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Based on facility policy review, facility document review, medical record review, and interview, the facility failed to ensure patients' rights were promoted to be free of abuse for one of three (Patient #1) sampled patients.

The findings included:

1. Review of the facility's "PRECAUTIONS, SEXUAL ACTING OUT" policy dated "05/2022" revealed all allegations of patient to patient sexual allegations should be investigated immediately.

2. Review of the facility's "PATIENT ABUSE AND NEGLECT" policy approved date 12/2021 revealed, " ... Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation ... shall protect patients from real or perceived abuse, neglect or exploitation from anyone, including staff members, students, volunteers, other patients ... Definitions ... Neglect ... Any circumstances which results from leaving unfinished or unattended one's duties and responsibilities for patient care which endangers a patient's life or development or impairs the patient's functioning ... Any alleged, suspected or witnessed abuse, neglect, exploitation or abandonment by an employee, family member, friend or caregiver shall be reported to the immediate supervisor as soon as it is known ... Investigate incidents and allegations in a timely manner ..."

3. Medical record review revealed Patient #1 was involuntarily admitted to the facility on 7/15/2022 with diagnoses that included Major Depressive Disorder with Psychotic features, Autism, Attention Deficit Hyperactivity Disorder, Bipolar and Anemia.
The patient was having suicidal ideations with a plan to run out in traffic. The patient reported an increase in worsening mood, thoughts of killing herself and a 'mental breakdown'. The patient had a physical altercation with a family member and reported that she blacked out. The patient had a history of being verbally and physically abused.

On 7/22/2022 Patient #3 reported that a male patient attempted to grab at her shirt and pull her pants down. The Patient Advocate sent an e-mail to the Chief Nursing Officer and the Risk Manager reporting the allegation.

In an interview on 8/17/2022 at 9:30 AM with the Patient Advocate and the Risk Manager, both verified that an investigation of the allegations had not been conducted.
Refer to A145

Based on facility document review, facility policy review, medical record review, and interview, the facility failed to ensure all patients were free of abuse as evidenced by not thoroughly investigating an allegation of abuse for one of three (Patient #1) sampled patients.

The findings included:

1. Review of the facility's "PRECAUTIONS, SEXUAL ACTING OUT" policy dated "05/2022" revealed, " ... Provision of a safe, therapeutic environment of care includes the prevention of patient to patient sexual incidents. Patients shall not have sexual contact with one another ... Patients are educated upon admission that they have a responsibility to report any sexual verbal/physical abuse or threats of sexual abuse by others. If the hospital determines that there has been an allegation of sexual familiarity (contact) between patients, an immediate investigation must take place ..."

2. Review of the facility's "PATIENT ABUSE AND NEGLECT" policy approved date 12/2021 revealed, " ... Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation. Crestwyn Behavioral Health shall protect patients from real or perceived abuse, neglect or exploitation from anyone, including staff members, students, volunteers, other patients, visitors, or family members ... Definitions ... Neglect ... Any circumstances which results from leaving unfinished or unattended one's duties and responsibilities for patient care which endangers a patient's life or development or impairs the patient's functioning ... Identification ... Identify possible incidents or allegations that need investigation ... Any alleged, suspected or witnessed abuse, neglect, exploitation or abandonment by an employee, family member, friend or caregiver shall be reported to the immediate supervisor as soon as it is known ... The supervisor will immediately notify the Chief Executive Officer, and Risk Manager for tracking and investigating alleged incident ... Investigate incidents and allegations in a timely manner ..."

3. Medical record review revealed Patient #1 was involuntarily admitted to the facility on 7/15/2022 with diagnoses that included Major Depressive Disorder with Psychotic features, Autism, Attention Deficit Hyperactivity Disorder, Bipolar and Anemia.

Review of the Intake Assessment dated 7/15/2022 at 23:01 revealed, " ... Pt [patient] referred by [Name of crisis center]. Pt presents endorsing a SI [suicidal ideations] with a plan to run into traffic. Pt reports thoughts to kill herself have worsened in the past two months. Pt reports experiencing increasing mood swings. Pt reports having a 'mental breakdown' Pt reports having a physical altercation with her aunt, she does not remember hitting her aunt, stating 'I blacked out.' Pt reports that her aunt is verbally and physically abusive. Pt reports hx of physical and emotional abuse ...Self- harming bx [behaviors] Pt used a stick to make superficial cuts to her [herself] ... binge eating ... Obsessive thoughts of dying ... assault charge ... childhood abuse and into adulthood ..."

Review of the practitioner progress notes from the 7/15/2022 admission to 8/14/2022 revealed Patient #1 continued having Major Depressive Disorder with psychotic features, attention seeking behaviors, anxiety, agitation, impulsiveness, hearing voices and aggressive behaviors, requiring dosage adjustments and changes in medications.

Review of a facility email document dated 7/22/2022 at 09:00 from the facility's Patient Advocate to the Risk Manager and Chief Nursing Officer revealed, "We have one patient that will be attending court this morning [Name of Patient #1] ... While speaking to her attorney this morning ... She [Patient #1] then stated that a male patient on the unit was attempting to grab at her shirt and pull down her pants which also made her uncomfortable. I just wanted to make sure you all were aware of her claims since she reported them to an outside source before voicing them to staff. Please let me know if there is anything else I can do to help with this situation ..."

In an interview on 8/17/2022 at 9:30 AM, in the lobby meeting room, with the Patient Advocate/Executive Assistant/Involuntary Admission Co-Ordinator (Patient Advocate) and the Risk Manager, the Patient Advocate stated on the day of court, Patient #1 stated "a male came in her room on the unit." The Patient Advocate stated that she sent an e-mail to the CNO and RM. The Patient Advocate and Risk Manager both stated they couldn't investigate because the patient couldn't give any additional information. The Risk Manager stated there was no other investigation other than the e-mail that was sent to the CNO and Risk manager.

In an interview on 8/17/2022 at 10:20 AM Patient #1, still a current inpatient at the facility, was asked if she had been abused or mistreated in the facility. Patient #1 stated, "[Name of Patient #3] touched my butt and tried to kiss me." Patient #1 stated it's been a while back and she doesn't remember everything because she was not stable then.

The facility failed to conduct an investigation to ensure the patient was free of abuse neglect and in accordance with the facility policy.

4. Medical record review revealed Patient #3 was Involuntarily admitted to the facility on 7/9/2022 to 8/1/2022 with diagnoses that included Schizoaffective Disorder Bipolar type, and Intellectual Disabilities.

Review of the Intake Assessment dated 7/9/2022 at 20:51 revealed, " ... Pt [patient] presented at CAC [Crisis Assessment Center] due to emergency commitment for being combative and threatening other citizens. Pt advised he was feeling suicidal and homicidal ... Pt threatened to harm staff and peers at shelter ... Pt is paranoid and delusional. Pt thinks someone is outside trying to do things to him ... "

Review of the 8/1/2022 Discharge Summary revealed, " ... Upon admission, the patient was agitated. He was paranoid in his thinking. He minimized his symptoms. He reportedly had been threatening toward staff members at the shelter where he had been residing He did try to fight others. He was very anxious and agitated and paranoid upon admission ... Early in his hospitalization, his thinking was disorganized. He appeared to be responding to internal stimuli. Gradually this improved ... He was not a behavioral problem ..."

Patient #1 stated Patient #3 had attempted to touch her butt and kiss her. Patient #3 had a history of threatening others. The facility failed to conduct an investigation to ensure Patient #1 was free of abuse and in accordance with the facility policy.

Based on facility policy, medical record review and interview, the facility failed to ensure the nursing staff conducted accurate patient assessments for one of three (Patient #1) sampled patients.

The findings included:

1. Review of the facility's "SKIN ASSESSMENT" policy reviewed on "07/2022" revealed, " ... POLICY ... upon admission, an ED visit, an elopement, or where there is concern that patient has sustained an injury, or engaged in self harm activity, it may be necessary to conduct a skin assessment ... PROCEDURE ... Observe the patient for any scars, wounds, bruising or other injuries and document on the skin assessment ... Document all skin assessment findings on the skin assessment in the nursing assessment ..."

2. Medical record review for Patient #1 revealed an admission to the facility on 7/15/2022 with diagnoses that included Major Depressive Disorder with Psychotic features, Autism, Attention Deficit Hyperactivity Disorder, and Bipolar.

Review of the Medical Progress Note dated 7/25/2022 revealed, " ... superficial abrasion/bruise to R [right] hip/abdomen area ..." There was no documentation how the patient received the bruise.

Review of the Nursing Assessment dated 7/25/2022 revealed no skin issues.

Review of 21 daily Nursing Assessments dated 7/26/2022 - 8/15/2022 revealed 20 of the 21 assessments documented there were no skin issues and failed to identify the bruising.

In an interview on 8/17/2022 at 9:00 AM the Risk Manager stated Patient #1 had been checked today (8/17/2022) and currently had a bruise on her hip.