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Based on record reviews and interviews, the hospital failed to follow its policy and procedure for resolving a patient's grievance. The hospital failed to investigate and report to DHH (Department of Health and Hospitals) a patient's allegation of sexual molestation and sexual assault for 1 of 1 patient's record reviewed for abuse or neglect from a total of 10 sampled patients (#6). There was a potential for the 23 inpatients on Building 6 to be victims of sexual molestation or assault with no investigation being conducted by administration. Findings:

Review of the hospital's policy titled "Complaints/Grievances Resolution Patient Advocate Function: Rights", revised 01/10 and presented by administration as the current policy for the grievance process, revealed the following:
1) Patients can file a complaint through the Patient Advocate, the Nurse Manager, or the Nursing Supervisor.
2) If the issue can't be resolved at the unit level, an objective patient advocate who is not directly responsible for the day-to-day care of the patient would represent the patient or family.
3) Complaints or grievances that endanger the patient, such as neglect or abuse, will be reviewed immediately upon receipt by the Patient Advocate, Director of Nursing, or Nursing Supervisor. During off shifts or weekends, the Nursing Supervisor will communicate with the Administrator On Call, Risk Manager, and Chief Executive Officer to resolve any immediate potential for harm.
4) All complaints of abuse or neglect will be considered a grievance.
5) When a report of sexual or physical abuse or neglect is received, the chief law enforcement agency as well as the Department of Health and Hospitals will be notified prior to the end of the business day subsequent to the day on which the hospital received the report. Further investigation will occur to identify, investigate, and resolve any deep systemic problems.
6) The procedure for handling the grievance included the following:
a) The Governing Board delegated the responsibility to monitor the effective operation of the process to the Grievance Committee. The Grievance Committee was composed of the CEO (chief executive officer), Risk Manager, DON (director of nursing), Director of Human Resources, and Patient Advocate.
b) Allegations of abuse or neglect cannot be resolved at the unit level. Investigation should be initiated immediately as directed by the nursing supervisor.
c) Unresolved written or verbal complaints/grievances will be forwarded to the Patient Advocate and considered a grievance.
d) The Patient advocate will meet with the patient involved along with staff involved in an effort to resolve the grievance within seven working days.
e) Written notice of the hospital's decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion will be sent to the patient.
f) Grievances which cannot be resolved or allegations of Abuse or Neglect are presented to the Medical Director.

Review of the hospital's "Complaint Log" for December 2012 and January 2013, presented by administration as the current list of complaints/grievances, revealed no documented evidence that a complaint or grievance had been received from Patient #6.

Review of the "December 2012 Healthcare Peer Review Reports", presented by administration as the list of incidents for December 2012 to the current date, revealed no documented evidence that an incident report had been completed by RNS6 or RNS16 related to the incident with Patients #6 and #7.

Review of the "Complaint Resolution Form" signed by Patient #6 on 12/17/12 revealed that "while under the care and medication of River Oaks I was sexually assaulted by roommate while sleeping He was rubbing my face and kissing me It woke me up and He was standing over me. later that day I saw where he also ejaculated (ejaculated) on my bed as well. I told the staff and nothing was done". Attached to the packet presented by administration was a "Progress Note" dated 12/17/12, with no documented evidence of a signature of the author of the note (identified by Director of NursingS2 as being from Registered Nurse (RN) ManagerS10). Review of the "Progress Note" revealed that the patient requested to meet one-to-one at 7:30 a.m. while in the day area. Further review revealed that the patient reported that he was sexually assaulted sometime on Friday, and when asked to clarify, the patient indicated that he was kissed on the elbow and touched on the forehead. He further indicated that he spoke to CounselorS13 about there being semen on his bed. Documentation further revealed that when asked if he (Patient #6) told anyone else, Patient #6 answered no, that he thought he had to tell his social worker. The author of the document indicated that there had been no previous reports brought to her by the patient of sexual assault or any problem at all. She further wrote that in report on 12/12/12 it was reported that Patient #6's roommate (Patient #7), thinking that Patient #6 was his grandmother, had kissed Patient #6 on the elbow. The author further documented that no complaints by Patient #6 or the staff had been reported to her regarding the incident until today (12/17/12).

Review of a letter dated 12/19/12 to Patient #6 from Patient AdvocateS12 (letter was attached to "Complaint Resolution Form") revealed that Patient AdvocateS12 informed Patient #6 that he had been trying to reach Patient #6 for several days to arrange to send a complaint form "in the event you wanted to expand on the information you left upon your discharge". Further review revealed that enclosed with the letter was a copy of the hospital's "Grievance Form" and a self-addressed stamped envelope.

Review of typed documentation dated 12/14/13 (should be 12/14/12) at 10:00 a.m. and signed by Patient AdvocateS12 (attached to the "Complaint Resolution Form" packet) revealed that Patient AdvocateS12 and Risk ManagerS3 went to the unit at the request of RN ManagerS10 to review Patient #6's chart and talk with the staff. Further review revealed that Patient AdvocateS12 and Risk ManagerS3 were informed of the incident on 12/12/12 with Patient #6 at this time, that Patient #6 was expanding his story, and that Patient #6 had refused to speak with anyone regarding the incident. Patient AdvocateS12 documented that Mental Health (MH) AideS14, RNS15, Director of Social ServicesS11, and RN ManagerS10 were present. Further review of Patient AdvocateS12's report revealed that the staff reported that Patient #6's roommate (Patient #7) was an older gentleman who admitted that during the night thought he was at home, called out for his dying grandmother, went to Patient #6, and thinking that he (Patient #7) was at home, may have kissed Patient #6's elbow. Further review revealed that at the time of the incident both patients came out the room and reported the incident to the 11:00 p.m. to 7:00 a.m. shift's nursing staff. Further review revealed that the patients were separated, room assignments were changed, and both patients returned to their respective rooms. Patient #7 was discharged during the 7:00 a.m. to 3:00 p.m. shift on 12/12/12. Review of Patient AdvocateS12's report revealed that MH AideS14 reported that Patient #6 spoke with him and began to complain about the incident after Patient #7 had been discharged. MH AideS14 further indicated that Patient #6 was insisting the he (MH AideS14) go to Medical records and write in Patient #7's chart that he (Patient #7) was a "pervert". MH AideS14 further indicated that Patient #6 refused a formal complaint form and was referred to RN ManagerS10. MH AideS14 reported that Patient #6 refused to talk with RN ManagerS10, refused to complete the complaint form, and said that the night shift had dealt with the incident at the time that it occurred, but he (Patient #6) was still upset with his roommate (Patient #7). Patient AdvocateS12 documented that there was no evidence of any misconduct discovered. Further review revealed that the video surveillance was reviewed, but since the patient rooms did not have video cameras, no information was discovered. Further review revealed that staff on the unit had spoken with Patient #6 on numerous occasions, and Patient #6 continued to change his story.

Review of the "Grievance Committee Meeting" minutes dated 12/19/12, presented by DONS2, revealed that Patient AdvocateS12, Risk ManagerS3, DONS2, and AdministratorS1 were in attendance. Further review revealed that old business included "Patient #6 investigation complete. Cert (certified) letter sent". Further review revealed the entry of "no allegations of abuse/neglect".

Review of Patient #6's medical record revealed that he was a 26 year old male admitted on 12/08/12 and discharged on 12/17/12 with diagnoses of Generalized Anxiety Disorder, Suicidal Ideation, Alcohol Abuse NOS (not otherwise specified), and Tobacco Use Disorder. Further review revealed that Patient #6 had a PEC (Physician Emergency Certificate) signed on 12/07/12 at 8:54 a.m. due to being suicidal, violent, and dangerous to self and others. A CEC (Coroner's Emergency Certificate) was signed on 12/09/12 at 9:58 a.m. with no documented evidence whether Patient #6 was suicidal, homicidal, or violent and the reasons Patient #6 was in need of immediate psychiatric treatment in a treatment facility.

Review of Patient #6's entire medical record revealed the following documentation:
"Psychiatric Discharge Summary" by PsychiatristS4 on 12/17/12 at 12:21 p.m. - "there was one incident which occurred during the course of his stay in which another patient crawled into his bed at night. There was primarily surprise in the patient and there was no evidence of any sexual contact";
12/09/12 at 9:30 p.m. by RNS5 - "expressed fear of another male patient. Reassured pt. (patient) that staff makes rounds q15 (every 15 minutes)...";
12/12/12 at 6:48 a.m. by RNS6 - patient awakened by roommate kissing on his elbow and became anxious, given prn (as needed) Valium; no distress noted;
"Psychiatric progress Note" 12/12/12 at 3:15 p.m. by PsychiatristS4 - situation with another patient discussed, getting in his bed;
12/13/12 at 8:30 p.m. by RNS5 - complains to staff that two nights ago on 11-7 (11:00 p.m. to 7:00 p.m. shift) that another patient woke him up touching him; stated he told staff and nothing was done; patient still upset about the incident;
12/16/12 at 7:30 p.m. by RNS8 - patient approached staff asking for copy of "report from earlier this week"; referred patient to nurse manager in the morning;
12/16/12 at 10:00 p.m. by RN SupervisorS9 - spoke with patient regarding his complaints of being "sexually molested"; patient claims that no one did anything about the incident; patient reported that he was sexually molested by his roommate who touched him on the forehead, kissed him on his elbow, and thinks he may have masturbated on his bed; patient was angry that no one talked to his roommate, no one looked at his sheets, and no one talked to him about the incident; patient was offered a complaint form, and he refused to complete it; refused to add to his satisfaction sheet that the patient touched him on the forehead and kissed him on the elbow; patient continued to maintain that this meant he was sexually assaulted; patient asked for a copy of the original report; patient admitted that he spoke to the social worker who also refused to look at his sheets, and he had to actually change his own sheets;
12/17/12 at 7:30 a.m. by RN ManagerS10 - patient with complaints of sexual assault this morning; spoke directly with patient who reported that a peer "kissed my elbows & touched my forehead"; reported that semen was on his bed, and he reported this to social worker (CounselorS13); patient was given a complaint form;
12/17/12 at 12:00 p.m. by RN ManagerS10 - patient asked about complaint and reported that he was going to turn it in up front; discussed procedure with patient; complaint received and turned in to DONS2; Risk ManagerS3 aware of allegations;
12/17/12 at 1:15 p.m. by Director of Social ServicesS11 - spoke with patient's mother to give information regarding patient having peer "sneak into his bed last week"; according to mother patient has been obsessing about it but all he said happened was that peer got into bed with him and started kissing his shoulder, patient immediately got out of bed and told staff, and peer was discharged next day;
12/12/12 at 9:05 a.m. and 5:05 p.m. by CounselorS13 - no documented evidence of discussion with Patient #6 about incident earlier this morning;
"Patient Monitor Record" dated 12/11/12 completed by RNS16 - Patient #6 was asleep in his room from 11:30 p.m. to 5:00 a.m. (on 12/12/12), in his room cooperative at 5:15 a.m., in the day room cooperative at 5:30 a.m. and 5:45 a.m., in his room cooperative at 6:00 a.m. and 6:15 a.m., and on the patio cooperative from 6:30 a.m. to 7:15 a.m.

In a face-to-face interview on 01/30/13 at 7:55 a.m., RNS6 indicated that he worked the night shift on 12/11/12. He further indicated that Patient #6 reported to RNS16, who was working as a MH Aide that night and making the every 15 minute observations of the patients, that his roommate (Patient #7) had kissed him on the elbow. He further indicated that he approached Patient #6 in the day area, and Patient #6 told him that Patient #7 had kissed him on his elbow thinking that he (Patient #6) was his (Patient #7) grandmother. RNS6 indicated that he gave Patient #6 Valium as ordered for anxiety to help him calm down. He further indicated that he asked Patient #6 if he wanted to complete a complaint form and showed him the posted number for the Patient Advocate. He further indicated that Patient #6 said he didn't want to complete a complaint form. RNS6 indicated that he reported the occurrence to RN ManagerS10. RNS6 indicated that he didn't know the exact time of the occurrence, but he administered the Valium at 5:45 a.m. RNS6 indicated that he didn't know the difference between a complaint and a grievance.

In a face-to-face interview on 01/30/13 at 8:15 a.m., RN ManagerS10 indicated that she knew of the incident involving Patient #6 and Patient #7 a few days before Patient #6's discharge of 12/17/12. She further indicated that it was reported to her that Patient #7 got up during the night and kissed Patient #6's elbow thinking that he (Patient #6) was his (Patient #7) grandmother. She further indicated that she went to speak with Patient #6 and offered him a complaint form which he accepted but did not complete. She further indicated that several days later Patient #6 began saying that he was sexually abused. RN ManagerS10 indicated that she went to Patient #6 on his date of discharge, and he didn't want to give the complaint form to her. She further indicated that Patient #6 was threatening to sue. RN ManagerS10 indicated the Patient #6 did not complain about Patient #7 ejaculating on his (Patient #6) sheet on the day of the occurrence. She further indicated that an observation of Patient #6's sheets was not done, because Patient #6 did not report the presence of semen on his sheets until 12/16/12. After reviewing Patient #6's medical record, RN ManagerS10 indicated that RNS6 should have completed an incident report, an investigation of the allegations presented by Patient #6 should have been conducted, and the allegation of sexual abuse should have been reported to DHH. RN ManagerS10 confirmed that she did not document the discussion that she had with Patient #6 which should have been the beginning of the investigation.

In a face-to-face interview on 01/30/13 at 9:10 a.m., CounselorS13 indicated that she remembered Patient #6 "very well actually". She further indicated that Patient #6 approached her the morning of 12/12/12 and reported that he woke up during the night, and Patient #7 was kissing his elbow and thought that he (Patient #7) "did something to his sheet". She further indicated that Patient #6 told her that he told the MH Aide about his sheets and asked if she wanted to see the sheets. CounselorS13 indicated that she told Patient #6 she didn't need to see his sheets if he told the MH Aide about it. She further indicated that she went to report this to RN ManagerS10 who said that she knew, and Patient #7 spoke to her (RN ManagerS10) about sleepwalking. CounselorS13 indicated that on the day of discharge, Patient #6 went to her group and complained that no one was helping him (regarding the occurrence during the night shift of 12/11/12). She further indicated that the topic of her group was the hospital's procedure regarding complaints. She further indicated that she finally told Patient #6 that "whenever there's a complaint it goes to the charge nurse". CounselorS13 confirmed that she did not document any of her conversations with Patient #6 regarding his complaints of being kissed on the elbow by Patient #7 and the possibility that Patient #7 ejaculated in his (Patient #6's) bed in Patient #6's chart. When asked why she didn't document her discussions with Patient #6, CounselorS13 indicated there wasn't a reason, but she was very busy. CounselorS13 indicated that she didn't know the difference between a complaint and a grievance, and she "thought they were pretty similar".

In a face-to-face interview on 01/30/13 at 10:50 a.m., RN SupervisorS9 indicated that she spoke with Patient #6 on 12/16/12 at 10:00 p.m. She further indicated that she spoke with RNS6 who reported that Patient #6's roommate (Patient #7) was sleepwalking and tried to get in bed with Patient #6 and kissed Patient #6 on the elbow. She further indicated that RNS6 administered Valium to Patient #6 and removed Patient #7 from Patient #6's room. She further indicated that she reviewed Patient #6's chart, but he started changing his story (meaning that touching the forehead and masturbation had not been mentioned in the record initially). She further indicated that she didn't take kissing on the elbow as a sexual event. RN SupervisorS9 indicated that she wrote the discussion in detail, because she thought PsychiatristS4 should know that Patient #6 was obsessing about the event and changing his story. When asked if she notified PsychiatristS4 about her observations, RN SupervisorS9 indicated that she did not call him, because PsychiatristS4 reads their notes.

In a face-to-face interview on 01/30/13 at 11:15 a.m., Patient AdvocateS12 indicated that he had never met with Patient #6. He further indicated that he became involved on 12/14/12 when RN ManagerS10 called him to request that he go to speak with her about what had been going on with Patient #6. He further indicated that he and Risk ManagerS3 went to the unit, and this was the first time he had heard of the incident. Patient AdvocateS12 indicated that he was told that Patient #6 had been kissed on the elbow by his roommate (Patient #7) who thought that he (Patient #7) was at home with his dying grandmother. He further indicated that he thought the incident had been resolved at the unit level after speaking with the staff present at the time on 12/14/12 and reviewing Patient #6's chart. Patient AdvocateS12 confirmed that he did not speak with the 2 nurses present at the time of the event, RNS6 and RNS16, as well as CounselorS13. Patient AdvocateS12 indicated that it was his responsibility to investigate allegations of abuse or neglect, and if there was an allegation of abuse or neglect, he was to report it to DHH. He further indicated that a patient reporting that he was kissed by another patient was not an allegation of abuse or neglect. Patient AdvocateS12 indicated that he did not see PsychiatristS4's progress note of 12/12/12 at 3:15 p.m. that revealed that another patient was getting in his bed and was not aware of Patient #6's subsequent allegations of sexual molestation and sexual assault. He further indicated that if he knew that Patient #6 had reported that another patient got into his bed, he may have taken it more seriously. He further indicated that he could not explain why he did not see PsychiatristS4's progress note when he reviewed Patient #6's medical record. After reviewing the documentation in Patient #6's medical record, Patient AdvocateS12 indicated that this was a patient grievance, and an investigation had not been conducted, because they felt that it had been resolved on the unit.

In a face-to-face interview on 01/30/13 at 11:45 a.m., DONS2 indicated that the event with Patient #6 was discussed in the Grievance Committee meeting. She further indicated that an incident report should have been completed. DONS2 indicated that she did not meet with anyone to discuss Patient #6, and she had no documentation of any investigation of the grievance.

In a face-to-face interview on 01/30/13 at 12:10 p.m., Risk ManagerS3 indicated that the first she knew of the incident with Patient #6 and Patient #7 was on 12/14/12 when she was notified by RN ManagerS10. She further indicated that MH AideS14 told her that after Patient #7 was discharged, Patient #6 wanted him (MH AideS14) to go to Medical Records and write on Patient #7's chart that he was a "pervert". She further indicated that MH AideS14 reported that he had offered Patient #6 to complete a complaint form, but Patient #6 refused and refused to speak with RN ManagerS10. Risk ManagerS3 indicated that she and Patient AdvocateS12 approached Patient #6, but he refused to speak with them. She further indicated that she did not speak with any of the nurses who worked the night shift of 12/11/12 when the incident occurred, and she had not spoken to CounselorS13. When asked if she considered that Patient #6's complaint was a grievance, Risk ManagerS3 answered "no because we would have handled this differently". She further indicated that they felt the complaint had been resolved. Risk ManagerS3 indicated that after reviewing the documentation in Patient #6's medical record, it should have been handled differently. She further indicated that last night was the first time that she saw RN SupervisorS9's note that Patient #6 had reported that he had been sexually molested. Risk ManagerS3 indicated that when RN SupervisorS9 received this allegation from Patient #6, RN SupervisorS9 should have reported it to Risk ManagerS3. Risk ManagerS3 confirmed that a report of an allegation of sexual molestation had not been reported to DHH, but "in retrospect, it should have been". Risk ManagerS3 indicated that those in attendance at the Grievance Committee meeting on 12/19/12 had reviewed the report submitted by Patient AdvocateS12 from 12/14/12 but did not review Patient #6's medical record.

Based on record review and interviews, the hospital failed to ensure that a patient who filed a grievance was provided a written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. The hospital failed to identify a patient's complaint as a grievance, conduct an investigation, and provide a written response to the patient for 1 of 1 patient grievance reviewed from a total of 3 grievances (#6). There was a potential for the 23 inpatients on Building 6 to file a complaint/grievance with no investigation being conducted and a written notice of the hospital's decision being sent to the patient by administration. Findings:

Review of the hospital's policy titled "Complaints/Grievances Resolution Patient Advocate Function: Rights", presented by administration as the current policy for the grievance process, revealed that written notice of the hospital's decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion will be sent to the patient.

Review of the hospital's "Complaint Log" for December 2012 and January 2013, presented by administration as the current list of complaints/grievances, revealed no documented evidence that a complaint or grievance had been received from Patient #6.

Review of the "Complaint Resolution Form" signed by Patient #6 on 12/17/12 revealed that "while under the care and medication of River Oaks I was sexually assaulted by roommate while sleeping He was rubbing my face and kissing me It woke me up and He was standing over me. later that day I saw where he also ejaculated (ejaculated) on my bed as well. I told the staff and nothing was done".

Review of all documentation presented by administration revealed no documented evidence that an investigation had been conducted and a response letter had been sent to Patient #6 that included the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

In a face-to-face interview on 01/30/13 at 11:15 a.m., Patient AdvocateS12 indicated that he had never met with Patient #6. He further indicated that he became involved on 12/14/12 when RN ManagerS10 called him to request that he go to speak with her about what had been going on with Patient #6. He further indicated that he thought the incident had been resolved at the unit level after speaking with the staff present at the time on 12/14/12 and reviewing Patient #6's chart. Patient AdvocateS12 confirmed that he did not speak with the 2 nurses present at the time of the event, RNS6 and RNS16, as well as CounselorS13. Patient AdvocateS12 indicated that it was his responsibility to investigate allegations of abuse or neglect, and if there was an allegation of abuse or neglect, he was to report it to DHH. He further indicated that a patient reporting that he was kissed by another patient was not an allegation of abuse or neglect. Patient AdvocateS12 indicated that he did not see PsychiatristS4's progress note of 12/12/12 at 3:15 p.m. that revealed that another patient was getting in his bed and was not aware of Patient #6's subsequent allegations of sexual molestation and sexual assault. He further indicated that if he knew that Patient #6 had reported that another patient got into his bed, he may have taken it more seriously. He further indicated that he could not explain why he did not see PsychiatristS4's progress note when he reviewed Patient #6's medical record. After reviewing the documentation in Patient #6's medical record, Patient AdvocateS12 indicated that this was a patient grievance, and an investigation had not been conducted, because they felt that it had been resolved on the unit. He confirmed that a written response letter had not been sent to Patient #6, since they had not viewed the complaint as a grievance.

In a face-to-face interview on 01/30/13 at 11:45 a.m., DONS2 indicated that the event with Patient #6 was discussed in the Grievance Committee meeting. She further indicated that an incident report should have been completed. DONS2 indicated that she did not meet with anyone to discuss Patient #6, and she had no documentation of any investigation of the grievance.

In a face-to-face interview on 01/30/13 at 12:10 p.m., Risk ManagerS3 indicated that the first she knew of the incident with Patient #6 and Patient #7 was on 12/14/12 when she was notified by RN ManagerS10. She further indicated that MH AideS14 told her that after Patient #7 was discharged, Patient #6 wanted him (MH AideS14) to go to Medical Records and write on Patient #7's chart that he was a "pervert". She further indicated that MH AideS14 reported that he had offered Patient #6 to complete a complaint form, but Patient #6 refused and refused to speak with RN ManagerS10. Risk ManagerS3 indicated that she and Patient AdvocateS12 approached Patient #6, but he refused to speak with them. She further indicated that she did not speak with any of the nurses who worked the night shift of 12/11/12 when the incident occurred, and she had not spoken to CounselorS13. When asked if she considered that Patient #6's complaint was a grievance, Risk ManagerS3 answered "no because we would have handled this differently". She further indicated that they felt the complaint had been resolved. Risk ManagerS3 indicated that after reviewing the documentation in Patient #6's medical record, it should have been handled differently. She further indicated that last night was the first time that she saw RN SupervisorS9's note that Patient #6 had reported that he had been sexually molested. Risk ManagerS3 indicated that when RN SupervisorS9 received this allegation from Patient #6, RN SupervisorS9 should have reported it to Risk ManagerS3. Risk ManagerS3 confirmed that a report of an allegation of sexual molestation had not been reported to DHH, but "in retrospect, it should have been". Risk ManagerS3 indicated that those in attendance at the Grievance Committee meeting on 12/19/12 had reviewed the report submitted by Patient AdvocateS12 from 12/14/12 but did not review Patient #6's medical record.

Based on record reviews and interviews, the hospital failed to ensure that each patient was free from all forms of neglect. The hospital failed to investigate a patient's allegation of sexual molestation/assault as required by hospital policy for 1 of 1 patient's record reviewed for abuse and neglect from a total of 10 sampled patients (#6). There was a potential for the 23 inpatients on Building 6 to be victims of sexual molestation or assault with no investigation being conducted by administration. Findings:

Review of the hospital policy titled "Abuse And Neglect", revised 06/10 and presented by Director of NursingS2 (DON) as the current policy, revealed that neglect was defined as the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well being. Further review of the section titled "allegation of patient abuse by another patient" revealed the following:
1) Any suspected or witnessed incidents of either abuse or neglect shall be reported immediately to the Nurse Manager/Charge Nurse or the Hospital supervisor in his/her absence, the Risk Manager, and the attending physician. In addition, an HPR (healthcare peer review) will be completed (the form used to document incidents);
2) All allegations shall be immediately investigated. Risk Management shall conduct a thorough and complete verbal and written investigation in collaboration with the appropriate Department Head, Supervisor, Human Resources, Patient Advocate, physician, and DON.
Further review of the section titled "investigation" revealed the following would be done:
1) Review of the patient's clinical record;
2) Interview with the patient making the allegation;
3) Interview and/or written statements from all staff that were on duty at the time of the alleged incident.
Further review revealed that the hospital investigation should occur as quickly as possible, preferably within 3 to 5 working days, and a summary report must be prepared by the Risk Manager and sent to the Director of Human Resources, the chief executive officer, and the corporate Risk Management department.
Review of the policy revealed that the policy did not define what would be considered patient-to-patient abuse.

Review of Patient #6's entire medical record revealed the following documentation:
"Psychiatric Discharge Summary" by PsychiatristS4 on 12/17/12 at 12:21 p.m. - "there was one incident which occurred during the course of his stay in which another patient crawled into his bed at night. There was primarily surprise in the patient and there was no evidence of any sexual contact";
12/09/12 at 9:30 p.m. by RNS5 - "expressed fear of another male patient. Reassured pt. (patient) that staff makes rounds q15 (every 15 minutes)...";
12/12/12 at 6:48 a.m. by RNS6 - patient awakened by roommate kissing on his elbow and became anxious, given prn (as needed) Valium; no distress noted;
"Psychiatric progress Note" 12/12/12 at 3:15 p.m. by PsychiatristS4 - situation with another patient discussed, getting in his bed;
12/13/12 at 8:30 p.m. by RNS5 - complains to staff that two nights ago on 11-7 (11:00 p.m. to 7:00 p.m. shift) that another patient woke him up touching him; stated he told staff and nothing was done; patient still upset about the incident;
12/16/12 at 7:30 p.m. by RNS8 - patient approached staff asking for copy of "report from earlier this week"; referred patient to nurse manager in the morning;
12/16/12 at 10:00 p.m. by RN SupervisorS9 - spoke with patient regarding his complaints of being "sexually molested"; patient claims that no one did anything about the incident; patient reported that he was sexually molested by his roommate who touched him on the forehead, kissed him on his elbow, and thinks he may have masturbated on his bed; patient was angry that no one talked to his roommate, no one looked at his sheets, and no one talked to him about the incident; patient was offered a complaint form, and he refused to complete it; refused to add to his satisfaction sheet that the patient touched him on the forehead and kissed him on the elbow; patient continued to maintain that this meant he was sexually assaulted; patient asked for a copy of the original report; patient admitted that he spoke to the social worker who also refused to look at his sheets, and he had to actually change his own sheets;
12/17/12 at 7:30 a.m. by RN ManagerS10 - patient with complaints of sexual assault this morning; spoke directly with patient who reported that a peer "kissed my elbows & touched my forehead"; reported that semen was on his bed, and he reported this to social worker (CounselorS13); patient was given a complaint form;
12/17/12 at 12:00 p.m. by RN ManagerS10 - patient asked about complaint and reported that he was going to turn it in up front; discussed procedure with patient; complaint received and turned in to DONS2; Risk ManagerS3 aware of allegations;
12/17/12 at 1:15 p.m. by Director of Social ServicesS11 - spoke with patient's mother to give information regarding patient having peer "sneak into his bed last week"; according to mother patient has been obsessing about it but all he said happened was that peer got into bed with him and started kissing his shoulder, patient immediately got out of bed and told staff, and peer was discharged next day;
12/12/12 at 9:05 a.m. and 5:05 p.m. by CounselorS13 - no documented evidence of discussion with Patient #6 about incident earlier this morning;
"Patient Monitor Record" dated 12/11/12 completed by RNS16 - Patient #6 was asleep in his room from 11:30 p.m. to 5:00 a.m. (on 12/12/12), in his room cooperative at 5:15 a.m., in the day room cooperative at 5:30 a.m. and 5:45 a.m., in his room cooperative at 6:00 a.m. and 6:15 a.m., and on the patio cooperative from 6:30 a.m. to 7:15 a.m.

In a face-to-face interview on 01/30/13 at 7:55 a.m., RNS6 indicated that he worked the night shift on 12/11/12. He further indicated that Patient #6 reported to RNS16, who was working as a MH Aide that night and making the every 15 minute observations of the patients, that his roommate (Patient #7) had kissed him on the elbow. He further indicated that he approached Patient #6 in the day area, and Patient #6 told him that Patient #7 had kissed him on his elbow thinking that he (Patient #6) was his (Patient #7) grandmother. RNS6 indicated that he gave Patient #6 Valium as ordered for anxiety to help him calm down. He further indicated that he asked Patient #6 if he wanted to complete a complaint form and showed him the posted number for the Patient Advocate. He further indicated that Patient #6 said he didn't want to complete a complaint form. RNS6 indicated that he reported the occurrence to RN ManagerS10. RNS6 indicated that he didn't know the exact time of the occurrence, but he administered the Valium at 5:45 a.m.

In a face-to-face interview on 01/30/13 at 8:15 a.m., RN ManagerS10 indicated that she knew of the incident involving Patient #6 and Patient #7 a few days before Patient #6's discharge of 12/17/12. She further indicated that it was reported to her that Patient #7 got up during the night and kissed Patient #6's elbow thinking that he (Patient #6) was his (Patient #7) grandmother. She further indicated that she went to speak with Patient #6 and offered him a complaint form which he accepted but did not complete. She further indicated that several days later Patient #6 began saying that he was sexually abused. RN ManagerS10 indicated that she went to Patient #6 on his date of discharge, and he didn't want to give the complaint form to her. She further indicated that Patient #6 was threatening to sue. RN ManagerS10 indicated that Patient #6 did not complain about Patient #7 ejaculating on his (Patient #6) sheet on the day of the occurrence. She further indicated that an observation of Patient #6's sheets was not done, because Patient #6 did not report the presence of semen on his sheets until 12/16/12. After reviewing Patient #6's medical record, RN ManagerS10 indicated that RNS6 should have completed an incident report, an investigation of the allegations presented by Patient #6 should have been conducted, and the allegation of sexual abuse should have been reported to DHH. RN ManagerS10 confirmed that she did not document the discussion that she had with Patient #6 which should have been the beginning of the investigation.

In a face-to-face interview on 01/30/13 at 9:10 a.m., CounselorS13 indicated that she remembered Patient #6 "very well actually". She further indicated that Patient #6 approached her the morning of 12/12/12 and reported that he woke up during the night, and Patient #7 was kissing his elbow and thought that he (Patient #7) "did something to his sheet". She further indicated that Patient #6 told her that he told the MH Aide about his sheets and asked if she wanted to see the sheets. CounselorS13 indicated that she told Patient #6 she didn't need to see his sheets if he told the MH Aide about it. She further indicated that she went to report this to RN ManagerS10 who said that she knew, and Patient #7 spoke to her (RN ManagerS10) about sleepwalking. CounselorS13 indicated that on the day of discharge, Patient #6 went to her group and complained that no one was helping him (regarding the occurrence during the night shift of 12/11/12). She further indicated that the topic of her group was the hospital's procedure regarding complaints. She further indicated that she finally told Patient #6 that "whenever there's a complaint it goes to the charge nurse". CounselorS13 confirmed that she did not document any of her conversations with Patient #6 regarding his complaints of being kissed on the elbow by Patient #7 and the possibility that Patient #7 ejaculated in his (Patient #6's) bed in Patient #6's chart. When asked why she didn't document her discussions with Patient #6, CounselorS13 indicated there wasn't a reason, but she was very busy.

In a face-to-face interview on 01/30/13 at 10:50 a.m., RN SupervisorS9 indicated that she spoke with Patient #6 on 12/16/12 at 10:00 p.m. She further indicated that she spoke with RNS6 who reported that Patient #6's roommate (Patient #7) was sleepwalking and tried to get in bed with Patient #6 and kissed Patient #6 on the elbow. She further indicated that RNS6 administered Valium to Patient #6 and removed Patient #7 from Patient #6's room. She further indicated that she reviewed Patient #6's chart, but he started changing his story (meaning that touching the forehead and masturbation had not been mentioned in the record initially). She further indicated that she didn't take kissing on the elbow as a sexual event. RN SupervisorS9 indicated that she wrote the discussion in detail, because she thought PsychiatristS4 should know that Patient #6 was obsessing about the event and changing his story. When asked if she notified PsychiatristS4 about her observations, RN SupervisorS9 indicated that she did not call him, because PsychiatristS4 reads their notes.

In a face-to-face interview on 01/30/13 at 11:15 a.m., Patient AdvocateS12 indicated that he had never met with Patient #6. He further indicated that he became involved on 12/14/12 when RN ManagerS10 called him to request that he go to speak with her about what had been going on with Patient #6. He further indicated that he and Risk ManagerS3 went to the unit, and this was the first time he had heard of the incident. Patient AdvocateS12 indicated that he was told that Patient #6 had been kissed on the elbow by his roommate (Patient #7) who thought that he (Patient #7) was at home with his dying grandmother. He further indicated that he thought the incident had been resolved at the unit level after speaking with the staff present at the time on 12/14/12 and reviewing Patient #6's chart. Patient AdvocateS12 confirmed that he did not speak with the 2 nurses present at the time of the event, RNS6 and RNS16, as well as CounselorS13. Patient AdvocateS12 indicated that it was his responsibility to investigate allegations of abuse or neglect, and if there was an allegation of abuse or neglect, he was to report it to DHH. He further indicated that a patient reporting that he was kissed by another patient was not an allegation of abuse or neglect. Patient AdvocateS12 indicated that he did not see PsychiatristS4's progress note of 12/12/12 at 3:15 p.m. that revealed that another patient was getting in his bed and was not aware of Patient #6's subsequent allegations of sexual molestation and sexual assault. He further indicated that if he knew that Patient #6 had reported that another patient got into his bed, he may have taken it more seriously. He further indicated that he could not explain why he did not see PsychiatristS4's progress note when he reviewed Patient #6's medical record. After reviewing the documentation in Patient #6's medical record, Patient AdvocateS12 indicated that this was a patient grievance, and an investigation had not been conducted, because they felt that it had been resolved on the unit.

In a face-to-face interview on 01/30/13 at 11:45 a.m., DONS2 indicated that the event with Patient #6 was discussed in the Grievance Committee meeting. She further indicated that an incident report should have been completed. DONS2 indicated that she did not meet with anyone to discuss Patient #6, and she had no documentation of any investigation of the allegation of sexual molestation.

In a face-to-face interview on 01/30/13 at 12:10 p.m., Risk ManagerS3 indicated that the first she knew of the incident with Patient #6 and Patient #7 was on 12/14/12 when she was notified by RN ManagerS10. She further indicated that MH AideS14 told her that after Patient #7 was discharged, Patient #6 wanted him (MH AideS14) to go to Medical Records and write on Patient #7's chart that he was a "pervert". She further indicated that MH AideS14 reported that he had offered Patient #6 to complete a complaint form, but Patient #6 refused and refused to speak with RN ManagerS10. Risk ManagerS3 indicated that she and Patient AdvocateS12 approached Patient #6, but he refused to speak with them. She further indicated that she did not speak with any of the nurses who worked the night shift of 12/11/12 when the incident occurred, and she had not spoken to CounselorS13. When asked if she considered that Patient #6's complaint was a grievance, Risk ManagerS3 answered "no because we would have handled this differently". She further indicated that they felt the complaint had been resolved. Risk ManagerS3 indicated that after reviewing the documentation in Patient #6's medical record, it should have been handled differently. She further indicated that last night was the first time that she saw RN SupervisorS9's note that Patient #6 had reported that he had been sexually molested. Risk ManagerS3 indicated that when RN SupervisorS9 received this allegation from Patient #6, RN SupervisorS9 should have reported it to Risk ManagerS3. Risk ManagerS3 confirmed that a report of an allegation of sexual molestation had not been reported to DHH and had not been investigated, but "in retrospect, it should have been". Risk ManagerS3 indicated that those in attendance at the Grievance Committee meeting on 12/19/12 had reviewed the report submitted by Patient AdvocateS12 from 12/14/12 but did not review Patient #6's medical record.