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Based on record review, interview, and observation, the hospital failed to ensure a safe setting was provided for patients.

1) Current observations on the Bloss unit revealed not all patients in their rooms were observed by 2 of 2 technicians (Personnel #4 and #5) for 6 of 19 patient rooms (Room #142, #144, #148, #154, #158 and #160).

2) 2 of 2 patients (Patient #1 and Patient #2) were not adequately monitored/supervised. (Patient #1) and (Patient #2) had a sexual encounter without staff knowledge.

3) The Bloss Unit exceeded the allowed bed capacity of 24 beds for 05/07/15 and 05/08/15. Patients slept on couches and in chairs, therefore, patient privacy was not ensured. This practice placed patients and/or staff the likelihood for injury due to overcrowding. It further compromised the provision of care that meets the patients' psychomedical and psychosocial needs.

4) A plastic trash bag with the potential for use in self-harm was observed easily accessible to patients on 05/13/15 on the Geriatric Unit.

(refer to A0142)

Based on record review, interview, and observation, the hospital failed to ensure a safe environment and patient privacy in that:

1) Current observations on the Bloss unit revealed not all patients in their rooms were observed by 2 of 2 technicians (Personnel #4 and #5) for 6 of 19 patient rooms (Room #142, #144, #148, #154, #158 and #160).

2) 2 of 2 patients (Patient #1 and Patient #2) were not adequately monitored/supervised. (Patient #1) and (Patient #2) had a sexual encounter without staff knowledge.

3) The Bloss Unit exceeded the allowed bed capacity of 24 beds for 05/07/15 and 05/08/15. Patients slept on couches and in chairs, therefore, patient privacy was not ensured. This practice placed patients and/or staff the likelihood for injury due to overcrowding.

4) A plastic trash bag with the likelihood for use in self-harm was observed easily accessible to patients on 05/13/15 on the Geriatric Unit.


Findings included:


1) During the observations on the hospital's Bloss Unit on 05/12/15, between 1005 and 1045, one patient was locked in the Quiet Room, pounding on the door. Several patients were pacing down the long hallway leading to patient rooms. At 1017, the mental health technician walked half-way down the hallway but did not check all patient rooms. Patients were noted to be in Rooms 142, 144, 148, 154, 158, and 160. A female patient in Room 160 was noted to be directly opposite to Room 144, a male patient room. Personnel #5 was asked whether patients were allowed to be in their rooms with the door closed and stated, "No." The patient in Room 160 closed his door twice between 1010 and 1029. The hospital's Chief Operating Officer made rounds at that time and walked by Room 160's closed door without inquiring about the patient status and/or opening the door. At 1032, Personnel #5 walked by the closed door of Room 160.


2) Patient #2's admitting diagnoses dated 04/13/15, at 1000, reflected Bipolar Disorder Type 1, with Psychotic Features. Past Psychiatric History included Suicidal Ideation, Heroin and Cocaine Use.

The Precaution Checklist dated 05/07/15, noted the patient was pacing in the large lounge between 2045 and 2345.

The Precaution Checklist dated 05/08/15, (time not legible) reflected Patient #2 was accused by another patient for entering her room and have consensual sex. The police were called to investigate and [the] patient was taken by police around 0435. The patient was documented "pacing in the large lounge" at 0030, 0045, 0010, 0115, 0145, 0200, 0215, 0230. The patient was documented taken by Police at 0435 and returning at 0815.


Patient #1's Medical Record reflected the following:

The 04/25/15, physician's pre-admission examination orders and preliminary plan of care timed at 0330, reflected, "PTSD (Post Traumatic Stress Disorder), Major Depressive Disorder...every fifteen minute suicide precautions..."

The Discharge Planning Log dated 04/25/15, timed at 0915, reflected, "Reports biological parents physically, emotionally and sexually abused her since she was a child...reports being raped within last month..."

The 05/08/15, Precaution Checklist reflected, "Close observation 15 minute checks...suicide precautions....location/behavior from 0000, 0015, 0030, 0045...0100, 0115...quiet ...room."

The Multidisciplinary Progress Notes dated 05/08/15, timed at 00:30 reflected, "Spoke with (technician)...stated a man was in her (Patient #1's) room and he made her touch his privates...(technician) notified nurse...patient claimed she walked into her room and male patient was standing inside her room...told her to come here and (male) threw her on the bed ...he must of heard something he just got up and left the room...at 0040...RN notified House Supervisor...at 0100...MD notified ...at 0115...nurse again spoke with patient...0220...police arrived on the scene...at 0420...stated she wanted to press charges against (male)."

During an interview, Patient #2 stated on 12/05/15, at 1010, that he and Patient #1 "had intercourse" and "people do it here all the time." Patient #2 denied a mental health technician provided oversight at that time. The patient was asked how easy it was to get from one patient room to another unnoticed by staff, and he answered, "Very easy."

On 05/12/15, at 2325, Personnel #7 was interviewed. Personnel #7 said (Patient #1) informed the MHT she was raped by a male patient.

On 05/12/15, at 2356, Personnel #10 was interviewed. Personnel #10 stated at the time the alleged event occurred he was in the office doing paperwork. Personnel #10 stated the unit was full with 24 patients plus APOWW's.


3) The Nursing Service Department Daily Patient Checklist dated 05/07/15, reflected, "24 patients on 3-11 with 3 APOWW's (apprehension by peace officer without warrant). The unit exceeded the 24 bed capacity by three patients (Patient #21, #22 and Patient #23).

The 05/08/15, Bloss Unit Assignment sheet from 6A to 6P reflected, "30 patients." The bed capacity was 24. This left six patient's without a bed.

Personnel #14 stated on 05/12/15, at 1315, that 3 patients slept in the day area on the Bloss Unit at the time of the alleged incident on the unit for 05/07/15 to 05/08/15 (bed capacity 24). Personnel #14 was asked by the surveyor why the hospital puts more patients on the unit than they have beds for. Personnel #14 did not offer an explanation. Personnel #14 did verify 05/08/15, during the dayshift there were 30 patients on the Bloss unit and the unit did exceed the 24 bed capacity.

On 05/12/15, at 2356, Personnel #10 was interviewed. Personnel #10 stated the unit was full 05/07/15 and 05/08/15 with 24 patients plus APOWW's.


4) Observations on the hospital geriatric unit's dining room on 05/13/15, at 12:20, noted ten patients were served lunch at a long table. At 12:40 a large black plastic trash bag was observed next to the locked trash can.

Personnel #13 was observed removing the black plastic bag and agreed it was used for refuse of the lunch meal.