HospitalInspections.org

Based on interview and record review, the facility failed to protect patients' rights by not providing a safe environment resulting in harm to 1 (P-1) of 10 patients reviewed and the potential for harm and/or unsatisfactory outcomes for all patients receiving care in the facility. Findings include:

See specific tags:
A-144 The facility failed to provide care in a safe setting.
A-145 The facility failed to protect a patient from abuse.

Based on interview and record review, the facility failed to provide immediate and follow-up care instructions to 1 (P-1) of 10 patients reviewed, resulting in a missed opportunity for immediate medical assessment and treatment. Findings include:

Review of "History and Physical," dated 07/17/25 revealed, "Patient (P-1) is a 11-year-old female admitted for worsening depression and overdose on Motrin. History of self-harm and cutting since age 9. P-1 was admitted to the facility on 07/16/25 at 1230. P-1 was discharged abruptly, on 07/20/25 at 1850, following parental notification of an alleged sexual assault.

An interview was conducted with Psychiatrist Staff J on 07/29/25 at 1055. Staff J stated, "Sunday, the NP (nurse practitioner) called and explained the allegations. The NP (Staff H) had talked with the mom, who wanted to pick up her child immediately for safety reasons. Staff J added that this was not a patient she was currently seeing but would have seen the next day. I was called in the evening and told "mom wants her now". Given the prior conversation, mom was really concerned. I ensured there was an adequate safety plan, so let ' s go ahead and discharge. I was still hoping for 1 to 2 days more to supervise and adjust her medications. We will continue and discharge instructions can be provided on Monday (next day)."

Staff J was next questioned if P-1 was assessed for injuries, mental or physical, following her report of alleged sexual assault. Staff J stated, "That would have to be ordered by the provider. She was not assessed after the incident that I know of. Medical doctors would do that; there was not a requested medical evaluation prior to discharge. There was no medical doctor on, they would have seen her over the next few days." Staff J was next questioned if she has ever consulted medical physicians, perhaps for a patient that may need to go to Emergency Room or for a S.A.N.E. (Sexual Assault Nurse Exam)? Staff J stated, "This is my first, I ' m not clear what was needed." Staff J was questioned if she offered any medical advice to the parent? Staff J stated, "No medical advice to the parent, I got pharmacy meds lined up. The therapist would reach out for the rest and the follow-up appointments."

Review of facility policy titled, "Behavioral Medicine Center Patient Abuse and Neglect Reporting," #6.01, (no date) revealed (17). Any adolescent patient involved in an incident of sexual abuse or sexual contact will be sent immediately the Child Abuse and Neglect Council (CAN) (patients ages 8 - 12) or SART/SANE (Sexual Assault Response Team/Sexual Assault Nurse Examiners) (patients 13 - 17 or younger minor females who have experience an onset of menses) after obtaining parent or guardian consent. An explanation of health risks will be provided and parental consent or refusal is to be thoroughly documented in electronic medical record Nursing Progress Notes by a registered nurse. The examination shall occur within 120 hours of the alleged incident. The decision as to whether or not to send a patient to SART/SANE shall be at the discretion of the Director of Psychiatric Nursing and/or the Program Executive, unless directed by law enforcement or the parent/guardian.

Review of facility policy titled, "Medical Consultation, #6.04, eff.08/83, revealed (1.) "The attending Psychiatrist is primarily responsible for requesting consultation when indicated and for referring patient to the Internal Medicine Physician or other qualified medical professional. The Attending Psychiatrist will enter an order in the electronic medical record to specify what service he/she wishes the consultant (i.e., opinion only, manage area of care specified, etc.) and (3.) "The consultant will enter treatment orders for any necessary follow-up care deemed necessary."

Review of "Discharge List," dated 01/01/25 through 07/28/25 demonstrated that Psychiatrist Staff J was listed as P-1's attending physician.

On 07/29/25 at 1126, review of P-1's discharge document titled, "My Safety Plan," dated 07/20/25 revealed instructions for calling a suicide hotline and generic precautions about avoidance of medications, weapons, and self-harm. During review of the form, Staff F stated that the signatures were from P-1's mother and the discharge RN. Three check-boxes above the signatures stated "(1.) Patient/Family able to verbalize discharge instructions. (2.) Patient verbalizes understanding of when/how to seek treatment. (3) List of educational materials given to patient include labs, medications, diagnosis. There was no mention of seeking immediate medical evaluation/treatment on the document.


Staff F was asked why the document was void of specific discharge instructions yet still signed by the nurse and P-1's parent? Staff F stated, "The discharge was rushed, we didn't want to escalate the situation." Staff F was next questioned if P-1 was advised to seek medical treatment for a possible sexual assault? Staff F stated that, "The plan was for a therapist to call and arrange the follow-up appointments and discharge instructions the following day." Staff F was requested to demonstrate documentation of the follow-up call. Staff F stated, "There was no call documented by therapy." Quality/Risk manager Staff F stated that she and RR advisor (Staff I) called the mother the following day (Monday, 07/21/25) and attempted to advise her of the discharge instructions, however, the parent hung up on them. Staff F stated that the parent had requested no further contact.

Review of facility policy titled, "Discharge Planning," #2.05, (no date) revealed, " (J). For patients discharging to a lower level of care, the Therapist/Social Worker shall ensure an appointment has been made with the next level provider within seven (7) days of discharge from (facility name) and noted on the Discharge Plan without exception."

Based on interview and record review, the facility failed to ensure 1 (P-1) of 10 patients reviewed, were free from abuse and/or neglect resulting in loss of dignity and respect, the increased potential for physical or psychological injury, and poor patient outcomes. Findings include:

At approximately 1300 on 07/2825, an interview was conducted with Nurse Executive (Staff D). Staff D provided an overview of the events leading to P-1s discharge. Staff D stated that an 11-year-old (P-1) was admitted to the facility for suicidal ideation. On Sunday, 07/20/25 at approximately 1500, she reported to her Nurse Practitioner that a Mental Health Tech (MHT/ Staff L) wearing a pink shirt, put his hand in her underwear and put his finger into her butt. P-1 requested "a female staff member, if the procedure was to be done again." Staff D stated that P-1's mother was notified of the allegation and immediately drove to the facility.

Review of untitled, undated document presented as "Administrative Investigation," revealed, "(P-1) stated that on Friday, July 18, 2025, she had urinated on herself in her room and (Staff L), the one with the scratchy voice that talks fast and wearing a pink shirt, helped her clean up... The report continued with very descriptive and explicit details of her verbal and physical interactions with Staff L over 2 nights. P-1's account described multiple accounts of sexual abuse and her confusion and embarrassment from the interactions with Staff L as P-1 also reported that "Staff L was kind and nice to her, offering more opportunities for conversations, fist bumps, and interactions, than to other patients".

At approximately 1230, Adolescent Unit manager (Staff G) provided a narrative report of her findings from viewing the video footage from 07/19/25 at 2330-07/20/25 at 1530. It should be noted that alleged perpetrator (Staff L) worked a double shift, from 1130 p.m. on 07/19/25 until 1500 on 07/20/25.Staff G stated that the alleged perpetrator (Staff L) was noted to be "rounding" on patients throughout the 16-hour video. Staff G added that no assault was visualized, as all cameras are in the hallways and no cameras show patients in their rooms. Review of the narrative document demonstrated numerous times where Staff L entered patients' rooms for a minutes at a time before being seen on camera again. Staff G stated that she looked for changes in proximity or frequency of interactions between Staff L and P-1, and none were noted. Additionally, she was not able to determine when the alleged assault may have taken place. Staff G was questioned if this observation of patient rounding is normal? Staff G stated that staff often talk with patients, in private, because listening, therapy and support are needed.

Following the incident, the facility re-educated staff on their "Code of Conduct" expectations. However, the facility failed to thoroughly investigate and identify opportunites to educate staff regarding ways to prevent abuse during hygiene and rounding.