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Based on record review, staff interview, observation of the Senior Care Unit (SCU), policy review and review of Emergency Department (ED) notes from Hospital #2 and #3, the hospital failed to protect and promote Patient #1's rights by failing to protect him from sexual assualt by Patient #2 on 06/18/2011 at 3:00 p.m..

Findings include:

On 06/22/2011 the State Agency received a self reported incident from Hospital #1 regarding a possible patient on patient rape. On 06/18/2011 at 3:00 p.m. Patient #2 was observed by staff leaving Patient #1's room pulling up his pants. Staff went to Patient #1's room. The patient was in bed with his diaper and pants pulled down. Fluids were observed on the bed, on his buttocks and around his rectal area. The patient was transported to an area hospital Emergency Departyment (ED) for a rape kit. Family and police were notifed and the accused patient was placed on 1:1 care.

On 07/01/2011 at 1:00 p.m. a tour of the nine (9) bed SCU was made with the Chief Nursing Officer (CNO). The unit was a hallway which contained nine (9) beds in Rooms #101 through #110. Room #105 was serving as the dayroom and the nursing station and did not have full visual of all of the unit's rooms. There was no wall safety mirror to correct this visual concern. After the tour, the 06/18/2011 census was reviewed. The census on that day was three (3) patients. The CNO stated that three (3) was their average census, they have 12 hour shifts and the hospital staffs the nine (9) beds in SCU with a Registered Nurse (RN) and a Certified Nursing Assistant (CNA). If any patient is on 1:1 care then another CNA would be called in to work so that each patient on 1:1 care would have a CNA assigned. At the time of the 06/18/2011 3:00 p.m. incident Patient #2 was not on 1:1 care. When staff became aware of the alleged sexual assault Patient #2 was then placed on 1:1 care.

Review of Patient #1's medical record revealed he was admitted to the SCU on 06/17/2011 to Room #103. His diagnoses included Mental Retardation Not Otherwise Specified. He was discharged on 06/30/2011.

Review of Patient #2's medical record revealed he was admitted to the SCU on 06/14/2011 to Room #104. His diagnoses included Bipolar Disorder/Mental Retardation. His weaknesses were listed as a long history of mental illness, behavioral outbursts, elopement risk and history of being destructive. He was discharged on 06/22/2011.


During an interview on 07/01/2011 at 2:08 p.m. Licensed Professional Counselor/National Certified Counselor (LPC/NCC) stated that she was called in to the SCU on 06/18/2011 by RN #1 and was informed of the patient on patient incident. She stated that the RN called Doctor #1, who requested Patient #1 be sent to the ED for a sexual assault kit. The LPC/NCC stated that she called a Licensed Practical Nurse (LPN), per the CNO's order, to transport and accompany Patient #1 to the ED. The LPC/NCC stated that when she interviewed Patient #2, he stated that he was masturbating in Patient #1's room.

On 07/06/2011 at 10:45 a.m. CNA #1 stated that on 06/18/2011 at approximately 3:00 p.m. she was in the dayroom with Patient #2 and another patient when RN #1 left the unit and went to medical records to retrieve a chart. The CNA stated that she left to go get juice and ice for the patient in the dayroom and that Patient #2's door was closed partway at that time. While she was getting the ice and juice she had no visual contact with any of the patients. When she returned to the dayroom she thought it was quiet and when she checked on Patient #2 he was coming out of Patient #1's room with his pants undone and shirt untucked. She sent Patient #2 to his room and notified the RN (who had returned to the unit). They both went into Patient #1's room to check on him. When the RN assessed the patient she noted that there was liquid on the bed and on Patient #1's buttocks area.

An interview with RN #1 on 07/06/11 revealed that on 06/18/2011 the Nurse Practitioner called the unit requesting an old chart. When the RN left the unit to go to medical records for the chart the CNA was in the dayroom with Patient #2 and another patient. RN #1 stated that she was gone from the unit for five (5) to 10 minutes. When she returned the CNA was in the hallway and Patient #2 was going into his own room zipping up his pants and tucking in his shirt. The CNA told the RN that Patient #2 had just come out of Patient #1's room. They entered Patient #1's room and found him asleep lying "partway on his stomach with pants partway down and diaper off." The RN stated that when she assessed Patient #1 she observed liquid on his bed and on his buttocks and rectal area. There was no blood or fecal material noted and the patient went right back to sleep. The RN then went to Patient #2's room to assess and talk to him. He stated, "My mind made me do it." with no specific statement regarding what "it" was. The RN then called the CNO and the Program Director.

Review of Patient #1's Nurses Notes (NNs) revealed:
"6-18-2011 300pm In bed appears to be sleeping...no distress noted another patient coming out of residents room pulling up his pants and tucking shirt, when further assessment done patients pants halfway pulled down along with diaper, fluids noted on bed and around patients rectal area. This writer had to arouse patient to ask if patient was in pain or had been assualted in any way, patient mumbled something and went back to sleep. No distress noted."
NNs documented that the Director of Nurses, the patient's doctor, Social Worker and another doctor were all called. Orders were received to send Patient #1 to the Emergency Room to have them do an assualt kit (rape kit). An attempt was made to call the patient's mother with no answer.
"6/18/11 2350 (11:50 p.m.) Received patient back from (hospital)...Pt (patient) constantly making moaning sound..."
On 06/19/2011 at 2:45 p.m. the patient's mother came to the unit to visit. She was told of the 06/18/2011 incident at that time by the nurse.

Review of the unit's 06/18/2011 incident reports/papers revealed that the facility's "Patient Observation Form: 1:1 Observation" for Patient #2 did not specify what time 1:1 observation was initiated or discontinued. Review of Patient #2's record revealed that he was on 1:1 observation on 06/15, 06/16, 06/19, 06/20 and 06/21/2011. Interview with the CNO on 07/06/11 confirmed that Patient #2 was on 1:1 prior to the 06/18/11 incident but was not on 1:1 observation at the time of the 06/18/11 incident. He was placed on 1:1 observation as soon as staff learned of the incident until his discharge on 06/22/2011.

Review of Hospital #2's ED record for Patient #1 revealed that on 06/18/2011 at 17:48 (5:48 p.m.) the patient presented to the ED with a chief complaint of "Sexual Assualt" but was not examed or admitted due to no nurse being available for an exam. He was sent to another hospital.

Review of Hospital #3's ED record revealed that Patient #1 was triaged at 7:44 p.m. on 06/18/2011. A sexual assault examination was conducted by two (2) nurses with Head, Neck, Oral and Genital Examinations revealing no findings. The evidence collection kit was turned over to the Police Department by Hospital #3, and Patient #1 and the LPN left the ED and returned to Hospital #1.

Review of the SCU's Community Agreement, to be signed by all patients, revealed:
"6. I agree not to verbally, emotionally, or physically abuse another patient..."

Review of Hospital #1's Policy #2020, Recognizing And Reporting Dependent Adult/Elder Abuse/Neglect, revealed, "Policy: provides for the protection of the elderly and/or dependent adult..."

Review of Hospital #1's Policy #4.000, Clinical Standards for Patient Rights, revealed: "Patients are provided protection from abuse, neglect, and exploitation." Further review of this policy revealed that the areas of ensuring the patient has the right to receive care in a safe setting and that the patient has the right to be free from all forms of abuse or harassment was not addressed.

Based on record review, staff interview, observation of the Senior Care Unit (SCU), policy review and review of Emergency Department (ED) notes from Hospital #2 and #3, the hospital failed to ensure that Patient #1 had the right to receive care in a safe setting. On 06/18/2011 at 3:00 p.m. Patient #1 was sexually assualted by Patient #2.


Findings include:

Cross Refer to A-0115 for the hospital's failure to protect and promote Patient #1's right to receive care in a safe setting. On 06/18/2011 Patient #1 was sexually assualted by Patient #2.

Based on record review, staff interview, observation of the Senior Care Unit (SCU), policy review and review of Emergency Department (ED) notes from Hospital #2 and #3, the hospital failed to ensure that Patient #1 was free from all forms of abuse or harrassment by failing to protect him from sexual assualt by Patient #2 on 06/18/2011 at 3:00 p.m..

Findings include:

Cross Refer to A-0115 for the hospital's failure to protect and promote Patient #1's right to be free from all forms of abuse or harrassment. Patient #1 was sexually assualted by Patient #2 on 06/18/2011.

Based on record review, staff interview, observation of the Senior Care Unit (SCU) and policy review, the hospital failed to ensure a Registered Nurse (RN) was physically present in the SCU to ensure the immediate availability of a RN to respond to patient needs. On 06/18/2011 RN #1 was out of the SCU for five (5) to 10 minutes, leaving a Certified Nurses Assistant (CNA) alone with three (3) patients. The CNA left the area to obtain ice. During that time Patient #1 was sexually assualted by Patient #2.

Findings include:

Cross Refer to A-0115 for the hospital's failure to ensure a RN was physically in the SCU to respond immediately to provide patient needs. RN #1 was gone out of the SCU for five (5) to 10 minutes leaving CNA #1 alone with three (3) patients. During that time the CNA left the area to retreive ice, could not visually see the patients and Patient #1 was sexually assualted by Patient #2.

Based on record review, staff interview, observation of the Senior Care Unit (SCU), policy review and review of Emergency Department (ED) notes from Hospital #2 and #3, the hospital failed to protect and promote Patient #1's rights by failing to protect him from sexual assualt by Patient #2 on 06/18/2011 at 3:00 p.m..

Findings include:

On 06/22/2011 the State Agency received a self reported incident from Hospital #1 regarding a possible patient on patient rape. On 06/18/2011 at 3:00 p.m. Patient #2 was observed by staff leaving Patient #1's room pulling up his pants. Staff went to Patient #1's room. The patient was in bed with his diaper and pants pulled down. Fluids were observed on the bed, on his buttocks and around his rectal area. The patient was transported to an area hospital Emergency Departyment (ED) for a rape kit. Family and police were notifed and the accused patient was placed on 1:1 care.

On 07/01/2011 at 1:00 p.m. a tour of the nine (9) bed SCU was made with the Chief Nursing Officer (CNO). The unit was a hallway which contained nine (9) beds in Rooms #101 through #110. Room #105 was serving as the dayroom and the nursing station and did not have full visual of all of the unit's rooms. There was no wall safety mirror to correct this visual concern. After the tour, the 06/18/2011 census was reviewed. The census on that day was three (3) patients. The CNO stated that three (3) was their average census, they have 12 hour shifts and the hospital staffs the nine (9) beds in SCU with a Registered Nurse (RN) and a Certified Nursing Assistant (CNA). If any patient is on 1:1 care then another CNA would be called in to work so that each patient on 1:1 care would have a CNA assigned. At the time of the 06/18/2011 3:00 p.m. incident Patient #2 was not on 1:1 care. When staff became aware of the alleged sexual assault Patient #2 was then placed on 1:1 care.

Review of Patient #1's medical record revealed he was admitted to the SCU on 06/17/2011 to Room #103. His diagnoses included Mental Retardation Not Otherwise Specified. He was discharged on 06/30/2011.

Review of Patient #2's medical record revealed he was admitted to the SCU on 06/14/2011 to Room #104. His diagnoses included Bipolar Disorder/Mental Retardation. His weaknesses were listed as a long history of mental illness, behavioral outbursts, elopement risk and history of being destructive. He was discharged on 06/22/2011.


During an interview on 07/01/2011 at 2:08 p.m. Licensed Professional Counselor/National Certified Counselor (LPC/NCC) stated that she was called in to the SCU on 06/18/2011 by RN #1 and was informed of the patient on patient incident. She stated that the RN called Doctor #1, who requested Patient #1 be sent to the ED for a sexual assault kit. The LPC/NCC stated that she called a Licensed Practical Nurse (LPN), per the CNO's order, to transport and accompany Patient #1 to the ED. The LPC/NCC stated that when she interviewed Patient #2, he stated that he was masturbating in Patient #1's room.

On 07/06/2011 at 10:45 a.m. CNA #1 stated that on 06/18/2011 at approximately 3:00 p.m. she was in the dayroom with Patient #2 and another patient when RN #1 left the unit and went to medical records to retrieve a chart. The CNA stated that she left to go get juice and ice for the patient in the dayroom and that Patient #2's door was closed partway at that time. While she was getting the ice and juice she had no visual contact with any of the patients. When she returned to the dayroom she thought it was quiet and when she checked on Patient #2 he was coming out of Patient #1's room with his pants undone and shirt untucked. She sent Patient #2 to his room and notified the RN (who had returned to the unit). They both went into Patient #1's room to check on him. When the RN assessed the patient she noted that there was liquid on the bed and on Patient #1's buttocks area.

An interview with RN #1 on 07/06/11 revealed that on 06/18/2011 the Nurse Practitioner called the unit requesting an old chart. When the RN left the unit to go to medical records for the chart the CNA was in the dayroom with Patient #2 and another patient. RN #1 stated that she was gone from the unit for five (5) to 10 minutes. When she returned the CNA was in the hallway and Patient #2 was going into his own room zipping up his pants and tucking in his shirt. The CNA told the RN that Patient #2 had just come out of Patient #1's room. They entered Patient #1's room and found him asleep lying "partway on his stomach with pants partway down and diaper off." The RN stated that when she assessed Patient #1 she observed liquid on his bed and on his buttocks and rectal area. There was no blood or fecal material noted and the patient went right back to sleep. The RN then went to Patient #2's room to assess and talk to him. He stated, "My mind made me do it." with no specific statement regarding what "it" was. The RN then called the CNO and the Program Director.

Review of Patient #1's Nurses Notes (NNs) revealed:
"6-18-2011 300pm In bed appears to be sleeping...no distress noted another patient coming out of residents room pulling up his pants and tucking shirt, when further assessment done patients pants halfway pulled down along with diaper, fluids noted on bed and around patients rectal area. This writer had to arouse patient to ask if patient was in pain or had been assualted in any way, patient mumbled something and went back to sleep. No distress noted."
NNs documented that the Director of Nurses, the patient's doctor, Social Worker and another doctor were all called. Orders were received to send Patient #1 to the Emergency Room to have them do an assualt kit (rape kit). An attempt was made to call the patient's mother with no answer.
"6/18/11 2350 (11:50 p.m.) Received patient back from (hospital)...Pt (patient) constantly making moaning sound..."
On 06/19/2011 at 2:45 p.m. the patient's mother came to the unit to visit. She was told of the 06/18/2011 incident at that time by the nurse.

Review of the unit's 06/18/2011 incident reports/papers revealed that the facility's "Patient Observation Form: 1:1 Observation" for Patient #2 did not specify what time 1:1 observation was initiated or discontinued. Review of Patient #2's record revealed that he was on 1:1 observation on 06/15, 06/16, 06/19, 06/20 and 06/21/2011. Interview with the CNO on 07/06/11 confirmed that Patient #2 was on 1:1 prior to the 06/18/11 incident but was not on 1:1 observation at the time of the 06/18/11 incident. He was placed on 1:1 observation as soon as staff learned of the incident until his discharge on 06/22/2011.

Review of Hospital #2's ED record for Patient #1 revealed that on 06/18/2011 at 17:48 (5:48 p.m.) the patient presented to the ED with a chief complaint of "Sexual Assualt" but was not examed or admitted due to no nurse being available for an exam. He was sent to another hospital.

Review of Hospital #3's ED record revealed that Patient #1 was triaged at 7:44 p.m. on 06/18/2011. A sexual assault examination was conducted by two (2) nurses with Head, Neck, Oral and Genital Examinations revealing no findings. The evidence collection kit was turned over to the Police Department by Hospital #3, and Patient #1 and the LPN left the ED and returned to Hospital #1.

Review of the SCU's Community Agreement, to be signed by all patients, revealed:
"6. I agree not to verbally, emotionally, or physically abuse another patient..."

Review of Hospital #1's Policy #2020, Recognizing And Reporting Dependent Adult/Elder Abuse/Neglect, revealed, "Policy: provides for the protection of the elderly and/or dependent adult..."

Review of Hospital #1's Policy #4.000, Clinical Standards for Patient Rights, revealed: "Patients are provided protection from abuse, neglect, and exploitation." Further review of this policy revealed that the areas of ensuring the patient has the right to receive care in a safe setting and that the patient has the right to be free from all forms of abuse or harassment was not addressed.

Based on record review, staff interview, observation of the Senior Care Unit (SCU), policy review and review of Emergency Department (ED) notes from Hospital #2 and #3, the hospital failed to ensure that Patient #1 had the right to receive care in a safe setting. On 06/18/2011 at 3:00 p.m. Patient #1 was sexually assualted by Patient #2.


Findings include:

Cross Refer to A-0115 for the hospital's failure to protect and promote Patient #1's right to receive care in a safe setting. On 06/18/2011 Patient #1 was sexually assualted by Patient #2.

Based on record review, staff interview, observation of the Senior Care Unit (SCU), policy review and review of Emergency Department (ED) notes from Hospital #2 and #3, the hospital failed to ensure that Patient #1 was free from all forms of abuse or harrassment by failing to protect him from sexual assualt by Patient #2 on 06/18/2011 at 3:00 p.m..

Findings include:

Cross Refer to A-0115 for the hospital's failure to protect and promote Patient #1's right to be free from all forms of abuse or harrassment. Patient #1 was sexually assualted by Patient #2 on 06/18/2011.

Based on record review, staff interview, observation of the Senior Care Unit (SCU) and policy review, the hospital failed to ensure a Registered Nurse (RN) was physically present in the SCU to ensure the immediate availability of a RN to respond to patient needs. On 06/18/2011 RN #1 was out of the SCU for five (5) to 10 minutes, leaving a Certified Nurses Assistant (CNA) alone with three (3) patients. The CNA left the area to obtain ice. During that time Patient #1 was sexually assualted by Patient #2.

Findings include:

Cross Refer to A-0115 for the hospital's failure to ensure a RN was physically in the SCU to respond immediately to provide patient needs. RN #1 was gone out of the SCU for five (5) to 10 minutes leaving CNA #1 alone with three (3) patients. During that time the CNA left the area to retreive ice, could not visually see the patients and Patient #1 was sexually assualted by Patient #2.