HospitalInspections.org

Based on review of facility policy, patient records, and confirmed in interview, the facility failed to ensure patients received care in a safe setting for one of six records (Patient #A) reviewed. Facility failed to monitor Patient #A with appropriate precautions for two days after his admission.

Findings included:

Review of the facility policy Patient Precaution Level's Procedure (issues 07/25/2014) it stated "all patient precautions and restrictions must be ordered by a physician and must be reviewed by a physician every twenty-four hours to assess the patient's clinical symptoms and renew or discontinue precautions and/or restrictions. They physician must document in their physician's progress notes the clinical justification for continuing all precautions and/or restrictions...
SAO V- Victim
Document on the High Risk Notification Form All staff made aware in shift report daily
Place close to nursing station if available
Sleep same sex hall
monitor daily for sexually provocative hypersexual behaviors"

Review of Patient #A chart revealed he is a 14 year old male who admitted to the facility on 07/19/2025 for SI with a plan and history of sexual victimization.

Review of Patient #A initial assessment under Potential for Sexual Victimization a selection of 'yes' with notes of 'at 2018 and 2024'
Risk summary from the initial assessment also included "per mother, patient was sexually assault[ed] at school in Nov 2024 and at church in 2018. Per mother, investigation is still on."

Review of Patient #A initial nursing assessment under potential for sexual victimization, nurse staff selected 'yes' for history of sexual victimization and indicated 'victim of sexual abuse'

Review of Patient #A physician orders revealed no documentation that SAO-V was ordered until 07/22/2025, three days after admission.

In an interview with Staff #4 on 07/25/25 at 1:30 PM in the conference room, she confirmed that "any history of sexual trauma would indicate SAO precautions." She acknowledged that Patient #A should have had SAO precautions at admission.