HospitalInspections.org

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Based on document review and interview, in one (1) of ten medical records reviewed, the facility failed to investigate an allegation of sexual interaction between two pediatric patients and implement actions to ensure the safety of patients in the Adolescence Behavioral Health Unit (Patient #1).

Findings include:

Patient #1, an 11-year-old female with psychiatric history was admitted on 11/25/2019 for psychiatric evaluation and treatment. On 12/10/2019, she was discharged back to her residential home in stable condition.

A report was submitted to the New York State Department of Health that indicated this patient reported that she engaged in sexual activity with a twelve-year-old patient who gained access to her room while staff was at the nurses' station.

On 05/25/2021, at 01:12 pm, during an interview with Staff D (Patient Services Administrator), she acknowledged that about a week after the patient was discharged, she received a notice that she had an encounter with a peer.

Review of facility's incident reports revealed no evidence that the allegation was documented and investigated to determine its validity and to prevent any possible re-occurrences in the future.

Review of "Allegation of Physical/Sexual Abuse of Patient" (Reviewed and Revised: 02/24/20) policy stated "In order to properly investigate allegations of physical/sexual assault the Security Department in conjunction with Patient Relations/Patient Services and Human Resources will follow standardized procedures to ensure the appropriate disposition of any allegations."

On 05/25/2021 at 11:41 am, during an interview with Staff C (Quality and Patient Safety Director), she stated that no investigation was conducted because the first name of the other patient provided by Patient #1 did not match any patient that was admitted when she was at the facility. Staff C added that the case was already reported to the New York State Justice Center by another facility.

On 05/25/2021 at 01:22 pm, during an interview with Staff A (Patient Care Director) she stated "Typically, we would inform Patient Services and Quality Department, if it requires an investigation, but we learnt about this through another source."

On 05/26/2021, at approximately 4 pm, these findings were brought to the attention of facility administrative personnel during an exit conference.