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Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure patient care plans were individualized and revised with problems, goals and interventions that would meet the assessed patient care needs for one (1) of ten (10) sampled patients, Patient #1 (P1).

The findings include:

Review of the facility's policy, "Suspected Abuse/Neglect/Exploitation of Patients and Reporting", dated 11/01/2019, revealed the purpose of the policy was to ensure patients were free from all forms of abuse, neglect, harassment or exploitation from staff, volunteers, other patients, or visitors.

Review of the facility's policy, "Patient Rights and Responsibilities", undated, revealed patients had the right to receive considerate, respectful and compassionate care with dignity and comfort, including consideration of their personal time, values, and beliefs. Further review revealed the patient had the right to be free from verbal or physical abuse, negligence or harassment. Continued review of the policy revealed patients had the right to expect reasonable safety. Additionally, patients had the right to participate in the development and implementation of their plans of care and to make decisions regarding that care.

Review of P1's face sheet revealed the facility admitted P1 on 05/16/2024 with diagnoses which included intermittent explosive disorder and seizure disorder. Further review revealed the facility assessed P1's insight as severely impaired and P1 had chronic poor impulse control. Continued review revealed the facility assessed P1 as intellectually disabled.

Review of P1's notes, dated 07/18/2024 at 10:40 AM, revealed the facility had not allowed P1 to attend group sessions due to inappropriate sexual behavior and language toward staff, and P1 had been verbally threatening staff. Further review revealed the facility's treatment team felt P1 required a behavior plan to reduce behaviors with the plan reviewed during the team meeting. Continued review revealed the facility assessed P1 to have problems with agitation, altered thought process, anxiety, confusion, violent behavior with possibility for restraint use, sexually acting out, impaired social interaction, and risk for violence directed toward self or others.

Review of P1's Care Plans revealed P1 was placed on 7.5 minute checks after the patient incident on 07/15/2024, in which P1 and P2 were found in a sexually inappropriate position, and had continued on them until discharge from the facility in January 2025. However, there was no evidence P1's care plan was updated with all the inappropriate interactions/behaviors.

During an interview with the Unit Manager (UM) 1, on 01/21/2025 at 2:30 PM, UM1 stated P1 had been involved with many altercations with other peers and staff since the 07/15/2024 incident and most staff and some peers were afraid of him. UM1 further stated P1 had inappropriate physical actions with peers and staff, both physically and sexually. UM1 stated she reviewed P1's care plan interventions each time he had an "incident" with another peer or staff and the "team" which included the therapist and other staff also reviewed the care plan. UM1 stated she realized the 7.5 minute checks wasn't working well to deter P1's behavior. UM1 continued to state the facility did have the ability to provide 1:1 care for P1, but she hadn't thought of that intervention. She also stated staff would have to be selected carefully because some staff were afraid of P1 and it might be a dangerous situation to place a staff member with P1 continuously.

Unable to interview P1, as he is currently in jail for an assault on a staff member.

Based on interview, record review, review of the facility's incident reports, and review of the facility's policies, it was determined the facility failed to ensure patients received care in a safe setting for four (4) of ten (10) sampled patients, Patient 1 (P1), P2, P3 and P4.

The findings include:

Review of the facility's policy, "Suspected Abuse/Neglect/Exploitation of Patients and Reporting", dated 11/01/2019, revealed the purpose of the policy was to ensure patients were free from all forms of abuse, neglect, harassment or exploitation from staff, volunteers, other patients, or visitors.

Review of the facility's policy, "Patient Rights and Responsibilities", undated, revealed patients had the right to receive considerate, respectful and compassionate care with dignity and comfort, including consideration of their personal time, values, and beliefs. Further review revealed the patient had the right to be free from verbal or physical abuse, negligence or harassment. Continued review revealed patients had the right to expect reasonable safety.

Review of P1's face sheet revealed the facility admitted P1 on 05/16/2024 with diagnoses which included intermittent explosive disorder and seizure disorder. Further review revealed the facility assessed P1's insight as severely impaired and P1 had chronic poor impulse control. Continued review revealed the facility assessed P1 as intellectually disabled.

Review of P1's notes, dated 07/18/2024 at 10:40 AM, revealed the facility had not allowed P1 to attend group sessions due to inappropriate sexual behavior and language toward staff, and P1 had been verbally threatening staff. Further review revealed the facility's treatment team felt P1 required a behavior plan to reduce behaviors with the plan reviewed during the team meeting. Continued review revealed the facility assessed P1 to have problems with agitation, altered thought process, anxiety, confusion, violent behavior with possibility for restraint use, sexually acting out, impaired social interaction, and risk for violence directed toward self or others.

Review of P1's Care Plans revealed P1 was placed on 7.5 minute checks after the patient incident on 07/15/2024, in which P1 and P2 were found having inappropriate sexual contact, and had continued on them until discharge from the facility in January 2025. However, there was no evidence P1's care plan was undated with all the behaviors following that date.

Interview with the Unit Manager (UM) 1 for the unit on which the resident resided, she stated P1 had been involved with many altercations with other peers and staff since the 07/15/2024 and most staff and some peers were afraid of him. She further stated he had inappropriate physical actions with peers and staff, both physically and sexually. She stated she realized the 7.5 minute checks weren't working well to deter P1's behavior.

Unable to interview P1, as he is currently in jail for an assault on a staff member.

During an interview with P1's State Guardian, she stated she was responsible for making decisions for the resident and had been called multiple times for incidents involving P1 and other peers and staff. She stated P1 was currently in jail but she doesn't know which incident caused his arrest. P1's State Guardian further stated she never gave permission for any of her guardianship patients to have sexual relations.

Review of the facility's Final Expanded Investigative Report, dated 10/16/2024, revealed P3 notified facility staff someone was hiding in her bathroom on 10/03/2024. Upon investigation, the facility determined P1 was in P3's bathroom. P1 stated he entered the bathroom to scare P3 but he later reported he performed oral sex on P3 in the shower. P3 denied oral sex. The facility transferred P3 to another unit.

Review of camera footage for 10/03/2024 revealed no footage was available at the time P1 and P3 exited P3's room.

Review of the facility's Final Expanded Investigative Report, dated 11/18/2024, revealed P1 touched P4 inappropriately twice on 11/04/2024. Further review revealed one (1) incident was witnessed by staff and the second (2nd) incident was reported by P4. Further review revealed P1 and P4 were attending an evening group meeting on 11/04/2024 when staff witnessed P1 put his hand on P4's butt and staff told P1 to stop. Following the group meeting, P1 and P4 were on the porch and P4 reported P1 touched her breast and stated he was "going to put his penis in P4's mouth" and come to P4's room to "do stuff to her". P4 stated in an interview to the facility staff she did not tell P1 he could touch her on the butt or breast. Continued review revealed P4 was moved to another unit.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure patients were free from abuse for four (4) of ten (10) sampled patients, Patient #1 (P1), P2, P3, and P4.

The findings include:

Review of the facility's policy, "Suspected Abuse/Neglect/Exploitation of Patients and Reporting", dated 11/01/2019, revealed the purpose of the policy was to ensure patients were free from all forms of abuse, neglect, harassment or exploitation from staff, volunteers, other patients, or visitors.

Review of the facility's policy, "Patient Rights and Responsibilities", revealed patients had the right to receive considerate, respectful and compassionate care with dignity and comfort, including consideration of their personal time, values, and beliefs. Further review revealed the patient had the right to be free from verbal or physical abuse, negligence or harassment. Continued review revealed patients had the right to expect reasonable safety. Additionally, patients had the right to participate in the development and implementation of their plans of care and to make decisions regarding that care.

Review of P1's face sheet revealed the facility admitted P1 on 05/16/2024 with diagnoses which included intermittent explosive disorder and seizure disorder. Further review revealed the facility assessed P1's insight as severely impaired and P1 had chronic poor impulse control. Continued review revealed the facility assessed P1 as intellectually disabled.

Review of P1's notes, dated 07/18/2024 at 10:40 AM, revealed the facility had not allowed P1 to attend group sessions due to inappropriate sexual behavior and language toward staff, and P1 had been verbally threatening staff. Further review revealed the facility's treatment team felt P1 required a behavior plan to reduce behaviors with the plan reviewed during the team meeting. Continued review revealed the facility assessed P1 to have problems with agitation, altered thought process, anxiety, confusion, violent behavior with possibility for restraint use, sexually acting out, impaired social interaction, and risk for violence directed toward self or others.

Review of P1's Care Plans revealed P1 was placed on 7.5 minute checks after the patient incident on 07/15/2024, in which P1 and P2 were found by staff to be having sexual contact, and had continued on them until discharge from the facility in January 2025

Interview with the Unit Manager (UM) 1 for the unit on which the resident resided, she stated P1 had been involved with many altercations with other peers and staff since the 07/15/2024 and most staff and some peers were afraid of him. UM1 further stated he had inappropriate physical actions with peers and staff, both physically and sexually. UM1 stated she realized the 7.5 minute checks wasn't working well to deter P1's behavior. UM1 continued to state the facility did have the ability to provide 1:1 care for P1, but she hadn't thought of that intervention. UM1 also stated staff would have to be selected carefully because some staff were afraid of P1 and it might be a dangerous situation to place a staff member with P1 continuously.

Unable to interview P1, as he is currently in jail for an assault on a staff member.

Review of the facility's Final Expanded Investigative Report, dated 10/16/2024, revealed P3 notified facility staff someone was hiding in her bathroom on 10/03/2024. Upon investigation, the facility determined P1 was in P3's bathroom. P1 stated he entered the bathroom to scare P3 but he later reported he performed oral sex on P3 in the shower. P3 denied oral sex. The facility transferred P3 to another unit.

Review of camera footage for 10/03/2024 revealed no footage was available at the time P1 and P3 exited P3's room.

Review of the facility's Final Expanded Investigative Report, dated 11/18/2024, revealed P1 touched P4 inappropriately twice on 11/04/2024. Further review revealed one (1) incident was witnessed by staff and the second (2nd) incident was reported by P4. Further review revealed P1 and P4 were attending an evening group meeting on 11/04/2024 when staff witnessed P1 put his hand on P4's butt and staff told P1 to stop. Following the group meeting, P1 and P4 were on the porch area and P4 reported P1 touched her breast and stated he was "going to put his penis in P4's mouth" and come to P4's room to "do stuff to her". P4 stated in an interview to the facility staff she did not tell P1 he could touch her on the butt or breast. Continued review revealed P4 was moved to another unit.