HospitalInspections.org

Based on record review and interview, the facility failed to provide an interdisciplinary treatment care plan that addressed the problems and needs of 2 of 10 patients (Patient #1 and Patient #2).

Patient #1 had been admitted on 03/19/2024 with a recent sexual assault history while at school in January of 2024. The sexual assault was documented on the initial Assessment and Referral Evaluation. The facility failed to target the patient's sexual trauma with specialized care plan interventions.

Patient #2 had been admitted on 03/18/2024 and exhibited sexually acting out [SAO] behavior. The SAO behavior was documented in the Patient Care Notes on 03/23/2024 and 03/24/2024. The facility failed to target the patient's SAO behavior with specialized care plan interventions.

Findings Included:

Record review of Patient #1's Face Sheet reflected the 12-year-old admitted to the facility on 03/19/2024 at 11:32 PM.

Patient #1's Assessment and Referral Evaluation dated 03/19/2024 at 10:48 PM reflected the patient was brought in voluntarily by his parents. The patient reported prior sexual trauma that occurred by a peer at his school in January of 2024. Patient #1's High Risk Form dated 03/19/2024 at 11:55 PM reflected the patient was a sexual victim for being inappropriately touched by a peer in January of 2024.

Patient #1's Psychiatric Evaluation dated 03/20/2024 at 1:36 PM did not include any history of sexual abuse or trauma.

Patient #1's Master Treatment Plan initiated on 03/20/2024 at 2:00 PM did not reflect the patient's recent sexual trauma.

During a personal interview on 07/10/2024 at 2:34 PM, Personnel #1 verified that the Master Treatment Plan had not been updated to reflect Patient #1's recent sexual trauma.

Record review of Patient #2's Face Sheet reflected the 12-year-old admitted to the facility on 03/18/2024 at 11:25 PM.

Patient #2's Assessment and Referral Evaluation dated 03/18/2024 reflected the patient was brought in voluntarily by his mother. There was no documented history of being a sexual victim or sexual perpetrator.

Patient #2's Psychiatric Evaluation dated 03/19/2024 at 2:07 PM did not include any history of sexual abuse or trauma.

Patient #2's Patient Care Notes dated 03/23/2024 at 5:00 PM reflected the following, " ...Patient was reported to be saying sexual comments to other patients. He stated he ejaculated on a pillow case 'in his sleep'. He was caught trying to pass this pillow case to the room next to him ..."

Patient #2's Patient Care Notes dated 03/23/2024 at 7:30 PM reflected the following, " ...Pt caught passing notes through window/wall opening. Notes were passed to female peers in the next room. First note reads 'Cum on my face', second note, 'Pls' ..."

Patient #2's Patient Care Notes dated 03/24/2024 at 12:27 PM reflected the following, " ...Patient was making sexual comments to another peer again today ..."

Patient #2's Master Treatment Plan initiated on 03/20/2024 at 2:00 PM did not reflect that Patient #2 was placed on SAO precautions for sexually inappropriate behavior that occurred on 03/23/2024 and 03/24/2024. This behavior was documented in Patient #2's Patient Care Notes.

During a personal interview on 07/10/2024 at 2:34 PM, Personnel #1 verified that the Master Treatment Plan had not been updated to reflect Patient #2's SAO behavior.

The facility policy on "Treatment Plan Process" last revised on 02/22/2021 reflected the following, " ...A. Master Problem List is initiated by the Admitting Nurse upon admission. This list is based on the intake information, the medical/psychiatric history and physical, the nursing assessment and an initial interview with the patient and/or family, and any other assessments already completed. B. Throughout the patient's stay, active medical and psychiatric problems are entered on the Master Problem List. These problems will be transferred onto the Master/Interdisciplinary Treatment Plan as appropriate at the time of staffing ..."