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Based on interview, record review, and review of facility policies, it was determined the facility failed to protect patient #1's right to be free from abuse. On April 7, 2011, patient #1 reported someone "stretched" her breasts. Facility staff believed the patient was delusional and did not report/investigate the allegation or implement interventions to protect the patient. Patient #1 was observed to have bruising on the patient's breasts during a shower on April 9, 2011. In addition, on April 9 or 10, 2011, staff observed patient #1's clothing lying on the floor of patient #2's (a known sex offender) bathroom. There was no evidence the facility investigated or reported the injury of unknown source or the patient's clothing being found on the floor in patient #2's bathroom. In addition, there was no evidence the facility protected patient #1 from further potential abuse. On April 12, 2011, patient #1 alleged having been sexually assaulted by patient #2 while on the patient care unit. However, staff did not transfer patient #1 to the Emergency Department for an examination until April 13, 2011; therefore, police were not notified timely. According to the facility's policy, "Reporting and Investigating Unusual Incidents," with the last revision date of June 2007, a "Class 3 Incident" included any injury of unknown cause if the injury required more than first aid, there was suspicion of abuse, neglect, or exploitation, or the facility's tracking and trending or similar injuries indicated suspected abuse, neglect, or exploitation. The policy stated a Class 3 incident also included sexual abuse/assault, individuals found out of level of supervision as required by the current treatment plan, or the incident was critical in nature or alleged an immediate threat to the health, safety, and welfare of individual or individuals. According to the policy, an incident report was required to be completed and retained on file; the House Coordinator should be notified immediately; an investigation was required to be conducted; the facility was required to immediately report the situation to Protection and Permanency, the Department Incident Management Administrator, and the Office of Inspector General; and a Class 3 Investigative Report was required to be faxed/mailed to the Department Incident Management Coordinator.

Refer to A0145.

Based on interview, record review, and review of facility policy, it was determined the facility failed to protect patient #1's right to be free from abuse. On April 7, 2011, patient #1 alleged someone "stretched" the patient's breasts. Patient #1 was observed by facility staff on April 9, 2011, to have an injury of unknown cause (bruises noted on both breasts and head) while staff assisted the patient with a shower/bath. The patient responded with a blank stare when asked about the cause of the bruising. The injury was not reported, the facility did not conduct an investigation to determine how the injury occurred, and no interventions were implemented to protect patient #1. In addition, patient #1's clothing was found on patient #2's (a known sexual offender) bathroom floor on April 9 or 10, 2011. Again, the facility failed to complete an incident report, failed to conduct an investigation, and failed to implement interventions to protect patient #1. On April 12, 2011, at approximately 2:30 p.m., patient #1 reported being sexually assaulted by patient #2. However, the patient was not transported to an Emergency Department for examination until April 13, 2011. The facility did not follow the policy on sending patients to the Emergency Department; therefore, police were not informed of the alleged sexual assault timely.

The findings include:

A review of the facility's policy, "Reporting and Investigating Unusual Incidents," with a revision date of June 2007, revealed it was the facility's policy to report, investigate, and manage incidents related to the protection of the individuals served. According to the policy, incidents were classified according to the potential for harm to individuals and included protocols for recording and follow-up. The policy revealed a "Class 3 Incident" included injuries of unknown cause if the injury required more than first aid; there was suspicion of abuse, neglect, or exploitation; or the facility's tracking and trending or similar injuries indicated suspected abuse, neglect, or exploitation. The policy stated a Class 3 incident also included sexual abuse/assault, individuals found out of level of supervision as required by the current treatment plan, or incidents that were critical in nature or alleged an immediate threat to the health, safety, and welfare of individual or individuals. According to the policy, an incident report was required to be completed and retained on file; the House Coordinator should be notified immediately; an investigation was required to be conducted; and the facility was required to immediately report the situation to Protection and Permanency, the Department Incident Management Administrator, and the Office of Inspector General.

Review of the facility policy related to sexual assault titled "Rape or Attempted Rape," revised August 2005, revealed the facility had a system in place for all suspected rape victims to be transported to the Emergency Room for an examination. Once the patient was transported to the Emergency Room, the facility staff was required to call the local Police Department and request the Police meet the patient in the Emergency Room.

A review of patient #1's medical record revealed patient #1 was admitted to the facility on March 1, 2011, after the patient had become delusional at home, reportedly was not sleeping, and was found walking outside the patient's home naked. Further review of a nurse's note dated April 7, 2011, at 8:40 a.m., revealed the patient reported, "Somebody stretched my [breasts]."

An interview was conducted on April 28, 2011, at 9:45 a.m., with RN #2, who documented the April 7, 2011 nurse's note. According to RN #2, patient #1 told the physician someone stretched her breasts, however, there were no marks/injuries observed on the patient's breasts and the nurse and physician believed the patient was delusional.

An interview with the physician on April 28, 2011, at 11:15 a.m., revealed patient #1 had no bruising and the physician had no reason to suspect abuse at that time.

An interview with a Nurse Aide on April 27, 2011, at 1:30 p.m., and April 28, 2011, at 2:30 p.m., revealed the Nurse Aide observed bruising to both of patient #1's breasts while assisting the patient with a shower/bath on April 9, 2011. According to the Nurse Aide, patient #1 did not respond when asked how the injury occurred, but instead the patient had a "blank stare." The Nurse Aide acknowledged that she failed to document the injury in the medical record or on an incident report and did not report the injury to anyone. In addition, the Nurse Aide stated that on approximately April 9, 2011, patient #1's clothing was found in patient #2's bathroom. The Nurse Aide stated patient #1 had a history of removing her clothes, wandering throughout the unit, and getting lost on the unit. The Nurse Aide stated the patient undressed "anywhere" and staff redirected her and dressed her in layers. According to the Nurse Aide, she was aware patient #2 was a sex offender but "never thought about it" and "never expected anything." However, there was no evidence the incident related to the patient's clothing was reported or investigated and no interventions were implemented to protect patient #1. Further interview with the Nurse Aide stated patient #1 was questioned again about the bruises on April 12, 2011, while the Nurse Aide assisted the patient with a shower/bath. According to the Nurse Aide, patient #1 stated that another patient had sexually assaulted her and gave a description of patient #2. The Nurse Aide stated the allegation was reported to the Registered Nurse on April 12, 2011.

Review of the nursing notes dated April 12, 2011, revealed patient #1 was assisted with a shower and the Nurse Aide noted bruises on the right side of the patient's head and both breasts. According to the nursing note, patient #1 reported being sexually assaulted by patient #2 and patient #2 "wanted to put his thing in her." Further review of the nursing note revealed patient #2 reportedly tried to push patient #1's head in the toilet. According to the nursing note, the nursing supervisor was notified.

Review of the Facility Investigation dated April 21, 2011, revealed patient #1 was observed on April 12, 2011, at approximately 2:50 p.m., to have bruises to the breasts and head which were alleged to have occurred when patient #2 sexually assaulted her. According to the investigative report, patient #2 confirmed having had sex with patient #1 on more than one occasion from April 2-12, 2011. Further review of the investigative report revealed patient #1's clothing was left in patient #2's bathroom and the clothing was found by a Nurse Aide on either April 9, 2011, or April 10, 2011 (the Nurse Aide did not recall the exact date). The Facility Investigator referred the alleged assault to the Police but the referral was not made until April 13, 2011 (nearly 24 hours later).

Review of a progress note written by a Physician Assistant on April 12, 2011, revealed patient #1 was assessed to have dark bruising on both breasts and a yellow bruise to the right temple. Documentation revealed the patient reported the sexual assault to the Physician Assistant. However, a sexual assault examination was not conducted until April 13, 2011, at 1:00 p.m.

Interview with the Registered Nurse (RN) on April 27, 2011, at 12:30 p.m., confirmed the Nurse Aide had reported patient #1's bruises to the RN on April 12, 2011. The RN stated patient #1 was assessed and bruises were noted on both breasts and a yellow-color bruise was noted on the right side of the patient's head. Patient #1 told the RN that patient #2 had sexually assaulted her. Patient #1 also reported to the RN that patient #2 hit patient #1 on the side of the head and tried to push patient #1's head in the toilet. Photos of the injuries were taken by the RN and an incident report was filed. There was no evidence found that patient #1 was transported to the Emergency Room on April 12, 2011, as required by facility policy.

Interview with the Physician Assistant (PA) on April 27, 2011, at 2:05 p.m., confirmed that the PA was called to assess patient #1's bruises on April 12, 2011, during the day shift. According to the PA, patient #1 stated, "Some guy tried to rape me," and had tried to force the patient to have anal intercourse, but had stopped when the patient resisted. The PA stated patient #1 had been assessed to need medical treatment for Lithium Toxicity (increased level of lithium noted in the blood) earlier that day and the patient had already been scheduled to be transferred from the psychiatric unit to the medical floor. The PA stated patient #1 could not give a timeframe regarding when the sexual assault occurred, and stated the incident was referred to the Facility Investigator.

Interview with the Facility Investigator on April 27, 2011, at 11:30 a.m., revealed an investigation was not initiated until April 12, 2011. According to the Investigator, on April 12, 2011, at 2:50 p.m., patient #1 told the Investigator that she had been sexually assaulted by patient #2, who asked the patient to do "other things." Patient #1 told the Investigator when the patient refused, patient #2 stuck patient #1's head in the toilet.

An interview with the Executive Director (ED) on April 27, 2011, at approximately 3:00 p.m., revealed the facility did not have a policy related to the supervision of sex offenders nor were there any special orders for the supervision of patient #2. Although the facility's policy stated injuries of unknown origin were required to be reported, documented, and investigated immediately, the ED stated an incident report would not have been filed regarding patient #1's bruises until the patient alleged she was sexually assaulted on April 12, 2011. The ED further stated the Nurse Aide should have reported finding patient #1's clothing on the floor of patient #2's bathroom.