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Based on interview and record review, 1 of 1 patients (#5) alleging peer abuse or harassment, experienced repeated episodes of abuse/harassment with no updates to the Individual Plan of Service (IPOS) and no documented response to some episodes, resulting in increased risk of patient abuse and harassment.

On 3/8/12 from approximately 1200 hours-1530 hours, patient #5's clinical record, Incident Reports and Recipient Rights Complaints were reviewed. No reports of patient abuse by staff were noted. Documentation of patient #5 being physically assaulted by a peer were noted on: 2/2/12, 2/3/12 and 2/28/12, resulting in facial contusions and a fall.

Recipient Rights Advisor (RRA) #1 provided copies of complaints filed by patient #5 on 1/12/12, alleging peer harassment, and on 2/1/12, alleging threats and intimidation by a peer. In a letter dated 1/12/12, RRA #2 advised patient #5 that being harassed by a peer was not a Code (Mental Health Code) protected right so there would be no investigation or intervention. In a letter dated 2/29/12, RRA #2 advised patient #5 that her complaint of being threatened and intimidated by a peer had been received on 2/1/12 and that RRA #2 contacted patient #5's therapist regarding the allegation on 2/21/12, 20 days after receiving the allegation. A Code protected right, to receive services in a safe, sanitary humane treatment environment, was noted for the latter allegation. On 3/8/12 from approximately 1345-1415 hours, these findings were verified with RRA #1. RRA #1 stated that protection from patient to patient harassment, alleged in the 1/12/12 complaint, is a Code protected right if the patient's sense of safety is compromised.

Patient #5's most recent IPOS (Individual Plan of Service) was dated 1/18/12. There were no goals or interventions related to peer conflicts, abuse or harassment. On 3/8/12 at approximately 1530 hours these findings were verified with the Director of Nursing.