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Based on record review and interview, the hospital failed to ensure:
1. Prevention of nonconsensual sexual contact for two (Patients #4 and #5) of six patients reviewed.
2. Exercise of patient rights for one (Patient #4) of six patients reviewed.

This failed practice had the likelihood to result in the contraction of sexually transmitted infection, pregnancy, loss of dignity and loss of trust in the caregivers. (See Tag 0145)

The hospital failed to ensure review of the sending facility's available records for one (Patient. #2) of six patients reviewed.

This failed practice had the likelihood to result in treatment plan decisions that did not address patient needs, thereby incresing patient risk for hospital readmission. (See Tag 0800)

Based on record review and interview, the hospital failed to ensure:
1. Prevention of nonconsensual sexual contact for two (Patients #4 and #5) of six patients reviewed.
2. Exercise of patient rights for one (Patient #4) of six patients reviewed.

This failed practice had the likelihood to result in the contraction of sexually transmitted infection, pregnancy, loss of dignity and loss of trust in the caregivers

PREVENTION OF NONCONSENSUAL SEXUAL CONTACT

Findings:

Patient #4

Review of an evening shift nursing note dated 07/17/25 at 9:30 PM showed Patient #4 had a distracted and disoriented thought process.

Review of a progress note dated 07/17/25 at 9:30 PM showed Patient #4 received a Haldol shot.

Review of a progress note dated 07/18/25 at 10:00 AM read in part, "[Patient #4] confused and is unaware."

Review of an internal hospital document dated 07/18/25 at 10:39 AM showed Patient #1 fondled the genitals of Patient #4 on 07/18/25 at 10:00 AM.

On 08/08/25 from 12:15 PM to 12:25 PM, Staff Q stated the incident occurred in the geriatric unit dayroom in the line of sight of the nurses' station and two nurses were present in the nurses' station at the time.

On 08/11/25 at 10:51 AM, Staff F stated the geriatric unit was fully staffed that day.


Patient #5

A review of an internal hospital document dated 07/31/25 showed Patient #2 went into the room of Patient #5, who was asleep, and had nonconsensual sexual contact with Patient #5.

A review of an internal hospital document dated 07/30/25 at 5:30 am read in part, "[Patient #2] says he went into [Patient #5's] room and stuck his penis in [Patient #5's] butthole. He says [Patient #5] was asleep. He said [Patient #5] did not give permission. He said there was blood on his penis."

A review of the handwritten law enforcement Voluntary Witness Statement by Patient #5 dated 07/30/25 at 9:00 am read in part, "I was asleep in my bed and a client woke me up by fingering me in my butthole and when he noticed me waking up he darted out of my room. 5-10 minutes after the incident, I was pooping out blood and my butthole is sore."

A review of a policy titled "Patient Rights" last revised 09/2023 read in part, "Patients have the right to be protected by the Hospital from neglect; from physical, verbal, and emotional abuse (including corporal punishment); and from all forms of misappropriation and/or exploitation."

On 08/12/25 at 11:57 AM, Patient #2 stated Patient #5 did not agree to have sexual intercourse.

On 08/12/25 at 2:12 PM, Staff CC stated the following:
1. It was easy for the BHAs to get laxed and start talking in the middle of the hallways instead of being where they could see the whole length of the hallways.
2. The BHAs behavior should have been corrected and was not.


EXERCISE OF PATIENT RIGHTS

Findings:

Patient #4

Review of hospital records showed non-consensual sexual contact between patients and did not show law enforcement was contacted. Specifically:

1. An evening shift nursing note dated 07/17/25 at 9:30 PM showed Patient #4 had a distracted and disoriented thought process.
2. A progress note dated 07/17/25 at 9:30 PM showed Patient #4 received a Haldol shot.
3. A progress note dated 07/18/25 at 10:00 AM read in part, "[Patient #4] confused and is unaware."
4. An internal hospital document dated 07/18/25 at 10:39 AM showed Patient #1 fondled the genitals of Patient #4 on 07/18/25 at 10:00 AM. The document read in part, "POLICE INVOLVEMENT?" and "no" was marked.
5. A policy titled "Special Precautions" dated 09/2024 read in part, "In the event of a non-consensual sexual encounter involving a patient ...Nurse/Clinical Nurse Leader/Supervisor will notify law enforcement."
6. A policy titled "Patient Rights" dated 09/2023 read in part, "Patients have the right to be protected by the Hospital from neglect; from physical, verbal and emotional abuse."

On 08/11/25 at 10:54 AM, Staff F stated law enforcement was not contacted.

On 08/12/25 at 3:25 PM, Staff F reviewed the Special Precautions policy and stated what occurred with Patient #1 and #4 was a sexual encounter and law enforcement should have been contacted.

The hospital failed to ensure review of the sending facility's available records for one (Patient. #2) of six patients reviewed.

This failed practice had the likelihood to result in treatment plan decisions that did not address patient needs, thereby incresing patient risk for hospital readmission.


Findings:

Patient. #2

Review of hospital records showed documentation of SAO behaviors by the sending facility prior to the patient's hospital admission and did not show documentation of SAO behaviors on the receiving hospital's intake forms or initial treatment plan.

Review of records faxed on 07/23/25 from the sending facility showed the patient had behavior concerns for sexually inappropriate behavior.

A review of records showed that Patient #2 was admitted to the ID Unit at Rolling Hills on 7/29/25.

Review of a hospital document titled "ADMISSION ORDER" dated 07/29/25 at 8:45 PM read in part, "Precautions for:...Sexual Acting Out" and the box was not checkmarked.

Review of a hospital document titled "INTAKE" dated 07/29/25 at 9:50 PM read in part, "sexual impulsivity" and the box was not checkmarked.

Review of a hospital document titled "HIGH RISK NOTIFICATION FORM" dated 07/29/25 at 10:00 PM read in part, "Sexually Acting Out Risk," and the box was not checkmarked.

Review of a hospital document titled "Initial Treatment Plan (Nursing)" dated 07/30/25 1:57 AM showed no problem, goal or intervention for impulsivity or SAO.

A review of a policy titled, "Admisions Process" last revised 01/2023 read in part, "Admissions personnel will review the admissions documents."

A review of a policy titled, "Assessment/Reassessment" last revised 07/2025 read in part,"The Intake process assissts in determining the treatment needs of a patient...The information obtained on initial inquiries includes: Information about the caller's current physician, condition/situation, including safety."

A review of a plicy titled "Observations, Patient" last revised 02/2025 read in part, "At admit, the attending physician may also order a special precaution level for...Sexual Acting Out."

On 08/08/25 at 10:06 AM Staff GG stated:

1) SAO precautions were not ordered, to my knowledge Patient #2 was coming in for aggression.
2) If SAO had been documented, Patientt #2 would have been a 1:1 observation level at admission and would have been on a different unit;

On 08/11/25 at 11:29 am Staff T stated:

1) The agency did send documents showing Patient #2 had SAO.
2) SAO was not listed on the patient's intake/admission documents.
3) The admission intake nurse should read all records sent from a referral source.

On 08/12/25 at 10:07 am Staff V stated:

1) The Patient #2 had no SAO precautions prior to 07/30/25 at 5:40 AM.