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The hospital failed 1 of 1 Patient (Patient #1) the right to receive care in a safe setting. Patient #1 engaged in sexual activity while an inpatient at Carrollton Springs Hospital.

Findings Include;

During record review the hospital Inpatient Progress Note 06/13/2022, there was an issue with having a sexual encounter with another person on the unit, Patient #1 was sent to ER and had a police report made. Patient #1 reported laying in bed and the other person reports that this was consensual.

During Record Review in Patient #1 completed a SANE Exam 24 hours later and was described in the following state the day after Exam; severe depression, tearful, sad, does not want to talk about it at all ...there is trauma reenactment as Patient #1 has a history of trauma ...also a history of having sexual encounter with a patient at another hospital ...still doesn't want to talk about that either ...engaged with interview, gets upset and becomes tearful.

During Record Review the SANE Exam reflected Patient #1 stated that last night, Patient #2 entered Patient #1's room and forced Patient #1 to perform oral sex and then partially penetrated Patient #1. The patient denies vaginal bleeding and vaginal pain. The patient wants a rape kit done. Patient stated that she hasn't showered or bathed since the incident. Patient reported current alcohol use, and illicit drug use (Marijuana, Cocaine and Heroin). No further complaints at this time.

During video observation and timeline review there was a 6 minutes time span of Patient #2 being in Patient #1's room and roommate was not present at the time incident took place.

During Interview with Hospital Staff #5 reported interviewing Patient #1 after hospital was informed of alleged event. Staff #5 indicated Patient # 1 reported; '"I think I was raped. 'Patient #1 became tearful and agitated 'having to talk about it.' Patient #1 stated did not want to talk about it or think about it.'Patient #1 stated the incident occurred sometime before dark and night med pass. Patient #1 reported throwing underwear and bedlinens from original room and placed in paper bags due to soiling them. Staff # 5 indicated she was able to retrieve them and provided them to the Police.

During Interview with Hosptial Staff #5 it was reported Patient #1 was transferred to Emergency Room by Carrollton Police Department and returned by Carrollton Police Department at 2225. Pateint #1 returned denying any suicidal ideation, homicidal ideation, or experiencing any hallucinations. Patient #1 was reported to be labile and cooperative. Following Patient #1 informing Staff #5 about the alleged incident, Patient #1 was infomred by Staff #5 that she would be moved to another unit and prior to moving to the other unit Patient #1 requested to go on a smoke break first and that she felt comfortable remaining on current unit and displayed no signs of fear, or anxiety about perpetrator who remained on the unit at the time.

During Interview with the SANE Examiner on 06/15/2022 at 3:00 PM it was that Patient #1 had alleged being drug into the bathroom and was sexually assaulted. Patient #1 had a SANE EXAM and was noted to have visible bruising, redness to genital area, and tears to anus. SANE Examiner indicated being told by Patient #1 that an unknown Nurse at the hospital stated 'You were not raped!'
SANE Examiner stated that Patient #1 did not advise Examiner of working as a self trafficker. Examiner reponded 'No!' Examiner was asked if Patient #1 informed the Examiner prior to this incident when was the last time participated in sexual activity. The Examiner stated that did not occur. There is no evidence of the Patient #1 being drug, or having injury of being drug. The Examiner was asked what Patient #1 demeanor was during exam. Pateint #1 was appropriate, not timid, or scared showed no signs of fear. Patient #1 displayed approprate demeanor.

During Interview with Staff #2, Staff # 2 reported that the allegations of Patient #1 being drug into the bathroom were new to the hospital. This was the first time the hospital had heard this allegation. Patient #1 never cried out, staff was rounding appropriately as video footage revealed. Staff were on the unit as well has other Pateint's this was not revealed to the hospital prior to now.

During Interview with Carrollton Police Department Investigator on 06/15/2022 reflected, Patient #1 told him, "Patient #1 and Patient #2 had been flirting back and forth all week. Patient #1 was not able to recall exactly what happened but somehow, Patient #2's penis ended up in my mouth. Then Patient #2 asked me to bend over the desk in my assigned room. Patient #2 was unable to penetrate my anus. Patient #1 said, 'I never told him, 'No or to Stop. I never screamed out for help or cried out to anyone.' He asked me if she wanted him to continue, she said 'I said No, but go ahead and finish.' So, they engaged in oral sex again then vaginal in the bathroom of her assigned room.' Investigator indicated this is nothing the Police Department is going to pursue on a criminal level, Patient #1 did tell him to finish and reported not wanting to press any charges. Investigator stated that receiving all the information on the alleged perpetrator, but will not going to interview and pursue Pateint #2 based on the interview with the alleged victim." The Investigator reported never being informed on the alleged allegation of being drug into the bathroom. There was no evidence of the patient being drug or having any physical injury of being drug.

Policy
The hospital Policy on Administration and Personnel
ROLE AND PURPOSE
1. Purpose . The Hospital's purpose is to operate as a for profit, acute care psychiatric hospital, providing a continuum of care including, but not limited to, acute care services, rehabilitative services, inpatient services, outpatient services, and partial hospitalization services. It is our mission to provide the highest quality treatment services to individuals and families suffering from the devastating effects of mental illness and/or addiction. We are committed to utilizing evidenced based treatment research and clinical protocols while continuously evaluating new and promising treatment methods. Our treatment services are delivered in a professional and compassionate environment from healthcare professionals who are dedicated to motivating others to choose a life of sobriety and mental wellness. We are dedicated to helping our patients realize their potential.
2. Governing Board . The Governing Board will support the role, purpose and mission of the Hospital. Generally, the Governing Board is responsible for the quality of care, quality improvement mechanisms, credentials review and delineation of privileges.
3.Bylaws . These Bylaws are intended to assist the Governing Board by outlining the Governing Board's general responsibility, authority, and expectation.
4. Nondiscrimination . The Hospital shall be operated, in all respects, on a nondiscriminatory basis, without regard to race, sex national origin, religion or physical handicaps. This policy shall relate to the admissions and treatment of patients and use of the facilities of the Hospital by employees, the public, and patients. Accommodation assignments of patients shall be made without regard to race, sex, national origin, religion or physical handicaps, and the hospital shall not discriminate as to hiring, firing, compensation terms, conditions, creed, religion, sex or national origin.
5 Patient Bill of Rights . The Governing Board shall establish a Patient's Bill of Rights in compliance with state law.

The hospital policy Patient's Bill of Rights dated 09/2021reflected, "When you apply for or receive mental health services in the State of Texas, you have many rights ...These rights apply to all persons unless otherwise restricted by law or court order. A judge or lawyer will refer to the actual laws ...You have the right to appropriate treatment in the least restrictive appropriate setting available ...You have the right to receive treatment of any physical problems which affect your treatment ...You have to right to be told about ...all the medications and treatment you will receive ...You have the right not to be given medication you don't need or too much medication, including the right to refuse medication ...You have a the right to receive a list of the medications prescribed for you by your physician, including the name, dosage, and administration schedule within four hours of the facility."

The hospital Abuse Policy "Suspected Adult Abuse" dated 09/2022, reflected.
Abuse - The infliction of mental or physical pain or injury by other than accidental means, unreasonable confinement, or deprivation ...necessary to the mental or physical health of the patient. Temporary discomfort that is part of an approved and documented treatment plan or use of documented emergency procedure shall not be considered abuse.
Neglect - The failure to provide care or services necessary to maintain the mental or physical health and well-being of the patient.
Exploitation - The use of a patient's person ...or breach of a fiduciary relationship through improper use of a client's person ...including situations where an individual obtains property or services from a patient from undue influence.
A. Patients have right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation. It is the policy of this facility to comply with local and state laws about mandated abuse reporting in order to ensure that patients are safe and free from mental, physical and verbal abuse, neglect and exploitation ... Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation. It tis the policy of this Facility to protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff members, student, volunteers, other patients, visitors or family members. This Facility mandates that, under the guidance of applicable laws, any healthcare worker having reasonable cause to believe that any person is in the state of abuse, exploitation or neglect shall report the information to the appropriate regulatory agency ...All allegations, observations or suspected cases of abuse that occur in the Facility will be investigated by the Facility."
3. Sexual Abuse
a. Sexual contact, sexual intercourse, sexual conduct, sexual penetration with a foreign object, incest, sexual
assault or sodomy inflicted on, shown to or intentionally practiced in
the presence of a child or dependent adult, if the child or dependent adult, is present only to arouse or gratify the sexual desires of any person.
b. Failure to make a reasonable effort to prevent sexual contact, sexual intercourse, sexual conduct, sexual assault or
sodomy inflicted on, shown to or intentionally practiced in the presence of a child or dependent adult, if the child or
dependent adult is present only to arouse or gratify the sexual desires of any person.
c. Compelling of encouraging the person to engage in sexual conduct.
d. Causing, permitting, encouraging or allowing the photographing, filming or depicting of the person knew or
should have known that the resulting photograph, film or depiction if obscene or pornographic.
8. The following criteria may be used to assist in the identification of abuse:
b. Rape/other forms of sexual abuse:
1. Involving the patient in any practice or scheme of conduct that may include sexual contact for the purposes of arousal of
gratification of the offender.
2. Trauma to the penis, vulvar and/or anal region
3. Sexual manipulation of penis, vulvar and/or anal region with a foreign object.

The hospital Policy on Sexual Acting Out (SAO) dated 12/2019 reflexed "Sexual behavior of any kind is prohibited in the Facility. Reports of sexual acting out between patients will be investigated. All allegations or observations of sexual behavior will be investigated by the facility."