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Based on interview, record review, and policy review, the facility failed to assess for appropriate room placement for four patients (#8, #9, #10, and #11) of four patients allegedly involved in non-consensual sexual activity. (There were two separate incidents each involving two of the patients.) The facility failed to take into account patient history of inappropriate sexual behavior and aggression, function level differences, and patient and staff concerns regarding roommate dynamics. These failures increased the risk for physical and sexual abuse for all patients in double occupancy rooms in the facility. The consideration of roommate appropriateness was significant given that the average length of stay in the facility for patients was three years. The facility census was 94. The census for patients sharing a double occupancy room was 54.

In addition, the facility failed to perform Root Cause Analysis (a process for identifying the causes of an unexpected occurrence) as per their policy of the first alleged sexual incident on 04/22/14 and implement new processes to prevent re-occurrence of that type of incident. This failure increased the potential for the second alleged sexual incident on 06/02/14 to occur and placed patients at immediate risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 06/26/14, prior to the surveyor team exit, the facility provided a plan of correction sufficient to abate the IJ by immediately implementing the following:
- Provided an assessment of all patients in double occupancy rooms for appropriate rooming of patients.
- Formulated a Policy and Procedure to ensure assessment of risk due to room placement of patients.
- Provided a checklist for all staff to evaluate bed assignments.
- Provided staff in-service of ongoing assessment and checklist completion for appropriate bed assignments.
- Incorporated bed assignments into the Psychiatric Technician (PT) deliverables (reporting) sheet as part of the PT reporting at daily shift change.
- Implemented weekly quality auditing of bed assignments with any concerns added to patient treatment plans.







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Based on interview, record review, and policy review, the facility failed to assess for appropriate room placement for four patients (#8, #9, #10, and #11) of four patients allegedly involved in non-consensual sexual activity. (There were two separate incidents each involving two of the patients.) The facility failed to take into account patient history of inappropriate sexual behavior and aggression, function level differences, and patient and staff concerns regarding roommate dynamics. These failures increased the risk for physical and sexual abuse for all patients in double occupancy rooms in the facility. The consideration of roommate appropriateness was significant given that the average length of stay in the facility for patients was three years. In addition, the facility failed to perform Root Cause Analysis (a process for identifying the causes of an unexpected occurrence) as per their policy of the first alleged sexual incident on 04/22/14 and implement new processes to prevent re-occurrence of that type of incident. This failure increased the potential for the second alleged sexual incident on 06/02/14 to occur. The facility census was 94. The census for patients sharing a double occupancy room was 54.

Findings included:

1. Record review of the facility's policy titled, "Assessment," dated 07/12, showed staff direction that:
- Nursing staff was responsible to utilize skills and knowledge to conduct assessment of patient needs.
- The Registered Nurse (RN) was to direct and implement the appropriate level of nursing care and interventions as determined by the assessment.
- The assessment data was to be used to develop the Individualized Treatment Plan (ITP).
- Further review of the policy showed no direction for assessment related to patient room assignments.

Record review of the facility's policy titled, "Treatment Planning and Documentation," dated 01/16/14, showed:
- The treatment team consisted of the psychiatrist, social worker (SW), nurse, psychiatric technician (PT), and other service providers assigned to work with a patient.
- The ITP was a patient's individualized plan which identified the patient's diagnosis, specific problems, specific goals, and specific interventions.
- The information used by the treatment team was based on the nursing triage and assessment form and review of the admitting physician/designee assessment.
- The plan included relevant interventions based on on-going assessment of patient's needs.
- The team reviewed and discussed the patient's case and the findings from each discipline's assessment.
- Further review of the policy showed no direction for assessment or interventions related to patient room assignments.

2. Record review of facility event report dated 04/23/14 showed Patient #10 complained on 04/22/14 that Patient #11, his roommate, had non-consensual sex with him and he didn't want that to happen again.

3. Record review of Patient #10's medical record showed:
- The Social Service Assessment dated 03/20/14 included that the patient had traumatic brain injury at age 14, history of inappropriate sexual behavior, and current memory deficits and confusion during conversation.
- The Annual Medical Psychiatric Assessment dated 03/21/14 included diagnosis of mild mental retardation.
- The ITP included a problem dated 04/15/14 of sexually inappropriate comments and/or gestures but there were no interventions specific to this behavior.
- The Significant Conflicts List had one item dated 04/23/14 that the patient said he was forced to have anal sex with his roommate (Patient #11).

4. Record review of Patient #11's medical record showed:
- The Social Service Assessment dated 05/30/14 included patient history of inappropriate sexual behavior and aggressive and assaultive behavior toward peers and staff.
- The Social Service Assessment also included that the patient targeted peers unable to defend themselves.
- The Annual Medical Psychiatric Assessment dated 05/30/14 included a diagnosis of antisocial personality disorder.
- The ITP included a problem of sexually inappropriate comments and/or gestures and an intervention initiated on 01/08/14 to fine the patient tokens for any type of antagonizing others. There were no interventions specific to sexually inappropriate behavior.
- Nursing progress notes dated 04/26/14 at 4:45 PM included Patient #11 stated that Patient #10 "is friendly 'til you try to get that ass, then he turns on you."

5. During an interview on 06/23/14 at 4:55 PM, Staff P, PT, stated that:
- She noted the beds in Patient #10 and Patient #11's shared room got closer together.
- PT staff was told by nurses that Patient #11 had a history of "picking on" lower functioning patients.
- She didn't think patients with different function levels should be roomed together.
- She was unaware of any new assessment processes since the alleged sexual incident between these patients.

6. During an interview on 06/24/14 at 9:14 AM, Staff F, PT, stated that:
- He thought Patient #11's ITP included the patient liked to harass lower functioning patients.
- Patient #10 was the ward's lowest functioning patient.
- He was unaware of any new assessment processes since the alleged sexual incident between these patients.

7. During a phone interview on 06/25/14 at 7:44 PM, Staff KK, Evening Shift Supervisor, stated that the treatment team decided on patient room assignments.

8. During an interview on 06/26/14 at 12:33 PM, Staff OO, SW, stated that:
- Prior to the alleged sexual incident on 04/22/14, there was a report that Patient #11 moved his bed closer and closer to Patient #10's bed.
- The beds were moved into a T shape so this would not re-occur.
- The treatment team felt this solved the problem and there was no need for room changes or increased level of supervision.

9. Record review of facility event report dated 06/03/14 showed Patient #8 complained on 06/02/14 that Patient #9, his roommate, had non-consensual sex with him, that had occurred before, and he was afraid of Patient #9. Further review of the report showed that Patient #8 stated Patient #9 told him not to tell or he would have "an enemy on the ward."

10. Record review of Patient #8's medical record showed:
- The Social Service Assessment dated 08/20/13 included the patient's history of being the victim of physical and sexual abuse.
- The current ITP for Patient #8 included a diagnosis of mild mental retardation.
- The current ITP also included the problem of severe deficits in social functioning but no mention of abuse history.

11. Record review of Patient #9's medical record showed:
- The Significant Conflicts List had one item that the patient asked for sex from another patient on 04/11/13.
- The Social Service Assessment dated 12/27/13 included that the patient had the tendency to ascribe false beliefs to others. The assessment included the example of a peer entered his room at the moment that he intended to masturbate (genital self-stimulation) and he asked the peer, "Do you want to have sex?," because he believed the peer could read his mind and entered the room knowing his intention for that moment.
- The ITP included the problem dated 01/15/14 of severe deficits in functioning but did not include interventions specific to ascribing false sexual beliefs to others.

12. During an interview on 06/24/14 at 10:28 AM, Staff G, RN, stated that Patient #8 complained on 06/02/14 that Patient #9 had non-consensual sex with him and he didn't want that to happen again.

13. During an interview on 06/23/14 at 4:15 PM, Staff I, PT, stated that he was unaware of any changes in assessment processes since the alleged sexual incident between Patient #8 and Patient #9.

14. During an interview on 06/24/14 at 9:14 AM, Staff F, PT, stated that Patient #8 was frequently naked in the room he shared with Patient #9 who complained about it prior to the alleged sexual incident on 06/02/14.

15. During an interview on 06/24/14 at 10:28 AM, Staff G, RN, stated that:
- Patient #9 complained that Patient #8 slept naked with his buttocks in the air and that Patient #8 was "asking for it."
- The treatment team and the Charge Nurse decided on bed assignments and did not always listen to the PTs who know the patients best.
- It was never a good idea to put low functioning patients with high functioning patients and she told the treatment team prior to the alleged 06/02/14 sexual incident that Patient #8 and Patient #9 should not be roomed together.

16. During an interview on 06/24/14 at 8:22 AM, Staff B, Chief Nursing Executive (CNE), stated that there was no specific assessment for use in decision making for patient room assignments.

17. During an interview on 06/24/14 at 3:00 PM, Staff R, Charge Nurse on evening shift, stated that:
- She was not involved in Patient #8 and Patient #9's room placement.
- It was not a good idea to put Patient #8 who was lower functioning with Patient #9 who was higher functioning.
- She didn't think it was right to place Patient #9 in the situation of Patient #8 often being naked in the room.
- The final decision on room placement was made by the treatment team and day shift Charge Nurse.
- A few days after Patient #8 and Patient #9 were placed in the same room, she reported to the day shift nurse that she didn't think that was a good fit.
- Patient #8 stopped being naked in the room so she did not take any further action.
- She was unaware of any new assessment processes since the alleged sexual incident with these patients.

18. During an interview on 06/25/14 at 2:25 PM, Staff GG, PT, stated that Patient #9 complained to him the first day he was on the ward (03/12/14) about Patient #8 being naked. He reported the complaint to a day shift RN, but did not remember which one, and didn't pursue the issue.

19. During an interview on 06/25/14 at 2:40 PM, Staff HH, PT, stated that:
- He overheard Patient #9 complain that Patient #8 was naked on the floor in front of their bathroom so Patient #9 would have to use the bathroom on the ward.
- He failed to report this because he heard the treatment team had already discussed the issue and the possibility of moving Patient #9.
- After some time, Patient #9 ceased to complain about Patient #8.

20. During an interview with the treatment team on 06/25/14 at 3:15 PM, Staff J, Head Nurse; Staff MM, SW; Staff NN, SW; Staff OO, SW; and Staff RR, Licensed Professional Counselor (LPC), stated that:
- They were unaware of Patient #8's sexual and physical abuse as noted in the Social Service Assessment dated 08/20/13.
- They were unaware of Patient #9's tendency to ascribe false beliefs to others, including sexual beliefs, as noted in the Social Service Assessment dated 12/27/13.
- They were unaware of staff concerns regarding Patient #8 being naked until Patient #9's mother called to complain about it [on 03/24/14 or 03/25/14].
- The treatment team implemented behavior modification for Patient #8 that included his being fined tokens whenever he was found naked in his room.
- After the alleged sexual incident, Patient #9 stated, "What should staff expect when Patient #8 was naked all the time?"

21. During an interview on 06/26/14 at 8:17 AM, Patient #8 stated that:
- Patient #9 forced sex on him and this happened more than once.
- He told staff about it because he wanted it to stop.
- There were times he was naked in his room but staff didn't catch him.

22. During an interview on 06/26/14 at 9:11 AM, Patient #9 stated that:
- When staff showed him his new room, his roommate (Patient #8) was bent over naked.
- Patient #8's behavior was "absolutely" a sexual advance.
- He told staff about Patient's #8's being naked in the room but they failed to do anything about it except ask Patient #8 to put on his clothes because he made Patient #9 uncomfortable.

23. During an interview on 06/26/14 at 12:33 PM, Staff OO, SW, stated that:
- Patient #8 was fined for tokens when found naked in the room after Patient #9's mother complained on approximately 03/24/14 or 03/25/14.
- This behavior decreased and the treatment team felt there was no need for room changes or an increased level of supervision.
- If the facility had in depth conversations about appropriate room placements after the 04/22/14 incident (with Patient #10 and Patient #11), the 06/02/14 incident (with Patient #8 and Patient #9) may not have occurred.

24. Record review of the facility policy titled, "Sentinel Event Investigation and Reporting," dated 11/05, showed that:
- All sentinel events would be reviewed using Root Cause Analysis.
- The sentinel event definition included an unexpected occurrence involving serious physical or psychological injury or risk of these.
- Root Cause Analysis was defined as a process for identifying the causes of such occurrences.
- Examples of such occurrences included sexual abuse or assault (including rape) of any patient receiving care, treatment and services.
- Sexual abuse or assault was defined as unconsented sexual contact including oral, vaginal, or anal penetration, fondling of the client's sex organs by another individual's hand, sex organ or object.
- Sexual abuse or assault was a reviewable sentinel event if the contact was witnessed by staff, there was clinical evidence the contact occurred, or the perpetrator admitted that the contact occurred.

25. During an interview on 06/24/14 at 9:00 AM, Staff A, Chief Operating Officer (COO), stated that:
- The alleged victims (Patient #8 and Patient #10) were each sent to the hospital for rape exam but the results had not been received.
- He did not believe that the 04/22/14 alleged sexual incident (with Patient #10 and Patient #11) had occurred.
- No Root Cause Analysis was performed after that incident.
- No new assessment processes were put into place in response to either incident.










































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