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Based on observation, interview and record review, the facility failed to monitor 3 (P-1, P-2, P-7) patients and failed to protect the rights of 1 (P-4) of 10 patients reviewed resulting in the loss of dignity, injury and potential negative outcomes to all patients in the facility. Findings include:

See specific tags:
144 - Failure to monitor patients
145 - Failure to protect patients from abuse

Based on observation, interview, and record review, the facility failed to provide monitoring for 3 (P-1, P-2, P-7) of 10 patients reviewed, resulting in: inappropriate patient to patient contact, injury to a patient, and the potential for poor outcomes for all patients. Findings include:

P-7
During facility tour of adolescent unit on 3/10/25, at 0945 P-7 with orders for 1:1 observation (elopement risk),was observed exiting the activity room to the left of the nursing station, entering the hallway and entering the day room in front of the nursing station and sitting down in a chair. Another staff member was in the dayroom, P-7 was not accompanied by her assigned 1:1 observer at the time of observation. Director of Clinical Services Staff E present during unit tour, confirmed the observation in an interview conducted in conference room on 3/10/25 at 1530.

P-1
Record review for P-1 revealed safety orders on 2/15/25, were for rounding observations every 15 minutes and a 1:1 observer. On 2/15/25, the 1:1 observer for P-1 (per review of video footage) left the day room at 1350, leaving P-1 without a 1:1 observer. P-1 assaulted another patient (P-4) after the 1:1 sitter walked away. P-4 sustained a carpet burn to the left arm.

On 3/11/25 at 1330 an interview with Chief Medical Officer (CMO) Staff U revealed it is his expectation that staff follow policy and procedures of the facility.

Review of policy titled, "Observations, Patient" provided at time of survey, dated 2/23/25, revealed: "To maintain patient health and safety ...1:1 team member is assigned to one patient. The assigned team member must remain close enough to intervene if the patient attempts inappropriate behaviors. This was not done.


50585

P-2
On 3/11/2025 at 0845, Risk Manager Staff D and Director of Quality Staff C reviewed an alleged incident between P-1 and P-2. According to the facility's description of the incident, "on 2/8/2025" (P-1) "reported to staff that patient (P-2) was in (their) bathroom and touched (their) breast and exposed (themselves).

According to the incident report investigation, the outcome revealed that "Patients were interviewed, video footage was reviewed. The following timeline was established and substantiated the sexual misconduct/boundary allegation."

1600 Both patients (P-1 and P-2) can be seen talking with another patient outside (P-1's) door.
1604 (P-2) is in (their) room and (P-1) and another patient can be seen talking to (P-1) from the doorway.
1609 P-2 can be seen sitting outside (another patient's room) with P-1 and 2 other patients.
1612 Both patients (P-1 and P-2) enter (P-1's) room (P-1) just ahead of (P-2) and door closes.
1613 (P-1) steps out of room and back in
1614 Different female patient enters room and both females leave
1615 (P-1) reenters room
1618 (P-1) seen at doorway of room
1619 - 1620 (P-2) leaves (P-1's) room and goes into room across from (P-1) fully clothed, BHT (Behavioral Health Technician) can be seen looking for him for locates him for observation.

On 3/11/2025 at 1120, a video review of the hallway activities outside P-1's with Risk Manager Staff D confirmed the timeline and activities as described in the description of the alleged incident.

According to the facility's interview of P-1 following the alleged incident, P-1 revealed that P-2 "went into my bathroom along (sic) and no one else was present. (They) was sitting on the toilet when I came in (they) began touching my breast I had on my shirt at that time. (They) pulled down (their) pants and I saw a drop of semen fall from (their) penis. The semen drop on the floor and I cleaned it up. I asked (them) to get out of my room and (they) did."

According to the facility's interview of P-2 following the alleged incident, P-2 revealed "I went into P-1's bedroom because (they) asked me too. I thought (they) was going to suck my dick. I remember being in the bathroom (they) ask me to pull down my pants. She got upset and asked me to leave (their) bedroom which I did. Patient very confused (they) reported I don't remember the whole thing but I did not touch (them) at all."

According to P-2's patient observation sheet for 2/8/2025, P-2 was observed by Behavioral Health Technician Staff V at 1606 and 1634 and documented as P-2 being in their bedroom. There was a 28-minute gap between the two recordings at 1606 and at 1634. Staff C was queried if an every 15-minute safety check was missing for P-2 and Staff C confirmed there was a missing 15-minute check during the time of the sexual misconduct allegation between P-1 and P-2.

On 3/11/2025 at 1125, a video review with Risk Manager Staff D of the unit and patients walking the hallways revealed that on 2/8/2025 at 1606, Staff V was sitting in a chair in the day room and P-2 was down the hallway and may or may not have been in their room (unable to determine from video). Staff D was asked whether staff could verify the safety check even though it appeared Staff D could not see P-2 and Staff D explained there was a proximity report that would tell the distance at the time of recording.

On 3/11/2025 at 1130, the proximity report for P-2's safety check at 1606 was requested. On 3/11/2025 at 1215, CNO Staff F revealed they were unable to produce the proximity report on their computer that would reveal the distance between Staff V and P-2 at 1606.

Staff V was asked to be interviewed on 3/11/2025 at 0900 and was not available.

On 3/11/2025 at 1250, the facility's policy "Electronic Patient Observations Using (DEVICE)," dated 2/23/2025 revealed that "Documentation of the observation is to be completed once the patient has been observed. If the beacon is not registering or the patient refuses to wear a beacon, the round may still be entered but the patient must be observed before it is completed." The policy also revealed that for "Q 15 Minute Rounds," "All patients are monitored at minimum once in every 15-minute block of time."

Based on record review and interview, the facility failed to protect one patient (P-4) from 2 physical assaults by peers and failed to follow facility policy regarding observation levels for abuse and neglect occurrences on unit, resulting in physical abuse and mental anguish to P-4 and the potential for harm to all patients served by the facility. Findings Include:

On 02/13/25, the medical record for P-4 was reviewed. P- 4, a 15-year-old female was admitted to the facility on 1/13/25, with diagnoses of disruptive mood dysregulation disorder and attention-deficit/hyperactivity disorder (ADHD, combined type).

Review of records revealed P-4 was physically assaulted twice in the day room (video review conducted at time of survey and confirmed the following events). The first assault occurred on 2/13/25 at 1819, by 2 peers (P-1 and P-3). P-1 hit P-4 in the head, and then P-3 started hitting P-4. Patients were separated by facility staff at 1820. P-4 complained of head pain after the assault on 2/13/25. The second physical assault to P-4 occurred on 2/15/25 at 1350:41, by 2 peers (P-1 and P-5), both peers started hitting/kicking P-4. Patients were separated by facility staff at 1350:49. P-4 sustained carpet burns to her left arm after the assault on 2/15/25.

Record review for P-3 revealed that rounding observations and orders remained at every 15 minutes after physical altercation with P-4 on 2/13/24. No changes in observation level noted on 2/13/25, they were not increased to every 5 minutes nor was a 1:1 sitter assigned.

Record review for P-1 revealed orders on 2/15/25, were for rounding observations every 15 minutes and a 1:1 observer. On 2/15/25 1:1 observer for P-1 (per review of video footage) left the day room at 1350, leaving P-1 without a 1:1 observer. P-1 assaulted P-4 after 1:1 sitter walked away.

Record review for P-5 revealed that rounding observations and orders remained at every 15 minutes after physical altercation with P-4 on 2/15/25. No changes in observation level noted on 2/13/25, they were not increased to every 5 minutes nor was a 1:1 sitter assigned.

On 3/11/25 at 1330 interviews with Chief Executive Officer (CEO) Staff A, Chief Nursing Officer (CNO) Staff F, and Chief Medical Officer (CMO) Staff U revealed nursing can always add observations or increase observation levels for the safety of patients, they are not allowed to decrease observation orders. CMO Staff U stated it is his expectation that staff follow policy and procedures of the facility.

Review of recipient rights policy titled, "Abuse and Neglect" provided at time of survey dated 2/23/25, revealed under heading "Abuse: a. If a patient commits abuse the registered nurse will place the patient committing the offense on Q5 minute observations or 1:1 observation.

Review of policy titled, "Observations, Patient" provided at time of survey, dated 2/23/25, revealed: "To maintain patient health and safety ...1:1 team member is assigned to one patient. The assigned team member must remain close enough to intervene if the patient attempts inappropriate behaviors ... The RN may increase the level of observation if the patient's condition changes. The psychiatric practitioner will be contacted as soon as possible for notification of the change in condition and to obtain an order for the observation level ...The RN may add a precaution if the patient's condition changes. The psychiatric practitioner will be contacted as soon as possible for notification of the change in condition and to obtain an order for the new precaution.