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Based on review of video footage, medical record reviews, review of facility policies, and interviews conducted, the facility failed to ensure the safety of patients in an acute care psychiatric setting after a male patient showed increased sexual activity in 2 (Patient #2 and Patient #17) of 17 patients reviewed. Refer to A142.

Due to the immediate actions completed by facility and verified by the surveys on 07/02/2025 the immediacy was removed. The action conducted included:

1. Staff Education and Awareness regarding Sexual Acting Out (SAO) Precautions. Risk Factors/ Behaviors Include: · History of past sexual abuse · Prior sexual acting out · Exposing self in public · Inappropriate touching · Excessive or public masturbation Potential Staff Responses: · Pair with gender specific staff (if possible) · Program in gender specific groups (if available) · Consider alternative treatment protocol if behavior escalates in mixed gender group setting · Place in single room; assign room in close proximity to the nurses station · Increase level of observation for severe or repeated behaviors to reduce impulse

2. Protocol Implementation Admission Screening: Patients with a known history of sexual acting out will be identified during the admission process through a review of prior medical records, intake assessments, and collateral information. Upon identification, they will be immediately placed on Sexual Acting Out (SAO) precautions. Leadership Rounds: Daily leadership rounds will be completed to verify the implementation of the level of precautions and room placement. Safety Huddles: SAO patients and those with recent sexual acting out behaviors will be discussed daily to ensure appropriate observation levels are assigned. Validation: Leadership will validate compliance through direct observation and documentation review during rounds.

3. Monitoring and Reporting- Daily Monitoring: SAO precautions will be reviewed daily during safety huddles and the Daily meeting. Computerized Report: Nursing managers will run a daily report to identify all in-house patients on SAO precautions. Quality Program- Track and trend monthly & report in our monthly and QAPI (Quality Assurance and Performance Improvement) meetings. This will be presented at our July QAPI meeting. An email to our quality team including our corporate quality of the changes and additions to our quality program.

4. Immediate Response to Incidents- Inappropriate Contact: Any patient involved in exposure or inappropriate touching will be placed on a 1:1 immediately until reevaluated by a provider. Proximity Adjustment: All patients on SAO precautions will be housed closer to the nursing station. Incident Reporting: If a patient reports harassment: Staff will immediately notify the provider and nursing team, the patient will be considered for transfer to a different unit, and an incident report will be completed and reviewed by leadership.

Verification that facility staff was informed and education was started was verified on 07/02/2025 through observations and interviews of 15 nurses and 10 unlicensed staff.

Based on review of facility policies and document, video footage, medical records, and interviews, the facility failed to do a full investigation and implement an ongoing performance improvement program for identified patient safety events in 1 of 3 events reviewed. Refer to A286.

Due to the immediate actions completed by facility and verified by the surveys on 07/02/2025 the immediacy was removed. The action conducted included:

1. Staff Education and Awareness regarding Sexual Acting Out (SAO) Precautions. Risk Factors/ Behaviors Include: · History of past sexual abuse · Prior sexual acting out · Exposing self in public · Inappropriate touching · Excessive or public masturbation Potential Staff Responses: · Pair with gender specific staff (if possible) · Program in gender specific groups (if available) · Consider alternative treatment protocol if behavior escalates in mixed gender group setting · Place in single room; assign room in close proximity to the nurses station · Increase level of observation for severe or repeated behaviors to reduce impulse

2. Protocol Implementation Admission Screening: Patients with a known history of sexual acting out will be identified during the admission process through a review of prior medical records, intake assessments, and collateral information. Upon identification, they will be immediately placed on Sexual Acting Out (SAO) precautions. Leadership Rounds: Daily leadership rounds will be completed to verify the implementation of the level of precautions and room placement. Safety Huddles: SAO patients and those with recent sexual acting out behaviors will be discussed daily to ensure appropriate observation levels are assigned. Validation: Leadership will validate compliance through direct observation and documentation review during rounds.

3. Monitoring and Reporting- Daily Monitoring: SAO precautions will be reviewed daily during safety huddles and the Daily Flash meeting. WellSky Report: Nursing managers will run a daily WellSky report to identify all in-house patients on SAO precautions. Quality Program- Track and trend monthly & report in our monthly and QAPI meetings. This will be presented at our July QAPI meeting. An email to our quality team including our corporate quality of the changes and additions to our quality program.

4. Immediate Response to Incidents- Inappropriate Contact: Any patient involved in exposure or inappropriate touching will be placed on a 1:1 immediately until reevaluated by a provider. Proximity Adjustment: All patients on SAO precautions will be housed closer to the nursing station. Incident Reporting: If a patient reports harassment: Staff will immediately notify the provider and nursing team, the patient will be considered for transfer to a different unit, and an incident report will be completed and reviewed by leadership.

Verification that facility staff was informed and education was started was verified on 07/02/2025 through observations and interviews of 15 nurses and 10 unlicensed staff.

Based on review of video footage, medical record, facility policies and documents, and interviews conducted, the facility failed to ensure the safety of patients in an acute care psychiatric setting after a male patient (Patient #13) showed increased sexual activity in 2 (Patient #2 and Patient #17) of 17 patients reviewed.

Findings included:

Review of facility video footage, undated and untimed, revealed one male staff rounding in the hall. Patient #13 and a second male patient are seen walking down the hallway. Then Patient #13 and Patient #2 are seen walking back down the hall together and entering Patient #13's room together. A behavioral health associate is observed rounding in the hall and he enters the room and quickly exits. He then is seen attempting to get other staff for help. Patient #2 exits the room without her glasses, wrapped only in a blanket. She was then observed wandering back and forth in the hallway, attempting to keep herself covered with the blanket; she appears distressed. She then goes off the camera entering into a side room, possibly the rocking room (room designed to provide a calming and therapeutic environment for patients experiencing distress, anxiety, agitation, or other emotional challenges). The nurse is seen entering Patient #13 room, then Patient #13 is seen dressed walking down the hallway and enters the day room where there are two female patients and one male patient and no staff present. The nurse and both behavioral health associates are seen with other staff members at the nurse's station in front of the day room, approximately 15 feet away. Patient #2 is eventually escorted off the unit and Patient #13 is placed on one to one.

Review of medical record revealed Patient #13 was admitted on 05/11/2025 at 9:05 AM for schizoaffective disorder, bipolar type. History of Bipolar, schizoaffective, MDD (major depressive disorder) and anxiety. Poor historian, restless. Multiple hospitalization history. Non-compliant with meds. Per APRN (Advance Practice Registered Nurse) progress note on 05/13/2025, "patient presents with pressured speech and manipulative behavior. Patient touched a female peer on the unit yesterday and exposed himself to 2 female patients today. SAO (Sexually Acting Out) precautions implemented. Poor insight and judgement noted". Per nursing note on 05/13/2025, "patient was violating female pt. Found hiding in his bathroom. Female found in her room trying to cover herself with a blanket. Police, supervisor notified". Patient placed on 1:1 observation. On 05/14/2025, "emergency treatment team meeting help with patient #13. Patient calm and cooperative but minimized the severity of the incident. Acknowledged the situation and accepted the current treatment goals. Boundaries were discussed. Acknowledges feeling inappropriate sexual urges when feeling down or depressed. Remains on 1:1 observation". Per collateral note on 05/14/2025, "mother reported that patient has engaged in several inappropriate sexual behaviors, including soliciting sexual favors from church members, exposing himself and masturbating in public".

Review of medical record revealed, Patient #2 was admitted on 05/13/2025 at 4:10 PM for altered mental status. Patient presented manic and anxious, speech hesitant, flight of ideas, inattentive, distractive, responding to internal stimuli, A/V (auditory/visual) hallucinations, has not eaten or slept in 3 days and distracted. Per incident note on 05/13/2025, a male patient was found hiding in his bathroom while Patient#2 was found naked trying to cover herself with a blanket. Nursing supervisor and police notified. Patient escorted to Unit B, ambulance called and arrived at 7:00 PM. Patient transported to [Hospital Name]. Patient #2 mother, house supervisor and Risk manager made aware.

Review of the medical record revealed Patient #17 admitted on 05/04/2025 at 11:34 AM for altered mental status, hesitant, pressured speech, responding to internal stimuli and staring at the wall or laying on table staring at the ceiling. Minimally responsive and preoccupied with internal thoughts. Previous history of schizoaffective disorder. Non-aggressive in ED (emergency department) but had history of homicidal ideation. Administered Vistaril (medication for anxiety) at 7 PM and Geodon (antipsychotic medication) at 10 PM at hospital. A/V hallucinations, paranoia and disoriented. Unable to answer questions. Per APRN progress note on 05/12/2025 at 8:56 PM, Patient #17 transferred to unit G due to safety concerns from inappropriate contact by another patient (Patient #13).

Review of the policy titled Precautions, Sexually Acting Out, last reviewed 5/25 stated Policy: Provision of a safe therapeutic environment of care includes the prevention of patient to patient sexual incidents. Patients shall not have sexual contact with one another. Patients are assessed for risk of sexual acting out behavior. Patients are educated upon admission that they have a responsibility to report any sexual verbal physical abuse or threats of sexual abuse by others. If the hospital determines that there has been an allegation of sexual familiarity (contact) between patients, an immediate investigation must take place. Procedure: During hospitalization, all patients will be assessed and observed for behavior which may increase potential for sexual acting out behavior (ie., inappropriate touching or sexual comments, etc.) Any changes in behavior or events which may impact on a patient's potential for sexual acting out behavior are to be reported to the charge nurse. The charge nurse will assess the patient and contact the attending physician covering practitioner to communicate the change in behavior. The practitioner shall order level of observation and precautions consistent with the assessed level of risk. Changes and level of observations or implementation of precautions will be communicated to all staff. Risk of sexual acting out behaviors will be addressed in the interdisciplinary treatment plan. Treatment plan will be updated as needed.

Review of May 2025 incident log revealed no reports of Patient #13 exposing himself or displaying inappropiate behvavior.

During an interview on 07/01/2025 at 12:00 PM, Staff A/ APRN stated I was notified by the techs for both incidents. For the touching I was made aware the day of and the exposing I was not in the building. The first incident that was brought to my attention; he was new to me, and I hadn't spoken to the patient yet. I saw him the following day on the 13th before the incident. I spoke to nursing in a text and the plan was to place the patient on sexually acting out precautions and to transfer the remaining females off the unit. The census was low and there weren't many females on the unit. I Do not recall exact time frame but Patient #2's situation was sometime in the afternoon. I spoke to the techs and nursing and at the time he was on SAO and monitoring while we figured out who to transfer off the unit. One on one would have been an extra layer of precautions. There was no formal training or education, I'm not aware of any documentation or education.

During an interview on 07/01/2025 at 1:15 PM, Staff D, BHT (Behavioral Health Technician) stated he needed to work on his personal boundaries. He walked up to people and was staring right in their face. The first day wasn't too bad. I knew there was something off with him, so I wanted to go read his chart to know what we were dealing with. He did have other behaviors prior. There were 2 other incidents. He put his hand on the thigh of another female patient who was playing cards with 2 other patients. The therapist and the female tech on the floor reported it. They wrote an incident report. That is when we began communication with the NP (ARNP). We started being more hypervigilant watching him. A female staff member said when she was handing him his food that he was inappropriately caressing her hand, and it made her uncomfortable. There was also an incident report for that. At that point he was having male staff interaction only. It progressed very quickly. A patient told me that while she was playing cards he came up to her and exposed his erect penis to her. There was an incident report for that also. It was reported to us later on, so we don't know exactly when it happened. The nurse was aware. I told the practitioner we needed to move the females off the unit because it was escalating. He said he was going to figure out how to do that. There wasn't much time before the incident happened after that. They said in hindsight, one to one would have been the best action to take.

During a telephone interview on 07/01/25 at 3:31 PM, Staff C, BHT stated he was brand new. It was the first time I had him. The first incident was in the day room and another tech witnessed him touching a female patient 's leg and his hand kept getting higher. Night shift said he purposely exposed himself to the female staff. He was a Q15 (every 15-minute checks) before the incident. I did not witness them (Patient #2 and Patient #13) going into the room. I heard voices and the second one was a female which prompted me to open the door. He was on top of her, both unclothed. I repeatedly told him to get off of her. They got off the bed. They were both flustered. She seemed shocked, pretty confused. She grabbed a sheet to cover herself. I made sure she got to her room safely. I kept Patient #13 in his room. I did try to call for help, but I don't think anyone heard me. I grabbed her a gown from the linen closet for her to dress herself. I let the other tech know what happened. I told the other nurse on the floor; she called the supervisor, and she was prompted to call the police. I am not sure when he went on 1:1 (one to one). Yes, I do feel it was sexual assault. I don't think there's a difference between Q15 checks and SAO. It ' s more of a heads up that this is what they have been doing, and to look out for it.

During an interview on 07/01/2025 at 4:27 PM, Staff E, House Supervisor stated I was called, and I called everybody; I called the managers and AOC (administrator on call). The floor did an incident report (a written account of the incident, including when, where, and how it happened, the individuals involved, and other relevant details - such as the nature and extent of injuries or damages), and we called the provider; she did not call back. I do not call DCF (Department of Children and Family); that would be risk management. The nurses called the police then we got the order for 1:1 from the provider. It was quick; in less than 2 hours. As soon as we call the provider and they give the order, we closed the room for evidence. We called the police then we got the 1:1 order. I transferred Patient #2 to unit B; I did not wait for that order. She was confused and disoriented. I cannot say there have been any changes or education. I didn't receive anything. We need more staff.

During an interview on 07/02/2025 at 11:04 AM, the CMO (Chief Medical Officer) stated we have to evaluate the risks before we implement one to one. In an ideal world, where staff are available it would be implemented immediately. In the real world, the resources are not readily available to do that. If the risk is high enough, we could certainly implement that to manage the risk.

Based on review of facility policies and documents, video footage, medical records, and interviews, the facility failed to do a full investigation and implement an ongoing performance improvement program for identified patient safety events in 1 of 3 events reviewed.

Findings included:

Review of the policy titled Precautions, Sexually Acting Out, last reviewed 5/25 stated Policy: Provision of a safe therapeutic environment of care includes the prevention of patient to patient sexual incidents. Patients shall not have sexual contact with one another. Patients are assessed for risk of sexual acting out behavior. Patients are educated upon admission that they have a responsibility to report any sexual verbal physical abuse or threats of sexual abuse by others. If the hospital determines that there has been an allegation of sexual familiarity (contact) between patients, an immediate investigation must take place. Procedure: During hospitalization, all patients will be assessed and observed for behavior which may increase potential for sexual acting out behavior (ie., inappropriate touching or sexual comments, etc.)Any changes in behavior or events which may impact on a patient's potential for sexual acting out behavior are to be reported to the charge nurse. The charge nurse will assess the patient and contact the attending physician covering practitioner to communicate the change in behavior. The practitioner shall order level of observation and precautions consistent with the assessed level of risk. Changes and level of observations or implementation of precautions will be communicated to all staff. Risk of sexual acting out behaviors will be addressed in the interdisciplinary treatment plan. Treatment plan will be updated as needed.

Review of the policy titled Risk Management Incident Investigation Policy, last reviewed 1/24 stated Policy: It is the policy of North Tampa Behavioral Health to utilize investigation as a preventative tool to strive to avoid incidents from reoccurring and to improve quality of care. Additionally, investigations helped to cultivate an educational mindset of safety amongst all levels of employees at the facility. Procedure: Determine if the incident requires an investigation after reviewing and evaluating the incident report. Control the scene. Determine immediate action to be taken after evaluating existing environment. Preserve the evidence. Gather data. Analyze data next slide share findings with the facility CEO, corporate risk management and corporate quality and compliance department. Write the investigative report. Complete the incident investigation report. Complete the incident data analysis, if required.

Review of May 2025 incident log revealed no reports of Patient #13 exposing himself or displaying innappropriate behavior.

Review of video footage revealed one male staff rounding in the hall. Patient #13 and a second male patient are seen walking down the hallway. Then Patient #13 and Patient #2 are seen walking back down the hall together and entering Patient #13's room together. A behavioral health associate is observed rounding in the hall and he enters the room and quickly exits. He then is seen attempting to get other staff for help. Patient #2 exits the room without her glasses, wrapped only in a blanket. She was then observed wandering back and forth in the hallway, attempting to keep herself covered with the blanket; she appears distressed. She then goes off the camera entering into a side room, possibly the rocking room. The nurse is seen entering Patient #13 room, then Patient #13 is seen dressed walking down the hallway and enters the day room where there are two female patients and one male patient and no staff present. The nurse and both behavioral health associates are seen with other staff members at the nurse's station in front of the day room, approximately 15 feet away. Patient #2 is eventually escorted off the unit and Patient #13 is placed on one to one.

Review of medical record revealed Patient #13 was admitted on 05/11/2025 at 9:05 AM for schizoaffective disorder, bipolar type. History of Bipolar, schizoaffective, MDD (major depressive disorder) and anxiety. Poor historian, restless. Multiple hospitalization history. Non-compliant with meds. Per APRN (advance practice registered nurse) progress note on 05/13/2025, "patient presents with pressured speech and manipulative behavior. Patient touched a female peer on the unit yesterday and exposed himself to 2 female patients today. SAO (Sexually Acting Out) precautions implemented. Poor insight and judgement noted". Per nursing note on 05/13/2025, "patient was violating female pt. Found hiding in his bathroom. Female found in her room trying to cover herself with a blanket. Police, supervisor notified". Patient placed on 1:1 observation. On 05/14/2025, "emergency treatment team meeting help with patient #13. Patient calm and cooperative but minimized the severity of the incident. Acknowledged the situation and accepted the current treatment goals. Boundaries were discussed. Acknowledges feeling inappropriate sexual urges when feeling down or depressed. Remains on 1:1 observation". Per collateral note on 05/14/2025, "mother reported that patient has engaged in several inappropriate sexual behaviors, including soliciting sexual favors from church members, exposing himself and masturbating in public".

Review of medical record revealed, Patient #2 was admitted on 05/13/2025 at 4:10 PM for altered mental status. Patient presented manic and anxious, speech hesitant, flight of ideas, inattentive, distractive, responding to internal stimuli, A/V (auditory/visual) hallucinations, has not eaten or slept in 3 days and distracted. Per incident note on 05/13/2025, a male patient was found hiding in his bathroom while Patient#2 was found naked trying to cover herself with a blanket. Nursing supervisor and police notified. Patient escorted to Unit B, ambulance called and arrived at 7:00 PM. Patient transported to [Hospital Name]. Patient #2 mother, house supervisor and Risk manager made aware.

Review of the medical record revealed Patient #17 admitted on 05/04/2025 at 11:34 AM for altered mental status, hesitant, pressured speech, responding to internal stimuli and staring at the wall or laying on table staring at the ceiling. Minimally responsive and preoccupied with internal thoughts. Previous history of schizoaffective disorder. Non-aggressive in ED (emergency department) but had history of homicidal ideation. Administered Vistaril (medication for anxiety) at 7 PM and Geodon (antipsychotic medication) at 10 PM at hospital. A/V hallucinations, paranoia and disoriented. Unable to answer questions. Per APRN progress note on 05/12/2025 at 8:56 PM, Patient #17 transferred to unit G due to safety concerns from inappropriate contact by another patient (Patient #13).

During an interview on 07/01/2025 at 12:00 PM, Staff A/ APRN stated I participated in the investigation. Patients with any sexually acting out we are implementing one on ones from the beginning. There was just education between staff; no formal training or education that I am aware of.

During a group interview on 07/01/2025 at 1:38 PM, Staff G, RN (Registered Nurse) and Staff H, RN stated we have had patients transferred from B unit and put on one to one for being touchy. Usually, manics are hypersexual and placed on Q5 (every 5) minute checks, 1 to 1 and medications added. We are not aware of any education about a sexual assault. They did do an in service on rounding; making sure to go in the room and see the patient. SAO are checks Q15 (every 15) minutes or Q5 minute as ordered. They have been going straight to one-on-one. We redirect them if we hear them making sexual comments. It's not acceptable for anyone to hear it.

During an interview on 07/01/2025 at 3:31 PM, C, Staff BHT (Behavioral Health Technician) stated there has been no additional training that I am know of.

During an interview on 07/01/2025 at 4:15 PM, Staff I, BHT stated she has not had any training, education, in servicing.

During an interview 07/01/2025 at 4:27 PM, the House Supervisor stated I can not say there have been any changes or education. I didn't receive anything. We need more staff.

During an interview on 07/02/2025 at 9:10 AM, the Risk Manager stated the BHT's were part of the RCA. We had a town hall meeting and spoke about Zero harm and the SAO policy with sign in sheets. There has been an increase in cases of sexually acting out across Acadia so they have launched a training series on Zero Harm. Observe for SAO behaviors, document them, and follow the providers monitoring orders. The focus is on reporting. Staff A, APRN was educated at the time during the RCA. They all participated in the RCA. I didn't document it. I sent out an email to all of the providers last night and I got an attestation from Staff A, APRN. The staff had to sign an attestation for the education on the SAO policy that we started last night.

During an interview on 07/02/2025 at 11:04 AM, the CMO stated we have to evaluate the risks before we implement one to one. In an ideal world, where staff are available it would be implemented immediately. In the real world, the resources are not readily available to do that. If the risk is high enough, we could certainly implement that to manage the risk.