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Based on a review of the facility's documents, policies and procedures, medical records, and staff interview, it was determined the facility failed to protect patients' rights. The facility failed to provide a written description of the Rights of Persons to the patient and/or health care proxy in four (#5, #6, #7, #8) of eight patients sampled (Refer to A116). The facility failed to obtain consent for psychotropic medication prior to administering the drugs for one (#8) of eight patients sampled (Refer to A117). The facility failed to provide a written copy of the rights to petition for the Writ of Habeus Corpus in two (#5, #7) of eight patients sampled (Refer to A121). The facility failed to adequately document the investigation for an allegation of sexual abuse for one (#2) of eight patients sampled (A145).

Based on review of medical records and staff interview it was determined the facility failed to provide a written description of the Rights of Persons to the patient and/or the health care proxy in four (#5, #6, #7, and #8) of eight patients sampled.

Findings included:

Review of the form, "Rights of Persons in Mental Health Facilities and Programs," revealed a section, located at the bottom of the form, which stated to check when applicable and initial/date/time when a copy is provided. The form stated a copy must be given to the person and to any authorized decision-maker for persons incompetent or incapacitated by age or disability.

Review of the medical record for Patient #5 revealed that on 06/22/2020 at 1:48 AM, the patient signed the Rights of Persons in Mental Health facilities form with the bottom section not filled out to indicate if the patient received a copy. On 06/23/2020 at 8:45 AM, Patient #5 was deemed incompetent to provide express and informed consent and therefore an authorized decision-maker was required. Further review of the medical record revealed on 07/01/2020 at 6:11 AM, a guardian advocate gave telephone consent for notification of persons' rights in a mental health facility. Review of the bottom section of the form revealed no indication the guardian advocate was provided a written copy of the patient's rights.

Review of the medical record for Patient #6 revealed that on 04/15/2020 at 5:35 PM, the patient was unable/refused to sign the acknowledgement that the patient's rights were explained. Review of the bottom section of the form revealed no indication if the patient received a written copy. Review of the medical record revealed on 04/16/2020 at 7:00 AM, the patient's health care proxy provided telephone consent for notification of persons' rights in a mental health facility. Review of the bottom section of the form revealed no indication the patient's health care proxy was provided a written copy of the patient's rights.

A review of the medical record for Patient #7 revealed on 05/20/20 at 3:30 AM signed the Rights of Persons in Mental Health Facilities and a written copy provided to the patient. Further review of the medical record revealed the health care proxy for Patient #7 provided telephone consent for acknowledgement of the patient's rights. Review of the bottom section of the form revealed no indication the patient's health care proxy was provided a written copy of the patient's rights.

A review of the medical record for Patient #8 revealed on 07/30/2020 at 7:50 PM, The Patient signed the acknowledgement of the Rights of Persons in Mental Health Facilities and documentation a written copy was provided. Further review of the medical record revealed the health care proxy for Patient #8 provided telephone consent for acknowledgement of the patient's rights. Review of the bottom section of the form revealed no indication the patient's health care proxy was provided a written copy of the patient's rights.

Interview on 08/27/2020 at 2:00 PM with the Director of Patient Safety confirmed the above findings.

Based on clinical record review and staff interview it was determined the facility failed to obtain consent for psychotropic medication administration prior to administration of the drugs in one (#8) of eight patients sampled.

Findings included:

Review of the medical record for Patient #8 revealed on 07/30/2020 at 10:00 AM Patient #8 was deemed incompetent to provide express and informed consent by the psychiatrist.

Review of the medical record for Patient #8 revealed on 07/31/2020 at 10:12 AM, the facility administered Zyprexa and Depakote (psychotropic medications) prior to obtaining consent for the psychotropic medication administration. Further review of the medical record revealed the consent for Specific Authorization for Psychotropic Medication was obtained from the patient's health care proxy after the medications had already been administered. Review of the consent form revealed the proxy provided consent for administration on 07/31/2020 at 2:52 PM.

Interview on 08/27/2020 at 2:00 PM with the Director of Patient Safety confirmed the above findings.

Based on medical record review and staff interview it was determined the facility failed to provide a written copy of the rights to petition for Writ of Habeas Corpus in two (#5 and #7) of eight patients sampled.

Findings included:

Review of the medical record for Patient #5 revealed no evidence the patient received written notice for the Writ of Habeas Corpus (information of his/her right to file a petition to question the cause and legality of a patient's detention).

Further review revealed the facility's designee signed the form on 6/23/2020 at 1:48 AM with the section left blank on the individual that the facility provided a copy of the notice.

A review of the medical record for patient #7 revealed no evidence the patient received written notice for Writ of Habeas Corpus. On 05/21/2020 at 12:15 AM, the facility's designee signed the form with the section left blank on the individual that the facility provided a copy of the notice.

Interview on 08/27/2020 at 2:00 PM with the Director of Patient Safety confirmed the above findings.

Based on facility document review, policy and procedure review, medical record review, and staff interview it was determined the facility failed to adequately document the investigation for an allegation of sexual abuse for one (#2) of eight patients sampled.

Findings included:

Review of the facility policy, "Patient and Non-Patient Safety Event Notifications," stated the purpose was to establish the policy and outline procedures for reporting unusual and adverse or untoward patient related and non-patient related events, or potential patient safety related events, that occur within or around the hospital facility and property.

The policy stated under Procedure (A) Reporting: (5) other adverse/untoward incidents that are to be reported to the Patient Safety Director/Risk Manager/designee through the Meditech QM module Risk Management section include, but are not limited to issues/concerns involving: (a) allegations of sexual abuse/rape; (6) department directors are responsible for reviewing all patient notification event reports to which they are assigned, completing a thorough investigation and documenting findings in the notification report within 15 days; (7) the Patient Safety Director/Risk Manager/designee will complete reports within 60 days; (B) Event Follow-up (3) the Patient Safety Director/Risk Manager/designee will track statistical data for analysis and process improvement purposes; (C) Event Notification Report Review and Analysis: the patient safety director/risk manager/designee is responsible: (a) for the regular and systematic review of Patient Notification event reports and (c) providing the governing body with quarterly summary reports and maintaining summary data for three years.

Review of the patient notification event reporting log revealed an event, described as a grievance, was received by the Administrative Nursing Supervisor on 7/04/2018 at 3:00 pm from the mother of sampled patient #2. Documentation revealed the patient was admitted from 6/3 - 6/8/2018 on the Behavioral Health Unit (BHU). It was alleged the patient was sexually molested during her admission and she was going to report it to the police.

Review of the facility documents (emails) revealed on 7/04/2018 at 3:00 pm the Nursing Supervisor reported the information to the Chief Nursing Officer (CNO) and Director of BHU. A handwritten facility document, dated 7/05/2018 at 9:00 am, by the Administrative Nursing Supervisor, stated the cameras were to be reviewed, and to check all patients and staff with the specific name reported. At 10:06 am a telephone call was placed to the patient's mother and a voicemail left. At 2:37 pm documentation revealed the patient's mother was called again and interviewed via telephone. The patient's mother stated it was "an employee" that molested her daughter. She provided a description of the employee and that he was assigned to "watch" her (the patient) on either the 6th, 7th or 8th. Review of the facility document, "Employee Investigation", revealed on 7/5/2018 the CNO and Director of BHU interviewed employees in question and reviewed video tape. There was no documentation of which employees were interviewed nor any details of the interviews, and no documentation of the video tape review. The facility was unable to produce the video to view or provide a copy of the video.

Review of the document, "Employee Investigation", revealed on 7/6/2018 at 3:55 pm an employee identified as the potential perpetrator was interviewed by the Vice President of Operations, the Director of BHU, and Vice President of Quality. Documentation revealed the employee was interviewed but denied any wrong doing. The employee was placed on temporary suspension while the investigation was completed. At 4:09 pm the facility made a report to Department of Children & Family (DCF) and at 4:39 pm a report to the Sheriff's office was made. Documentation revealed a Sheriff's deputy presented to the facility on 7/6/2018 at 5:00 pm and a police report was completed. Documentation stated the deputy called the patient's mother and she reported the patient received multiple text messages from the employee (specific first name used and same as the employee interviewed). The deputy was provided with the phone number from which the alleged perpetrator was texting the patient from. When compared with the phone number of the employee which was interviewed by the facility it did not match.

Review of a facility document, written by the Director of BHU, revealed on 7/12/2018 the Director of BHU met with a detective conducting the investigation. The detective was provided two additional employee names as well as staffing sheets, and a copy of the video.

Review of a facility document, written by the Director of BHU, revealed on 7/18/2018 at 9:40 am, the Infection Control Coordinator fielded a call from an Adult Protective Investigator. The Investigator requested additional employee information on another male employee that was working at the time of the alleged sexual assault incident. Documentation stated the VP of Human Resources provided the requested information. Documentation stated the employee was then interviewed but he denied any inappropriate behavior. The employee was suspended at that time pending completion of the investigation. Documentation stated the detective called and requested the personal contact information for the employee. On 7/20/2018 the facility received an arrest notification from AHCA for this employee. Documentation revealed the employee was terminated on 7/25/2018 due to AHCA ineligible status.

Review of the facility documents, policy and procedures, and the facilities investigation revealed lack of evidence a comprehensive and thorough investigation was completed with documentation of findings; analysis of the investigation with potential for process improvements to ensure all patients were free from all forms of abuse. The VP of Quality was interviewed on 8/27/2020 at 1:50 pm and confirmed the above findings and that all documents related to the investigation and actions of the facility were provided at the time of the survey.

Based on review of the facility policy and procedures, documents, medical records, and staff interview it was determined the facility failed to ensure an adverse patient event was analyzed, and preventive actions were implemented for one (#2) of eight patients sampled; and failed to ensure the governing body, medical staff, and administrative officials were responsible and accountable for ensuring clear expectations for safety were established.

Findings included:

Review of the facility policy, "Patient and Non-Patient Safety Event Notifications," stated the purpose was to establish the policy and outline procedures for reporting unusual and adverse or untoward patient related and non-patient related events, or potential patient safety related events, that occur within or around the hospital facility and property.

The policy stated under Procedure (A) Reporting: (5) other adverse/untoward incidents that are to be reported to the Patient Safety Director/Risk Manager/designee through the Meditech QM module Risk Management section include, but are not limited to issues/concerns involving: (a) allegations of sexual abuse/rape; (6) department directors are responsible for reviewing all patient notification event reports to which they are assigned, completing a thorough investigation and documenting findings in the notification report within 15 days; (7) the Patient Safety Director/Risk Manager/designee will complete reports within 60 days; (B) Event Follow-up (3) the Patient Safety Director/Risk Manager/designee will track statistical data for analysis and process improvement purposes; (C) Event Notification Report Review and Analysis: the patient safety director/risk manager/designee is responsible: (a) for the regular and systematic review of Patient Notification event reports and (c) providing the governing body with quarterly summary reports and maintaining summary data for three years.

On 8/24/2020 at approximately 9:15 am a list of requested documents was provided to facility administrative staff which included a list of alleged abuse or neglect with facility documentation of investigation and actions implemented. The facility reported no allegations of abuse or neglect. On 8/26/2020 at 9:15 am the VP of Patient Safety stated upon further investigation the facility had a grievance on 7/4/2018 which alleged sexual misconduct against an employee on the Behavioral Health Unit (BHU).

Review of the patient notification event reporting log revealed an event, described as a grievance, was received by the Administrative Nursing Supervisor on 7/04/2018 at 3:00 pm from the mother of sampled patient #2. Documentation revealed the patient was admitted from 6/3 - 6/8/2018 on the BHU. It was alleged the patient was sexually molested during her admission and she was going to report it to the police. Interview with Vice President of Quality on 8/27/2020 at 1:50 pm confirmed the event reporting system had a category for abuse and confirmed the employee entered the event received on 7/04/2018 at 3:00 pm as a grievance.

Review of the facility documents (emails) revealed on 7/04/2018 at 3:00 pm the Nursing Supervisor reported the information to the Chief Nursing Officer (CNO) and Director of BHU. A handwritten facility document, dated 7/05/2018 at 9:00 am, by the Administrative Nursing Supervisor, stated the cameras were to be reviewed, and to check all patients and staff with the specific name reported. At 10:06 am a telephone call was placed to the patient's mother and a voicemail left. At 2:37 pm documentation revealed the patient's mother was called again and interviewed via telephone. The patient's mother stated it was "an employee" that molested her daughter. She provided a description of the employee and that he was assigned to "watch" her (the patient) on either the 6th, 7th or 8th. Review of the facility document, "Employee Investigation", revealed on 7/5/2018 the CNO and Director of BHU interviewed employees in question and reviewed video tape. There was no documentation of which employees were interviewed nor any details of the interviews, and no documentation of the video tape review. The facility was unable to produce the video to view or provide a copy of the video.

Review of the document, "Employee Investigation", revealed on 7/6/2018 at 3:55 pm an employee identified as the potential perpetrator was interviewed by the Vice President of Operations, the Director of BHU, and Vice President of Quality. Documentation revealed the employee was interviewed but denied any wrong doing. The employee was placed on temporary suspension while the investigation was completed. At 4:09 pm the facility made a report to Department of Children & Family (DCF) and at 4:39 pm a report to the Sheriff's office was made. Documentation revealed a Sheriff's deputy presented to the facility on 7/6/2018 at 5:00 pm and a police report was completed. Documentation stated the deputy called the patient's mother and she reported the patient received multiple text messages from the employee (specific first name used and same as the employee interviewed). The deputy was provided with the phone number from which the alleged perpetrator was texting the patient from. When compared with the phone number of the employee which was interviewed by the facility it did not match.

Review of a facility document, written by the Director of BHU, revealed on 7/12/2018 the Director of BHU met with a detective conducting the investigation. The detective was provided two additional employee names as well as staffing sheets, and a copy of the video.

Review of a facility document, written by the Director of BHU, revealed on 7/18/2018 at 9:40 am, the Infection Control Coordinator fielded a call from an Adult Protective Investigator. The Investigator requested additional employee information on another male employee that was working at the time of the alleged sexual assault incident. Documentation stated the VP of Human Resources provided the requested information. Documentation stated the employee was then interviewed but he denied any inappropriate behavior. The employee was suspended at that time pending completion of the investigation. Documentation stated the detective called and requested the personal contact information for the employee. On 7/20/2018 the facility received an arrest notification from AHCA for this employee. Documentation revealed the employee was terminated on 7/25/2018 due to AHCA ineligible status.

Review of the facility documents, policy and procedures, and the facility investigation revealed lack of evidence a comprehensive and thorough investigation was completed with documentation of findings; analysis of the investigation with potential for process improvements and preventative actions and mechanisms to ensure all patients were free from all forms of abuse. The VP of Quality was interviewed on 8/27/2020 at 1:50 pm and confirmed the above findings and that all documents related to the investigation and actions of the facility were provided at the time of the survey.