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Based on interview, record review, policy review and video review, the facility failed to protect two patients (#9 and #10), from sexual misconduct, when Patient #9, with a history of sexual acting out aggressor (SAO-A, abnormal sexual acting out in a way that pressures others to engage in the activity) and Sexual Maladaptive Behavior (SMB, sexual activity that is not age appropriate, and involves threats or aggression) was roomed with Patient #10, who had no identified history of SAO/SMB. Sexual misconduct occurred between Patient #9 and Patient #10 while unsupervised in their room, as observed on video recording from 06/20/18 between 8:20 PM and 8:48 PM. (Refer to A-0144).

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Patient's Rights. The facility census was 85.

The severity of these practices had the potential to place all patients at risk for their safety, also known as Immediate Jeopardy (IJ).

On 06/27/18, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect the patients.

As of 06/28/18, at the time of the survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- All current room assignments were evaluated for all patients with SMB who had been assigned roommates.
- Room changes were completed to reduce risk of harm to others.
- All SMB patients were placed in rooms with continuous visual monitoring at all times, when a SMB patient had a shared room.
-Revision of the facility's policy titled, "Observation/Monitoring," was completed to include the following clarification to SMB precaution to be defined as "a patient who engages in sexual behavior, not ordinary for his/her age, and has the potential for sexual aggression based on past and/or current behaviors." Additional terminology would also include 24 hour visual observation if a room was shared with another patient.
-Revision of the facility's policy titled, "Assessment: Room Assignments," included "SMB identified patient will be placed in a blocked room (without a roommate) when available. When a blocked room is unavailable, SMB patients will only be placed in a room with another SMB patient with continuous visual monitoring in effect at all times in which both patients are in the room together."
-The leadership team acknowledged confusion related to multiple terminologies in the Review of Intake Assessment process and a Handoff communication sheet and this was revised to replace Sexually Acting Out-Aggressor (SAO-A) and Sexually Acting Out-Victim (SAO-V) with Sexually Maladaptive Behavior (SMB) alert notice.
-Education related to the above corrective actions was implemented effective 06/27/18 to all Intake staff, Nursing staff, Behavioral Health Technicians/Program Security Technicians, and providers, prior to the start of their next shift and would continue until all were trained.
-New hire orientation would be revised to address the above changes to policies. Ongoing education related to these policies would occur as a part of mandatory education each quarter.
-Additional education related to proper assessment of SMB history was provided to Intake Staff effective 06/27/18 and would continue prior to the start of their next shift, effective 06/27/18.
- Overnight Nursing Supervisor would perform nightly rounding, a minimum of two times per shift, to verify all identified SMB patients were monitored per policy. This procedure was to be adopted as a permanent practice. Any identification of non-compliance would be corrected immediately with re-education at the time of deficiency. The Director of Nursing (DON) would complete formal disciplinary action up to and including termination.
- The leadership team would verify appropriate patient room assignments through review of the precautions and room assignment board located in each nursing station daily. This monitor would be added as a permanent line item on the Administrator on Call (AOC) Leadership Rounds form and monitored permanently for 100 percent compliance. The results would be reported monthly to the Performance Improvement Committee. Any identification of non-compliance would be immediately corrected with re-education completed at time of deficiency. The DON would complete a formal disciplinary action up to and including termination.
- The Director of Risk Management/Performance Improvement would conduct direct observation of evening and overnight shifts via camera reviews of a minimum of three times weekly, on all units, to monitor staff compliance, with requirements to be posted at locations where SMB patients can be visualized simultaneously during bedtime hours.
- Leadership team would review 100 percent of Intake Assessments, Handoff Communication sheets, admission orders, and room assignments daily, to ensure that the SMB history was appropriately assessed, communicated, and SMB precaution was implemented.







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Based on interview, record review, policy review and video review, the facility failed to protect two patients (#9 and #10) from sexual misconduct, of two patients reviewed for sexual misconduct, when Patient #9, with a history of sexual acting out aggressor (SAO-A, abnormal sexual acting out in a way that pressures others to engage in the activity) and Sexual Maladaptive Behavior (SMB, sexual activity that is not age appropriate, and involves threats or aggression) was roomed with Patient #10, who had no identified history of SAO/SMB. These failures had the potential to affect all patients who were housed with SMB patients. There were 13 patients identified with SMB, 11 patients identified as SAO-A and two patients identified as sexual acting out-victim (SAO-V, the person whom inappropriate sexual activity has been inflicted). The facility census was 85.

Findings included:

1. Review of the facility's policy titled, "Assessment: Room Assignment," dated 03/13/18, showed that room assignments will be based upon assessment of the patient's risk to victimize or be victimized by others at the time of admission. Patients who have been identified as either SAO-A or Sexual Acting Out-Victim SAO-V) will not be assigned to the same room unless additional personnel are assigned to monitor patients while in room together. SAO-A patient's will only be roomed with patients with no identified history of sexually acting out behavior unless additional personnel are assigned to monitor patients while in room together.

2. Review of the video dated 06/20/18 showed the following:
-At 8:20 PM Patient #9 and his roommate, Patient #10 were both lying on their beds.
-At 8:21 PM Patients #9 and #10 shut the door, turned their light on and off again and moved to the corner of the bedroom. Patient #10 lowered his shorts and exposed his penis while Patient #9 was facing the wall with Patient #10 behind him. This lasted approximately seven seconds.
-At 8:22 PM both patients returned to their own beds.
-At 8:23 PM the patients moved back to the corner of the room. Patient #10 exposed his penis and Patient #9 was against the wall. Patient #10 was standing behind him. This lasted approximately 14 seconds and they both returned to their beds.
-At 8:24:21 PM Patient #9 got up from his bed and kneeled over patient #10 who was lying on his bed. Patient #9 performed oral sex on patient #10 for approximately six seconds and then masturbated patient #10 for approximately two seconds before he returned to his own bed.
-At 8:24:42 PM Patient #9 went to patent #10's bed and performed oral sex on patient #10 for approximately six seconds and then walked to the doorway of the room.
-At 8:25 PM Patient #9 kneeled over Patient #10 again and performed oral sex for 22 seconds and then returned to his bed.
-At 8:26 PM Patient #10 went to Patient #9's bed and performed oral sex on Patient #9 for approximately six seconds and returned to his bed.
-At 8:27 PM Patient #9 left his bed and kneeled over Patient #10 and performed oral sex for approximately nine seconds and returned to his bed.
-At 8:28:27 PM Patient #9 kneeled over Patient #10 and performed oral sex for approximately 10 seconds.
-At 8:28:48 PM Patient #9 quickly stood up and walked to the doorway due to the staff completing their 15-minute rounds. Patient #9 was removed from the room immediately.

3. Review of Patient #9's medical record showed:
- An Intake Assessment completed on 06/11/18, which documented a history of SMB toward others by exposing himself to two younger girls in the home, grabbing his penis and shaking it at them, grabbing his brothers butt, exposing and pointing to his penis to his foster mom, and watching pornography.
- A Family Session Note completed on 06/18/18, which documented that he had previously had a problem with sexual behavior which involved two children in an adopted home and an order was written for a SMB evaluation.
- An Individual Session Note, SMB evaluation, completed on 06/19/18, which documented that the patient was sexually abused when he was very young and had sexual activity with two of his adoptive siblings, male and female. Staff M, Licensed Professional Counselor (LPC), documented in the note that because of his exposure to sexual experiences at such a young age and his inability to control himself, he would need close supervision in a highly structured setting.

Review of Patient #10's medical record completed on 06/18/18 showed that the patient had no identified history of SAO/SMB.

4. During an interview on 06/26/18 at 2:00 PM, Staff F, LPC, stated that Patient #10 had told her that the sexually acting out behavior was his roommate's (Patient #9) idea, and she stated that Patient #10 was a follower and a people pleaser. She stated that Patient #10 did not want to speak with anyone else about it and refused our interview.

During an interview on 06/27/18 at 10:00 AM, Staff M, LPC, stated that she could recommend blocked rooms (no roommate allowed) for SMB patients to the physician or to the nurse in charge, and they would obtain an order, but she thought the facility would be a highly structured setting with close supervision, so she did not recommend a blocked room. She stated a SAO-A and SAO-V should never room together and they should only room with patients with no history of SMB because they will be more likely to tell someone. She stated the facility had previously used a Vulnerability Assessment to make room assignments as part of a previous plan of correction, but they had decided it was not a reliable assessment and had quit using it.

During an interview on 06/27/18 at 2:45 PM, Staff T, Medical Director, stated SMB needed levels for the types of behavior they were displaying, and the staff needed heightened awareness of those levels for room assignments and monitoring of the patients. He stated that the providers (physicians, nurse practitioners, etc.) wrote the orders for blocked rooms when recommended, but one had not been recommended for Patient #9.

During an interview on 06/26/18 at 1:20 PM, Staff G, Registered Nurse (RN), stated that she was Charge Nurse from time to time. Prior to admission, the Intake Counselor would take a full history from either the family, the representative of the group home or wherever the patient is being admitted from. The Charge Nurse was responsible for patient room assignment based on the intake assessment. Staff G, RN, stated that when she made a bed assignment for an SMB patient, she would put them in with an older child or someone really outspoken.

During an interview on 06/26/18 at 1:40 PM, Staff H, RN, stated that when she was Charge Nurse, she used the history on the Intake Assessment form to assign rooms. If the patient was sexually aggressive then she would put them into a room with someone more outspoken.

During an interview on 06/26/18 at 2:30 PM, Staff K, RN, stated that she floated to the children's units and would occasionally take the Charge Nurse role, and would be responsible for the room assignment of new patients. She would put SMB patients in a visually accessible room if at all possible, and would assign them to a room with a very verbal child if they had to have a roommate. Staff K added that she relied on the Behavioral Health Technicians to keep her informed of any issues that she may not be aware of.

These interviews showed that instead of preventing inappropriate sexual activity from occurring between patients, nursing staff relied on psychiatric patients, after they were the victims of inappropriate sexual activity or inappropriate sexual advances, to communicate the inappropriate sexual activity to a facility staff member.

During an interview on 06/26/18 at 2:00 PM, Staff I, RN, stated that when she was in the Charge Nurse position she would not put a child with SMB into a room with another SMB, SOA-A or SOA-V child. She would get a full history and then call the Physician for an order to place in a blocked room.

During an interview on 06/26/18 at 2:20 PM, Staff J, RN, stated that the Intake Counselor assigned precaution levels for room assignments, and that nursing had to actually see sexual behavior before they called the Physician for a blocked room. Staff J added that a sexual aggressive patient would not have a roommate.






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