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Based on review of medical records, review of meeting minutes for the facility's investigation, review of policies, and staff interview; the facility failed to ensure that Patient #2 was safe from sexual assault by Patient #1 and that the safety and security of Patient #s 2, 8, and 9 were protected at all times. The facility had a census of 48 patients in the psychiatric units at the time of the survey.

Findings include:

The facility failed to implement additional measures when Patient #1 was found wandering into other patients rooms and the facility failed to interview the patients whose rooms were entered by Patient #1 to determine what occurred and the length of time Patient #1 was in the other patients rooms. One patient (Patient #2) alleged that she was raped by Patient #1.

Please see 42 CFR 482.13(c)(2); A 144 - Patient Rights: Care in Safe Setting, for more detail.

Based on review of medical records, review of meeting minutes for the facility's investigation, review of facility policies, and staff interview; the facility failed to ensure that Patient #2 was safe from sexual assault by Patient #1 and that the safety and security of Patient #s 2, 8, and 9 were protected at all times. The facility had a census of 48 patients in the psychiatric units at the time of the survey.

Findings include:

Review of Patient #1's medical record on 12/06/10 revealed there were two occasions documented in the record the patient was found wandering in other patients' rooms and was re-directed by staff on the date of 11/28/10 at 1:15 AM and on 11/29/10 at 2:00 PM and 12:14 AM. The record lacked documentation the staff spoke with the patients whose rooms Patient #1 had entered in order to determine what had occurred and the length of time Patient #1 was in the other patients' rooms.

The medical record for Patient #2 was reviewed on 12/06/10. On 11/30/10, at 3:00 PM documentation revealed Patient #2 was found to be non-compliant with medication earlier in the morning and at that time Patient #2's fellow patient (Patient #10) reported to staff that Patient #1 (another male patient) had raped Patient #2. When questioned further by staff, Patient #2 stated she had been raped the past three nights. The patient stated she had told other staff previously who did nothing. At 3:15 PM, the patient recanted her accusations that she had told other staff previously and then said she was afraid to tell anyone because Patient #1 had told her he would hurt her. The staff talked with the doctor, the social worker, the Psychiatric Resident, and Patient #2's guardian and Patient #2 was taken to the emergency room for a rape examination.

On 12/06/10, the meeting minutes for the facility's investigation of Patient #2's allegations of rape by Patient #1, were reviewed for the meeting held on 12/01/10. A synopsis by staff revealed information had been gathered to determine event time lines and the results of findings. The meeting minutes stated that Patient #9, who was discharged on 11/29/10, had made a statement to nursing staff prior to her discharge that Patient #1 had been wandering into other patients' rooms and that Patient #8 had reported to nursing staff on 11/30/10 that Patient #1 had entered her room and made inappropriate contact by massaging her back.

On 12/07/10, the medical record for Patient #8 was reviewed. The psychiatry note dated 10:22 AM on 11/30/10 stated the "patient is distraught over another patient coming into her room last night. He did touch her, however denies any sexual contact".

On 12/07/10, the medical record for Patient #9 was reviewed. The medical record lacked documentation that the patient had reported another patient wandering into other patients' rooms.

On 12/07/10 the policy for Abuse, Neglect, and Exploitation was reviewed. The policy was specific for what to do for patients who present to the facility with suspected abuse, neglect, or exploitation and suspected staff to patient abuse or neglect. The policy addressed assessment, reporting, treatment and care of patients alleging abuse while receiving care at the facility. The policy lacked direction for patient to patient suspected abuse.

The policy for Patient Monitoring and the policy for Census Check and Safety Monitoring were reviewed on 12/07/10. These policies address the hourly patient safety checks during the day and the half hour patient safety checks at night. These policies lacked direction and guidelines for hallway monitoring. This was verified by Staff A, E, and J on 12/08/10 at 10:15 AM. Staff could not provide a hallway monitoring policy prior to exit on 12/08/10.

Through this investigation the facility identified system failures which included that that no one documented the assessment of potential contact with female patients after Patient #1 was noted wandering in and out of their rooms and there were concerns about the integrity of the hallway monitoring. At that time, different staff were assigned to interview staff, to secure medical records, to reeducate staff on hallway monitoring and to review medical records to create a timeline.

Staff A, E, and G were interviewed on 12/07/10 at 2:20 PM and Staff A, E, and J were interviewed on 12/08/10 at 10:15 AM . During these interviews, the staff verified the above information and that no additional interventions were initiated when Patient 1 was found wandering into other patients' rooms, prior to 11/30/10.