The Centers for Medicare and Medicaid Services (CMS) determined Emerald Coast Behavioral Hospital violated the Medicare condition of participation on patient rights by failing to implement observation precautions, which resulted in the sexual abuse for one patient. One patient in the Intensive Care Unit was found performing oral sex on another patient in his bedroom. The second patient had Alzheimer’s Disease and was evaluated as being disoriented to time, place and situation. The second patient told a nurse that the sexual contact was not consensual. In the days before the incident, the first patient had been ordered under constant observation and sexual aggression precautions, including 24/7 observation, video monitoring in his bedroom and no roommate. Review of video recordings showed the two patients were left alone when the mental health technician took other patients outside to smoke and the RN in the nurse’s station helped another nurse move a patient from a wheelchair to a chair. The two patients spent 20 minutes alone together in the sexually aggressive patient’s room with the door closed before being discovered. Interviews revealed that the RN on duty at the time believed it was facility policy for precautionary orders to expire after 24 hours if they are not renewed. The facility’s CEO said that this was not facility policy, and that this was a “breakdown in communication” with the nurse. As a result of these deficiencies, Emerald Coast lost its “deemed” status with CMS, and was scheduled to undergo a full accreditation survey by AHCA. The subsequent unannounced recertification survey found condition level deficiencies and inadequate numbers of staff.