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Based on interviews and record reviews, the hospital failed to have an effective governing body legally responsible for the conduct of the hospital as an institution as evidenced by:

1. Failure to respond timely to a system failure that jeopardized the health and safety of patients with potential harm to other patients (refer to A049)

2. Failure to ensure that the quality of nursing services was effectively assessed and monitored, and ensure the identified problems were effectively resolved (refer to A273)

3. Failure to ensure that nursing staff provided care to meet the needs of the patients (refer to A392)

4. Failure to ensure that laboratory services provided under the contract were safe and effective (refer to A084)

The cumulative effect of these systemic problems resulted in the governing body's inability to govern the hospital effectively in compliance with the statutorily-mandated Condition of Participation for the Governing Body.

Based on interview and record review, the hospital failed to hold the medical staff accountable for the issues of sexual incidents in the adolescent unit. This resulted in an ineffective management of the sexual incidents frequently recurring in the unit.

Findings:

During an interview and record review on 7/19/19 at 1:30 p.m., the chief executive officer (CEO), he stated the governing body meets quarterly. Review of the minutes, dated April, July, and November 2018, March 8, 2019, and May 9, 2019, did not indicate any documentation or discussion of any sexual incidents in the adolescent unit. The minutes were not even readily available for review.

On concurrent interview and record review with the CEO, he stated the Medical Executive Committee (MEC) meets on monthly basis. Review of the minutes from January 2019 to June 2019 of the MEC also indicated no discussion of the sexual incidents in the adolescent unit.

Review of the hospital's policy, "PROCESS IMPROVEMENT PROGRAM" dated 1/2019, indicated the Governing Board has the ultimate responsibility and authority to establish, maintain, and support an effective process improvement program. The Governing Board assures that the necessary structures are established and processes are implemented to assess and continually improve the overall quality and efficiency of patient care. The Medical Executive Committee is delegated the authority and accountability necessary for the delivery and assessment of all processes that contribute to the prevention of problems and the continual improvement of the quality, appropriateness, and efficiency of patient care outcomes. It indicated the committee will recommend and implement appropriate actions and assess the effectiveness of such actions, in collaboration with the quality council, when significant problems in patient care and clinical performance or opportunities to improve care are identified and document the findings and results of medical Executive committee.

Based on interview and record review, the hospital failed to ensure the services provided under the laboratory contract were provided in a safe and effective manner when 50 laboratory samples were found to be missing and the Quality Director does not have a system to evaluate the quality of the service provided by the contracted vendors. These failures had the potential to put the hospital at risk for receiving unsafe and ineffective services from the contracted vendors.

Findings:

During a review and interview on 7/19/19 at 1:30 p.m. with CEO on the Governing Board Minutes, dated June 2019, 50 laboratory samples were reported missing in May 2019 from the hospital's laboratory vendor. When asked about this incident, the CEO stated it was lost in the laboratory site. There were no other documentation about this incident.

During an interview with Director of Quality Assurance (DQA) on 7/19/19 at 2:45 p.m., she stated she did not do onsite visits to any of the hospital's contract vendors. She further stated the laboratory vendor provides the hospital with quarterly quality reports.

Based on interview and record review, the facility failed to comply with the Condition of Coverage for Patient Rights as evidenced by:

1. Failure to ensure patients to receive care in a safe setting (refer to A144)

2. Failure to ensure patients were free from sexual abuse (refer to A145)

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the provision of quality of healthcare in a safe environment.

Based on interview and record review, the facility failed to ensure staff provided adequate supervision:

1. Patient 8 had sex with another peer in the room when he was supposed to be under 1:1 supervision; and,

2. From March 2019 to June 2019, sixteen (16) patients (Patients 5, 6, 9, 15, 16, 17, 18, 19, 21, 22, 23, 24, 25, 26, 27, and 30), who were on Q15 minutes monitoring, had various incidents involved.

This failure had the potential for all patients to be unprotected from various possible incidents.

Findings:

1. Review of Patient 8's Discharge Summary, dated 4/25/19, indicated Patient 8 was a 17-year-old transgender female (denoting or relating to a person whose sense of personal identity and gender does not correspond with their birth sex) with history of sexually trafficked and abducted.

Review of Patient 8's Psychiatrist Progress Notes, dated 3/14/19, indicated the patient was found with a male peer in her room after shift change at about 11:10 p.m. Both patients did not wear clothes. Patient 8 reported they had consensual sex.

Review of Patient 8's Patient Observations, dated 3/14/19, indicated the patient was on every 15 minutes observation and should be on 1:1 monitoring when he was in the room for sexual precautions.

2. Review of Patient 5's Progress notes, dated 6/3/19 at 7:30 p.m. indicated the patient was 55-year-old female and she shouted, yelled, and cursed another male peer, who was seen going out of the patient's room. She stated another male peer came to her room and touched her.

Review of Patient 6's Psychiatrist Progress Notes, dated 6/2/19, indicated the patient was 50-year-old male with schizoaffective disorder (a serious mental disorder in which people interpret reality abnormally). It indicated throughout day, the patient remained inappropriate, threatening on the unit the psychiatrist overheard multiple times by staff he was walking up to a peer and saying "I am going to fucking rape you and then you are going to put your finger in my ass." and making obscene sexual gestures at the peer, to the point that peer complained multiple times to staff feeling unsafe to leave her room.

Review of Patient 6's Patient Observations, dated on 6/2/19, indicated the patient was on every 15 minutes monitoring and the monitoring had changed to every 5 minutes at 11:30 p.m. at the end of the day.

Review of Patient 9's clinical record indicated he was 32-year-old male, admitted on 2/16/19 with diagnoses including paranoid schizophrenia and severe amphetamine use disorder. On 2/18/19, he informed the psychiatrist that he was sex-deprived.

Review of Patient 16's Discharge Summary, dated 3/12/19, indicated the patient was a 33-year- old female and admitted on 2/24/19 on 5150 hold for being gravely disabled. On admission, she presented herself as disorganized, and tangential paranoid.

Review of Patient 16's Progress notes, dated 3/2/19, at approximately 5:35 p.m., a peer informed staff nurse Patient 9 went in to Patient 16's room. Patient 16 was found on her knees in bed while Patient 9 was found standing behind her back with his pants down below his waist.

Review of Patients 9 and 16' Patient Observations, dated 3/2/19, indicated both patients remained on every 15 minutes monitoring for sexual precautions.

Review of Patient 15's Discharge Summary, dated 5/7/19, indicated Patient 15 was a 17-year- old female with history of major depressive disorder, post traumatic stress disorder, and sexual and physical abuse. She was admitted under 5150 for suicidal behavior.

Review of Patient 15's Progress notes, dated 4/30/19 at 4:30 p.m., staff noticed Patient 15 was sexually inappropriate as exhibited by sucking on a peer's fingers.

Review of Patient 15's Progress notes, dated 5/1/19 at 7 p.m., in activity room, staff saw Patient 22 sucking Patient 15's left middle finger.

Review of Patient 22's Discharge Summary, dated 5/6/19, indicated the patient was "sexually acting out" by licking female peer's finger.

Review of Patients 15 and 22's Patient Observation, dated 5/1/19, indicated both patients were placed on every 15 minutes observation for sexual acting out precautions.

Review of Patient 17's Discharge Summary, dated 5/26/19, indicated the patient was a 14-year-old male and admitted under 5150 hold for danger to self with suicidal ideation.

Review of Patient 17's Progress Notes, dated 5/25/19, indicated at approximately 7:30 p.m., a staff reported Patient 17 was seen kissing Patient 24 on the lips in the activity room.

Review of Patient 17's Patient Observations, dated 5/25/19, indicated when the incident occurred the patient was on every 15 minutes monitoring for sexual precaution.

Review of Patient 24's Progress Notes, dated 5/25/19, indicated the patient was a 14-year-old female, had poor boundaries with a male peer, and required consistent redirection. Staff saw the patient kissed Patient 17.

Review of Patient 24's Patients Observations, dated 5/25/19, indicated when the incident occurred, the patient was on every 15 minutes monitoring for sexual precautions.

Review of Patient 24's Progress Notes, dated 5/27/19 at 11:44 a.m., indicated anther female patient punched her face twice after they got into a verbal altercation in the cafeteria. Patient 24 had a swelling on the bottom lip and complained of 7 of 10 pain (0-10 pain scale, 10/10 is the worst pain).

Review of Patient 24's Patients Observations, dated 5/27/19, indicated the patient was on Q15 minutes monitoring.

Review of Patient 18's Discharge Summary dated 3/22/19, indicated Patient 18 was a 14-year-old male and admitted under 5150 hold for danger to self for having suicidal thoughts.

Review of Patient 18's Progress Notes, dated 3/19/19 at 9:30 a.m., while kids were lined up in front of the nurses' station to go to the gym, the nurse went back to the nurses' station to get a clip board. When the nurse came back to the line, she saw Patient 18 and another female peer were kissing at a corner, which was an area that was not a direct view from the nurses' station.

Review of Patient 18's Patient Observations, dated 3/19/19, indicated the patient was on every 15 minutes observation for sexual acting out.

Review of Patient 19's Progress Notes, dated 6/24/19, indicated Patient 19 kissed a female peer at 4:20 p.m. when they were going to a gym.

Review of Patient 19's Patient Observations, dated 6/24/19, indicated the patient was on Q15 minutes monitoring when the incident occurred.

Review of Patient 21's Progress Notes, dated 3/8/19, indicated the patient had a fight with another peer, which resulted in a bump on the back of the head.

Review of Patient 21's Patient Observations, dated 3/8/19, indicated when the incident occurred, the patient was on Q5 minutes monitoring

Review of Patient 21's record indicated there was no evidence a progress note or Incident Report Form was initiated regarding the 3/8/19 incident.

During an interview on 7/19/19 at 1:35 p.m., the nursing house supervisor stated there should always be an incident report for investigation and progress notes written when an incident happened.

Review of Patient 23's Progress Notes, dated 6/10/19, indicated the patient was involved in a verbal altercation with a female peer. Patient 23 was physically attacked by the female peer while being in the activity room.

Review of Patient 23's Patient Observations, dated 6/10/19, indicated when the incident occurred, the patient was on Q15 minutes monitoring.

Review of Patient 25's Progress notes, dated 6/10/19 at 8:21 p.m., indicated the patient was a 15-year-old female, went to the back of the activity room with another peer, where they knew it was a blind spot, and kissed.

Review of Patient 25's Patient Observations, dated on 6/10/19, indicated when the incident occurred, the patient was on Q15 minutes monitoring.

Review of Patient 26's Progress notes, dated 3/15/19, indicated the patient was a 15-year-old female and discharged on that day.

During an interview on 7/19/19 at 10:23 a.m., Director of Quality Assurance (DQA) stated after Patient 26's discharge, her mother called and stated the patient was sexually assaulted by her roommate during the hospitalization. DQA stated she investigated and the patient's roommate stated both had kissed but, Patient 26 started kissing.

Review of Patient 27's Progress Notes, dated 6/24/19, indicated the patient was a 15-year-old female and kissed another peer in a hallway going toward a gym.

Review of Patient 27's Patient Observations, dated on 6/24/19, indicated the patient was on Q15 minutes monitoring.

Review of Patient 30's Progress Notes, dated 4/27/19 at 4:50 p.m., indicated the patient was seen kissing another peer and she stated "He kissed me first."

Review of Patient 30's Patient Observations, dated on 4/27/19, indicated the patient was on Q15 minutes monitoring.

During an interview with Director of Quality Assurance (DQA) on 7/17/19 at 1 p.m., the incidents were reviewed. DOQ stated even though the patients were under various monitoring, the incidents happened so quickly and staff could not prevent them.

Review of the hospital's job description for registered nurses (RN), dated 5/1/18, indicated RNs are responsible for providing professional nursing care to patient in a supportive and therapeutic environment.

Based on interview and record review, the facility failed to ensure staff supervise patients to be free from sexual abuse when Patient 2 sexually assaulted Patient 1 and Patient 4, who was under every 15 (Q15) minutes and every 5 (Q5) minutes monitoring, was able to perform various forms of sexual activities with three female peers at six different times. This failure had the potential for all patients to be unprotected from sexual abuse.

Findings:

1. Review of Patient 1's Discharge Summary, dated 6/1/19, indicated the patient was a 16-year-old male and admitted to the hospital on 5/20/19 with diagnoses of major depressive disorder, PTSD (Post Traumatic Stress Disorder), ADHD (Attention Deficit Hyperactive Disorder), and social anxiety disorder.

Review of Patient 1's Progress Notes, dated 5/29/19 at 11:16 a.m., indicated "a peer pressured/threatened him into letting peer perform manual and oral sex on/to him in the activity room...on 5/27(/2019) ([Patient 1] reports "she gave me a hand job") and on 5/28(/2019) (pt [patient] reports "she performed oral sex on me.")" The patient reported the peer threatened him into participating in acts and the peer was "scary". The patient stated both incidents occurred in the back of the activity room between 8 p.m. to 9 p.m. There was no evidence staff was present and supervised patients in the activity room during the incidents occurred.

Review of patient 1's Patient Observations, dated 5/27/19 and 5/28/19, indicated the patient was on Q15 minutes monitoring when the incidents occurred.

Review of Patient 2's Discharge Summary, dated 6/1/19, indicated on 5/25/19, the patient was a 15-year-old female (whom identified himself as male) and admitted to the hospital with diagnoses of general anxiety, major depression, and borderline personality.

Review of Patient 2's Progress Note, dated 5/29/19 at 1:13 p.m., indicated on 5/28/19, the patient reported he performed oral sex on a peer in the back of the activity room. The patient also reported he and some peers touched each other's private areas and gave a peer a hand job between 8 p.m. to 9 p.m. There was no evidence the staff supervised them during the incident.

Review of Patient 2's Patients Observations, dated 5/27/19 and 5/28/19, indicated the patient was on Q15 minutes monitoring when the incident occurred.

Review of the police report, dated 7/23/19, indicated Patient 1, the victim, wanted to press charges against Patient 2. Patient 2 was released from the hospital into the custody of Child Protective Services (CPS) and this case was forwarded to the Santa Clara County Juvenile District Attorney.

During an interview on 7/17/19 at 2:00 p.m., the Director of Quality Assurance (DQA) stated that during the events no staff supervised the patients in the activity room and there should be always staff to supervise the patients.

2. Review of Patient 4's Discharge Summary, dated 5/11/19, indicated the patient was a 14-year-old male and admitted on 5/2/19 under 5150 hold (California law code for temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness) with diagnoses including bipolar disorder (any of several psychological disorders of mood characterized by alternating episodes of depression and mania), severe depression with psyche features. During his course of hospitalization, Patient 4 continued to have mood lability and significant difficulty with impulse control. He required 5 minute checks and one-on-one for a lot of his hospital stay as he was hypersexual.

Review of Patient 4's Psychiatrist Progress Notes, dated 5/4/19, indicated he has said provocative statements to nursing staff and he has called them "honey" that was said in a way that felt malicious and sexualized. He was also intrusive of others. He knocked a hoodie off of a peer's head while he was on every 15 min monitoring for sexual acting out. It indicated the patient had inappropriate touching with female peers and seems to be hypersexual with no history of abuse. He was placed on every 15 minutes observation for sexual precautions.

Review of Patient 4's Nurses progress notes, dated 5/5/19, indicated a peer reported to nursing staff, on 5/4/19 between 6 to 7 p.m., Patient 4 and Patient 3, who was 16-year-old female, were in the activity room covered up with a blanket and appeared to be fondling each other underneath the blanket. There were no staff present in the activity room at that time. Patient 4 remained on every 15 minutes observation.

Review of Patient 3's Progress Notes, dated 5/5/19 at 1:54 p.m., indicated the patient reported Patient 4 made inappropriate comments, stating "He told me he wants to have sex" and kissed her in the activity room. It stated the incident was consensual and unwitnessed.

Review of Patient 3's discharge summary dated 5/6/19, indicated on 5/5/19, she was observed to be crying, feeling emotional, and upset. She reported she had oral sex with Patient 4 in her room. Patient 4 pretended to be in the shower by turning the water on, snuck out of shower in between every 15 minute observation, went into Patient 3's room, and had oral sex with her.

Review of Patient 4's Patient Observations, dated 5/5/19, indicated the patient was on every 15 minutes monitoring when the incident occurred.

Review of Patient 28's Progress Notes, dated 5/5/19 1:54 p.m., indicated the patient reported Patient 4 made inappropriate remarks on her, stating "He told me he wants to have sex" and kissed her in the activity room. It stated the kiss was consensual.

Review of Patient 28's Discharge Summary, dated 5/4/19, indicated patient 28 was a 15-year-old female under the guardianship of her parents. Patient 28 had a diagnosis of autism spectrum disorder (a serious developmental disorder that impairs the ability to communicate and interact)

Review of Patient 4's Patient Observations indicated on 5/5/19 he was on every 15 minutes monitoring and at 4 p.m. on that day, the patient was placed on 1:1 monitoring. On 5/9/19 8:30 a.m., the monitoring had changed to every 5 minutes.

Review of Patient 4's Patient Observations, dated 5/9/19, the patient was on every 5 minutes monitoring when the physical altercation occurred.

Review of Patient 7's Discharge Summary, dated 5/16/19, indicated the patient was a 15-year-old female with diagnoses of major depressive disorder and was undergoing intensive outpatient program. She was admitted on 5/10/19 under 5150 hold for danger to self due to suicidal ideation.

Review of Patient 7's nurses progress notes, late entry dated 5/14/19 for 5/11/19, indicated on 5/11/19, Patient 7 reported to staff on 5/10/19, while in the activity room before bedtime, Patient 4 grabbed her hand and placed it on his private part. She immediately pulled her hand away. A peer, who was in the same room at the same time, stated she saw both of them sitting next to each other. Patient 7 also reported sometime in the morning of 5/11/19, Patient 4 went into her room and touched her breast. She told Patient 4 to leave her room and he did. Patient 7 felt uncomfortable and verbalized she wanted to press charges. Incident was reported to law enforcement and to the attending physician. Patient 4 was on every 5 minutes monitoring at the time of the incident.

During a telephone interview with the director of nursing (DON) on 7/19/19 at 11:50 a.m., she stated for the incident with Patient 4, "the 1:1 monitoring should have been done clearly".

Based on interview and record review, the facility failed to comply with the Condition of Coverage for the Quality Assessment and Performance Improvement (QAPI) program as evidenced by:

1. Failure to identify and correct problems with regards to the sexual allegations that occurred in the units (refer to A273, A283, and A286)

2. Failure to identify omission of reporting of alleged sexual abuse and other forms of abuse in the hospital (refer to A392); and

3. Failure to evaluate the effectiveness of the services provided by the laboratory contracted services when 50 laboratory samples were reported lost in May 2019 (refer to A084).

The cumulative effect of these systemic problems resulted in an ineffective QAPI program that did not involve all hospital departments and services in compliance with the statutorily mandated Condition of Participation for Quality Assessment and Performance Improvement.

Based on interview and record review, the hospital failed to use their data to monitor the effectiveness and safety of services provided on the high incidents of sexual encounters between patients in the adolescent unit. This resulted in the reoccurrences of sexual assaults of adolescent patients in the unit.

Findings:

During the survey, the survey team reviewed approximately 25 sexual incidents occurred in the adolescent unit, from March 2019 to June 2019 (refer to A392).

During an interview and record review on 7/19/19 at 8:30 a.m., Director of Quality Assurance (DQA) showed some data and incident reports completed by their staff. There were no documentation of what the hospital or nursing services did to resolve these sexual incidents.
These were not brought to the Medical Executive Committee meetings nor was it in the Governing Board minutes.

Review of the hospital's policy, "PROCESS IMPORVEMENT PROGRAM" dated 2/2019, indicated the hospital is dedicated to providing quality care and services for all patients in a safe, clean, and therapeutic environment. The facility fulfills its responsibilities to patients, professionals, support staff, and the community through continuous and systematic measurement, assessment, and improvement of its systems and processes. The process improvement program is designed to provide a coordinated, objective, and systematic approach to facility-wide quality assurance activities. The program based on desired patient outcomes by assessing and improving those governance, managerial, clinical, and support processes that most affect patient outcomes. The objectives are to enhance, maintain, and continually improve the quality of patient care through intra-and/or interdepartmental/service measurement and assessment of patient care, resolution of problems and ongoing pursuit of opportunities to improve patient care. Facility-wide quality assessment and robust process improvement activities include safety, risk management and quality control activities. Quality assessment findings are communicated to the medical staff and the governing board at least quarterly.

Based on interview and record reviews, the hospital failed to use their data collection on sexual incidents with quality improvement activities to prevent the reoccurrences of these incidents to the patients. This failure placed all patients in the hospital at risk for victims of sexual abuses.

Findings:

During an interview and record review on 7/19/19 at 8:50 a.m. with QAPI director stated their quality council meets every month. She also showed their tracking system of incidents in the various units of the hospital. there were also no performance improvement activities geared towards the improvement of the recurring sexual incidents in the adolescent unit.

Review of the hospital's policy, "PROCESS IMPORVEMENT PROGRAM" dated 2/2019, indicated the hospital is dedicated to providing quality care and services for all patients in a safe, clean, and therapeutic environment. The facility fulfills its responsibilities to patients, professionals, support staff, and the community through continuous and systematic measurement, assessment, and improvement of its systems and processes. The process improvement program is designed to provide a coordinated, objective, and systematic approach to facility-wide quality assurance activities. The program based on desired patient outcomes by assessing and improving those governance, managerial, clinical, and support processes that most affect patient outcomes. The objectives are to enhance, maintain, and continually improve the quality of patient care through intra-and/or interdepartmental/service measurement and assessment of patient care, resolution of problems and ongoing pursuit of opportunities to improve patient care. Facility-wide quality assessment and rebust process improvement activities include safety, risk management and quality control activities.

Based on interview and record review, the hospital's QAPI failed to address the issues of sexual incidents in the adolescent unit. This failure led to repetitive sexual events in the unit.

Findings:

During a review and interview on 7/19/19 at 8:30 a.m., the QAPI director showed the hospital's tracking system for their adverse events, near missed medication errors, restraints suicide risks, falls and contrabands. She stated the sexual incidents in the adolescent unit are entered through the incident report which the staff fills out after the incident occurs.

During the survey, the survey team reviewed approximately 25 sexual incidents occurred in the adolescent unit, from March 2019 to June 2019 (refer to A392).

There were no documentation this was discussed with the governing body, medical staff, and administrative officials who are responsible for the operations of the hospital. There were no documentation that the majority of these were reported to the State Agency as alleged sexual or physical abuses.

Based on interview and record review, the facility failed to comply with the Condition of Coverage for Nursing Services as evidenced by:

1. Failure to provide adequate supervision to prevent Patient 2's sexual assault to Patient 1 (refer to A392).

2. Failure to provide adequate supervision to prevent Patient 4's various forms of sexual activities with three female peers at six different times and a physical altercation with another peer (refer to A392).

3. Failure to provide adequate supervision to prevent Patient 8's sexual activity (refer to A392).

4. Failure to effectively monitor 16 patients (Patients 5, 6, 9, 15, 16, 17, 18, 19, 21, 22, 23, 24, 25, 26, 27, and 30) who had various incidents involved. (Refer to A392).

The cumulative effects of these systemic problems resulted in the facility's inability to ensure the provision of quality in a safe environment.

Based on interview and record review, the facility failed to ensure staff provided adequate supervision when:

1. Patient 2 sexually assaulted Patient 1 in the activity room, twice at different times;

2. Patient 4, who was under every 15 (Q15) minutes and every 5 (Q5) minutes monitoring, was able to perform various forms of sexual activities with three female peers at six different times. Also, Patient 4 had a physical altercation with another peer;

3. Patient 8 had sex with another peer in the room when he was supposed to be under 1:1 supervision; and,

4. From March 2019 to June 2019, sixteen (16) patients (Patients 5, 6, 9, 15, 16, 17, 18, 19, 21, 22, 23, 24, 25, 26, 27, and 30), who were on Q15 minutes monitoring, had various incidents involved.

These failures resulted in serious emotional trauma to the affected patients and had likelihood of potential reoccurrences to all patients in the hospital.

On 7/18/19 at 3:07 p.m., Immediate Jeopardy (IJ) was called for lack of effective supervision and monitoring and removed on 7/18/19 at 8:30 p.m. with an acceptable removal plan from the hospital.

Findings:

1. Review of Patient 1's Discharge Summary, dated 6/1/19, indicated the patient was a 16-year-old male and admitted to the hospital on 5/20/19 with diagnoses of major depressive disorder, PTSD (Post Traumatic Stress Disorder), ADHD (Attention Deficit Hyperactive Disorder), and social anxiety disorder.

Review of Patient 1's Progress Notes, dated 5/29/19 at 11:16 a.m., indicated "a peer pressured/threatened him into letting peer perform manual and oral sex on/to him in the activity room...on 5/27(/2019) ([Patient 1] reports "she gave me a hand job") and on 5/28 (/2019) (pt [patient] reports "she performed oral sex on me.")" The patient reported the peer threatened him into participating in acts and the peer was "scary". The patient stated both incidents occurred in the back of the activity room between 8 p.m. to 9 p.m. There was no evidence staff was present and supervised patients in the activity room during the incidents occurred.

Review of patient 1's Patient Observations, dated 5/27/19 and 5/28/19, indicated the patient was on Q15 minutes monitoring when the incidents occurred.

Review of Patient 2's Discharge Summary, dated 6/1/19, indicated on 5/25/19, the patient was a 15-year-old female (whom identified himself as male) and admitted to the hospital with diagnoses of general anxiety, major depression, and borderline personality.

Review of Patient 2's Progress Note, dated 5/29/19 at 1:13 p.m., indicated on 5/28/19, the patient reported he performed oral sex on a peer in the back of the activity room. The patient also reported he and some peers touched each others' private areas and gave a peer a hand job between 8 p.m. to 9 p.m. There was no evidence the staff supervised them during the incident.

Review of Patient 2's Patients Observations, dated 5/27/19 and 5/28/19, indicated the patient was on Q15 minutes monitoring when the incident occurred.

Review of the police report, dated 7/23/19, indicated Patient 1, the victim, wanted to press charges against Patient 2. Patient 2 was released from the hospital into the custody of Child Protective Services (CPS) and this case was forwarded to the Santa Clara County Juvenile District Attorney.

During an interview on 7/17/19, at 2:00 p.m., the Director of Quality Assurance (DQA) stated that during the events no staff supervised the patients in the activity room and there should be always staff to supervise the patients.



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2. Review of Patient 4's Discharge Summary, dated 5/11/19, indicated the patient was a 14-year-old male and admitted on 5/2/19 under 5150 hold (California law code for temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness) with diagnoses including bipolar disorder (any of several psychological disorders of mood characterized by alternating episodes of depression and mania), severe depression with psyche features. During his course of hospitalization, Patient 4 continued to have mood lability and significant difficulty with impulse control. He required 5 minute checks and one-on-one for a lot of his hospital stay as he was hypersexual.

Review of Patient 4's Psychiatrist Progress Notes, dated 5/4/19, indicated he has said provocative statements to nursing staff and he has called them "honey" that was said in a way that felt malicious and sexualized. He was also intrusive of others. He knocked a hoodie off of a peer's head while he was on every 15 min monitoring for sexual acting out. It indicated the patient had inappropriate touching with female peers and seems to be hypersexual with no history of abuse. He was placed on every 15 minutes observation for sexual precautions.

Review of Patient 4's Nurses progress notes, dated 5/5/19, indicated a peer reported to nursing staff, on 5/4/19 between 6 to 7 p.m., Patient 4 and Patient 3, who was 16-year-old female, were in the activity room covered up with a blanket and appeared to be fondling each other underneath the blanket. There were no staff present in the activity room at that time. Patient 4 remained on every 15 minutes observation.

Review of Patient 3's Progress Notes, dated 5/5/19 at 1:54 p.m., indicated the patient reported Patient 4 made inappropriate comments, stating "He told me he wants to have sex" and kissed her in the activity room. It stated the incident was consensual and unwitnessed.

Review of Patient 3's discharge summary dated 5/6/19, indicated on 5/5/19, she was observed to be crying, feeling emotional, and upset. She reported she had oral sex with Patient 4 in her room. Patient 4 pretended to be in the shower by turning the water on, snuck out of shower in between every 15 minuted monitoring, went into Patient 3's room, and had oral sex with her.

Review of Patient 4's Patient Observations, dated 5/5/19, indicated the patient was on every 15 minutes monitoring when the incident occurred.

Review of Patient 28's Progress Notes, dated 5/5/19 1:54 p.m., indicated the patient reported Patient 4 made inappropriate remarks on her, stating "He told me he wants to have sex" and kissed her in the activity room. It stated the kiss was consensual.

Review of Patient 28's Discharge Summary, dated 5/4/19, indicated patient 28 was a 15-year-old female under the guardianship of her parents. Patient 28 had a diagnosis of autism spectrum disorder (a serious developmental disorder that impairs the ability to communicate and interact)

Review of Patient 4's Patient Observations indicated on 5/5/19 he was on every 15 minutes monitoring and at 4 p.m. on that day, the patient was placed on 1:1 monitoring. On 5/9/19 8:30 a.m., the monitoring had changed to every 5 minutes.

Review of Patient 4's Progress Notes, dated 5/9/19 at 9:28 p.m. the patient hit another peer.

Review of Patient 4's Patient Observations, dated 5/9/19, the patient was on every 5 minutes monitoring when the physical altercation occurred.

Review of Patient 7's Discharge Summary, dated 5/16/19, indicated the patient was a 15-year-old female with diagnoses of major depressive disorder and was undergoing intensive outpatient program. She was admitted on 5/10/19 under 5150 hold for danger to self due to suicidal ideation.

Review of Patient 7's nurses progress notes, late entry dated 5/14/19 for 5/11/19, indicated on 5/11/19, Patient 7 reported to staff on 5/10/19, while in the activity room before bedtime, Patient 4 grabbed her hand and placed it on his private part. She immediately pulled her hand away. A peer, who was in the same room at the same time, stated she saw both of them sitting next to each other. Patient 7 also reported sometime in the morning of 5/11/19, Patient 4 went into her room and touched her breast. She told Patient 4 to leave her room and he did. Patient 7 felt uncomfortable and verbalized she wanted to press charges. Incident was reported to law enforcement and to the attending physician. Patient 4 was on every 5 minute monitoring at time of the incident.

During a telephone interview with the director of nursing (DON) on 7/19/19 at 11:50 a.m., she stated for the incident with Patient 4, "the 1:1 monitoring should have been done clearly".

3. Review of Patient 8's Discharge Summary, dated 4/25/19, indicated Patient 8 was a 17-year-old transgender female (denoting or relating to a person whose sense of personal identity and gender does not correspond with their birth sex) with history of sexually trafficked and abducted.

Review of Patient 8's Psychiatrist Progress Notes, dated 3/14/19, indicated the patient was found with a male peer in her room after shift change at about 11:10 p.m. Both patients did not wear clothes. Patient 8 reported they had consensual sex.

Review of Patient 8's Patient Observations, dated 3/14/19, indicated the patient was on every 15 minutes observation and should be on 1:1 monitoring when he was in the room for sexual precautions.



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4. Review of Patient 5's Progress notes, dated 6/3/19 at 7:30 p.m. indicated the patient was 55-year-old female and she shouted, yelled, and cursed another male peer, who was seen going out of the patient's room. She stated another male peer came to her room and touched her.

Review of Patient 6's Psychiatrist Progress Notes, Dated 6/2/19, indicated the patient was 50-year-old male with schizoaffective disorder (a serious mental disorder in which people interpret reality abnormally). It indicated throughout day, the patient remained inappropriate, threatening on the unit the psychiatrist overheard multiple times by staff he was walking up to a peer and saying "I am going to fucking rape you and then you are going to put your finger in my ass." and making obscene sexual gestures at the peer, to the point that peer complained multiple times to staff feeling unsafe to leave her room.

Review of Patient 6's Patient Observations, dated on 6/2/19, indicated the patient was on every 15 minutes monitoring and the monitoring had changed to every 5 minutes at 11:30 p.m. at the end of the day.

Review of Patient 9's clinical record indicated he was 32-year-old male, admitted on 2/16/19 with diagnoses including paranoid schizophrenia and severe amphetamine use disorder. On 2/18/19, he informed the psychiatrist that he was sex-deprived.

Review of Patient 16's Discharge Summary, dated 3/12/19, indicated the patient was a 33-year- old female and admitted on 2/24/19 on 5150 hold for being gravely disabled. On admission, she presented herself as disorganized, and tangential paranoid.

Review of Patient 16's Progress notes, dated 3/2/19, at approximately 5:35 p.m., a peer informed staff nurse Patient 9 went in to Patient 16's room. Patient 16 was found on her knees in bed while Patient 9 was found standing behind her back with his pants down below his waist.

Review of Patients 9 and 16' Patient Observations, dated 3/2/19, indicated both patients remained on every 15 minutes monitoring for sexual precautions.

Review of Patient 15's Discharge Summary, dated 5/7/19, indicated Patient 15 was a 17-year- old female with history of major depressive disorder, post traumatic stress disorder, and sexual and physical abuse. She was admitted under 5150 for suicidal behavior.

Review of Patient 15's Progress notes, dated 4/30/19 at 4:30 p.m., staff noticed Patient 15 was sexually inappropriate as exhibited by sucking on a peer's fingers.

Review of Patient 15's Progress notes, dated 5/1/19 at 7 p.m., in activity room, staff saw Patient 22 sucking Patient 15's left middle finger.

Review of Patient 22's Discharge Summary, dated 5/6/19, indicated the patient was "sexually acting out" by licking female peer's finger.

Review of Patients 15 and 22's Patient Observation, dated 5/1/19, indicated both patients were placed on every 15 minutes observation for sexual acting out precautions.

Review of Patient 17's Discharge Summary, dated 5/26/19, indicated the patient was a 14-year-old male and admitted under 5150 hold for danger to self with suicidal ideation.

Review of Patient 17's Progress Notes, dated 5/25/19, indicated at approximately 7:30 p.m., a staff reported Patient 17 was seen kissing Patient 24 on the lips in the activity room.

Review of Patient 17's Patient Observations, dated 5/25/19, indicated when the incident occurred the patient was on every 15 minutes monitoring for sexual precaution.

Review of Patient 24's Progress Notes, dated 5/25/19, indicated the patient was a 14-year-old female, had poor boundaries with a male peer, and required consistent redirection. Staff saw the patient kissed Patient 17.

Review of Patient 24's Patients Observations, dated 5/25/19, indicated when the incident occurred, the patient was on every 15 minutes monitoring for sexual precautions.

Review of Patient 24's Progress Notes, dated 5/27/19 at 11:44 a.m., indicated anther female patient punched her face twice after they got into a verbal altercation in the cafeteria. Patient 24 had a swelling on the bottom lip and complained of 7 of 10 pain (0-10 pain scale, 10/10 is the worst pain).

Review of Patient 24's Patients Observations, dated 5/27/19, indicated the patient was on Q15 minutes monitoring.

Review of Patient 18's Discharge Summary dated 3/22/19, indicated Patient 18 was a 14-year-old male and admitted under 5150 hold for danger to self for having suicidal thoughts.

Review of Patient 18's Progress Notes, dated 3/19/19 at 9:30 a.m., while kids were lined up in front of the nurses' station to go to the gym, the nurse went back to the nurses' station to get a clip board. When the nurse came back to the line, she saw Patient 18 and another female peer were kissing at a corner, which was an area that was not a direct view from the nurses' station.

Review of Patient 18's Patient Observations, dated 3/19/19, indicated the patient was on every 15 minutes observation for sexual acting out.

Review of Patient 19's Progress Notes, dated 6/24/19, indicated Patient 19 kissed a female peer at 4:20 p.m. when they were going to a gym.

Review of Patient 19's Patient Observations, dated 6/24/19, indicated the patient was on Q15 minutes monitoring when the incident occurred.

Review of Patient 21's Progress Notes, dated 3/8/19, indicated the patient had a fight with another peer, which resulted in a bump on the back of the head.

Review of Patient 21's Patient Observations, dated 3/8/19, indicated when the incident occurred, the patient was on Q5 minutes monitoring

Review of Patient 21's record indicated there was no evidence a progress note or Incident Report Form was initiated regarding the 3/8/19 incident.

During an interview on 7/19/19 at 1:35 p.m., the nursing house supervisor stated there should always be an incident report for investigation and progress notes written when an incident happened.

Review of Patient 23's Progress Notes, dated 6/10/19, indicated the patient was involved in a verbal altercation with a female peer. Patient 23 was physically attacked by the female peer while being in the activity room.

Review of Patient 23's Patient Observations, dated 6/10/19, indicated when the incident occurred, the patient was on Q15 minutes monitoring.

Review of Patient 25's Progress notes, dated 6/10/19 at 8:21 p.m., indicated the patient was a 15-year-old female, went to the back of the activity room with another peer, where they knew it was a blind spot, and kissed.

Review of Patient 25's Patient Observations, dated on 6/10/19, indicated when the incident occurred, the patient was on Q15 minutes monitoring.

Review of Patient 26's Progress notes, dated 3/15/19, indicated the patient was a 15-year-old female and discharged on that day.

During an interview on 7/19/19 at 10:23 a.m., Director of Quality Assurance (DQA) stated after Patient 26's discharge, her mother called and stated the patient was sexually assaulted by her roommate during the hospitalization. DQA stated she investigated and the patient's roommate stated both had kissed but, Patient 26 started kissing.

Review of Patient 27's Progress Notes, dated 6/24/19, indicated the patient was a 15-year-old female and kissed another peer in a hallway going toward a gym.

Review of Patient 27's Patient Observations, dated on 6/24/19, indicated the patient was on Q15 minutes monitoring.

Review of Patient 30's Progress Notes, dated 4/27/19 at 4:50 p.m., indicated the patient was seen kissing another peer and she stated "He kissed me first."

Review of Patient 30's Patient Observations, dated on 4/27/19, indicated the patient was on Q15 minutes monitoring.

During an interview with Director of Quality Assurance (DQA) on 7/17/19 at 1 p.m., the incidents were reviewed. DOQ stated even though the patients were under various monitoring, the incidents happened so quickly and staff could not prevent them.

Review of the hospital's job description for registered nurses (RN), dated 5/1/18, indicated RNs are responsible for providing professional nursing care to patient in a supportive and therapeutic environment.