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Based on Record Review, Observation, and Interview the hospital failed two (2) Patients, Patient #1 and Patient #2, the right to be from from all forms of abuse. Patient #1 and Patient #2 were able to go into the room, and of Patient #2 for more than 10 minutes without supervision. Patient #1 alleged that they engaged in inappropriate sexual contact. Patient #2 denies the act.

Findings Include

During Observation, the video footage revealed Patient #1 was seated in the Group Room. Patient #2 entered the Group Room and stood over Patient #1 seated in the chair rocking back and forth. Patient #1 clearly leans forward and Patient #2 clearly leans downward towards Patient #1 who remained seated. Patient #2 then exits the Group Room. Patient #1 exits the room following Patient #2 into his room for over 10 minutes without observation.

During Observation Patient #1 is observed exiting Patinet #2's room adjusting her shirt. She by passes Staff #5, without making any outcrys of abuse or and shows no physical sign of discomfort or distress.

During Observation Staff #5 was observed outside of the Group Room. Staff #5 did not intervene and or engage either Patient.

During Observation Staff #5 was observed walking down the hallway to check on Patients. Staff #5 by passd Patient #1 in the hallway, without intervening why Patient #1 was observed exiting Patient #2's room. Staff #5 appeared confused as to why the Patient would be coming out of Patient #2's room Staff #5 did not enter the room to check for safety and or to see if Patient #2 was in the room.

Record Review reflected Patient #1 was sexually assaulted at the age of 16.

Record Review reflected, Patient #1 complained of vaginal soreness. Patient #1 made the outcry she was not receiving her medication and she is going to get HIV as a result.

During Interview Staff #2 reported traveling with Patient #1 to the Emergency Room for further examination. Patient #1 did not reveal any distress. Patient #1 asked to notify her mother on the telephone. Staff #2 indicated Patietn #1 did not want anyone in the room with her when her mother arrived. Staff #2 indicated she and the hospital nurse stepped outside the doorway. Shortly after Staff #2 indicated Patient #1's grandmother exited the room and informed her that she did not believe Patient #1 was raped. Patient #1 has a history of being a Poor Historian the grandmother stated. Patient #1's mother then exited the room and stated she does not believe Patient #1 was raped. Patient #1 has a history of making these stories up and she has been expelled from a Group Home, and another hospital for making the same allegations. Upon mother and grandmother arriving Staff #2 reported Patient #1's first words to them were, "Can we go home now!' Patient #1's mother informed the Patient that she was okay and was able to return to Millwood Hospital.

During attempts to interview Staff #5, 3 telephone calls were made to this staff and there were no response. There were conserns of failure to intervene, and possibly defect the Patients from walking down the hall and entering Patient #2's room. There were concerns of Staff #5 not engaging Patient #1 exiting Patient #2 room. There were concerns that Staff #5 did not enter into Patient #2's room to check his whereabout or inquire as to why Patient #1 did exited the room.

During record review Patient #1 was moved to another unit and Patient #2 was discharged the following day.

Policy
The hospital Policy on Patient Rights 11/2021 reflected, "It is the policy of Millwood Hospital and Excel Centers to ensure that all patients receive a copy of the Patient handbook, which includes the Patient Bill of Rights as well as an oral explanation of those rights both in their primary language and in simple non-technical terms. We will strive to abide by and respect all patient rights without regard to race, religion, creed ethnicity, gender, age, sexual orientation or handicap. Millwood Hospital and Excel Centers shall support and protect the fundamental human, civil constitutional and statutory rights of the individual patient and recognize and respect personal dignity of the patient at all times.

The hospital Policy on Assessment of Safety Risk Factors/ Patient Precautions 09/2022 reflected, "Patients assessed to be at heightened risk of suicide as determined in the conclusions of either the intake assessment, nursing assessment, psychiatric evaluations, or based upon patient statements and/or behaviors, may be placed on suicide precautions commensurate with the assessed level of risk. Staff responsible for monitoring patients on suicide precautions shall maintain the patient in a safe environment and take measures to protect the patient from self-harm."

The hospital Policy on Abuse, Neglect 05/2023, reflected, "IT is the Policy of Millwood hospital to report all incidents of patient abuse, neglect, and exploitation as soon as possible after the time the incident is identified."

The hospital Policy Assessment of Safety Risk Factors/Patient Precautions Preventions, 05/2023 reflected, "On admission to all levels of care, Millwood Hospital screens patients for history of sexual aggression and/or victimization history/behaviors. Patients who have a history of sexual aggression or who are exhibiting sexually aggressive behaviors will be placed on an appropriate observation level and unit precautions to provide safe, therapeutic environment. The admission clinician is responsible for completing the initial risk assessment regarding sexual aggression/victimization and documenting it on the admission assessment screen. The physician and nurse place the patient on the appropriate precaution and observation level. Patients should be educated regarding their responsibility to report verbal or physical sexual threats, abuse and the consequences of prohibited behavior on the unit. Patients at risk for sexual victimization should be evaluated for level of functioning and need for addition protection, i.e., developmentally disabled sedated, post-ECT, or medically compromised patients."