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Based on interview and document review, the facility failed to ensure staff appropriately assessed, and monitored 1 of 10 patients (P2) who was alleged to have sexually assaulted another patient. The facility's lack of appropriate monitoring resulted in Condition level noncompliance related to the risk to other patients on the NE8 mental health unit. See A144.

Based on interview and document review, the hospital failed to provide care in a safe setting for patients on unit NE8 on 1/31/19, when the hospital became aware of an allegation that P2 sexually assaulted P1 on 1/30/19, but the hospital failed to increase P2's supervision status.

Findings include:

Emergency room record review revealed P1 was admitted to the hospital on 12/16/18, after an outburst at her group home and a fall. P1 stated staff pushed and choked her at her group home. P1's demographic information page revealed P1 was admitted with diagnoses that included Intermittent Explosive Disorder, Borderline Personality Disorder and Moderate Intellectual Disabilities. P1 was placed on a 72 hour hold. P1 was housed on the NE8 mental health unit of the hospital. P1 was placed on every 15 minute checks for safety. P1 was discharged on 1/30/19, at 3:53 p.m.

Medical record review revealed P2 was admitted to the hospital on 1/14/19, with diagnoses that included Schizophrenia, Stimulant induced Psychotic Disorder and Cannabis induced Psychotic Disorder. P2's Emergency Department (ED) Visit Note, dated 1/14/19, revealed P2 was brought in to the ED by law enforcement related to agitation, and hitting a wall at his apartment. He was sexually inappropriate with staff, responding to internal stimuli, was tense and restrained by law enforcement before his arrival. P2 was placed on a 72 hour hold and admitted to NE8 mental Health unit. Social worker (SW) note, written by SW-H dated 1/14/19, revealed P2's case manager told her that the patient was a risk to the community because the patient is hypersexual. P2 was placed on every 15 minute checks for safety. P2 was discharged on 2/1/19, at 2:34 p.m. to law enforcement.

During an interview with SW-K on 2/7/19, at 11:20 a.m., she stated that she opened an email on the morning of 1/31/19, that indicated P1 told her case manager that she had been sexually assaulted on 1/30/19, by another patient while still at the hospital. The description of the alleged perpetrator given in the email indicated P2 was the most likely suspect. SW-K stated she reported the allegation to her supervisor and the nurse manager on the unit. SW-K stated she did not know if P2's supervision was increased after the allegation was made.

During an interview on 2/6/19, at 11:35 a.m. administrative registered nurse (RN)-I stated the Interdisciplinary Team (IDT) met on Friday 2/1/19, to investigate the allegation. At that time, the team decided to review the video of the hallway to see if the two patients had been alone together. Later that day, 2/1/19, P2 was taken away by law enforcement.

During an interview on 2/6/19, at 3:30 p.m., which occurred during the medical record review of P2's medical record, administrative nurse (RN)-B confirmed that P2's supervision level was never changed from every 15 minute observations, even after staff members became aware of the sexual assault allegation on the morning of 1/31/19, until he was discharged to law enforcement on the afternoon of 2/1/19.

Video review on 2/6/19, of the hallway on NE8 on 1/30/19, revealed P1 and P2 entered an empty room twice on 1/30/19, once at 2:17 p.m. for about 30 seconds, and then again at 2:20 p.m. for about 1 minute and 40 seconds.

During an interview on 2/7/19, at 1:25 p.m. administrative RN-P confirmed that hospital policies related to abuse protections and sexual assault do not address what to do with an alleged perpetrator related to his/her supervision for the safety of other patients during the hospital's internal investigation into an incident.

An interview with law enforcement officer (LEO)-R on 2/6/19 at 1:15 p.m. revealed P2 was charged with Criminal Sexual Conduct related to the assault that P1 alleged occurred on 1/30/19.

The policy titled Safety Assistant and Observation Levels Used in Mental Health dated effective 11/3/17, and provided by hospital staff was reviewed. Under the section V. Procedure: An order for one-to-one Safety Assistant or alternative observation levels is to be made by a Practitioner and the supervision is to be provided for by nursing staff. The Practitioner will make an order for one-to-one supervision or alternative observation levels when such supervision is believed necessary to maintain safety of patients in the hospital. One-to-one supervision or alternative observation levels may be ordered for patients who appear to have current and excessively high likelihood of behaving in such a way as to cause significant injury to themselves or others while in the hospital. Examples of such behavior include, but are not limited to, suicide attempts, sexual acting out and assaults.