HospitalInspections.org

Based on a review of facility documents, policy and procedures and staff interviews, it was determined that the facility failed to submit a level I incident within 24 hours and to immediately contact the Administrator on Call for support and notification when one patient (P) (P#1) of four patients reviewed alleged a sexual assault had occurred.


Findings include:


A review of the facility's Incident Log from 11/1/24 to 1/27/25 revealed P#1 was named in a incident on 1/14/25.


A review of the incident revealed that a Behavioral Health Associate (BHA) EE completed the report involving Boundary Violation Issues. It was classified as a Level 1 severity and signed by Director of Risk Management (DRM) AA on 1/16/25.


A review of the document titled "Police Department Investigative Supplement" dated 1/16/25 at 1225 revealed local police responded to a call regarding a miscellaneous investigation at the facility. Upon arrival the officer made contact with Director of Risk Management (DRM) AA and was advised there was a possible situation that occurred between two patients alleging sexual assault. DRM AA informed the officer of the details based on the information he had received from P#1, P#2, staff and his own internal investigation.


A review of "Police Department Detective Report" revealed 1/21/25 at 1000 a detective traveled to the facility and made contact with DRM AA and was escorted onto the unit to make contact with P#1. DRM AA was present during the interview and advised the detective that P#1 had been going through periods of psychosis. P#1 was apprehensive on speaking about the alleged sexual assault and did not call P#2 by his name. P#1 articulated what he could remember and at no point did P#1 state that the alleged sexual assault was nonconsensual. P#1 stated that he believed that P#2 was HIV positive. The detective advised P#1 on what terms he could press charges and P#1 advised that he did not wish to press charges. The detective stated that P#1 appeared to be lucid and alert during the interview. The detective further documented that due to due to P#1's apparent consent and lack of willingness to pursue charges the case would be closed.


A review of the facility's policy titled "Risk Management Incident Reporting Policy," #xxxx. RISK.0210, review date 01/23 revealed the purpose of incident report was to raise awareness of actual or potential exposures to harm. The Incident Report would enable the facility to manage risk, increase safety, and improve the quality of health care provided in the facility through risk control intervention and monitoring the effectiveness of the interventions and corrective action plan. The Incident Report would help the various facility committees and administration in identifying and analyzing potential areas of risk and implementing measures to improve the overall quality of care and promote a culture of safety throughout the facility. A further review revealed it was the policy of facility to implement Risk Management Incident Reporting procedures.
4.0 PROCEDURE:
Any facility staff member who witnessed, discovered, or had direct knowledge of an incident must complete an Incident Report before the end of the shift/workday.
Under-reporting or failure to report a known incident would not acceptable.
An "incident" is an unanticipated event which results in, or nearly causes, a negative impact on patient care or visitor safety. Any harm caused can be temporary, long-term, or permanent and range in severity from no obvious or significant injury, up to death.
4.1. Supervisor would review the Incident Report for legibility, completion, and date. Supervisor would notify facility Risk Manager of a serious incident as well as take the lead in investigating non-serious incidents.
4.2. The Incident Report would be routed to the facility Risk Manager within 24 hours of incident.
4.3. Completed, reviewed, and signed Incident Reports would be entered into the Risk Management Information System ("RiskQuality/HAS" incident reporting system). "Level I" and "Level II" incidents would be entered within 24 hours. "Level III" and "Level IV" incidents would be entered within 5 calendar days.
4.4. If the incident involved a patient, staff would chart relevant factual information in the patient's medical record. When documenting incidents in the medical records, staff would chart precisely what happened without making reference to an "error" or that an Incident Report was completed. Staff would not attribute any cause to the unanticipated event.
The patient, visitor, volunteer, contracted or agency staff would not complete an Incident Report. Incident Reports would be confidential and proprietary documents that would only be completed by employees of facility.

5.0 RESPONSIBILITY:

5.1. All staff must be trained on the importance of incident reporting required under the facility Risk Management program.
5.2. The Shift Supervisor or a Facility Designated Individual would conduct a preliminary incident review. Facility Risk Manager would investigate and would document the investigation's findings, including determining a final severity level classification.
5.3. The facility Risk Manager would notify Corporate Risk Management of all Initial "Level I" and "Level II" incidents within 24 hours.
5.4. The facility Risk Manager or Designee would notify appropriate agencies of reportable incidents as required i.e., DOJ, OIG, State Agency, etc.
5.9. Facility Risk Manager must review and sign all Incident Reports. Recommendations and/or outcomes would be noted on the Incident Report.

INCIDENT TYPE CATEGORIZATION:
04.
Misconduct / Sexual / Boundary Allegation:
Misconduct / Body Exposure:
04d. Patient/Patient
04e. Staff Involvement
04f. Patient/Visitor

Sexual Intercourse:
04h. Patient/Patient
04i. Staff Involvement
04j. Patient/Visitor

Boundary Violation / Issues:
04k. Boundary Violation/Issues - Pt/Pt
04l. Boundary Violation/Issues - Staff Involvement
04m. Boundary Violation/Issues - Other

7.0 SEVERITY LEVEL CLASSIFICATION:
The severity level index would be utilized by the facility Risk Manager for initial severity classification in agreement with Corporate Risk Management. After the investigation, and in conjunction with Corporate Risk Management's analysis, the final severity level would be documented.
In states where the facility would be required to report certain adverse events to an outside regulatory agency, it would be done within State/agency requirements with notification of such external reporting obligations to Corporate Risk Management and Corporate Quality and Compliance.
7.1 All Incident Reports received by the facility Risk Manager would be assigned an initial
severity classification level in accordance with established Corporate Risk Management
criteria, approved by the facility leadership and Governing Board.
7.2 The severity level index would be utilized by the facility Risk Manager and facility
leadership to identify significant incidents in an effort to facilitate referral of issues
needing further evaluation and/or action to address and monitor failures in systems to
improve the quality of care.
7.3 The following severity level classifications would be assigned in incident reporting:
7.3.1 Level I (Major): Incidents which would be considered serious events This may include sentinel events.
Sentinel Event: Identifies a patient safety-related incident (not primarily related to the natural course of an illness or underlying condition of an individual served) that reaches an individual served and results in death, severe harm, or permanent harm where intervention was required to sustain life.

8.0 INCIDENT INTERVENTION:

It would be the expectation that part of reporting the incident includes describing the actions taken to mitigate damages and/or prevent further loss. Every incident reported requires that the interventions be identified. For example, any time that law enforcement was contacted, the facility would document who contacted the police and the subsequent police involvement.


A review of the facility's policy titled "Administrator on Call (AOC)," #LD-10, last reviewed 3/24 revealed the facility would provide leadership report on a 24/7 basis regarding all hospital operations. The purpose would be to identify the positions of leadership in the AOC role and the process by which information would be communicated daily.
The AOC responsibility rotates weekly, Monday through Sunday among the leadership staff. The Nursing Supervisor would contact the AOC for administrative support and notification of all events listed below as directed. Sentinel events would be reported by the AOC to the CEO, attending physician, and facility Risk Manager immediately. Report of events would be given daily to administration in the facilities flash meeting.
Sentinel Event: The event has resulted in an unanticipated death or major permanent loss of function, not related to the natural course of the patient's illness or underlying condition or the event is one of the following (even if the outcome was not death or major permanent loss of function unrelated to the natural course of the patient's
g. Rape
Other Facility Related Events: These are other events that would pose a risk to facility, staff, and/or patients that had not been defined above:
f. All sexual allegations (AOC to contact CEO and Risk Manager)


An interview was conducted in the conference room with DRM AA on 1/27/25 at 3:47 p.m. DRM AA stated that he did remember P#1. On 1/14/25 DRM AA stated that he was informed by one of the patient advocates that there was a patient P#2 on the Cypress unit being disruptive and making a lot of inappropriate comments. On 1/15/25 DRM AA stated that the Director of Clinical Services (DCS) GG came to his office and voiced some concerns. DCS GG gave DRM AA a brief rundown of P#1's condition and expressed that P#1 was having trouble sitting due to some rectal pain. DCS GG then stated that she had some concerns that P#2 may have done something to P#1 and due to his condition, he would not have been able to articulate anything. DRM AA stated that he immediately interviewed P#2 who denied any sexual or inappropriate interactions with P#1. DRM AA stated that at this time P#1 had been moved to another unit so he went and interviewed P#1. DRM AA stated that P#1 was difficult to communicate with, giving him blank stares, and asking to have questions repeated. P#1 denied that nothing inappropriate happened multiple times. DRM AA stated he asked P#1 if it would be ok for DCS GG to sit in while he continued to interview P#1 about alleged sexual assault and P#1 stated yes. P#1 continued to deny anything inappropriate or sexual happened between him and P#2.

DRM AA stated that Advanced Nurse Practitioner (ANP) CC was called to evaluate P#1 due to reporting P#1 was having trouble sitting down due to rectal pain. ANP CC and RN II went into the room to attempt a full examination.

DRM AA stated that ANP CC and RN II noticed a small amount of blood in P#1's brief. ANP CC stated that P#1 denied anything happened to him at the facility.

DRM AA stated that on 1/16/25 he received and incident report two days after the alleged incident from Behavioral Health Associate (BHA) EE, which was dated 1/13/25-1/14/25 stating that P#2 was making comments about performing oral sex on P#1 "again" which indicated something may have happened prior. DRM AA stated that it is unusual that the BHA write an incident report. It is usually done by the Registered Nurse (RN) due to the possible involvement of a patient assessment needing to be done. DRM AA stated that it is the policy of the facility that something of this severity is reported immediately. DRM AA stated that he spoke with BHA EE who stated that P#1 admitted to him that the alleged sexual assault happened in front of the nurse's station.

DRM AA confirmed that there were no cameras in the facility. DRM AA stated that BHA EE reported what P#1 told him to the Registered Nurse (RN) FF but was uncertain whether the night supervisor was aware of the alleged incident.

DRM AA stated that he reviewed the medical record for P#2 and noticed there was documentation in the chart of the alleged sexual assault against P#1 so he went back to P#1 and interviewed him again and P#1 denied any inappropriate sexual contact between him and P#2.

DRM AA stated upon returning to his office to contact the local Police Department, he noticed a police officer outside at the facility. DRM AA stated that he gave the police officer all the information concerning P#1 and was informed by the officer that they were at the facility to perform a well check on P#1 at the request of his mother.

DRM AA stated that P#1's mother stated that she wanted a forensic exam done due to a possible sexual assault, him having trouble sitting down and blood in his briefs. DRM AA stated that P#1 was transported to a local hospital and examined. DRM AA also stated that when P#1 returned to the facility he had started HIV prophylaxis due to P#2 being HIV positive.

DRM AA stated that the police asked if they could speak with P#1 and they were advised yes, but P#1 would have to agree to speak with them and due to his condition that P#1 was not very verbal so the police officer deferred to speak with P#1. DRM AA stated that on Tuesday 1/14/25 a detective came to the facility to speak with P#1 and he was present during the interview. P#1 stated that he was unsure whether the sexual assault happened, it could have been a dream but if it did happen, P#2 asked him to pull his penis out and he did and let him "do it" in front of the nurse's station. DRM AA stated that P#1 was very confused and just really could not say whether something happened or not. DRM AA stated that P#1 did not indicate that a sexual assault occurred so the only thing he could press charges for was the non-disclosure of P#2 being HIV positive. P#1 declined to press charges.

DRM AA stated that the night supervisor received a call at 0648 on the morning of 1/14/25 with allegations of sexual assault and per facility policy the Administrator on Call (AOC) is to be notified immediately, which she did not do.

DRM AA further stated that RN FF also did an incident report after BHA EE advised her of what P#1 had told him.

DRM AA stated that they could not locate the incident report from RN FF. DRM AA stated that he looked all over the department and could not find the incident report from RN FF.

DRM AA stated that additional education was given to the staff on the unit and hospital wide education was done for Incident Reporting.


An interview was conducted with DCS GG on 1/28/25 at 1100 in the conference room. DCS GG had been with the facility for two years. DCS DD remembers P#1 as really guarded and not responding to anyone. DCS GG stated that P#1 started to come around by day five or six. When P#1 was transferred from Cypress to Azalea she remembers speaking to P#1 and seeing him use his hands and motion towards his penis and buttocks as if he had to use the bathroom. DCS GG asked P#1 if he had to go to the bathroom and he stated no. DCS GG stated that she had a video conference call with the mother to keep her updated on P#1's progress. DCS GG stated she and another staff member overheard staff talking about the alleged sexual abuse that allegedly happened to P#1 a few days prior. DCS GG stated she was angry and immediately reported what she had heard to DRM AA. DRM AA stated that he was not aware and had not heard anything. DRM AA immediately started an internal investigation. DCS GG stated that P#1 was more interactive on the Azalea unit than when he was on the Cypress unit. P#1 was sent to the Emergency Department (ED) due to the alleged sexual abuse and once he returned, he was placed on the Magnolia unit.


A telephone interview was conducted with RN FF on 1/28/25 at 6:14 p.m. RN FF has been with the facility for two years. RN FF stated that when she first encountered P#1 it was night shift on 1/13/25. RN FF stated that P#1 was isolated and withdrawn. RN FF stated that he would pace a lot between his room, the hall, and the day room. RN FF stated she tried to verbally communicate with P#1 but he would just mumble. RN FF stated that later on that night BHA EE reported to her that P#1 told him that he recalls P#2 lowering his pants and when he realized what was going on he pushed P#2 away. RN FF stated she was told this may have happened at the end of the hall by the exit doors or in front of the nurse's station. RN FF stated after she was notified, she then notified the night supervisor. RN FF stated that when she arrived at the nurse's station to start her shift P#2 was sitting at the nurse's station and making gestures. RN FF stated that after she took report from RN DD, P#2 was still trying to be sexually inappropriate. P#2 made an accusation that something transpired 1/13/25 on the day shift between him and P#1. RN DD stated that was not possible because P#2 was trying to be sexually inappropriate with other patient's and required constant redirection, so they had been watching him all day at the nursing station. RN FF stated that at the time of the alleged incident neither P#1 nor P#2 was on a one to one (safety intervention where a staff member is assigned to continuously monitor a patient at risk of harm). RN FF stated that after she reported what she was told about the alleged sexual assault to the night shift supervisor, she wrote an incident report, progress note and called the physician to let them know what was going on. RN FF also stated that due to P#2's behavior the night shift staff watched P#1 and P#2 extremely close all night long. RN FF stated that she did witness a P#1 and P#2 talking but they were never in each other's personal space. RN FF stated that after she wrote up the incident report, she put it in "the box", she did not physically hand her report to anyone. RN FF stated that DRM AA stated that he did not receive the incident report.


A telephone interview was conducted with BHA EE on 1/29/25 at 6:50 a.m. BHA EE has been with the facility for 6 months. BHA EE stated that he first made contact with P#1 on the evening of 1/12/25 after he was admitted but the interaction was very brief. He took P#1's vitals and helped him get settled but he did notice that P#1 was in and out of psychosis. BHA EE stated on Monday 1/13/25 he started his evening shift between 6:25 p.m. and 7:00 p.m. and was told by RN DD that P#2 and another patient had been arguing over P#1 so just be mindful and keep an eye on P#1 and P#2. BHA EE stated he advised P#2 to leave P#1 alone because he was 18 years old and probably had a woman. Another BHA on shift had taken some of the patients out for a smoke break and BHA EE stated that P#2 came up to him and told him that "P#1 was not 18 years old and did not have a girlfriend and if he did, he would not have let me do what I did to him earlier." BHA EE stated he asked P#2, what happened? BHA EE stated that P#2 pointed to an area in the lobby and said, "I gave him (P#1) head (oral sex) in the lobby and sucked his dick." BHA EE stated that he immediately told RN DD what P#2 had alleged and RN DD stated that could not have happened because the day shift crew had been watching P#2 very closely all day due to his behavior. BHA EE stated he started to do rounds and P#2 started making extremely inappropriate comments to him. BHA EE stated after the night shift nurse RN FF took report from RN DD, he advised RN FF what was going on with P#2 and what he alleged happened. BHA EE stated that RN FF talked to P#2 about his behavior and redirected him away from P#1.

BHA EE stated that P#2 continued to sexually act out (SAO) and make inappropriate comments. BHA EE stated that he went to the night shift supervisor about the continuous inappropriate comments. The supervisor talked to P#2 and advised him that he needed to stop with the inappropriate comments and redirected him. BHA EE stated that P#2's inappropriate comments continued so he asked the supervisor who was aware of what had been going on all night, if he could file a grievance against P#2 but she told him to fill out a progress note. BHA EE stated that the night shift supervisor showed him how to write and submit the progress note.

BHA EE stated that towards the end of his shift about 5:30 a.m. on 1/14/25 in his presence P#1 asked another BHA on shift if there were any rooms on the other side and she advised him that she thought the other side was full. BHA EE further stated that P#1 asked if she could lock his room door? and then P#1 exhibited catatonic behavior and stated, "never mind, it will be ok." BHA EE stated that he witnessed P#1's heart racing really fast and he could tell that P#1 wanted to say something but he didn't. BHA EE stated that he and the other BHA told P#1 what P#2 alleged happened and asked him (P#1) did it happen and P#1 said yes. BHA EE stated that he was very specific with P#1 and asked him if P#2 gave him head, and P#1 stated, "yes it happened." BHA EE further stated he asked P#1 where it happened and P#1 pointed towards the lobby and stated" it happened in the lobby" which is where P#2 had been saying all night that it happened. BHA EE stated that he asked P#1 did he give consent and P#1 gave him a blank stare and then said no. BHA EE stated that P#1 said he felt like he was in a deep stare for about five seconds and when he snapped out of it and realized what was happening, he slapped his head and hand out of the way. BHA EE stated that he reported to RN FF what P#1 said happened and RN FF said she would document it, write an incident report and report it to the night shift supervisor. BHA EE stated that he was advised by the night shift supervisor to also write an incident report which he started but did not finish. BHA stated that he was delayed in submitting the incident report due to the severity of the alleged incident and he wanted to make sure he documented all the information correctly.