HospitalInspections.org

Based on document reviews, observations, and interview, it was determined that the Condition of Participation for Patient Rights was not met as evidenced by the hospital's failure to ensure a patients' rights to receive care in a safe supervised and to be free from abuse. The hospital's failures resulted in these two (2) minor patients (Patient #2 and Patient #3) being allowed to lie down together, under blankets in the common area, and engaging in sexual activities.

Finding:

Standard: §482.13(c)(2) Patient Rights: Care in a Safe Setting also known as A-0144 - Based on document reviews, observation, and interviews, the hospital failed to ensure two (2) patients, under the age of 18, received care in a safe, supervised setting in the Emergency Department's ("ED's") Diagnostic Evaluation Area ("DEA") for Adolescents. On 2/2/2022, the hospital's failures resulted in these two (2) minor patients (Patient #2 and Patient #3) being allowed to lie down together, under blankets in the common area, and engaging in sexual activities. See A-0144 for details.

Standard: §482.13(c)(3) Patient Rights: Free from Abuse/Harassment also known as A-0145 - Based on document reviews, observations, and interview, the hospital failed to ensure two (2) patients, under the age of 18, were free from abuse in the Emergency Department's ("ED's") Diagnostic Evaluation Area ("DEA") for Adolescents. On 2/2/2022. the hospital's failures to provided supervision to Patient #2 and Patient #3 allowed the minors to lie down together, under blankets in a common area, and engage in sexual activities. See A-0145 for details.

The cumulative effect of this deficient practice resulted in noncompliance with this Condition of Participation.

Based on document reviews, observation, and interviews, the hospital failed to ensure two (2) patients, under the age of 18, received care in a safe, supervised setting in the Emergency Department's ("ED's") Diagnostic Evaluation Area ("DEA") for Adolescents. On 2/2/2022, the hospital's failures resulted in these two (2) minor patients (Patient #2 and Patient #3) being allowed to lie down together, under blankets in the common area, and engaging in sexual activities.

Finding:

On 2/11/2022, the Division of Licensing and Certification ("DLC") received the following information from the hospital: On 2/9/2022, the Associate Vice President ("AVP") was made aware by a staff Registered Nurse ("RN") that she (meaning the RN) was told by the legal representative of Patient #2 that the patient (Patient #2) was bragging about touching the genital area of another patient and shared the specific location of where the incident occurred in the ED's DEA. The AVP reviewed six (6) days of video and found an incident that occurred on 2/2/2022 at 11:44 AM and the alleged incident was the two patients (Patients #2 and #3) lying on the unit floor under the television with blankets on, talking progressed to kissing on the lips, and touching of genitalia by both patients lasting for approximately three (3) minutes.

An investigation was initiated by the DLC into the reported incident.

A review of the hospital's "Parental Support of Pediatric Patients in the Emergency Department" policy and procedure, dated 12/17/2021, was conducted. The policy/procedure stated, in part, the following:
- "A parent/legal guardian is to be accountable for the pediatric patient during their Emergency Department visit. The parent/legal guardian is expected to be at patient bedside throughout their ED stay 24 hours a day/7 days a week to maintain such accountability. The policy affects all patients <18 y/o [less than 18 years old] unless the patient is an emancipated minor per the court system."
- "If due to parent or patient safety as determined in conjunction with primary RN [Registered Nurse], a parent/legal guardian cannot be physically at bedside, a plan of accountability will be placed in the patient chart and updated daily by the primary nurse for the AM shift and communicated to the Charge RN and Nurse Manager for the unit."
- "In recognition of parent/guardian wellness, a parent who needs to take a brief period of leave from the patient bedside in order to meet personal issues may collaborate with the primary RN and unit leadership to craft expectations including: Preferred Choice: The swapping of bedside presence with another parent/guardian, or they may designate another adult (grandparent, older sibling, etc.) to do so. Mutually agreed brief length of time. Phone number for contact where the parent/guardian can be reached at all times."
- "If the parent does not stay at the bedside in order to facilitate the patient care process and maintain advocacy for a minor child without a clear defined plan with the nursing team, and/or does not maintain alignment with crafted expectations mutually agreed upon with the nursing staff, the following steps are to be undertaken to ensure patient safety:
- Notify the parent verbally that they are a necessary part of the patient care process and ask them to return or stay in accordance with any agreements.
- If they do not respond, notify ED nursing leadership who will initiate another contact, and partner with the parent in order to ensure patient safety and advocacy during their acute care phase.
- If no return/engagement of parents occurs, unit leadership is to partner with hospital leadership, and contact City of Bangor Police and Department of Health and Human Services for notification of patient safety concerns and to facilitate support.
- Documentation of discussions will be placed in patient chart, and through standard safety reporting tools/venues."

The hospital's "Patient Rights and Responsibilities" policy and procedure, dated 12/17/2018, was reviewed and required departments to provide a brochure to patients. The brochure stated, in part, "You have the right to receive care in a safe setting free from harassment, neglect exploitation, and verbal, mental, physical, or sexual abuse."

The hospital's "Management of Behavioral Patients in the Emergency Department" policy, dated 11/14/2018, stated, in part, "EMMC desires to provide a safe, secure, comfortable, and spacious place for patients with behavioral health concerns while assessing and treating their immediate psychiatric needs."

Patient #2's medical record was reviewed and indicated the following:
- The patient was a minor and presented and was admitted to the hospital in early January 2022 due to escalating and more aggressive behaviors;
- The patient was admitted to the ED's DEA for Adolescents;
- The patient's history included, but was not limited to, disinhibited social engagement disorder, unspecified impulse control disorder, and conduct disorder;
- There was no evidence in the patient's record that indicated that a parent/guardian was at the bedside or other arrangements had been made for supervision on four (4) days (1/25/2022, 1/28/2022, 1/29/2022 and 2/2/2022), including the date of the reported incident. On 3/3/2022 at 11:15 AM, the ED Assistant Nurse Manager and Accreditation and Licensing Compliance Officer confirmed the record did not contain evidence for the four (4) dates above.

Patient #3's medical record was reviewed and indicated the following:
- The patient was a minor and presented and was admitted to the hospital in early January 2022 due to self-harming behaviors;
- The patient was admitted to the ED's DEA for Adolescents;
- The patient's history included, but was not limited to, sexualized behaviors towards a younger family member, another family member, and two (2) peers of the opposite gender on a school bus;
- The patient's history also included aggressive and assaultive behaviors towards staff which included, but not limited to, sexualized behavior;
- There was no evidence in the patient's record that indicated that a parent/guardian was at the bedside or other arrangements had been made for supervision on nine (9) days (1/7/2022, 1/18/2022, 1/20/2022, 1/23/2022, 1/25/2022, 1/27/2022, 1/28/2022, 1/29/2022, and 1/31/2022). On 3/3/2022 at 11:15 AM, the ED Assistant Nurse Manager confirmed the record contained no evidence for the nine (9) dates above.

An email string between a legal representative for Patient #3 and the AVP of the ED, dated 2/1/2022, was provided to surveyors by the AVP on 3/2/2022. The email string stated the following:
- At 9:30 AM, the legal representative wrote he/she had been alerted that hospital staff had been allowing a minor of the opposite gender, who was also in the ED, to go in Patient #3's room to hang out; "No one should be in [his/her] room with [him/her]. This same [minor of the opposite gender] was not wearing [underwear] on Sunday and was exposing [herself/himself] when [he/she] was climbing up on the security counter wall and when rolling around on the mattress on the floor which was out in the common area"; the legal representative of the minor of the opposite gender had stated indicated that the minor was in the ED in part "due to sexualized behaviors/comments"; "This is a perfect storm"; When this was discussed with hospital staff, their response was ''we can see what is going on in the room on camera''; and the legal representative wrote "I am feeling very uncomfortable with this situation. Can you please address it?"
- At 10:01 AM, the AVP responded that she would call the legal representative and "it will immediately stop"; and
- At 10:40 AM, the legal representative wrote he/she was informed by an individual with Patient #3 yesterday that Patient #3 and the minor of the opposite gender were "under the covers in the common area"; patients were told by the individual with Patient #3 many times to stop getting under the covers; the legal representative for the minor of the opposite gender was in the minor's room with the door closed, either sleeping or studying; he/she had been told that the legal representative of the minor of the opposite gender is in the minor's room for a long time with the door closed; he/she has been told that the minor of the opposite gender was going to Patient #3's room in the doorway and saying, "tickle tickle tickle"; "These kids should not be outside of ear and eye shot period"; we can guide Patient #3 but perhaps the legal representative for the minor of the opposite gender needs to guide the minor of the opposite gender as well as the two (2) kids are "stating the Security and nurses are allowing it."

Surveyors observed the video from four (4) security cameras that focused on the area of ED's DEA for Adolescents where Patient #2 and Patient #3 were on 2/2/2022. One of the videos, that did not have audio, showed an unsupervised period from 11:33 AM until 11:57 AM when an unidentified staff entered the video. The video showed the following:
- Between 11:33 AM and 11:57 AM (24 minutes), no staff or legal representatives were visible. During this time, Patient #2 and Patient #3 were lying down on the floor next to each other, with pillows and blankets, in the common area of the unit. They were seen kissing and engaging in sexual activity with each other. Patient #2 then created a fort by moving a table, that had two (2) seats attached on both sides, into the corner of the room and adding a blanket, mattress, and a sheet - One side of the table was touching the wall; one side with the chairs was touching a different the wall; one side with the two (2) chairs was covered with a blanket; and the other side was enclosed by a mattress with a sheet draped over the mattress. Patient #3 entered the fort at 11:55 AM and Patient #2 also entered the fort, while Patient #3 was in the fort and exited approximately 20 seconds later.
- Between 11:57 AM and 12:06 PM, unidentified staff #1 entered the common area where the fort was, provided Patient #2 with a drink, and then left the area; unidentified staff #2 then entered the common area, while Patient #2 was outside the fort, and went to another patient in a second corner of the area near the fort; Patient #2 then removed the mattress from the fort entrance and then covered the fort entrance with the sheet before entering the fort joining Patient #3 who was already in the fort; both patients remained in the fort for one (1) minute before unidentified staff #2 went over to the fort and looked in, removed the sheet, again looked in, and then removed the blanket; unidentified staff #2 then left the area and Patient #2 and Patient #3 remained under the table; unidentified staff #1 arrived approximately one (1) minute after unidentified staff #2 left and was joined shortly thereafter by unidentified staff #3; both staff moved the table which Patient #2 and Patient #3 still remained under; both staff left the area while Patient #2 and #3 remained lying on the floor beside one another with blankets covering them; and approximately one (1) minute later Patient #3 left the area.

On 2/23/2022 at 3:00 PM, Security Officer #1, who worked on 2/2/2022 in the ED DEA Unit, was interviewed. When asked if anyone told him to watch Patient #2 and Patient #3 during his shift on 2/2/202, he stated, "No, but I remember when [Patient #3] came in a few days before, nursing mentioned basically to keep an eye on [him/her], [he/she] has a history."

On 2/24/2022 at 8:04 AM, Security Officer #2, who worked on 2/2/2022 in the ED DEA Unit, was interviewed. On 2/2/2022, he was assigned to monitor the video, which included the timeframe between 11:28 AM and 12:06 PM. He stated, "I was not made aware of the incident until today; I did not observe any inappropriate behaviors of [Patient #2] and [Patient #3]; and did not see a blanket fort." He continued stating, "I was not aware of any sexualized behavior of [Patient #3]."

On 2/24/2022 at 11:19 AM, RN #2, who worked on 2/2/2022 in the ED DEA Unit on 2/2/2022, was interviewed by phone. She stated that security informed her that Patient #2 and Patient #3 were under the table and they could not be under the table; the table was in the corner of the common area and covered with blankets; she removed the blankets; told Patient #2 to get out from under the table; and the patient did not move so she asked Patient #3 to come out instead.

On 2/24/2022 at 11:30 AM, RN #1, who worked on 2/2/2022 in the ED DEA Unit on 2/2/2022, was interviewed. She stated that when she entered the unit there was a fort built with blankets and a table; Patient #2 and Patient #3 were under the table; she asked Patient #2 to come out; she told him/her that was not appropriate; and told security to not let Patient #2 and Patient #3 to get in there together. Later, she heard security telling Patient #2 to get out of the fort and that is when she moved the table/fort so the patients would come out. She informed the ED Charge Nurse, and the decision was made to move Patient #3 to the overflow area. In a later interview on 2/28/2022 at 2:00 PM, RN #1 stated that a legal representative or an alternative person for Patient #2 was not at the hospital and the legal representative for Patient #3, was on a lunch break when she observed the fort. She further stated the patients have cameras on them twenty-four (24) hours a day, so staffing expectations do not change; we would expect security to tell them of any inappropriate behaviors; she was aware that Patient #2 has been lying outside of Patient #3's room with a blanket on 2/2/2022; and she had informed Patient #2 he/she was not to be alone with peers of the opposite gender or any peers and he/she and was to be visible at all times. The RN also stated that at times she had six (6), seven (7), or eight (8) patients and she relied on the security cameras to observe the patients.

On 2/24/2022 at 12:00 PM, the ED Charge Nurse, who worked on 2/2/2022 in the ED DEA Unit on 2/2/2022, was interviewed. She stated that, on 2/1/2022, she was informed of concerns made by the legal representative of Patient #3 and she made staff aware that day that there were to be no blankets in the common area, and no one could be in each other's room. On 2/2/2022, RN #1 informed her of inappropriate events that occurred between Patient #2 and Patient #3 and she informed the AVP of the ED.

On 2/24/2022 at 1:05 PM, the AVP of the ED was interviewed. She stated the following:
- On 2/1/2022, she received an email from the legal representative for Patient #3 regarding inappropriate behavior between Patient #2 and Patient #3; she called the legal representative for Patient #3; and informed her that the ED Charge Nurse was working on the concern right now;
- On 2/8/2022, the legal representative for Patient #2 asked her why Patient #3 had been moved to a different unit and if something had happened. The AVP stated that at the time she did not know of anything that happened;
- On 2/10/2022, RN #3 reported to her that she (RN #3) had received a phone call from the legal representative of Patient #2 and she (RN #3) was told Patient #2 reported playing "touchy feely" under the TV in the general milieu; she (AVP) then requested the videos of 2/2/2022; viewed the videos; immediately notified hospital leadership; and made sure the patients were separated; and
- On 2/11/2022, she notified the police, Child Protective Services, the legal representative for Patient #2, and the legal representative for Patient #3.

On 2/24/2022 at 2:20 PM, the Security Manager was interviewed. When asked if it is possible for Security to watch all the cameras, he stated, "No, not all at once." He stated that at any one time the Security Officer watching videos has approximately thirty-seven (37) cameras to watch and it was not possible for all cameras to be watched at the same time. He stated if they (Security) pulled up one (1) camera view, they lose complete view of all other cameras on that screen.

On 2/28/2022 at 10:40 AM, the legal representative for Patient #3, who was at the hospital on 2/2/2022, was interviewed by phone. He/She stated that he/she took lunch break from 11:30 AM to 12:45 PM on 2/2/2022 and informed security he/she was leaving; it was well known on the ED DEA Unit to keep a close eye on Patient #3 and another male/female patient; and he/she was not made aware of the fort until approximately two (2) days later.

On 2/28/2022 at 12:11 PM, the legal representative for Patient #2 was interviewed by phone. He/She stated he/she found out about the events on 2/2/2022 from Patient #2; Patient #2 told him/her the following: "I touched [him/her]; [he/she] wanted to have oral sex; [he/she] told me to spit in [his/her] hand; and he/she [described two sexual acts]." The legal representative went on to state on 2/10/2022 he/she notified RN #3 of what Patient #2 reported and he/she received confirmation from the AVP of the ED that there was video evidence of the reported incident.

On 2/28/2022 at 1:00 PM, RN #3 was interviewed via phone. She stated on 2/10/2022 the legal representative for Patient #2 told her that Patient #2 told him/her that Patient #3 had put his/her hands down Patient #2's pants and two (2) specific sexual acts were described. She then requested Security to begin reviewing the video footage and she immediately called the AVP of the ED.

Based on the above, the hospital failed to ensure two (2) minor patients (Patient #2 and Patient #3) received care in a safe, supervised setting. On 2/1/2022, the legal representative of Patient #3 sent emails to the AVP of the ED expressing concerns related to observations that had been made; what the response was when concerns had been addressed with hospital staff; he/she was "feeling very uncomfortable with this situation"; and asked for the concerns to be address. On 2/2/2022, the hospital failed to provide a safe supervised setting which resulted in these two (2) minor patients being able to lie down together, under blankets in the common area, and engage in sexual activities.

Based on document reviews, observations, and interview, the hospital failed to ensure two (2) patients, under the age of 18, were free from abuse in the Emergency Department's ("ED's") Diagnostic Evaluation Area ("DEA") for Adolescents. On 2/2/2022. the hospital's failures to provided supervision to Patient #2 and Patient #3 allowed the minors to lie down together, under blankets in a common area, and engage in sexual activities.

Finding:

On 2/11/2022, the Division of Licensing and Certification ("DLC") received the following written information from Associate Vice President ("AVP") of the Emergency Department of the hospital: On 2/9/2022, the Associate Vice President ("AVP") was made aware by a staff Registered Nurse ("RN") that she (meaning the RN) was told by the legal representative of Patient #2 that the patient (Patient #2) was bragging about touching the genital area of another patient and shared the specific location of where the incident occurred in the ED's DEA. The AVP reviewed six (6) days of video and found an incident that occurred on 2/2/2022 at 11:44 AM and the alleged incident was the two patients (Patients #2 and #3) lying on the unit floor under the television with blankets on, talking progressed to kissing on the lips, and touching of genitalia by both patients lasting for approximately three (3) minutes.

The Centers for Medicare and Medicaid ("CMS") defines abuse as "as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. Neglect, for the purpose of this requirement, is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness."

An investigation was initiated by the DLC into the reported incident.

A review of the hospital's "Parental Support of Pediatric Patients in the Emergency Department" policy and procedure, dated 12/17/2021, was conducted. The policy/procedure stated, in part, the following:
- "A parent/legal guardian is to be accountable for the pediatric patient during their Emergency Department visit. The parent/legal guardian is expected to be at patient bedside throughout their ED stay 24 hours a day/7 days a week to maintain such accountability. The policy affects all patients <18 y/o [less than 18 years old] unless the patient is an emancipated minor per the court system."
- "If due to parent or patient safety as determined in conjunction with primary RN [Registered Nurse], a parent/legal guardian cannot be physically at bedside, a plan of accountability will be placed in the patient chart and updated daily by the primary nurse for the AM shift and communicated to the Charge RN and Nurse Manager for the unit."
- "In recognition of parent/guardian wellness, a parent who needs to take a brief period of leave from the patient bedside in order to meet personal issues may collaborate with the primary RN and unit leadership to craft expectations including: Preferred Choice: The swapping of bedside presence with another parent/guardian, or they may designate another adult (grandparent, older sibling, etc.) to do so. Mutually agreed brief length of time. Phone number for contact where the parent/guardian can be reached at all times."
- "If the parent does not stay at the bedside in order to facilitate the patient care process and maintain advocacy for a minor child without a clear defined plan with the nursing team, and/or does not maintain alignment with crafted expectations mutually agreed upon with the nursing staff, the following steps are to be undertaken to ensure patient safety:
- Notify the parent verbally that they are a necessary part of the patient care process and ask them to return or stay in accordance with any agreements.
- If they do not respond, notify ED nursing leadership who will initiate another contact, and partner with the parent in order to ensure patient safety and advocacy during their acute care phase.
- If no return/engagement of parents occurs, unit leadership is to partner with hospital leadership, and contact City of Bangor Police and Department of Health and Human Services for notification of patient safety concerns and to facilitate support.
- Documentation of discussions will be placed in patient chart, and through standard safety reporting tools/venues."

The hospital's "Patient Rights and Responsibilities" policy and procedure, dated 12/17/2018, was reviewed and required departments to provide a brochure to patients. The brochure stated, in part, "You have the right to receive care in a safe setting free from harassment, neglect exploitation, and verbal, mental, physical, or sexual abuse."

The hospital's "Management of Behavioral Patients in the Emergency Department" policy, dated 11/14/2018, stated, in part, "EMMC desires to provide a safe, secure, comfortable, and spacious place for patients with behavioral health concerns while assessing and treating their immediate psychiatric needs."

Patient #2's medical record was reviewed and indicated the following:
- The patient was a minor and presented and was admitted to the hospital in early January 2022 due to escalating and more aggressive behaviors;
- The patient was admitted to the ED's DEA for Adolescents;
- The patient's history included, but was not limited to, disinhibited social engagement disorder, unspecified impulse control disorder, and conduct disorder;
- There was no evidence in the patient's record that indicated that a parent/guardian was at the bedside or other arrangements had been made for supervision on four (4) days (1/25/2022, 1/28/2022, 1/29/2022 and 2/2/2022), including the date of the reported incident. On 3/3/2022 at 11:15 AM, the ED Assistant Nurse Manager and Accreditation and Licensing Compliance Officer confirmed the record did not contain evidence for the four (4) dates above.

Patient #3's medical record was reviewed and indicated the following:
- The patient was a minor and presented and was admitted to the hospital in early January 2022 due to self-harming behaviors;
- The patient was admitted to the ED's DEA for Adolescents;
- The patient's history included, but was not limited to, sexualized behaviors towards a younger family member, another family member, and two (2) peers of the opposite gender on a school bus;
- The patient's history also included aggressive and assaultive behaviors towards staff which included, but not limited to, sexualized behavior;
- There was no evidence in the patient's record that indicated that a parent/guardian was at the bedside or other arrangements had been made for supervision on nine (9) days (1/7/2022, 1/18/2022, 1/20/2022, 1/23/2022, 1/25/2022, 1/27/2022, 1/28/2022, 1/29/2022, and 1/31/2022). On 3/3/2022 at 11:15 AM, the ED Assistant Nurse Manager confirmed the record contained no evidence for the nine (9) dates above.

An email string between a legal representative for Patient #3 and the AVP of the ED, dated 2/1/2022, was provided to surveyors by the AVP on 3/2/2022. The email string stated the following:
- At 9:30 AM, the legal representative wrote he/she had been alerted that hospital staff had been allowing a minor of the opposite gender, who was also in the ED, to go in Patient #3's room to hang out; "No one should be in [his/her] room with [him/her]. This same [minor of the opposite gender] was not wearing [underwear] on Sunday and was exposing [herself/himself] when [he/she] was climbing up on the security counter wall and when rolling around on the mattress on the floor which was out in the common area"; the legal representative of the minor of the opposite gender had stated indicated that the minor was in the ED in part "due to sexualized behaviors/comments"; "This is a perfect storm"; When this was discussed with hospital staff, their response was ''we can see what is going on in the room on camera''; and the legal representative wrote "I am feeling very uncomfortable with this situation. Can you please address it?"
- At 10:01 AM, the AVP responded that she would call the legal representative and "it will immediately stop"; and
- At 10:40 AM, the legal representative wrote he/she was informed by an individual with Patient #3 yesterday that Patient #3 and the minor of the opposite gender were "under the covers in the common area"; patients were told by the individual with Patient #3 many times to stop getting under the covers; the legal representative for the minor of the opposite gender was in the minor's room with the door closed, either sleeping or studying; he/she had been told that the legal representative of the minor of the opposite gender is in the minor's room for a long time with the door closed; he/she has been told that the minor of the opposite gender was going to Patient #3's room in the doorway and saying, "tickle tickle tickle"; "These kids should not be outside of ear and eye shot period"; we can guide Patient #3 but perhaps the legal representative for the minor of the opposite gender needs to guide the minor of the opposite gender as well as the two (2) kids are "stating the Security and nurses are allowing it."

Surveyors observed the video from four (4) security cameras that focused on the area of ED's DEA for Adolescents where Patient #2 and Patient #3 were on 2/2/2022. One of the videos, that did not have audio, showed an unsupervised period from 11:33 AM until 11:57 AM when an unidentified staff entered the video. The video showed the following:
- Between 11:33 AM and 11:57 AM (24 minutes), no staff or legal representatives were visible. During this time, Patient #2 and Patient #3 were lying down on the floor next to each other, with pillows and blankets, in the common area of the unit. They were seen kissing and engaging in sexual activity with each other. Patient #2 then created a fort by moving a table, that had two (2) seats attached on both sides, into the corner of the room and adding a blanket, mattress, and a sheet - One side of the table was touching the wall; one side with the chairs was touching a different the wall; one side with the two (2) chairs was covered with a blanket; and the other side was enclosed by a mattress with a sheet draped over the mattress. Patient #3 entered the fort at 11:55 AM and Patient #2 also entered the fort, while Patient #3 was in the fort and exited approximately 20 seconds later.
- Between 11:57 AM and 12:06 PM, unidentified staff #1 entered the common area where the fort was, provided Patient #2 with a drink, and then left the area; unidentified staff #2 then entered the common area, while Patient #2 was outside the fort, and went to another patient in a second corner of the area near the fort; Patient #2 then removed the mattress from the fort entrance and then covered the fort entrance with the sheet before entering the fort joining Patient #3 who was already in the fort; both patients remained in the fort for one (1) minute before unidentified staff #2 went over to the fort and looked in, removed the sheet, again looked in, and then removed the blanket; unidentified staff #2 then left the area and Patient #2 and Patient #3 remained under the table; unidentified staff #1 arrived approximately one (1) minute after unidentified staff #2 left and was joined shortly thereafter by unidentified staff #3; both staff moved the table which Patient #2 and Patient #3 still remained under; both staff left the area while Patient #2 and #3 remained lying on the floor beside one another with blankets covering them; and approximately one (1) minute later Patient #3 left the area.

On 2/23/2022 at 3:00 PM, Security Officer #1, who worked on 2/2/2022 in the ED DEA Unit, was interviewed. When asked if anyone told him to watch Patient #2 and Patient #3 during his shift on 2/2/202, he stated, "No, but I remember when [Patient #3] came in a few days before, nursing mentioned basically to keep an eye on [him/her], [he/she] has a history."

On 2/24/2022 at 8:04 AM, Security Officer #2, who worked on 2/2/2022 in the ED DEA Unit, was interviewed. On 2/2/2022, he was assigned to monitor the video, which included the timeframe between 11:28 AM and 12:06 PM. He stated, "I was not made aware of the incident until today; I did not observe any inappropriate behaviors of [Patient #2] and [Patient #3]; and did not see a blanket fort." He continued stating, "I was not aware of any sexualized behavior of [Patient #3]."

On 2/24/2022 at 11:19 AM, RN #2, who worked on 2/2/2022 in the ED DEA Unit on 2/2/2022, was interviewed by phone. She stated that security informed her that Patient #2 and Patient #3 were under the table and they could not be under the table; the table was in the corner of the common area and covered with blankets; she removed the blankets; told Patient #2 to get out from under the table; and the patient did not move so she asked Patient #3 to come out instead.

On 2/24/2022 at 11:30 AM, RN #1, who worked on 2/2/2022 in the ED DEA Unit on 2/2/2022, was interviewed. She stated that when she entered the unit there was a fort built with blankets and a table; Patient #2 and Patient #3 were under the table; she asked Patient #2 to come out; she told him/her that was not appropriate; and told security to not let Patient #2 and Patient #3 to get in there together. Later, she heard security telling Patient #2 to get out of the fort and that is when she moved the table/fort so the patients would come out. She informed the ED Charge Nurse, and the decision was made to move Patient #3 to the overflow area. In a later interview on 2/28/2022 at 2:00 PM, RN #1 stated that a legal representative or an alternative person for Patient #2 was not at the hospital and the legal representative for Patient #3, was on a lunch break when she observed the fort. She further stated the patients have cameras on them twenty-four (24) hours a day, so staffing expectations do not change; we would expect security to tell them of any inappropriate behaviors; she was aware that Patient #2 has been lying outside of Patient #3's room with a blanket on 2/2/2022; and she had informed Patient #2 he/she was not to be alone with peers of the opposite gender or any peers and he/she and was to be visible at all times. The RN also stated that at times she had six (6), seven (7), or eight (8) patients and she relied on the security cameras to observe the patients.

On 2/24/2022 at 12:00 PM, the ED Charge Nurse, who worked on 2/2/2022 in the ED DEA Unit on 2/2/2022, was interviewed. She stated that, on 2/1/2022, she was informed of concerns made by the legal representative of Patient #3 and she made staff aware that day that there were to be no blankets in the common area, and no one could be in each other's room. On 2/2/2022, RN #1 informed her of inappropriate events that occurred between Patient #2 and Patient #3 and she informed the AVP of the ED.

On 2/24/2022 at 1:05 PM, the AVP of the ED was interviewed. She stated the following:
- On 2/1/2022, she received an email from the legal representative for Patient #3 regarding inappropriate behavior between Patient #2 and Patient #3; she called the legal representative for Patient #3; and informed her that the ED Charge Nurse was working on the concern right now;
- On 2/8/2022, the legal representative for Patient #2 asked her why Patient #3 had been moved to a different unit and if something had happened. The AVP stated that at the time she did not know of anything that happened;
- On 2/10/2022, RN #3 reported to her that she (RN #3) had received a phone call from the legal representative of Patient #2 and she (RN #3) was told Patient #2 reported playing "touchy feely" under the TV in the general milieu; she (AVP) then requested the videos of 2/2/2022; viewed the videos; immediately notified hospital leadership; and made sure the patients were separated; and
- On 2/11/2022, she notified the police, Child Protective Services, the legal representative for Patient #2, and the legal representative for Patient #3.

On 2/24/2022 at 2:20 PM, the Security Manager was interviewed. When asked if it is possible for Security to watch all the cameras, he stated, "No, not all at once." He stated that at any one time the Security Officer watching videos has approximately thirty-seven (37) cameras to watch and it was not possible for all cameras to be watched at the same time. He stated if they (Security) pulled up one (1) camera view, they lose complete view of all other cameras on that screen.

On 2/28/2022 at 10:40 AM, the legal representative for Patient #3, who was at the hospital on 2/2/2022, was interviewed by phone. He/She stated that he/she took lunch break from 11:30 AM to 12:45 PM on 2/2/2022 and informed security he/she was leaving; it was well known on the ED DEA Unit to keep a close eye on Patient #3 and another male/female patient; and he/she was not made aware of the fort until approximately two (2) days later.

On 2/28/2022 at 12:11 PM, the legal representative for Patient #2 was interviewed by phone. He/She stated he/she found out about the events on 2/2/2022 from Patient #2; Patient #2 told him/her the following: "I touched [him/her]; [he/she] wanted to have oral sex; [he/she] told me to spit in [his/her] hand; and he/she [described two sexual acts]." The legal representative went on to state on 2/10/2022 he/she notified RN #3 of what Patient #2 reported and he/she received confirmation from the AVP of the ED that there was video evidence of the reported incident.

On 2/28/2022 at 1:00 PM, RN #3 was interviewed via phone. She stated on 2/10/2022 the legal representative for Patient #2 told her that Patient #2 told him/her that Patient #3 had put his/her hands down Patient #2's pants and two (2) specific sexual acts were described. She then requested Security to begin reviewing the video footage and she immediately called the AVP of the ED.

Based on the above, the hospital failed to ensure two (2) minor patients (Patient #2 and Patient #3) were adequately supervised to prevent sexual activity in a common area of the unit. On 2/1/2022, the legal representative of Patient #3 sent emails to the AVP of the ED, expressing concerns related to observations that had been made; what the response was when this had been addressed with hospital staff; and expressed he/she was "feeling very uncomfortable with this situation"; and asked for the concerns to be address. On 2/2/2022, the hospital failed to provide adequate supervision which resulted in these two (2) minor patients being able to lie down together, under blankets in the common area, and engage in sexual activities.

Based on document review and interviews, the hospital failed to ensure the development of policies and procedures that addressed a process for tracking and documenting the Coronavirus 2019 ("COVID-19") vaccination status of any staff who had obtained any booster dose as recommended by the Federal Center for Disease Control and Prevention ("CDC"). In addition, the hospital failed to ensure their policies and procedures addressed the confirmation of recognized clinical contraindications to COVID-19 vaccines, as indicated by Federal CDC, before granting medical exemptions.

Findings:

1. On 2/22/2022 a review of the Northern Light Health, "SARS-CoV 2 Workforce Member Vaccination Policy," dated 2/16/2022 was conducted. The policy did not address a process for tracking and documenting the COVID-19 vaccination status of any staff who had obtained any booster doses as recommended by the CDC.

On 2/23/2022 at 10:46 AM, the Vice President of Human Resources and Patient Experience confirmed the Northern Light Health, "SARS-CoV 2 Workforce Member Vaccination Policy," dated 2/16/2022, did not address a process for tracking and documenting the COVID-19 vaccination status of any staff who had obtained any booster doses as recommended by the CDC.

2. The Northern Light Health's "SARS-CoV2 Workforce Member Vaccination Policy," dated 2/16/2022, did not include a process of how the hospital would confirm the submitted medical exemption documentation was a recognized clinical contraindication to the COVID-19 vaccine, as indicated by the Federal CDC, before granting medical exemptions. It was noted that the policy indicated the reference at the end of the policy was the Maine CDC rules. The Maine CDC rules and the Federal requirements are different in relation to medical exemptions. The Maine rules allows a Provider to make a determination based on his/her professional judgement and the Federal requirements require documentation of recognized clinical contraindications to the COVID-19 vaccine.

On 2/23/2022 at 11:17 AM, the Vice President of Human Resources and Patient Experience confirmed the Northern Light Health, "SARS-CoV 2 Workforce Member Vaccination Policy," dated 2/16/2022, did not include a procedure for the review of medical exemptions to ensure the reason specified by the provider was a recognized clinical contraindication for COVID-19 vaccination as determined by the CDC. She stated that the ADA Federal Law 42 US Chapter 126 section 12101 is used by this facility to determine acceptable reasons for granting a medical exemption and the policy did not include that information.