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Based on interview and document review, the facility failed to follow their policy to protect patients from potential abuse during investigation of an allegation of an inappropriate interactions between an employee (E)1 and a patient (P)2.

Findings include:

The facility received a letter of concern from an anonymous employee via email dated 11/7/22, which alleged E1 had "poor boundaries" with P2 on the Golf unit. The letter of concern revealed the author had fear of retaliation, wished to remain anonymous, and had been informed from several staff members of the Golf unit of concerns related to E1's lack of boundaries with P2. The letter revealed staff had observed the following concerning interactions between E1 and P2 which included P2 blowing kisses and touching E1's buttocks, without E1 correcting P2's behavior. The letter indicated E1 routinely played cards with P2, allowed P2 to whisper in her ear, and E1 and P2 engaged in sitting together closely in an unprofessional manner. The letter indicated the author had been told employees of the Golf unit had voiced concerns to the unit supervisor, which then the supervisor would inform E1 the name of the employee who voiced concerns. The letter identified the employees of the Golf unit had indicated E1 would then tell P2 of the complaint and would allow P2 to "target" the employee who reported the concern.

During an interview on 11/15/22, at 1:20 p.m. the director of nursing (DON) stated she received the email, which was sent from the local public library, on the afternoon of 11/7/22. The DON confirmed the email with attached letter of concern had identified E1 would not maintain professional boundaries during interactions with P2. The DON stated on 11/7/22, she had spoken with human resources regarding the concern with E1 not maintaining boundaries with P2, and it had been determined to remove E1 from the Golf unit, where P2 resided. The DON stated E1 was then re-assigned to another unit on 11/8/22, as they felt the behavior was an isolated issue with P2 as the only patient E1 had an inappropriate relationship with. The DON stated at that time, E1 had received education regarding maintaining staff and patient boundaries. The DON identified video footage of E1 and P2 was reviewed on 11/9/22, and a decision was made to suspend E1 as of 11/10/22, The DON stated on 11/8/22, the facility leadership enlisted outside investigators within the Mental Health and Substance Abuse Treatment Services (MHSATS) system to complete an internal investigation due to the nature and possible extent of the complaint.

On 11/16/22, at 11:36 a.m. during a telephone interview, E1 stated she had worked at the facility for approximately five years, and was typically assigned to the Golf unit. E1 stated she had been reassigned from the Golf unit to the Bravo unit on 11/8/22, due to concerns with a patient on the Golf unit. E1 stated she presented for her shift the morning of 11/10/22, and had been told she had been placed on suspension due to concerns with maintaining professional boundaries with patients. E1 stated she had been told nothing else, she left the facility and had not been contacted by the facility since. E1 stated she had not received any education within the last few weeks regarding maintaining staff and patient boundaries.

Review of E1's work schedule from 11/7/22, to 11/15/22, identified the following:
- 11/7/22, E1 had been pulled from the Golf unit to the Hotel unit, and had worked eight (8) hours.
- 11/8/22, E1 had been pulled from the Golf unit to the Bravo unit, and had worked 8 hours.
-11/9/22, E1 was on medical leave and did not work.
-11/10/22, to 11/15/22, E1 was on an LOA (leave of absence).

On 11/16/22, at 1:21 during a follow up interview, the DON stated she had wanted to remove E1 from patient care immediately after receiving the anonymous email, however, due to the complainant being anonymous and identifying one specific patient, they felt it was best at the time to reassign E1 to another unit. The DON stated once they had a chance to review some of the video footage of interactions between E1, P2 and other patients on the Golf unit, concerns had been noted, and a decision was made to remove E1 from the facility.

Review of the hospital policy Vulnerable Adult Maltreatment Reporting - Mental Health and Substance Abuse Treatment Services (MHSATS) effective 1/5/21, identified it was the purpose of the policy to provide procedures for identifying and managing vulnerable adults (VA's), reporting suspected maltreatment of VAs, and internally reviewing maltreatment allegations. The policy directed immediate corrective action would take place when allegations are made; and steps would be taken to protect the safety of clients.