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Based on observation, interview, and document review, the hospital failed to ensure a patient's right to receive care in a safe setting, for 1 of 15 patients reviewed (P1), when the hospital failed to thoroughly investigate a discharged patient's allegation of sexual assault by another inpatient during hospitalization on the adolescent psychiatric unit.

Findings include:

Observations on the adolescent behavioral health unit on 08/15/16 at 10:10 a.m. established that the unit has the capacity to serve 16 patients and includes two private rooms and seven semi-private rooms. All patient rooms have private bathrooms which include a shower and a toilet. Bathroom doors do not lock. The two private patient rooms are dedicated to patients with high risk behaviors, such as aggression, suicide risk, or sexual inappropriateness. The frequency of observation checks by staff is based on patient acuity levels. The minimum observation check is every 15 minutes, including during the night.

Medical record review indicated that P2 was admitted to the adolescent behavioral health unit on 07/21/16 after attempting to run away from home and making suicidal statements. On admission, P2 exhibited defiant behavior and depression but P2 was not actively suicidal nor did P2 have a suicide plan. P2 was placed in a semi-private room. P2 had no history of inappropriate sexual behavior or aggressive behavior toward others. P2 was on 15-minute observation checks by staff, including during the night. P2 willingly participated in the unit's programs and activities without any problems. P2 showed kindness toward peers on the unit and had no difficulties with other patients on the unit. P2 was discharged to home on 07/26/16.

Medical record review indicated that P1 was admitted to the adolescent behavioral health unit on 7/24/2016 after an argument with his parents when he threatened suicide. On admission, P1 exhibited rebellious behavior and had a learning deficit but P1 was not actively suicidal nor did P1 have a suicide plan. P1 was admitted into a semi-private room, where P2 was already assigned. P1 was on 15-minute observations checks by staff, including during the night. P1 and P2 were room mates from 07/24/16 - 07/26/16. P1 willingly participated in the unit's programs and activities without any problems and showed no fear of P2 during group or individual therapies. There was no evidence that P1 expressed any concerns about P2 from 07/24/16 - 07/26/16 nor were there any staff observations of difficulties between the two patients. After P2 was discharged on 07/26/16, P1 remained hospitalized on the adolescent unit for an additional two days through 07/28/16. During that time from 07/26/16 to 07/28/16, P1 did not express any concerns about P2's behavior or allege that P2 had sexually assaulted him. P1 was discharged to home on 07/28/16. A patient safety event report, dated 08/02/16, indicated that RN/D received a telephone call from a youth camp. The youth camp caller reported that P1 was at camp and had reported to camp staff that he was sexually assaulted by P2 while hospitalized on the adolescent behavioral health unit from 07/24/2016 - 07/28/2016. P1 told camp staff that he was exposed to verbal threats and inappropriate sexual touching of his genitals by P2 which had occurred once when P1 was in bed and a second time when P1 was in the shower. The investigation section of the patient safety event report contained no information. The outcome/resolution section of the patient safety event report indicated that there was no validity to P1's allegation.
An interview was conducted with RN/D on 08/15/16 at 3:00 p.m. RN/D stated that after P1 was discharged from the hospital, she received a telephone call on 08/02/16 pertaining to an allegation that P1 was sexually assaulted by another patient during P1's inpatient stay from 07/24/16 - 07/28/16. RN/D contacted Risk Management about the phone call, who advised RN/D to complete a patient safety event report and forward it to Risk Management for investigation. RN/D completed the patient safety event report immediately on 08/02/16 and sent it to Risk Management. RN/D did not investigate the matter. Risk Management stated it was their role to complete the investigation.

An interview was conducted with Risk Manager (RM)/B on 08/16/16 at 10:00 a.m. RM/B stated it was her role was to oversee the process for patient safety events, including the coordination of disciplines necessary to review the event and ensure that follow-up measures maximized patient safety. RM/B stated it is her responsibility to ensure that all patient safety events are investigated thoroughly, completely, and timely. RM/B received a patient safety event report on 08/02/16 regarding P1's allegation that he was sexually assaulted by another inpatient during hospitalization. RM/B stated she delegated the investigation pertaining to P1 to the adolescent behavioral health unit, which was contrary to what RN/D stated. RM/B acknowledged that the patient safety event report regarding P1's allegation was incomplete and that the Risk Management Department did not investigate P1's allegation in accordance with established hospital procedures that are designed to protect the safety and well-being of patients on the adolescent behavioral health unit.

The policy titled Patient/Visitor Safety Event Reporting dated March 13, 2014, indicated "these will be investigated promptly with timely resolution and patient follow-up to ensure the patient is safe. Patient relations/risk management will coordinate investigation and resolution process collaboratively with the quality department as indicated. Patient relations/risk management will communicate outcome and resolution to key stake holders and will monitor events to identify potentially recurring problems that might affect the quality of patient care. Data is analyzed, trended and reported in aggregate to key stakeholders quarterly."