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Based on record review and interview, the hospital failed to provide care in a safe setting. This deficient practice was evidenced by failure of the hospital staff to perform timely observation rounds for 2 (#1, #2) of 3 (#1-#3) patients sampled resulting in the 2 (#1, #2) patients to have sexual intercourse.
Findings:

Review of the hospital policy and procedure titled, "Observations, Patient, No: POC-28" last revised in November 2023, revealed, in part: "In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the nurse. Procedure: The physician will order one of three levels of observation at time of admission and as the patient's condition warrants a change: 15 minute check (Q15), 5 (Q5) minute check, One-to-one. Q15 Minute Rounds: All patients are monitored at minimum once in every 15 minute block of time. Q5 Minute Rounds: All patients are monitored at minimum once in every 5 minute block of time."

Review of Patient #1's medical record revealed Patient #1 was admitted to Unit "a" on 02/24/2025 under a Physician's Emergency Certificate and the diagnosis of unspecified psychotic disorder. Patient #1 had a physician level of observation order for Q5 minute check.

Review of Patient #2's medical record revealed Patient #2 was admitted to Unit "a" on 02/22/2025 under a Physician's Emergency Certificate and the diagnoses of bipolar disorder, severe with psychotic features. Patient #2 had a physician level of observation order for Q15 minute check.

Review of the "Hospital/Licensed Provider Abuse/Neglect" form revealed, in part, on 02/25/2025 at 8:15 PM Patient #1 and Patient #2 were found by staff engaging in sexual intercourse.

In an interview on 03/24/2025 at 11:24 AM, S2Director of Risk Management confirmed Patient #1 and Patient #2 were found by staff engaging in sexual intercourse on 02/25/2025. S2Director of Risk Management confirmed Patient #1 had an order for Q5 minutes observation rounds and Patient #2 had an order for Q15 minutes observation rounds. S2Director of Risk Management confirmed hospital staff missed three observation rounds for Patient #1 and one observation round for Patient #2. S2Director of Risk Management confirmed the incident on 02/25/2025 between Patient #1 and Patient #2 occurred during the time of missed observation rounds.

Based on record review and interview, the hospital failed to ensure a registered nurse (RN) supervised the care for each patient. This deficient practice was evidenced by failure of the registered nurse to supervise staff to ensure timely observation rounds performed for 2 (#1, #2) of 3 (#1-#3) patients sampled resulting in the 2 (#1, #2) patients to have sexual intercourse.
Findings:

Review of the hospital policy and procedure titled, "Assignment of Nursing Staff, No: NSG-01"" last revised in February 2023, revealed, in part: "To assure quality nursing care and a safe patient care environment, nursing personnel staffing and assignments are based on at least the following: A registered nurse plans, supervises and evaluates the nursing care of each patient."

Review of the hospital policy and procedure titled, "Observations, Patient, No: POC-28" last revised in November 2023, revealed, in part: "In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the nurse. Procedure: The physician will order one of three levels of observation at time of admission and as the patient's condition warrants a change: 15 minute check (Q15), 5 (Q5) minute check, One-to-one. Q15 Minute Rounds: All patients are monitored at minimum once in every 15 minute block of time. Q5 Minute Rounds: All patients are monitored at minimum once in every 5 minute block of time."

Review of Patient #1's medical record revealed Patient #1 was admitted to Unit "a" on 02/24/2025 under a Physician's Emergency Certificate and the diagnosis of unspecified psychotic disorder. Patient #1 had a physician level of observation order for Q5 minute check.

Review of Patient #2's medical record revealed Patient #2 was admitted to Unit "a" on 02/22/2025 under a Physician's Emergency Certificate and the diagnoses of bipolar disorder, severe with psychotic features. Patient #2 had a physician level of observation order for Q15 minute check.

Review of the "Hospital/Licensed Provider Abuse/Neglect" form revealed, in part, on 02/25/2025 at 8:15 PM Patient #1 and Patient #2 were found by staff engaging in sexual intercourse.

In an interview on 03/24/2025 at 1:02 PM, S2Director of Risk Management confirmed that the RN was responsible for ensuring observation rounds were conducted as ordered. S2Director of Risk Management confirmed Patient #1 and Patient #2 were found by staff engaging in sexual intercourse on 02/25/2025. S2Director of Risk Management confirmed hospital staff missed three observation rounds for Patient #1 and one observation round for Patient #2. S2Director of Risk Management confirmed the incident on 02/25/2025 between Patient #1 and Patient #2 occurred during the time of missed observation rounds. S2Director of Risk Management confirmed the RN did not effectively supervise staff to ensure timely observation rounds were performed.