HospitalInspections.org

Based on record review and interview, the hospital failed to ensure all allegations of abuse were handled as grievances. The deficient practice is evidenced by failure to document the complaint as a grievance and failing to provide a written notice of the grievance resolution and results decision after a complaint of sexual abuse was made for 1 (Patient#1) of 1 (Patients #1) reviewed for grievances.
Findings:

Review of the medical record for Patient #1 revealed the patient disclosed to S5CSW on 02/11/2025 that he had been sexually assaulted the previous day.

Review of the Hospital's incident report revealed the following, in part:
Note by S3RN- "On 02/10/2025 at 6:05 PM, myself and S4LPN was watching cameras and saw Patient #1 in Patient #2's room and we saw Patient #2 pull Patient #1's penis out and perform oral sex on Patient #1, after a minute or so Patient #2 appeared to get Patient #1 to go to his bathroom and that is when Patient #1 left the room and went to dayroom and sat down."

During an interview on 02/20/2025 at 12:20 PM, S1ADM and S2DON reported they did not file a grievance for Patient #1 after the incident occurred and the patient did not receive a letter after the incident was investigated.

Based on record review and interview, the hospital failed to ensure a patient remained free from abuse for 1 (Patient #1) of 1 (Patients #1) patients reviewed, as evidenced by failure to implement immediate interventions to prevent further occurrence after a witnessed episode of sexual interaction.
Findings:

Review of the hospital's incident report dated 02/10/2025 revealed the following, in part:
Patient to patient sexual assault.
Date of incident 02/10/2025. Time of incident 6:03 PM, 7A-7P shift.
Date of discovery 02/11/2025 at 11:50 AM. Location main campus, Unit A. Specific location patient room.
Victim Patient #1
Aggressor Patient #2
Video surveillance- yes. Video was reviewed by S1AIT and S2DON.
Video showed the following:
6:02 PM Patient #2 and Patient #1 both seen in the day room.
6:03:18 PM Patient #2 is seen at his door talking to someone off camera.
6:03:27 PM Patient #1 seen entering Patient #2's room.
6:03:31 PM Patient #2 seen fondling Patient #1's penis.
6:03:48 PM Patient #2 seen inserting Patient #1's penis in his mouth.
6:03:59 PM Oral activity noted to be finished.
6:04:02 PM Patient #2 seen taking Patient #1's hand and leads him into the door of the bathroom.
6:04:08 PM Patient #1 is noted to turn around and walk away.
6:04:12 PM Patient #1 noted to exit patient's room.
6:04:20 PM Patient #1 returns to day room.
6:04:35 PM Patient #2 returns back to the day room
.
On 02/19/2025 at 2:15 PM, S1AIT played the video of Patient #1 and Patient #2. Timeline above was accurate. No sound was noted during the video. Patient #1 did not appear to resist the advances, until Patient #2 held his hand and was trying to get Patient #1 to the bathroom and then Patient #1 let go of Patient #2's hand and walked out. Then Patient #2 left out of his room shortly after Patient #1 left the room.

Video of the hallway where Patient #2's room was viewed. Patient #2 went inside his doorway and was summoning Patient #1 to Patient #2's room. Then you could see Patient #1 exiting room 18:04:15-20. Patient #2 exited the room 1-2 seconds after Patient #1 left the room.

Review of the Hospital's incident report revealed the following, in part:
Note by S3RN- 02/10/2025, At 6:05 PM, myself and S4LPN was watching cameras and saw Patient #1 in Patient #2's room and we saw Patient #2 pull Patient #1's penis out and perform oral sex on Patient#1, after a minute or so Patient #2 appeared to get Patient #1 go to his bathroom and that is when Patient #1 left the room and went to dayroom and sat down.

During an interview on 02/20/2025 at 9:30 AM, S4LPN reported he saw the video monitoring in the nurse station and saw Patient #1 and Patient #2 in Patient #2's room and then he saw Patient #2 delivering oral sex and S4LPN went out to go to the room and they had already walked out of the room. S4LPN further reported that Patient #1 and Patient #2 didn't say anything about what happened, they both just carried on with their daily routine.

During an interview on 02/20/2025 at 9:38 PM, S5MHT indicated she had gotten up out of her chair to talk to another MHT and she saw S4LPN coming out of nurse room and by the time he came out and she got up Patient #1 and Patient #2 had already came out Patient #2's room.

Review of Therapist notes revealed the following, in part:
(Meeting with Patient #2) At 11:39 AM, therapist met with assigned patient regarding the incident that took place on 02/10/2025 at approximately 6:05 PM. There was a sexual contact incident between Patient #1 and Patient #2.
Therapist met with Patient #2 regarding sexual inappropriate contact with another patient. Patient #2 was reluctant to discuss the incident and made light of the situation. As Patient #2 discussed the incident he was laughing and slightly grinning. According to Patient #2, Patient #1 comes by the room to say "Hi" to everyone throughout the day. The difference in 02/10/2025 is that Patient #1 entered Patient #2's room instead of continuing down the hall. Patient #2 is unsure why the patient entered his room on this day. Patient #2 admitted to touching Patient #1's private area initially and states, "He touched mine and that was that he ran out." Patient #2 further admits to performing oral on the patient and states, "It was fast." Patient #2 states there was no communication between the two prior to the incident. Patient #2 further explains there was no consent to touch by either himself or Patient #1. The patient admitted it was wrong, and it was "spur of the moment."

(Meeting with Patient #1) At approximately 11:50 AM, S6CSW, initiated a conversation with Patient #1 to discuss the incident that took place yesterday, 02/10/2025, at approximately 1800 with Patient #2.
The therapist informed the patient that a report was made of the incident and the therapist wanted to hear from him about what took place in Patient #2's room. The patient was informed that there are cameras on the facility. Initially Patient #1 stated nothing happened. The Therapist asked the patient what he went into the bedroom for, he stated because Patient #2 wanted him to look at his toilet. The therapist asked Patient #1 did he go into Patient #2's room willing and he stated yes. He was asked what happened in the bedroom and he said nothing. The Therapist informed Patient #1 that therapist was there for him if he needs to talk or discuss anything and if nothing else he could return to the dayroom. As the therapist and MHT walked back into dayroom, Patient #1 tapped the therapist on shoulder and stated he needed to talk. Patient #1 and the therapist walked back down the hall and Patient #1 stated, "I was raped." The therapist asked him what happened, and he stated Patient #2 asked him to come with hime to his bedroom to look at his toilet. He stated once he entered the bedroom Patient #2 pulled his pants down and began to suck his d**k. The therapist asked did he tell him to stop. He stated "no, but I did not want him to do that." The therapist asked why he did not stop him and he stated he was scared but Patient #2 asked him to go into the bathroom and he ran out of the room.

In an interview on 02/19/2025 at 1:40 PM, SAIT verified the facility became aware of the incident shortly after it occurred on 02/10/2025 and at the time the sexual conduct was considered as consensual. SAIT verified there were no orders for increased observation on 02/10/2025. SAIT verified on 02/11/2025 Patient #1 reported that the sexual act was not consensual. S1AIT then reported to the police department. Police came to the hospital and questioned both Patient #1 and Patient #2. Patient #2 was place on 1:1 after physician was notified (02/11/2025). Law enforcement charged Patient #2.

During an interview on 02/20/2025 at 12:00 PM, S4LPN reported he had told the MHTs to keep Patient #1 and Patient #2 separated. When asked if had charted anything related to what he told the MHTs, S4LPN and S2DON reviewed the record and reported there was not any charting completed related to the MHTs being told to keep the two patients separated.