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Based on document review and interview, it was determined that the Hospital failed to protect and promote each patients' rights by failing to ensure a process was in place for the treatment, reporting, and investigation of allegations of sexual abuse. As a result, the Condition of Participation, Patient Rights, 42 CFR 482.13, was not in compliance.

Findings include:

1. The Hospital failed to ensure the patients were free from sexual abuse; failed to offer a rape kit; failed to report incident to police, DCFS and IDPH. See deficiency at A 145.


The Immediate Jeopardy was identified on 12/7/2022 due to the Hospital's failure to ensure patients were free from all forms of abuse by failing to ensure a process was in place for the treatment, reporting, and investigation of allegations of sexual abuse, at 42 CFR 482.13, Patient Rights. The IJ was announced on 12/7/2022 at 3:30 PM during a meeting with the Chief Executive Officer, Director of Clinical Services, Human Resources Director and Chief Medical Officer. The IJ was not removed by the survey exit date of 12/8/2022.

Based on document review and interview, it was determined that for 4 of 4 adolescent clinical records (Pt #1, Pt #2, Pt #3 and Pt #4) reviewed for inappropriate sexual behavior, the Hospital failed to ensure patients were free from all forms of abuse by failing to ensure a process was in place for the treatment, reporting, and investigation of allegations of sexual abuse. This could potentially affect all 24 current and future residents at the Hospital who report an allegation of sexual abuse.

Findings include:

1. On 12/5/2022, the Hospital's policy regarding sexual abuse was requested of E #1 (Chief Executive Officer). E #1 stated that the Hospital did not have a policy/procedure for sexual abuse.

2. On 12/5/2022, the Hospital's policy titled "Precautions, Sexual Acting Out" (6/2022) noted "Provision of a safe, therapeutic environment of care includes the prevention of patient to patient sexual incidents. Patients shall not have sexual contact with one another. Patients are assessed for risk of sexual acting out behavior ...If the Hospital determines that there has been an allegation of sexual familiarity (contact) between patients, an immediate investigation must take place ...The practitioner shall order level of observation and precautions consistent with the assessed level of risk ..."

3. On 12/5/2022, the clinical record of Pt #2 was reviewed. Pt #2 was admitted to 3rd floor male & female adolescent unit on 10/27/2022. Pt #2's clinical record, dated 10/27/2022 to 11/14/2022, indicated:
-Pt #2's intake record, dated 10/27/2022, noted, "Abuse/Neglect - yes - sexual - Pt allegedly the victim of sexual assault by her brother ..."
-Pt #2's Psychiatric and Medical Diagnosis and Problems, dated 10/27/2022, noted, "Pt #2 was admitted to the Hospital on 10/27/2022 with the diagnoses of GAD (generalized anxiety disorder); ODD (oppositional defiant disorder) and RAD (reactive attachment disorder) ...Pt #2 reports history of sexual abuse from her brother and has been in DCFS (Department of Children and Family Services) for past 5 years ..." Discharge summary noted, " ...Pt #2 has been in DCFS for 5 years, admitted to inpatient adolescent unit for 12 days ... Pt #2 was discharged to a residential facility on 11/14/2022."
-Pt #2's rounding sheets (documented every 15 minutes) completed for suicide precautions, elopement precautions and sexually acting out precautions (SAO precautions began on 11/5/2022 until discharge on 11/14/2022).

4 .On 12/5/2022, the clinical record for Pt #4 was reviewed and included that Pt #4 was admitted to the 3rd floor male & female adolescent behavioral health unit on 10/27/2022. Pt #4's clinical record, dated 10/27/2022 to 11/9/2022, indicated:
-Pt #4's Psychiatric and Medical Diagnosis and Problems, dated 10/27/2022, noted, "Pt #4 was admitted to the Hospital with the diagnoses of major depressive disorder, recurrent, moderate; intermittent explosive disorder and conduct disorder.
-MD #1's admitting orders, dated 10/27/2022 included, " ...observations every 15 minutes, assault precautions and elopement precautions ...MD #1's order, dated 10/31/2022, noted, " ...sexually acting out precautions (dated 10/31/2022)-accusations that Pt #4 has had sexual intercourse with another peer ...Pt #4 was discharged on 11/9/2022 to a group home."

5. On 12/5/2022, the Hospital's incident report #1 (written by E #6 -former RN Manager) dated 11/4/2022 at 6:00 PM noted, "Date/Time of Incident - 10/30/2022 at 10:30 PM - Sexual Intercourse -After staff was alerted to alleged misconduct between Pt #2 and Pt #4, camera review was complete. Pt #2 was observed going into Pt #4's room for approximately 8 minutes then Pt #4 exited the room. Pt #2 on suicide and elopement [precautions] at the time. Interventions or Treatment - Pt #2 placed on SAO precautions ...Notification DON [Director of Nursing] at 11/4/2022 at 6:00 PM."

6. On 12/5/2022, the Hospital's incident report #2 dated 11/4/2022 at 6:00 PM, noted, "Date/Time of Incident -10/30/2022 at 10:45 PM - Boundary Violation/Issues -Pt/Pt - Upon being notified of alleged misconduct between patients, camera review was completed. Pt #4 was observed approaching Pt #2 in her doorway making physical contact. A thrusting motion was observed for 5 seconds. Pt #4 on suicide, assault and elopement precautions at the time. Interventions or Treatment - Pt #4 placed on SAO precautions ...Notification DON at 11/4/2022 at 6:00 PM.

7. On 12/5/2022, the Hospital's "Allegation of Sexual Contact - Incident Investigation Report" (undated) was reviewed and indicated, "Summary of Incident - Patients on the unit reported to the therapist on 10/31/2022 that Pt #2 and Pt #4 had been having sex. Upon investigation, camera review showed that on 10/29/2022, Pt #4 ran to the doorway of Pt #2's room and gave her a peck on the lips. On 10/30/2022, Pt #2 entered Pt #4's room at 10:31 PM, a BHA (behavioral health associate) rounded at 10:38 PM and did not see Pt #2 in the room. Pt #2 and Pt #4 exited the room at 10:39 PM in conversation. On 10/30 at 10:42 PM, video showed Pt #4 in the hallway by the window with his back to the hall. Pt #4 then went to the doorway to Pt #2's bedroom for several seconds simulating intercourse through their clothing. On 10/31/2022, E #2 (Clinical Director) interviewed Pt #2 as to the events and Pt #2 adamantly denied any sexual contact. Pt #2 stated that she just brushed up against Pt #4 in the day room when walking by him and that is all she had done. On 10/31/2022, E #5 (former Chief Administrative Officer) interviewed Pt #4 who also denied sexual contact. On 11/1/2022, staff overheard Pt #2 having a conversation with her mother and her sister at the nursing station saying she had had sex with a patient and thought she might be pregnant and had asked for a pregnancy test. On 11/2/2022 when Pt #2 was interviewed by E #2, Pt #2 said that she did have sex with Pt #4 and described a very graphic encounter. On 11/1/2022, Pt #4 still adamantly denied any sexual contact with Pt #2. E #3 (Director of Nursing) met with Pt #2 and Pt #4 a third time together. Pt #4 still denied any sexual contact initially. Pt #2 stated that it happened as she reported it. Pt #4 still adamantly denied. Eventually, Pt #4 stated that there was "dry" sex. Via video review and patient interview, the Hospital was unable to substantiate the allegation of sexual intercourse but were able to substantiate physical boundary violations." The investigation report did not include the separation of Pt #2 and Pt #4; offering Pt #2 a rape kit; report incident to police, DCFS and IDPH.

8. On 12/6/2022, Pt #3's clinical record was reviewed and indicated that Pt #3 was admitted to the Hospital's 3rd floor male and female adolescent unit from 10/5/2022 to 10/18/2022 and from 10/21/2022 to 11/8/2022, and the record included:
-Pt #3's Psychiatric and Medical Diagnosis dated 10/5/2022 noted "major depressive disorder severe without psychosis, ADHD and PTSD. MD #1's admitting precaution orders dated 10/5/2022 noted, " ...elopement precautions and fall precautions ...Sexually acting out precautions were ordered on 10/7/2022 ..."
-Pt #3's Psychiatric and Medical Diagnosis and Problems dated 10/21/2022 noted "Pt #3 was admitted on 10/21/2022 with the diagnoses of major depressive disorder recurrent severe without psychosis, status post suicide attempt, significant self-injury; PTSD (posttraumatic stress disorder) and borderline personality disorder traits ...MD #1's admitting precaution orders dated 10/21/2022 noted " ...observations every 5 minutes, suicide precautions, elopement precautions and sexually acting out precautions ...." Pt #3's rounding sheets dated 10/21/2022 to 11/8/2022 were completed and documented every 5 minutes as ordered.
-Pt #3's incident report dated 10/11/2022 noted "3rd floor dayroom at 1:30 PM -Pt #3 met with Social Worker (E # 7) regarding impulsive thoughts Pt #3 was experiencing regarding sexual advances with another patient (unknown). Pt #3 admitted to being sexually active with another patient (unknown) by touching and groping patient under a table in the dayroom. Pt #3 requested closer observation due to her inability to control herself sexually. Another patient (Pt #11) accused Pt #3 of sexual & physical assault consisting of choking and stabbing with marker. There was no incident report or internal investigation regarding an allegation of Pt #3 sexually assaulting Pt #11. The intervention after this report was Pt #3 was put on 1:1 monitoring, the patients were separated and Pt #3's room was blocked. Pt #3 was moved to the 4th floor (female adolescent unit) on 11/1/2022. On 12/7/2022, E #2 (Clinical Director) stated that she was not aware of any sexual assault allegation incident regarding Pt #3.

9. On 12/6/2022, Pt #1's clinical record dated 10/24/2022 to 11/4/2022 indicated:
-Pt #1's Psychiatric and Medical Diagnosis and Problems dated 10/24/2022 noted "Pt #1 was admitted to the Hospital on 10/24/2022 with the diagnoses of major depressive disorder, severe, recurrent, no psychosis; panic disorder; posttraumatic stress disorder; ARFID ,(avoidant/restrictive food intake disorder) and anxiety disorder." MD #1's admitting orders dated 10/24/2022 noted "Observations every 5 minutes - suicide risk". Pt #1's rounding sheets dated 10/24/2022 to 11/4/2022 were completed and documented every 5 minutes as ordered. On 12/7/2022 at 11:45 AM, an interview was conducted with the Clinical Director (E#2). E #2 stated that during camera review, it was discovered that Pt #1 and Pt #3 were observed kissing in the hallway. The Hospital did not investigate or report this incident.

10. On 12/5/2022 at 1:50 PM, an interview was conducted with the CEO (E #1). E #1 stated that the Hospital does not have a sexual abuse policy. E #1 stated that corporate told her that the Hospital has an abuse policy and a SAO (sexually acting out) policy. E #1 stated that she does not know if a patient should be sent to the Hospital after a sexual assault. E #1 stated that with mentally ill patients, a report of sexual assault may or may not have happened as reported. E #1 asked surveyor what the state needed for sexual abuse policy based on regulations. E #1 stated that currently, the Hospital does not have a process in place for sexual abuse allegations. E #1 stated that a Risk Compliance staff member will be starting in January 2023. E #1 stated that the allegation of sexual abuse between Pt #2 and Pt #4 was not reported because there was no sexual intercourse. E#1 stated that the internal investigation of the camera review noted that Pt #2 and Pt #4 were in Pt #4's room unmonitored for approximately 8 minutes. E#1 stated the video camera reviewed also noted Pt #4 "humping" Pt #2 over Pt #2's clothes in the hallway.

11. On 12/5/2022 at 2:15 PM, an interview was conducted with the Clinical Director (E #2). E #2 stated that she is not sure if a patient who reports a sexual abuse allegation should be sent to the Hospital or what exactly needs to be done. E #2 stated that the allegation was not reported to DCFS or IDPH. E #2 stated that the allegation was going to be reported to DCFS on the day that DCFS came to the Hospital to investigate the allegation. DCFS came to the Hospital on 11/4/2022.

12. On 12/6/2022 at 9:15 AM, an interview was conducted with the Social Worker (E#7). E #7 stated that she heard rumors (not sure of exact date) that Pt #2 was having sex with Pt #4. E #7 stated that she was part of the internal investigation regarding this allegation. E #7 stated that she met with both patients in a room with the Compliance Director (who no longer works at the Hospital), Pt #2 and Pt #4. Pt #2 stated that she did have intercourse with Pt #4. Pt #4 stated that he did not have sexual intercourse with Pt #2. E #7 stated that Pt #2 and Pt #4 were placed on SAO precautions after learning about the allegation. (Per clinical records, SAO precautions were implemented 4 days after the incident.)

13. On 12/6/2022 at 10:30 AM, an interview was conducted with the Psychiatrist (MD #1). MD #1 stated that he heard from the staff that there was a report that Pt #2 and Pt #4 had intercourse. MD #1 stated that Pt #2 never reported any allegation of sexual abuse to him. MD #1 stated that he knew that an internal investigation took place at the Hospital. MD #1 stated that the conclusion of the investigation was that intercourse did not happen, so Pt #2 did not need to the be sent to the Hospital for a rape kit. MD #1 stated that all allegations should be reported to DCFS and IDPH.

14. On 12/6/2022 at 1:40 PM, an interview was conducted with the Registered Nurse (E #8). E #8 stated that she overheard a phone conversation (unsure of date) between Pt #2 and her mother. Pt #2 told her mother that she had intercourse with Pt #4. Pt #2 told her mother that she might be pregnant and may need help. E #8 stated that she talked to Pt #2 after the phone conversation. Pt #2 stated that she was hurt that Pt #4 was denying the intercourse because Pt #2 knew that the intercourse did happen. E #8 stated that she did not do an incident report but did report this conversation to her supervisor. E #8 stated that when she began working at the Hospital, she was trained to "keep in mind that the patients may lie about allegations."