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Based on record review and staff interviews, it has been determined that the hospital failed to meet the Condition of Participation of Patient Rights for Patient ID #s 1 and 2, who were both patients on the "D-Pod" Unit.

Findings are as follows:

1. The hospital failed to ensure Patient ID #1's safety in an environment that a reasonable person would consider to be safe, (refer to A 144).

2. The hospital failed to ensure a patient's right to be free from all forms of abuse for Patient ID #1 who was sexually assaulted while in the D-Pod Unit of the Emergency Department, (refer to A 145).

Based on record review and staff interviews, it has been determined that the hospital failed to ensure Patient ID # 1's safety in an environment that a reasonable person would consider to be safe resulting in this patient being sexually assaulted while in the emergency department.

Findings are as follows:

On 12/5/2022, the Rhode Island Department of Health received reports which indicated that Patient ID # 1 alleged she/he was sexually assaulted by Patient ID # 2 on 12/2/2022 while in the D-Pod Unit of the Emergency Room at this hospital.

Record review for Patient ID # 1, who is 24 years old, revealed that she/he presented to the Emergency Department of this hospital in December of 2022 to be evaluated for mania. His/her past medical history includes, but is not limited to, bipolar 1 disorder with severe mania and anxiety disorder.

While in the Emergency Department, Patient ID # 1 was described as "tangential" (speech wandering) and was "talking to the wall." Ambulance staff who brought Patient ID # 1 to the Emergency Department reported to medical staff that Patient ID # 1 was "manic with flight of ideas and delusional thoughts."

Record review for Patient ID # 2, who is 44 years old, revealed that she/he presented to the Emergency Department of this hospital in December of 2022 with altered metal status and aggressive behavior. His/her past medical history includes, but is not limited to, mood disorder, psychosis, and alcohol use.

Record review for Patient ID # 2 revealed a document titled, "Initial Evaluation ..." dated 12/2/2022 at 12:46 PM stated in part that due to a language barrier, an interpreter was required to communicate with Patient ID # 2. The note further states, " ...During the evaluation the Pt [patient] reached out to shake the interpreter's hand and while doing so made a sexual gesture to the palm of her hand. After the evaluation the patient was found to be wandering into other patient's rooms ..."

Record review for Patient ID # 1 revealed an "ED Provider Note" completed by Employee A, Physician Assistant, dated 12/2/2022 at 2:30 PM states in part that Patient ID # 1 alleged she/he was sexually assaulted "by another behavioral health patient." The note states that "Security did not witness the event" but walked into Patient ID # 1 having his/her "pants down by [his/her] feet and another ...patient penetrating [him/her] with [his/her] right hand." Employee A further states that she spoke to Patient ID #1 who reported that Patient ID # 2 "came into the room and pulled [his/her] pants down then began rubbing [his/her] [external genitalia] with [his/her] right index and middle finger for about a minute." Additionally, Employee A's note indicates that Patient ID # 1's story was consistent with what she/he reported to other employees in D-Pod.

During a surveyor interview on 12/7/2022 at 9:15 AM with Employee B, Registered Nurse, she revealed that on 12/2/2022 at approximately 1:40 PM, a female security guard came into the nurse's station and informed her and the Assistant Clinical Manager, that Patient ID # 2 walked into Patient ID # 1's room but was redirected back to his/her room and no physical contact occurred between both patients. She revealed that shortly after, while distributing lunch trays, she overheard two security guards discussing that Patient ID # 2 had pulled Patient ID # 1's pants down and touched his/her genitalia. She stated that she was "shocked and confused" because she was told that that no physical contact had occurred between both patients. She revealed that she then brought Patient ID # 1's lunch tray to him/her at which point Patient ID # 1 asked her, "Does this usually happen here?" and then revealed that a patient came into his/her room, pulled his/her pants down and started "Fingering" him/her.

During a surveyor interview on 12/7/2022 at 11:30 AM with Employee A, she revealed that she was informed that Patient ID #2 had gone into Patient ID # 1's room and sexually assaulted him/her. She revealed that when she asked Patient ID # 1 what happened, she/he said that Patient ID # 2 "walked" past security, pulled down his/her pants, and stated touching his/her external genitalia. Employee A then revealed she met with Patient ID # 2 and asked him/her what happened with Patient ID # 1, to which she/he held his/her hands in the air as if to say, "I don't know." She revealed that she asked Patient ID # 2 which hand she/he used to touch Patient ID # 1 and she/he told her she/he used his/her right hand. Additionally, Employee A, revealed that Patient ID # 2 indicated she/he used his/her right second and third fingers to touch Patient ID # 1's external genitalia.

During a surveyor interview on 12/6/2022 at 1:38 PM with Employee C, Security Guard, he indicated he was present in D-Pod on 12/2/2022 when Patient ID # 2 entered Patient ID # 1's room. Employee D revealed that Patient ID # 2 was outside of his/her room after speaking to a physician and an interpreter and was "flapping his hands like a bird" when she/he suddenly "ran" into the room where Patient ID # 1 was located. Employee D stated he went after Patient ID # 2 as he was "standing inches away from [him/her]" and observed Patient ID # 2 grab Patient ID # 1's legs while she/he was laying down on a stretcher and pulled his/her blue scrub pants down. Employee D indicated he saw Patient ID # 2's hands in Patient ID # 1's groin area and revealed Patient ID # 1 did not have underwear. Employee D stated he saw Patient ID # 2 "reaching out" towards Patient ID # 1's groin but is "not sure if [she/he] touched [him/her]" as he was behind Patient ID # 2 attempting to pull him/her away from Patient ID # 1 by grabbing Patient ID # 2's hands.

During a surveyor interview on 12/7/2022 at 9:58 AM with Employee D, Physician, he described what occurred on 12/2/2022 between Patient ID # 1 and # 2 as a "chaotic incident" and indicated that Patient ID # 2 should not have been able to be in the same room with Patient ID # 1. He stated that there was "some kind of breakdown in security" since patients are not allowed to be out of their rooms while in D-Pod.

During a surveyor interview on 12/6/2022 at 11:30 AM with Employee E, Manager of Security, he indicated that while security guards are posted in D-Pod, they are expected to continuously visualize the patients.

Based on record review and staff interview, it has been determined that the hospital failed to ensure patients are free from all forms of abuse for a patient who was sexually assaulted while in the D-Pod lounge in the Emergency Department, Patient ID #1.

Findings are as follows:

On 12/5/2022, the Rhode Island Department of Health received reports which indicated that Patient ID #1 alleged she/he was sexually assaulted by Patient ID #2 on 12/2/2022 while in the D-Pod Unit of the Emergency Room at this hospital.

Record review for Patient ID #1, who is 24 years old, revealed that she/he presented to the Emergency Department of this hospital in December of 2022 to be evaluated for mania. His/her past medical history includes, but is not limited to, bipolar 1 disorder with severe mania and anxiety disorder.

While in the Emergency Department, Patient ID #1 was described as "tangential" (speech wandering) and was "talking to the wall." Ambulance staff who brought Patient ID #1 to the Emergency Department reported to medical staff that Patient ID #1 was "manic with flight of ideas and delusional thoughts."

Record review for Patient ID #2, who is 44 years old, revealed that she/he presented to the Emergency Department of this hospital in December of 2022 with altered metal status and aggressive behavior. His/her past medical history includes, but is not limited to, mood disorder, psychosis, and mild alcohol use.

Record review for Patient ID #2 revealed a document titled, "Initial Evaluation ..." dated 12/2/2022 at 12:46 PM stated in part that due to a language barrier, an interpreter was required to communicate with Patient ID #2. The note further states, " ...During the evaluation the Pt [patient] reached out to shake the interpreter's hand and while doing so made a sexual gesture to the palm of her hand. After the evaluation the patient was found to be wandering into other patient's rooms ..."

Record review for Patient ID #1 revealed an "ED Provider Note" completed by Employee A, Physician Assistant, dated 12/2/2022 at 2:30 PM states in part that Patient ID #1 alleged she/he was sexually assaulted "by another behavioral health patient." The note states that "Security did not witness the event" but walked into Patient ID #1 having his/her "pants down by [his/her] feet and another ...patient penetrating [him/her] with [his/her] right hand." Employee A further states that she spoke to Patient ID #1 who reported that Patient ID #2 "came into the room and pulled [his/her] pants down then began rubbing [his/her] [genitalia] with [his/her] right index and middle finger for about a minute." Additionally, Employee A's note indicates that Patient ID #1's story was consistent with what she/he reported to other employees in D-Pod.

During a surveyor interview on 12/7/2022 at 9:15 AM with Employee B, Registered Nurse, she revealed that on 12/2/2022 at approximately 1:40 PM, a female security guard came into the nurse's station and informed her and the Assistant Clinical Manager, that Patient ID #2 walked into Patient ID #1's room but was redirected back to his/her room and no physical contact occurred between both patients. She revealed that shortly after, while distributing lunch trays, she overheard two security guards discussing that Patient ID #2 had pulled Patient ID #1's pants down and touched his/her genitalia. She stated that she was "shocked and confused" because she was told that that no physical contact had occurred between both patients. She revealed that she then brought Patient ID #1's lunch tray to him/her at which point Patient ID #1 asked her, "Does this usually happen here?" and then revealed that a patient came into his/her room, pulled his/her pants down and started "Fingering" him/her.

During a surveyor interview on 12/7/2022 at 11:30 AM with Employee A, she revealed that she was informed that Patient ID #2 had gone into Patient ID #1's room and sexually assaulted him/her. She revealed that when she asked Patient ID #1 what happened, she/he said that Patient ID #2 walked past security, pulled down his/her pants, and stated touching his/her genitalia. Employee A then revealed she met with Patient ID #2 and asked him/her what happened with Patient ID #1, to which she/he held his/her hands in the air as if to say, "I don't know." She revealed that she asked Patient ID #2 which hand she/he used to touch Patient ID #1 and she/he told her she/he used his/her right hand. Additionally, Employee A, revealed that Patient ID #2 indicated she/he used his/her right second and third fingers to touch Patient ID #1's genitalia.

During a surveyor interview on 12/7/2022 at 9:58 AM with Employee D, Physician, he described what occurred on 12/2/2022 between Patient ID #1 and #2 as a "chaotic incident" and indicated that Patient ID #2 should not have been able to be in the same room with Patient ID #1. He stated that there was "some kind of breakdown in security" since patients are not allowed to be out of their rooms while in D-Pod.