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Based on document review, videotape review, observations, and interview it was determined that the Hospital failed to ensure patients were protected from sexual assault, and the opportunity to commit self harm or suicide. This deficient practice placed current and future patients at risk for serious harm. As a result, the Condition of Participation (42 CFR 482.13) Patient Rights was not in compliance.

Findings Include:

1. The Hospital failed to ensure that staff properly monitored patients who were placed on sexual aggression/sexual victimization precautions, to prevent the opportunity for sexual assault. (A -144A)

2. The Hospital failed to ensure that staff properly monitored the safety of patients, including escorting them to and from the bathroom. (A - 144B)

The immediate jeopardy (IJ) began on May 5, 2018 due to the Hospital's failure to monitor patients during bathroom use thus, placing all psychiatric patients at potential risk for serious harm. An allegation of rape followed.

An IJ was identified on May 16, 2018.

The IJ was announced on May 16, 2018 at 3:15 PM, during a meeting with the Chief Executive Officer (E #1), Chief Nursing Officer (E #2), and Associate Hospital Administrator/ Director of Risk Management (E #9). The Hospital failed to fully implement and evaluate corrective actions. The IJ was not removed by the exit date of May 17, 2018.

A. Based on document review, videotape review, and interviews, it was determined that for 2 of 2 patients (Pt. #1 and Pt. #2), the Hospital failed to ensure that staff adequately monitored patients on sexual aggression and sexual victimization precautions, to prevent the opportunity for sexual assault.

Findings Include:

1. The Hospital's policy titled, "Patient Rights and Responsibilities" (revised 01/2012) was reviewed on 5/15/18 and included, "render care in a way that...protects the personal dignity of each patient..."

2. The Hospital's "Unit Guidelines" (undated) were reviewed on 5/15/18. The guidelines included, "...Staff must be present in the hallway when there's a patient in the hallway or room..."

3. The Hospital's "Practice Guidelines for Suicide Precaution Patients and Bathroom/Hallway Monitoring" (reviewed 5/8/18) was reviewed on 5/15/18. The guidelines included, "...Staff instructed to monitor patient more frequently and re-check on patient at close interval while in the bathroom..."

4. The Hospital's policy titled, "Precautions System" (revised 01/2015) was reviewed on 5/14/18. The policy included, "...Sexual Aggression...Patient will not be alone with other patients at anytime..."

5. On 5/14/18 at 11:00 AM, Pt. #1's medical record was reviewed. Pt. #1 was a 14 year old female admitted on 4/27/18, with a diagnosis of disruptive mood dysregulation. Pt. #1's precautions included suicide, assault, self-injury, and sexual victimization.

6. A Registered Nurse's (E #5) progress notes dated 5/6/18 included, "Pt. [Pt. #1] was requesting to speak to a female Nurse ...Pt. [Pt. #1] was tearful and reported to RN (Registered Nurse) that yesterday after lunch she [Pt. #1] went to her bathroom in room 211 to urinate. When she [Pt. #1] opened the bathroom door, male peer [Pt. #2] came into the bathroom and had sex with her [Pt. #1]. Pt. [Pt. #1] reported ...that the sex was non-consensual ...Pt. [Pt. #1] reported peer [Pt. #2] ejaculated inside of her then left the bathroom without speaking ...RN immediately separated Pt. [Pt. #1] from peer [Pt. #2], notified hospital supervisor ...notified police department ...notified psychiatrist..."

7. Pt. #1's emergency room record dated 5/7/18 included, "Diagnosis...sexual assault of child by bodily force by person unknown to victim ..."

8. On 5/14/18 at 1:00 PM, Pt. #2's medical record was reviewed. Pt. #2 was a 16 year old male admitted on 5/5/18, for disruptive mood dysregulation disorder. Pt. #2's precautions included self-injury, assault, elopement, sexual aggression, and sexual victimization.

9. On 5/14/18 between 1:05 PM and 2:15 PM, a video of the incident on 5/5/18 between 1:00 PM to 1:38 PM, was reviewed. At 1:00 PM, the alleged sexual assault victim (Pt. #1) and the alleged perpetrator (Pt. #2) were sitting at a table in the 2 West day room with other patients and a staff member, participating in a group exercise. Pt. #1 and Pt. #2 were sitting next to each other, but not talking. At 1:14 PM, Pt. #1 spoke to Pt. #2 and both got up from the table, sat together in a corner of the day room, and engaged in conversation. At 1:28 PM, both patients left the day room.

10. A video camera in the 2 West corridor captured a staff member unlocking the door to room 211 at 1:28 PM, and allowed Pt. #1 to enter. At 1:29 PM, the same staff member unlocked the door to Room 216 for Pt. #2. The staff member walked away from the unlocked rooms, back toward the day room. Approximately 15 seconds later, Pt. #2 exited Room 216, and walked into Room 211. Pt. #2 was in Room 211 with Pt. #1 for more than 6 minutes. Pt. #2 exited Room 211 at 1:35:37 PM and Pt. #1 left Room 211 at 1:37:13 PM.

11. On 5/15/18 at approximately 9:00 AM, an interview was conducted with Pt. #1 on a female only Unit (2 North). The Clinical Nurse Officer (E #2) and a Behavioral Health Technician (E #10) were present during the interview for Pt. #1's comfort. Pt. #1 stated that on Saturday 5/5/18, she left the day room to go the bathroom, Pt.#2 entered the bathroom where she [Pt. #1] was and began to touch her inappropriately. Pt. #1 stated Pt. #2 lowered her to the floor and sexually assaulted her. Pt. #1 stated that she has nightmares about the sexual assault.


12. On 5/15/18 at approximately 9:30 AM, an interview was conducted with Pt. #2. Pt. #2 stated that on Saturday May 5, 2018 he was sitting in the day room and Pt. #1 asked him if he wanted to have sex. Pt. #2 stated that he and Pt. #1 agreed that she [Pt. #1] would go to the bathroom and that he [Pt. #2] would also go to the bathroom. Pt. #2 stated that the plan was for him to meet Pt. #1 in the bathroom and have sexual intercourse. Pt. #2 stated that he initially went to a separate bathroom from Pt. #1 and then went to room 211 to the bathroom where Pt. #1 was waiting for him. Pt. #2 stated that he had consensual sex with Pt. #1 in the bathroom.

13. On 5/14/18 at 2:30 PM, an interview was conducted with the Charge Nurse (E #3). E #3 was able to verbalize the protocol for hallway and bathroom patient monitoring. E #3 stated that when patients are in the bathroom, staff must remain in the hallway.

14. On 5/15/18 at 1:20 PM, an interview was conducted with a Behavioral Health Technician (E #4). E #4 was able to verbalize the protocol for hallway and bathroom patient monitoring. E #4 stated that staff must wait in the hallway when patients are in the bathroom.

15. On 5/14/18 at approximately 11:09 AM, an interview with the Chief Nursing Officer (E #2) was conducted. E #2 stated that on 4/10/18 the staff were educated to remain in the hallway when patients are in the hallway or room.

16. On 5/15/18 at 1:05 PM, an interview was conducted with Pt. #1's Physician (MD #2). MD #2 stated that the expectation is that the staff will "closely monitor patients" when on precautions like sexual victimization and sexual aggression.


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B. Based on document review, observation, and interview, it was determined, that for 6 of 6 patients (Pts. #11 - 16), the Hospital failed to ensure that staff properly monitored the safety of patients, including escorting them to and from the bathroom.

Findings include:

1. On 5/16/18 at 1:00 PM, the Hospital's "Plan for Improving Monitoring Patients on Units," implemented on 5/7/18, was reviewed. The Plan included, "Whenever patients are escorted to the bathroom, the staff must wait to escort them out..."

2. On 5/15/18 between 1:10 PM and 2:45 PM, a video tape of the 2 South corridor on 5/11/18 between 9:45 AM and 10:45 AM, and on 5/11/18 from 12:15 PM to 1:20 PM, was reviewed. Two (2) South is a Psychiatric Intensive Treatment Unit for male children. During the 2 hours of video, 6 children (Pts. 11 - 16) were observed being escorted to a patient room (Room 200). The door to Room 200 was unlocked by a staff member each time, to allow the male child to enter and use the washroom. On every occasion, the staff member left the room and walked out of the video range (approximately 25 feet from Room 200).

- At 9:53:50 AM, a Registered Nurse (E #7) unlocked Room 200, allowing Pt. #11 to enter. Pt. #11 was on suicide precautions, but had "zero plan" for suicide. E #7 left Pt. #11 alone in the room, but remained in the corridor checking vital signs, approximately 20 feet from room 200. Pt. #11 left Room 200 at 9:56:30 AM. Pt. #11 was unobserved, for 2 minutes and 40 seconds.

- At 9:59:50 AM, a Program Specialist (E #8) unlocked Room 200, allowing Pt. #12 to enter. Pt. #12 was on suicide precautions, with a plan to "overdose, shoot self, bash head on wall". E #8 left Pt. #12 alone in the room and walked toward the camera, and out of view. Pt. #12 emerged from Room 200 at 10:00:45 AM, less than 1 minute after entering.

- At 10:05:00 AM, E #8 unlocked Room 200, allowing Pt. #13 to enter. Pt. #13 was on assault and elopement precautions. E #8 left Pt. #13 alone in the room. Pt. #13 left at 10:05:15 AM, but returned at 10:05:40 AM and re-entered Room 200, unescorted by staff. (The door had been left unlocked.)

- At 10:05:45 AM, E #8 escorted Pt. #12 (second time) to Room 200, where Pt. #13 remained, and went into the room with both boys. There is only 1 washroom and 1 toilet. At 10:08:05, E #8 and Pt. #12 left the room. Pt. #13 was still in Room 200. At 10:14 AM, a housekeeper entered Room 200 and left approximately 1 minute later. Pt. #13 left the room at 10:16 AM.

- At 10:25:15 AM, E #8 escorted Pt. #14 to Room 200, and unlocked the door, allowing Pt. #14 to enter. Pt. # 14 was on homicidal, assault, and elopement precautions. E #8 left the room. At 10:33:55 AM, E #8 made safety rounds, entered Room 200, and left approximately 10 seconds later. Pt #14 left the room at 10:35:30 AM.

3. On 5/15/18 at approximately 1:00 PM, the Chief Nursing Officer (E #2) stated that lunch on 2 South is at 12:30 PM, and most of the boys on 2 South go to the first floor cafeteria. A few boys remain on the Unit for lunch. Video of the 2 South corridor on 5/11/18 from 12:15 PM to 1:20 PM, was observed.

- Between 12:15 PM and 12:56 PM, there was no activity in the corridor.

- At 1:02:45 PM, a Behavioral Health Technician (E #4) escorted Pt. #15 and unlocked room 200, allowing Pt. #15 to enter. Patient 15 was on assault precautions. E #4 left the room within 10 seconds of entering the room. At 1:05:30 PM E #4 went into room 200 and left approximately 10 seconds later. At 1:06:40 PM, Pt. #15 left room 200.

- At 1:12:45 PM, E #4 escorted Pt. #16 and unlocked room 200, to allow Pt. #16 to enter. Pt. #16 was on homicidal, assault, and elopement precautions. E #4 left the room within 10 seconds of opening the door, and Pt. #16 left the room at 1:13:25 PM.

4. On 5/16/18 at 8:40 AM, an interview was conducted with the Chief Nursing Officer (E #2). E #2 stated that staff do not have to be in or near the room when patients use the washroom. Staff can be anywhere in the hall. Staff are expected to check the patients in the washroom more often than every 15 minutes, but stated there was no set time interval for checking. E #2 stated that a Nurse who is administering vital signs is unable to monitor the hall when concentrating on the other patients. E #2 stated it can take as little as 30 seconds for a patient to hang themselves.