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Based on document review, video surveillance and interview, it was determined that the Hospital failed to ensure patients exhibiting sexually acting out behaviors were monitored to ensure the safety of patients and that staff were removed from assignment after an allegation of abuse. This potentially places any patient in the Hospital at risk for serious harm, serious injury or serious impairment. 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 patients exhibiting sexually acting out behaviors were monitored to ensure the safety of patients. This failure led to an alleged sexual assault of a vulnerable behavioral health unit patient (Pt #1). See deficiency at A - 145 A

2. The Hospital failed to ensure that patients remain free from abuse, by not removing alleged staff from duty pending investigation of an abuse allegation. See deficiency at A - 145 B

The immediate jeopardy began on 5/7/2023, due to the Hospital's failure to ensure that staff were removed from assignment after an allegation of abuse and patients were monitored. This resulted in an alleged sexual assault of a vulnerable behavioral health patient; and was identified on 5/22/2023 at 42 CFR 482.13, Patient Rights. The IJ was announced on 5/22/2023 at 3:15 PM during a meeting with the Chief Executive Officer, Chief Nursing Officer, Director of Performance Improvement, Chief Operating Officer and Chief Clinical Officer and was removed by the survey exit date of 5/23/2023.

A. Based on document review, video surveillance and interview, it was determined that for 1 of 1 behavioral health patients (Pt #1) involved in an incident of alleged sexual assault, the Hospital failed to ensure patients exhibiting sexually acting out behaviors were monitored to ensure the safety of patients. This failure led to an alleged sexual assault of a vulnerable behavioral health unit patient (Pt #1).

Findings include:

1. The Hospital's policy titled, "Patient Observation" (dated 11/2022), included, "Staff assigned to conduct walking rounds, as part of routine safety monitoring and observation duty shall ensure that the patient hallway is monitored during any assigned room time ...MHA [mental health associate]: While monitoring hallways and patient care areas ensure patients are: not entering rooms not assigned to them ...Visually observe patients when behind closed doors, open the door and visually observe the safety of the patient ..."

2. The Hospital's policy titled, "Patient Precautions" (dated 3/2021), included, "Sexual Acting Out: Sexual victimization-Patients who are vulnerable for sexual victimization due to intellectual disability (ID), developmentally challenged, sexually provocative/hypersexual behaviors, victims of sexual abuse ...Interventions to consider but not limited to the following: ...monitor person-to person interactions, the physician and staff to meet with the patient who has been placed on SAO precautions and communicate the clear expectation that the patient is not to engage in sexual activity with others while in the hospital, redirect patients who are observed in sexually provocative behaviors, sexual activity between patients while in the hospital, whether consensual or not, is prohibited ..."

3. The clinical record for Pt #1 was reviewed on 5/18/2023. Pt. #1 was admitted to the Hospital's 2 North behavioral health unit on 4/26/2023. Pt #1 was on SAO (sexually acting out), suicide (high risk), SIP (self-injury), and elopement precautions upon admission. Pt #1 was transferred to the ITU (Intensive Treatment Unit)/acute) on 5/2/2023, due to "inappropriate and disruptive behavior".

- The Nurse-to-Nurse Report upon admission (4/26/2023) included, "Suicidal ideation with a plan to stab herself with a knife or overdose cut arm with knife yesterday. Pt having out of control rages not compliant with medications. Poor boundaries SAO ..."

- Pt #1's level of observation order (dated 4/26/2023) was "Every 15 minutes" (rounding).

- The Psychosocial Assessment (dated 4/29/2023), included, "Per report, the patient with ID [intellectual disability] and autism ...The patient has a history of suicide attempts and SAO behaviors ...She [Pt #1's mother/guardian] notes that the patient is sexually inappropriate and doesn't like to take no for an answer when people reject her sexual advances ...She feels that the patient is not high functioning enough ...the patient has the mentality of a 9 year old ...Abuse History: ...the patient was sexually abused twice by individuals that she did not know ...Sexual Victimization: Victim of sexual abuse".

4. On 5/9/2023, an allegation of sexual abuse was made by Pt #1, indicating that Pt #2 entered her room , pulled down her pants, and that she was sexually assaulted. Pt #1 was sent out to the local hospital for medical evaluation.

5. A Nursing Note (dated 5/9/2023 at 8:30 PM), documented by the Nursing Supervisor on-call (E #5), included, "Pt observed in the milieu [open social environment] anxious and alleging that she was raped by a peer. Pt stated he went inside my room and pulled my pants down ...Pt was sent out to [local Hospital] at 8:15 PM w/a [with a] female staff escort..."

6. The Discharge Summary (dated 5/17/2023), included, " ...On 5/9/2023 patient was transferred to the emergency room. Patient stated that she was raped by a peer. Patient was medically cleared and returned. Patient continued to report that she was sexually assaulted at [Hospital] ..."

7. An Investigation Summary (of incident), dated 5/9/2023, included, "...[Pt #1]...The patient has sexual abuse and rape history. During all admissions, including the current one, the patient is hyper-sexual and requiring constant redirection regarding conversations, behaviors, and contact of sexual nature. At the time of admission, the patient was admitted to our general adult unit. She was transferred to our Intensive Treatment Unit due to her sexualized and inappropriate behaviors with peers .... [Pt #2/alleged perpetrator] was admitted on 5/4/2023 after becoming non-compliant with medications and increasing symptoms of depression. On 5/9/2023, during phone time, the patients [Pt #1 and Pt #2] were noted to be talking in the hallway by [Pt #1]'s room. They engaged in two quick kisses and a hug. Then [Pt #2] entered [Pt #1's] room and closed the door. He exited the room 2.5 minutes later...At this point, [Pt #1] exits her doorway and walks to the dayroom. She talks to staff and reports that she was sexually assaulted by [Pt #2]. The investigation was reported and initiated by the Chief Compliance Officer (E #7). Following the investigation, there were no changes made to ensure or prevent similar subsequent events from occurring. As of 5/23/2023 45% of staff have not been educated to the new changes implemented and audits have not begun to verify sustained compliance.

8. The clinical record for Pt #2 was reviewed on 5/18/2023. Pt #2's clinical record indicated that the patient was admitted to the unit and placed sexually acting out, assault, and elopement precautions. According to Pt #2's discharge summary, "the night prior to discharge, patient was inappropriate with female peers on the unit. Patient reported he had intercourse with her and that it was consensual ..."

- Pt #2's Psychosocial Assessment (dated 5/8/2023), indicated that he had potential for sexual perpetration due to psychosis with sexual preoccupation. Pt #2's level of observation was "Every 15 minutes." Pt #2 discharged on 5/10/2023.

9. Video footage from ITU on 5/9/2023 (date of alleged event with Pt #1 and Pt #2) was reviewed with the Chief Compliance Officer (E #7). The video indicated that Pt #1 and Pt #2 had verbal exchange outside of Pt #1's room. Pt #2 then had physical contact (kissing/hugging) with Pt #1 outside of Pt #1's door. Both patients then entered Pt #1's room. The door was closed, and Pt #2 exited Pt #1's room approximately 3 minutes later. The assigned MHA/hall monitor was behind the nurse's station attending to other patients at the time of the alleged incident. No other staff were in the hallway at the time of the incident. The nurse's station is located on the same side of the hallway as Pt #1's room. Therefore, staff are unable to visualize Pt #1's room from the nurse's station.

10. On 5/18/2023 at 1:15 PM, an interview was conducted with the Nursing Supervisor (E #5). E #5 stated that she spoke to Pt #1 regarding the allegation with Pt #2. E #5 stated that Pt #1 said that she was raped by another male patient as he pulled down her pants and penetrated her. E #5 stated that Pt #1 was sent to the ER and did not return until Pt #2 was discharged. E #5 stated that patients on SAO are protected by blocking their room, monitoring them closely, and doing rounds as required. E #5 stated that this incident with Pt #1 was reported to the police.

11. On 5/22/2023 at 9:05 AM, an interview was conducted with the MHA (E #8/assigned hall monitor on date of 5/9/2023 incident). E #8 stated that he was behind the nurse's station assisting other patients when the alleged incident occurred between Pt #1 and Pt #2. E #8 stated that someone should always be in the halls to monitor the patients for safety. E #8 stated that patients who are on SAO precautions should have their doors always opened, and other patients are not allowed in their rooms.

12. On 5/22/2023 at 9:10 AM, an interview was conducted with E#4 (RN). E #4 stated that she was on duty on the evening that Pt #1 made the allegation against Pt #2. E #4 stated that she sent Pt #1 out to the hospital following the allegation and the nursing supervisor was made aware. E #4 stated that patients on SAO precautions are not allowed to close their doors and no other patients are allowed to enter their room. E #4 stated that sexual activity is not allowed in the Hospital.

13. On 5/22/2023 at 9:35 AM, an interview was conducted with the Chief Compliance Officer (E #7). E #7 stated that regarding Pt #1's allegation on 5/9/2023, Pt #1 and Pt #2 were only in the room approximately 2.5 minutes and Pt #1 invited Pt #2 into the room. E #7 stated that, however, the Hospital's policy is to keep the patient room doors open when the patients are in the room.

B. Based on document review and interview, it was determined that for 1 of 4 (Pt #1) patients reviewed for abuse, the Hospital failed to ensure that patients remain free from abuse, by not removing alleged staff from duty pending investigation of an abuse allegation.

Findings include:

1. The Hospital's policy titled, "Hospital Staff Responsibility for Patient, Visitor, and Employee Safety (dated 3/2021), included, " ...Allegations of Patient Abuse: Allegations shall be managed as follows: When an allegation is made, the staff member involved may be removed from the unit and/or suspended pending investigation...The Administrative Team shall work in conjunction with Human Resources to determine disciplinary course of action upon completion of the investigation."

2. The clinical record for Pt #1 was reviewed on 5/18/2023. Pt. #1 was admitted to the Hospital's 2 North behavioral health unit on 4/26/2023. Pt #1 was on SAO (sexually acting out), suicide (high risk), SIP (self-injury), and elopement precautions upon admission. Pt #1 was transferred to the ITU (Intensive Treatment Unit)/acute) on 5/2/2023, due to "inappropriate and disruptive behavior".

3. On 5/7/2023, Pt #1 made an allegation against a male staff (E #3/mental health associate) indicating that he made sexual passes towards her, "he wants to have oral sex with me". E #4/assigned RN was made aware of the allegation by another MHA (E #6). E #3 remained working on the unit after the abuse allegation was made towards him. Pt #1's observation level remained at "Every 15-minute rounds", following the alleged event.

4. An MHA Note (dated 5/7/2023 at 9:00 PM), included, "Pt was observed as ...teary. She was addressed by the nurse and by the MHA reporting she was verbally assaulted by the MHA staff. She states an MHA made sexual passes towards her making her uncomfortable ...She fears for her life. Q [every]15 min rounds as safety precautions ..."

5. Investigative Summary of incident (dated 5/9/2023), included, "On 5/7/2023, the patient reported to staff that a staff member who had been working all day had made sexually inappropriate statements to her in the dayroom. The following day, the patient changed her story and added that the staff member came to her room, shut the door and 'fingered' her. She said that he left and said he would be back for oral sex..."

- The alleged staff member (E #3) was not removed from patient care immediately upon notification of an abuse allegation. E #3 was allowed to work until the end of the shift on 5/7/2023 (11:30 PM).

6. On 5/18/2023 at 1:15 PM, a phone interview was conducted with the Nursing Supervisor (E #5). E #5 stated that an abuse allegation should immediately be reported to the nursing supervision. E #5 stated that staff are immediately removed from the unit, pending an abuse allegation investigation.

7. On 5/22/2023 at 9:35 AM, an interview was conducted with the Chief Compliance Officer (E #7). E #7 stated that when they have an abuse allegation, they have to take into consideration and look at who the alleger is. E #7 stated that E #3 (alleged staff) was not taken off duty, because they don't want to just go and disrupt the unit by removing staff for all allegations. E #7 stated that they have to look at the clinical presentation of the patient as part of the investigation.