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Based on document review and interview, it was determined that the Hospital failed to ensure patients exhibiting sexually acting out behaviors were identified and monitored to ensure the safety of patients. This potentially places any patient in the Hospital at risk for serious harm, serious injury or serious impairment. As a result, the Condition of Participation, Patient Rights, 42 CFR 482.13, was not in compliance.

Findings include:

1. The Hospital failed to ensure patients exhibiting sexually acting out behaviors were identified and monitored, which resulted in the sexual assault of a vulnerable behavioral health patient. See deficiency at A-145.

The immediate jeopardy began on 5/7/2023, due to the Facility's failure to ensure patients were monitored. This resulted in the sexual assault of a vulnerable behavioral health patient; and was identified on 5/17/2023 at 42 CFR 482.13, Patient Rights. The IJ was announced on 5/17/2023 at 11:30 AM during a meeting with the Chief Executive Officer, Director of Nursing and Director of Performance Improvement/Risk, and was not removed by the survey exit date of 5/17/2023.

Based on document review and interview, it was determined that for 2 of 2 behavioral health unit patients (Pt #2 & Pt #3) involved in an incident of alleged sexual assault, the Hospital failed to ensure patients exhibiting sexually acting out behaviors were identified and monitored to ensure the safety of patients.

Findings included:

1. The Hospital's policy titled, "Sexual Allegation, Aggression and Sexual Victimization: Prevention Response & Notification Plan (2/23)" was reviewed on 5/16/2023 and required, "Observation: Unit Staff: Observe patients for specific behaviors/precursors to sexual acting out behaviors: ... inappropriate touching ... lingering near patient bedrooms. ...Maintain awareness of patient location at all times."

2. The clinical record of Pt. #1 was reviewed on 5/15/2023. Pt. #1 was admitted on 5/6/2023 with a diagnosis of psychotic disorder.
- The multidisciplinary progress note (E#6/Registered Nurse), dated 5/7/2023 at 1:34 PM included that at 9:52 AM, hall staff discovered 2 male patients (Pt. #2 and Pt. #3) running out of a patient's room (Pt. #1). "Patient [Pt. #1] reported, 'I was on my way to the shower. Two of them came over. ... The one guy with the short hair [Pt. #2] pulled my left arm and the other [Pt. #3] was by the bed. The one guy asked for head and then the other one said to do it. They both went inside me. I told them 'No' and they kept going and told me not to scream or say nothing." Pt. #1 was visibly upset and refusing to speak to any staff.

3. On 5/15/2023, Pt #2's clinical record, dated 4/29/2023 to current, was reviewed and indicated that Pt #2 was admitted to the Hospital on suicidal precautions and elopement precautions.
-Pt #2's psychiatric progress notes dated 5/1/2023 noted Pt #2 was placed on sexually acting out precautions. "Pt #2 has been masturbating frequently. Staff have had to block Pt #2's room to any roommates because of his inappropriate behaviors."
-Pt #2 continued to be on SAO precautions, as of 5/15/2023.

4. The clinical record of Pt. #3 was reviewed on 5/15/2023. Pt #3 was admitted to the Hospital on 5/4/2023 and was placed on suicide/elopement precautions, requiring every 15 -minute safety checks. Pt #3's intake assessment, dated 5/4/2023 at 2:16 PM, did not include any indication of sexually acting out behaviors. The nurse's note, dated 5/7/2023, indicated that Pt #3 had been pacing outside Pt #1's room for approximately 1 and ½ hours before the incident involving Pt #1. Pt #3 was discharged on 5/12/2023.

5. On 5/15/2023, the Hospital's sexual abuse allegations, dated March 2023 to current, were reviewed and included an incident report, dated 5/5/2023 (2 days prior to the incident with Pt #1), regarding Pt #2: "[Pt #2] was accused by female peer that [Pt #2] entered her room and stood by bathroom pulling out his penis (flash) and asking her if she wanted for him to suck her breast. Female peer reports no physical contact that it was just a flash. [Pt #2] denied going inside female peer's room."

6. On 5/15/2023 at 10:05 AM, an interview was conducted with Pt #1 (currently a patient on 2 South). Pt #1 stated "They [Pt #2 and Pt #3] raped me in my room."

7. On 5/15/2023 at 10:50 AM, an interview was conducted with Pt #2. Pt #2 stated "I had sex with [Pt #1]."

8. The MHS (E#3), who was witness to the sexual assault of Pt. #1, was interviewed on 5/16/2023 at 10:45 AM. E#3 stated that he was performing safety rounds and saw Pt #2 running from Pt #1's room. E #3 stated that he knew Pt #1's room was a female room and went to Pt #1's room and saw Pt #3 and Pt #1 were both naked having sex. E#3 stated, "Someone should always be in the hall to watch patients and prevent from going into other patients' rooms. When only one person performs rounds, it is very difficult."

9. The RN supervisor (E#5), working on 5/7/2023, was interviewed via telephone on 5/15/2023 at 1:30 PM. E#5 responded to a code called on the 2-north unit during the time of the incident with Pt #1. E#5 stated, "When I arrived, [Pt. #3] was running around yelling stating, 'I did not rape her, she consented." E#5 stated, "Patients who have demonstrated sexually acting out should be placed on 1:1 (staff to patient)."

10. The nurse (E#6), caring for Pt. #1 on 5/7/2023, was interviewed on 5/15/2023 at 2:25 PM. E #6 stated, "Pt #1 was preparing to take a shower. As Pt #1's roommate and I were walking to the station, I saw Pt #2 walking down the hall with his hands down his pants. I was worried about what he would do. The next thing I know, our staff was yelling down the hall to call a code. I went to the room as Pt #2 was running from the room and saw Pt #1 with no clothes on."

11. The Director of Performance Improvement and Risk Management (E#8) was interviewed on 5/16/2023 at 9:15 AM. E#8 stated that Pt. #2 had been placed on SAO precautions and had a blocked room after the 5/5/2023 incident. E#8 was aware of the recent sexual incident related Pt. #2 (involving Pt #1) and precautions were not increased. After the incident occurred on 5/7/2023, all the female patients were moved from the 2N hallway, and the hallway was made all male. E#8 stated, "[Pt. #3] has already been discharged and when [Pt. #2] is discharged, we will return the hallway to coed again. All our units/hallways are coed. Best practice would be to have someone assigned to always watch the hallways, but that is not in our policy." E #8 stated that no other investigations/staff training/patient safety precautions were completed/implemented after this event.