HospitalInspections.org

This CONDITION is not met as evidenced by:

Based on observation, interview and record review the facility failed to protect patient's rights by failing to protect a patient (#1) from being subjected to sexual harassment, placing all patients at risk for loss of their rights. Findings include:

---The facility failed to provide care in a safe setting by failing to protect a patient (#1) from being subjected to sexual harassment to patients on the Adolescent's Unit. (A-0144)

Based on record review and interview the hospital failed to provide a safe environment for one (#1) of two patients who were involved in a sexually inappropriate situation resulting in Patient #1 (a minor) being subjected to sexual harassment in an unsafe setting. Findings include:
An interview was conducted with the Recipient Rights Officer (RRO) on 10/20/2015 at approximately 1218. The RRO reported that an inappropriate sexual encounter occurred on 08/17/2014 between two boys on the adolescent unit. The Recipient Rights Officer explained that the boys were in their room discussing girls, and the older of the two (Patient #2) asked Patient #1 if it would be okay if he (Patient #2) removed his pants. After removing his pants, the Patient #2 went on to question the Patient #1 about whether or not he was a virgin, and if a girl had ever performed oral sex on him. Patient #2 then asked Patient #1 if he (#2) could see his (#1's) penis and finally Patient #2 proposed 'if you give me a blow job, I'll give you one.' The recipient rights officer stated that Patient #2 got an erection during the discussion and exposed himself to Patient #1. A mental health worker (MHW) approached the room during environmental rounds and found the door closed. The MHW opened the door and observed Patient #1 sitting on the floor next to Patient #2's bed with a blanket over his head, while Patient #2 was lying in bed adjusting his boxer shorts. The MHW asked, "What's going on here?" The boys immediately replied, "Nothing happened." The two boys were separated; the MHW informed the charge nurse of the incident and the older boy was placed on 1:1 supervision. The Recipient Right's Officer stated the older patient was on sexual precautions as he sexually assaulted a family member and was put on probation.
The Recipient Rights Officer reported that when Patient #1 was asked why he had a blanket over his head, he replied "I didn't want to look at it (#2's penis). I felt like I was going to be raped." Based on the statements made by Patient #1, it was apparent that the situation made the child feel uncomfortable and fearful for his safety.
The Recipient Rights Officer was asked why a younger male was placed in a room with an older teen who was on sexual precautions and she explained that many errors occurred with this incident and she (the RRO) was unclear why the intake nurse did not think there was any type of threat to a potential roommate at the time of admission. The RRO reported that the intake nurse did not communicate with the charge nurse regarding the placement of a 14 year old male in a room with a 17 year old male on sexual precautions. The RRO said that "the intake nurse did not ask questions about the conditions of the probation for the 17 year old. He was on probation for sexual assault toward his sister." The RRO further stated that #2 "was not supposed to be alone in the presence of anyone under the age of eighteen, however, the staff placed a 14 year old boy in a room with him. The seventeen year old should have been in a room by himself."
An interview was conducted with Clinical Nurse manager (D) and the Recipient Rights Officer on 10/20/2015 who confirmed that the facility acknowledged that an appropriate room placement did not occur on 08/17/2014 which resulted in an unsafe environment for Patient #1.