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Based on document review, interview, and observation, it was determined that for 1 of 1 (Pt #1) patient with complaints of alleged sexual advance, the Hospital failed to ensure that the patient was protected from potential inappropriate sexual advances. As a result the Condition of Participation, 42 CFR 482.13, Patient Rights was not in compliance. This potentially affects all current and future patients with dementia, on the Older Adult Behavioral Health Unit (OABHU).

Findings include:

1. The Hospital failed to ensure a complaint allegation was investigated, as required. See deficiency at A - 118.

2. The Hospital failed to ensure that patient was placed in a safe environment. See deficiecy at A - 144.

Based on document review, and interview it was determined that for 1 of 1 Older Adult Behavioral Health Unit (OABHU) patient with an allegation of potential inappropriate sexual advances, the Hospital failed to ensure the allegation was investigated, as required.

Findings include:

1. On 9/28/18 at approximately 10:00 AM, the Hospital's policy entitled, "Serious Reportable Event Policy," (undated) included, "...Policy...The goals of this policy include care...by identifying sentinel events in order to understand the causes of actual or potential harm...NQF (National Quality Forum) Serious Reportable Events...7...C. Sexual abuse/assault on a patient ...within or on the grounds of a healthcare setting."

2. The Hospital policy titled, "Safety Event Analysis and Reporting Policy" (Last Revised 1/8/2018) was reviewed and included, " ...Policy ...Procedure: Occurrence of Patient Safety Event-an event not consistent with routine patient care, generally accepted performance standards ...resulted in injury or loss to a patient ...1. If applicable: Take immediate action to protect patient and involved parties ...Notify care provider and immediate supervisor. 2. Enter event in online safety event reporting system (web based, online documentation system for reporting safety events). 3. Conduct initial review and investigation of event.

3. The clinical record of Pt #1 was reviewed on 09/27/18 at approximately 9:30 AM. Pt #1 was admitted on 08/11/18 to the Older Adult Behavioral Health Unit with a diagnosis of depression from the Emergency Department. Pt #1's initial psychiatric evaluation (08/12/18) at 10:02 AM included, " ...increasing depression and anxiety attack. The patient (Pt #1) denies suicidal or homicidal ideation ...no other specific medical complaints ..."

- Behavioral Health Counselor (E #5) progress notes (08/16/18) at 1:13 PM included, " ...Patient (Pt #1) was very upset and in tears and said ...a male peer had entered her room, naked, gotten into bed with her and made inappropriate comments ...writer still consoling patient she asked for chocolate ice cream as a coping mechanisms ..."

- The progress notes (08/16/18) at 2:19 PM the documentation by E #1 (Social Worker) included, " ...met with the patient to debrief following an event with another patient that upset her ...reported to write that a male patient entered her room confused and was starting to remove his hospital gown and asking to get in bed with her ...she immediately left her room and that's when she yelled out to staff for help ..."

4. On 9/27/18 at approximately 2:00 PM a video regarding an inappropriate sexual advance incident that occurred on 08/16/18 at approximately 12:27 PM was reviewed. The video surveillance showed Pt #2 entering into Pt #1's room with Hospital gown on, at approximately 12:28 PM, and stayed in the room for approximately 50 seconds. The video showed Pt #1 rushing out of the room and running towards the nurses station, and Pt #2 coming out of the room undressed walking towards his (Pt #2's) room.

5. On 09/27/18 at approximately 2:30 PM, E #6 (Director of OABHU) was interviewed. E #6, stated, "I spoke with her (Pt #1's) family and notified of the incident that had occurred. I had explained exactly what had happened to her (Pt #1's) daughter. Her (Pt #1's) daughter was worried about her mother's safety. Yes, it has been documented in the Risk Master (Incident Log Online)."

6. On 09/28/18 at approximately 9:30 AM, E #8 (Administrative Director of OABHU) was interviewed. E #8 stated, "Nothing is reported in the Risk Master (Incident Reporting Online), the Unit Director (E #6) assumed that it was reported in the Risk Master. "Sentac Process" (Patient Grievance Process Online). Since this incident was not reported, the grievance process was not done. The individuals that were supposed to follow-up did not receive this incident...No we do not have any grievance follow-up with the family."

Based on document review, interview, and observation, it was determined that for 1 of 1 (Pt #1) clinical record reviewed of a patient with a complaint of an alleged sexual advances by another patient (Pt #2), the Hospital failed to ensure that the patient was placed in a safe environment.

Findings include:

1. The clinical record of Pt #1 was reviewed on 09/27/18 at approximately 9:30 AM. Pt #1 was admitted on 08/11/18 to the Older Adult Behavioral Health Unit with a diagnosis of depression from the Emergency Department. Pt #1's initial psychiatric evaluation (08/12/18) at 10:02 AM included, " ...increasing depression and anxiety attack. The patient (Pt #1) denies suicidal or homicidal ideation ...no other specific medical complaints ..."

- Behavioral Health Counselor (E #5) progress notes (08/16/18) at 1:13 PM included, " ...Patient (Pt #1) was very upset and in tears and said ...a male peer had entered her room, naked, gotten into bed with her and made inappropriate comments ...writer still consoling patient she asked for chocolate ice cream as a coping mechanisms ..."

- The progress notes (08/16/18) at 2:19 PM the documentation by E #1 (Social Worker) included, " ...met with the patient to debrief following an event with another patient that upset her ...reported to write that a male patient entered her room confused and was starting to remove his hospital gown and asking to get in bed with her ...she immediately left her room and that's when she yelled out to staff for help ..."

- The progress notes (08/16/18) at 7:18 PM the documentation by E #3 (Social Worker) included, " ...nurse leader called patient's daughter ...to inform her the incident between her mother and another patient as previously documented. The details of the event as shared by patient were explained to her. She expressed concern and was worried about her mother's safety. We assured her that the proper protocols are now in place including other patient receiving 1:1 monitoring."

2. The clinical record of Pt #2 was reviewed on 09/25/18 at 3:30 PM. Pt #2 was admitted on 08/15/18 with a diagnosis of dementia. Pt #2's Emergency Room record dated 08/15/18 at 7:51 AM, included, " ...wife stated that he (Pt #2) has been belligerent and behavior inappropriately for the last two weeks ...has been walking around naked, being hypersexual and impulsive. She reports ...he (Pt #2) left the house last night to make sexual advances to the neighbor and made inappropriate sexual advances to the wife this morning ..."

- Pt #2's psychiatric evaluation on 08/16/18 at 6:34 PM, included, "Patient (Pt #2) came from home with worsening agitation and sexual inappropriate behavior has been going on for months but now getting much worse, tried to advance on neighbor, on unit has already gone into room of female patient completely naked, now on 1:1 (one-to-one) sitter, admits he is doing this but does not know why, feel bad about it but says he cannot control himself and adamant about this." Pt #2 was placed on the standard 15 minute precautions (monitoring of patients every 15 minutes to ensure safety).

3. The policy titled, "Precautions and Monitoring" (07/2018) included, "...To establish a protocol for the management of precautions and monitoring for patient safety on the inpatient behavioral unit...all patients are maintained within 'constant view' ...d. One-to-One (1:1) observations:...ii. The nurse implements and documents the initiation of one-to-one observation...2. Assaultive/Aggressive behavior..."

4. The Hospital's policy entitled, "Patient Rights and Responsibilities," (last reviewed 9/2017) included, "Purpose: To define the policy and related processes for...to assure that patient rights and responsibilities are clearly defined, protected and prompted."

5. On 09/27/18 at approximately 1:10 PM, E #4 (Registered Nurse) was interviewed. E #4 stated, "Yes, this incident occurred around lunch time. She (Pt #1) had returned to her room after lunch. So, his (Pt #2's) room is across from her (Pt #1's) room. He went into her room and started removing his gown, by then she woke up and came running outside asking for help."

6. On 9/27/18 at approximately 2:00 PM a video regarding an inappropriate sexual advance incident that occurred on 08/16/18 at approximately 12:27 PM was reviewed. The video surveillance showed Pt #2 entering into Pt #1's room with Hospital gown on, at approximately 12:28 PM, and stayed in the room for approximately 50 seconds. The video showed Pt #1 rushing out of the room and running towards the nurses station, and Pt #2 coming out of the room undressed walking towards his (Pt #2's) room.

7. On 09/27/18 at approximately 2:30 PM, E #6 (Director of OABHU -Older Adult Behavioral Health Unit) was interviewed. E #6, stated, "I spoke with her (Pt #1's) family and notified of the incident that had occurred. I had explained exactly what had happened to her (Pt #1's) daughter. Her (Pt #1's) daughter was worried about her mother's safety. I also advised her (Pt #1) to call her daughter so that, she (Pt #1) can be calmed a little bit to relieve her (Pt #1) anxiety. Yes, I had clearly explained to her (Pt #1) that, her mother was not physically touched by the other patient. The other patient had removed his gown and exposed his private parts to her, meanwhile she (Pt #1) came out of the room asking for help."

8. On 09/28/18 at approximately 9:30 AM, E #8 (Administrative Director of OABHU) was interviewed. E #8 stated, "...No we do not have any hallway monitoring, we only have every 15 minutes monitoring of the patient...Yes, if this patient (Pt #2) was placed on 1:1 observation it could have been avoided..."

9. On 09/28/18 at approximately 11:30 AM, MD #1(Medical Director) was interviewed. MD #1 stated, "I did not see him (Pt #2) prior to this event. Yes, he (Pt #2) should have been on 1:1 monitoring, but I did not see him until after the event, he (Pt #2) was placed on 1:1 observation."