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Based on review of facility policy, medical record review, review of facility documentation, review of video recordings, and interviews, the facility failed to ensure patients were monitored to provide a safe environment for 1 patient (Patient #1) of 5 patients reviewed after Patient #2 entered Patient #1's room without staff's knowledge and Patient #1 alleged she was sexually assaulted by Patient #2.

The findings included:

Patient #1 was admitted to the facility on 9/22/2022 with Unspecified Depressive Disorder and Post Traumatic Stress Syndrome. Patient #2 was admitted on 9/30/2022 with Major Depressive Disorder and Suicidal Ideations. On 10/6/2022, Patient #1 informed facility staff of an alleged sexual assault which allegedly occurred on 10/5/2022 where Patient #2 entered her room and sexually assaulted her. Patient #1 had physician orders for constant observation and at the time of the alleged incident, the facility failed to ensure she was monitored by the unit staff. The patients' rooms were located on the same hallway. Video review showed Patient #2 entered Patient #1's room on 10/5/2022 at 6:14 AM and exited the room at 6:29 AM and there were no staff on the hallway to monitor the patients. There was a closed door which was secured with a bolt and obscured the direct observation of the patients on the unit hallway.

During a conference with the Vice President of Behavioral Health and the Quality Manager on 11/2/2022 at 11:33 AM, the facility was informed of an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation, has caused, or is likely to cause injury, harm, impairment, or death) at 42 CFR PART 482.13, Conditions of Participation, Patient Rights.

During a conference with the Vice President of Behavioral Health Administrator, the Quality Manger, and the Unit Manager on 11/2/2022 at 12:00 PM, the facility presented an acceptable Removal Plan which showed the following immediate actions were implemented:

1. The allegation was made on 10/6/2022 at 2:15 PM. The House Supervisor was notified at 2:30 PM of the allegation.
a. The patients were immediately separated on the unit while statements were obtained from the alleged victim (AV) Patient #1, the alleged preparator (AP) Patient #2, and the unit staff.
b. The AP was placed on 1:1 status immediately and transferred to the Men's acute unit on 10/6/2022 by 4:30 PM to ensure safety of the AV and all patients. The Vice President of Behavioral Health and senior leadership made this decision per facility policy
c. Observation during the investigation showed the AP was on the Child Adolescent Unit (CAU) in the day room with a 1:1 sitter in direct observation of the patient. On 11/2/2022 at 4:25 PM, the AP had been discharged.

2. The bolt on the door which prevented unit staff from complete observation of the unit was removed by the facility supervisor on 10/7/2022 ensuring the door could be opened to allow unblocked visibility of the unit hallway.
a. Observation showed the door was functionable and was able to be opened to allow staff direct visualization of the entire unit.

3. The male and female patients (on the entire unit) were separated in the day room on 10/7/2022 by 10:00 AM.
a. Observation on 11/2/2022 at 4:25 PM showed male and female patients were separated in the day room on different sides of the unit.

4. Prior to patients returning to their rooms, the bedrooms of male and female patients were separated to opposite ends of the hallway on 10/7/2022 by 3:00 PM.
a. Observation on 11/2/2202 at 4:30 PM showed there were no patients in the rooms. Observation showed the unit was separated with the female and male rooms in different areas on the unit.

5. On 10/7/2022 at 4:00 PM Registered Nurses (RN) and House Supervisors were educated by the AOC (Administrator on Call) and started hourly rounding to ensure staff was maintaining patient observations.
a. The AOC followed up with the RN's and House Supervisors 4 times (x) per shift on the dayshift and 3 times per shift on the night shift beginning 10/7/2022-10/13/2022 to ensure staff was maintaining patient observations.
b. The House Supervisors and Children and Adolescent Unit RN's will complete hourly rounding of all patients on Constant Observation (CO) and 1:1 monitoring to ensure staff was completing observations as ordered, white board indicating correct level of observation, placement in camera room, and utilization of CO scrub top. All house supervisors and RN's will receive 1:1 education on rounding tool and rounding expectations.
c. On 10/13/2022 a rounding tool was implemented for the House Supervisors and Unit RN's to utilize for the hourly rounding.
d. Observation on 11/2/2022 showed the rounding tool was in place and was completed hourly by the staff.
e. Monitoring: 100% of hourly rounding will be monitored for completion for 30 continuous days by the Unit Manager.
f. The results will be reported by the Unit Manager to Facility Leadership every 2 weeks and to the Vice President who will report to Senior Leadership Team monthly.
g. Review of the rounding tool showed documentation the hourly rounding was completed and was currently in process.
h. Observation on 11/2/2022 at 4:15 PM on the Child Adolescent Unit showed all patients were in day room with staff present. There were 2 constant observation patients in the day room and the staff were monitoring the patients.

6. From 10/10/2022 to 10/14/2022 100% of shift reports were observed by the Unit Manager to ensure observation status was correctly communicated on all patients on the Child and Adolescent Unit and all Program Counselors (PC) assigned to the Child Adolescent Unit were present during the shift report.
a. Interviews on 11/2/2022 at 4:20 PM with PC #1 and RN #1 showed the staff understood the hourly rounding and they attended the morning shift report to obtain information regarding constant observation and 1:1 patients including their location and any specific behaviors or needs.

7. On 10/7/2022 at 4:30 PM markings were placed on the floor indicating staff placement for patient observations while the patients are in the bedrooms.
a. Education was provided by the AOC to the RN's, PC's and House Supervisors during the shifts to ensure the staff were strategically located on the unit for continuous observation.
b. The AOC followed up with the RN's and House Supervisors 4 times per shift on the day shift and 3 times per shift on night shift.
c. The VP of Behavioral Health and the AOC discussed status of rounding 2 times daily from 10/7/2022-10/13/2022.
d. Observation on 11/2/2022 at 4:15 PM on the Child Adolescent Unit showed the 'X markings' were on the floor which allowed for observation of the unit.

8. Unit Managers, Assistant Managers, and Department supervisors provided 1:1 education to all staff with direct contact patient care on maintaining patient safety, patient observations, and monitoring.
a. This education was started on 10/10/2022 with a completion date 10/14/2022 for 100% of the staff.
b. The staff were required to sign an attestation form upon completion of the education.
c. 0n 10/17/2022 138 of 141 staff (98%) had completed the training. The 3 additional staff members were PRN (as needed) employees who had not worked on the unit. On 10/18/2022, the 3 employees had completed the training (100%).
d. On 11/2/2022 the attestation forms were reviewed and confirmed 100% of the staff had completed the training by 10/18/2022.
e. Interviews on 11/2/2022 at 4:20 PM with PC #1 and RN #1 showed the staff understood the hourly rounding and they attended the morning shift report to obtain information regarding constant observation and 1:1 patients including their location and any specific behaviors or needs. They had completed the training and signed the attestation form.
f. Monitoring: The Quality Manager will report to facility Nursing Leadership then report to the VP of Behavioral Health, and then reported to the Senior Leadership Team.

During a conference on 11/2/2022 at 4:45 PM with the Vice President of Behavioral Health, the Quality Manager, and the Nurse Manger, the Removal Plan was reviewed, interviews were completed with facility staff and observations were completed which showed the facility's Removal Plan was acceptable. Based on review of the Removal Plan, the Immediate Jeopardy was removed effective 10/19/2022. The facility remains out of compliance at 42 CFR PART 482.13, Conditions of Participation, Patient Rights (Condition).

Refer to A-0144

Based on review of facility policy, medical record review, review of facility documentation, review of video recordings and interviews, the facility failed to ensure patients were monitored to provide a safe environment for one patient (Patient #1) of 5 patients reviewed when Patient #2 entered Patient #1's room without staff's knowledge and Patient #1 alleged she was sexually assaulted by Patient #2.

The findings included:

Review of facility policy, Patient Monitoring and Safety Measures, last revised 3/2022, showed "...it is policy...to provide a sufficient degree of patient monitoring to maintain a safe and therapeutic patient care environment for patients...one to one [1:1] monitoring means one observer to one patient, in close proximity with no physical barriers in the same room/area...constant observation means one observer within line of sight to one or more patients in the same room/area. This may also be accomplished via closed circuit monitoring during specific hours in designated areas...Routine Observation: every [q] 15 minute checks...[a] routine observation checks are usually completed by the Program Counselors assigned to the care of specific patients but may be completed by any staff member; [b] all patients are to be evaluated by staff at least every 15 minutes; [d] during the routine observation checks the Program Counselor will observe each patient for the following: physical safety, emotional status and interpersonal interaction with the other patients...patients on constant observation will wear specific colored scrub shirts to promote identification and awareness..."

Medical record review showed Patient #1 was admitted the facility on 9/22/2022 at 10:22 PM with diagnoses including Unspecified Depressive Disorder and Posttraumatic Stress Disorder (PTSD). She was discharged on 10/6/2022.

Medical record review of an Admission History and Physical (H&P) dated 9/23/2022 at 10:52 AM showed Patient #1 had been at school and had eloped into the woods with a male and was caught by authorities. She then expressed thoughts of "killing herself" which was reported as a "natural response by the patient when she got in trouble". Previous history showed Patient #1 had reported abuse by her father and PTSD with traumatic history. She had "...sexual compulsions that she needs to work on that makes her make bad decisions..."

Medical record review showed Patient #2 was admitted to the facility on 9/30/2022 at 12:17 PM with diagnoses including Major Depressive Disorder, Suicidal Ideations, and Panic Disorder.

Medical record review of a Behavioral Health Progress Note for Patient #1 dated 10/4/2022 at 11:53 AM showed "...reports more irritable she is not contracting for safety, she is acting very gamey she discussed with her therapist she wants to be on continuous observation because she will not contract for safety or self [safety] of others in case I erupt..."

Medical record review of a Behavioral Therapist Progress Note for Patient #1 dated 10/6/2022 at 2:47 PM showed "...pt. told therapist that another pt. [patient] came into her room after he got his blood drawn [approximately 5:00-6:00 AM] about 2-3 days ago and allegedly sexually assaulted her. The pt. states that she did not want to have sexual contact with the male pt. but states she was too scared to say no. Pt. states she felt that she had to comply. A nurse told the therapist that she spoke to the male pt. and the male pt. admitted to going into the pt.'s room. The male pt. states that he was only in her room for a minute. The therapist observed the pt. become tearful after this conversation with the nurse..."

Medical record review of a Nurses Note dated 10/6/2022 at 4:01 PM showed "...it was brought to my attention at approximately 2:15 PM by one of my techs [technicians] that pt. [Patient #1] confided in her that she had been sexually assaulted by another male pt. Said nurse interviewed pt. alone, pt. reported to nurse that 1 night ago, male pt. [identified as Patient #2] entered her room during the night and forced himself onto her and had sex with her against her will. Pt. was very anxious, tearful, and clearly upset. She stated she was scared to tell anyone...House Supervisor then notified by phone at 2:30 PM. Counselor notified. House Supervisor and counselor with said nurse talked with each individual in a conference room...when we talked to the male pt. [Patient #2] he then changed his story after we told him cameras were being reviewed saying he went into her room only to talk because he was feeling down for about 10 minutes..."

Medical record review of a Nurses Note for Patient #2 dated 10/6/2022 at 4:32 PM showed "...it was brought to my attention at approx. [approximately] 2:15 PM by one of my techs that pt. [Patient #1] confided in her that she had been sexually assaulted by another male pt. Said nurse interviewed pt. alone, pt. reported to nurse that 1 night ago, male pt. [identified as Patient #2] entered her room during the night and forced himself onto her and had sex with her against her will...nurse interviewed the male pt. [Patient #2] alone, he stated that he never entered her room but just stood in her doorway to talk. House Supervisor then notified by phone at 2:30 PM...when we talked to the male pt. [Patient #2] he then changed his story after we told him cameras were being reviewed saying he went into her room only to talk because he was feeling down for about 10 minutes..."

Medical record review of a Nurses Note for Patient #2 dated 10/6/2022 at 6:39 PM showed "...met pt. in chalk room with unit nurse and therapist to interview him about the sexual assault allegation. [Patient #2 stated] It was early morning and I could not sleep. I was feeling down and was wanting to hurt himself. So I went to talk to [Patient #1]. I walked in the room and shut the door. I was in there for 5, maybe 10 minutes, and she helped me with breathing exercises. Staff were further down in the hall talking amongst themselves. I acknowledge that I should have talked to staff..."

Review of facility documentation related to the sexual allegation showed the incident occurred on 10/5/2022 where Patient #1 alleged Patient #2 forced himself upon the patient and engaged in "sex with her against her will". The facility's camera footage showed evidence of Patient #2 entering Patient #1's room at 6:19 AM on 10/5/2022 and was seen exiting the room at 6:29 AM. There was no video surveillance in the patient rooms to substantiate Patient #1's allegation of sexual abuse, however the video review did substantiate the male patient did enter the female patient's room. The facility concluded the patients were left unmonitored for a period of time and the facility failed to monitor the patients who were vulnerable and were admitted to the facility for psychiatric treatment.

Review of facility camera video footage on the Child Adolescent Unit for 10/5/2022 showed the following:
6:14 AM: the house supervisor and 1 Registered Nurse (RN) walked down the hallway on the unit. There was no additional staff observed on the unit.
6:18 AM (14 seconds): Patient #2 was in room #30. He walked to the edge of doorway and looked out the door. There were no staff on the hallway.
6:18 AM (32 seconds): Patient #2 exited room #30 and positioned himself against the wall where he was not visible down the hallway and walked down the hallway.
6:19 AM (8 seconds): Patient #2 entered room #35 which was Patient #1's room.
6:29 AM (52 second): Patient #2 exited room #35 into the hallway and walked down the hall toward the nurses station and linen cart.

Another camera view:
6:24 AM: there was a sitter positioned in the hallway which was behind a locked door. She was sitting in a recliner chair with a blanket applied over her lower extremities. The sitter did not have direct visualization of the hallway where rooms #30 and #35 were located. She could not have seen Patient #2 exiting room #30 and entering room #35.

During an interview on 10/13/2022 at 11:45 AM, the Vice President (VP) of Behavioral Health and Quality Management stated Patient #1 had made the allegation of sexual abuse by a male peer, Patient #2, which occurred early in the morning on 10/5/2022. The facility's video review showed Patient #2 entered Patient #1's room on 10/5/2022 at 6:19 AM and exited the room at 6:29 AM but there was no additional confirmation to substantiate the allegation of sexual assault.

During a telephone interview on 10/13/2022 at 2:30 PM, Therapist #1 stated Patient #1 stated a male patient came into her room and had sex with her which she did not want. The male patient (Patient #2) stated he did not have sex with her and he went to her room to talk to her.

During a telephone interview on 10/13/2022 at 2:50 PM, RN #1 stated she had spoken with Patient #1 who stated she had sex with Patient #2 and she did not want to. Patient #2 denied having sex with the patient but he did admit he went into Patient #1's room.

During an interview on 10/17/2022 at 9:45 AM, the Vice President of Behavioral Services and the Quality Manager confirmed the following:
1. There was a physical barrier in the hallway which obscured the visibility of the unit staff in ensuring all patients were continuously monitored. The secured door was unable to stay open which caused a barrier for visibility. Patient #1 or Patient #2 could not be constantly monitored or observed.
2. The unit staff, including the RN and Program Counselor's (PC's), were not in strategic placement to provide continuous monitoring for the patients, which left an opportunity for the male patient to enter the female's patient room without the unit staff being aware of the situation.
3. The daily staffing sheets were not accurately and fully documented to ensure the unit staff was aware of specific monitoring per facility policy.
4. The female patient had orders for constant monitoring which did not occur on 10/5/2022. There was moving of patients on the unit on 10/5/2022 which caused confusion as to which patients should be continuously monitored or had a 1:1 sitter.

During a telephone interview on 10/17/2022 at 11:45 AM, RN #2 stated during the night shift on 10/4/2022, the unit was very busy because multiple patients had acute behaviors. Other patients had reported they had seen Patient #1 hugging and kissing other male patients and the decision was made to move Patient #1 to another room which was on the same hallway as Patient #2. She had not noticed Patient #1 was to be on constant observation. The double door which separated the hallway was latched and the staff were unable to get the screw out to release the door, so the staff were unable to open the door to enable direct visualization of the entire hallway. She stated "...I had told the PC's [Program Counselors] to remain in the hallway at all times, related to the behaviors...I thought the PCs were on the unit and could monitor those patients. I had no idea of the alleged incident until I came back to work a few nights after. I was told that [Patient #1] had alleged [Patient #2] had went into her room and allegedly had sex with her..."

During a telephone interview on 10/17/2022 at 11:55 AM, PC #1, stated "...we had to move multiple patients that night related to behaviors and conflicts. We were not sure if [Patient #1] was on constant observation as the order was not clear, and we could not see the report log. Around 6:12 AM-6:13 AM, I went off the unit to talk to [unit RN] about the night to give her a report on the patients so I was off the unit..."