #1 on the SNU on 09/08/2025 at 4:00 P.M. MHT #1 stated that it is okay for one patient to be unattended in the self-regulation room.

The surveyor interviewed MHT #2 on the SNU on 09/08/2025 at 4:10 P.M. MHT #2 stated that it is okay for one patient to be unattended in the self-regulation room.

The policy titled "Self-Regulation Room Policy and Procedure," implemented on 01/18/2024, states that, "This policy applies to the special needs inpatient psychiatric unit." The policy states that, "Staff must supervise any client use of this room" and that, "When staff is not in the room, the door must remain locked."

Hospital policy indicates that staff must supervise any patient use of the self-regulation room, yet three staff interviews as well as a flyer used for re-education to the direct care staff indicated that one patient can be in the self-regulation room without any staff/unattended. The practice of leaving one patient unattended in the self-regulation room is a violation of the hospital's own policy and could potentially lead to a future event(s) where patient care in a safe setting is compromised.