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Based on interview, record review, and review of facility policies, it was determined the facility failed to protect the rights of patients to be free from abuse for one of ten selected for review (Patient #1). On 05/29/12, Patient #1 reported to facility staff an allegation of rape perpetrated by the patient's roommate (Patient #2). Although facility staff separated the alleged perpetrator from the victim, the facility failed to ensure other patients on the unit were protected from the alleged perpetrator. Four hours and fifteen minutes after the allegation was made to staff, and prior to completion of the investigation, a newly admitted patient (Patient #3) was placed in the same room with the alleged perpetrator. Additionally, the facility's policies/procedures, Reporting of Suspected Abuse and/or Neglect, Incident Reporting, Suspected Abuse/Neglect/Exploitation, Rape and Attempted Rape, and Reporting and Investigating Unusual Incidents, had no provision for the protection of other patients during the facility's investigation. The facility's failure to ensure a system was in place to protect other patients from abuse placed the twenty-one remaining patients in the unit census of twenty-three patients at risk for abuse.

The findings include:

Review of the facility's policies/procedures related to abuse/neglect revealed no provision for protection of other patients during the facility's investigation of an alleged abuse/neglect incident. Review of the facility policy/procedure, Reporting of Suspected Abuse and/or Neglect of a Patient by Hospital Employees, dated as reviewed 10/24/11, revealed an employee accused of abuse or neglect would be reassigned to a non-patient care area, or placed on leave, until cleared of the allegation. The policy did not address abuse by another patient. Review of the facility policy/procedure, Reporting and Investigating Unusual Incidents, dated as revised June 2007, revealed no provision for protection of patients during the facility's investigation. Review of the policy/procedure, Suspected Abuse/Neglect/Exploitation, dated as reviewed 10/28/11, revealed no provision for protection of patients from an alleged perpetrator that was also a patient. Review of the facility policy/procedure, Rape or Attempted Rape; Psychiatric Center, dated as revised August 2005, revealed no provision for the protection of other patients in the unit during an investigation. Interview with the Director of the Psychiatric Center on 05/31/12, at 5:58 PM, confirmed the policies/procedures provided were the current policies/procedures the facility followed related to abuse/rape.

Review of the nursing notes in the medical record of Patient #1 dated 05/29/12, at 9:00 PM, revealed staff heard a noise from Patient #1's room. The patient was found lying on the floor and informed staff the patient had been "punched and knocked down" by Patient #2. According to the nursing notes, Patient #1 informed staff that Patient #2 (roommate of Patient #1) had been raping the patient "every night." The nursing notes documented staff had notified the Nursing Supervisor on duty, Patient #1's guardian, and the physician.

Review of the nursing notes for Patient #2 dated 05/29/12, at 9:30 PM, revealed he/she had been moved to another room. Further review of the nursing notes dated 05/29/12, at 9:55 PM, revealed Patient #2 was to be within eye sight of staff when the patient was out of the room.

Review of the medical record of Patient #3 revealed the facility admitted the patient on 05/30/12, at 1:15 AM. Documentation revealed facility staff placed Patient #3 in the same room with the alleged perpetrator, Patient #2, four hours and fifteen minutes after the allegation had been reported to staff that Patient #2 allegedly raped Patient #1.

Interview with the Nursing Supervisor on 05/31/12, at 12:50 PM, revealed she had been notified by staff and informed of the allegation involving Patient #1 and Patient #2 at the time of the allegation. According to the Nursing Supervisor, she spoke with Patient #1 and notified the Emergency Department physician of the allegation. The Nursing Supervisor stated she had notified the local Police Department and she was present when the police officer spoke with Patient #1. According to the Nursing Supervisor, although she notified the facility's legal liaison and was told to follow the facility's policy/procedure which stated a rape kit was to be completed, the police officer did not feel a rape examination was indicated and Patient #1 was not sent to the Emergency Department for completion of a rape examination. The Nursing Supervisor stated the policies/procedures only provided directions on what to do for the alleged victim and did not provide instructions on how to protect others from the alleged perpetrator. The Nursing Supervisor acknowledged she had not considered how to protect other patients from the alleged perpetrator following the allegation of abuse.

(Ref. A0145)

Based on interviews, record reviews, and review of facility policies/procedures, it was determined the facility failed to ensure all patients were free from all forms of abuse or harassment. The facility failed to put interventions in place to protect twenty-three of twenty-three patients on the Cumberland unit after Patient #1 reported an allegation of sexual abuse perpetrated by Patient #2 on 05/29/12. Although Patient #2 had been placed on "within eye sight" level of supervision when out of the room following the incident, a newly admitted patient (Patient #3) was placed in the same room with Patient #2 four hours and fifteen minutes after the patient was alleged to have committed sexual abuse of Patient #1. The facility's policy/procedure had no provision for the protection of other patients in the unit during the facility's investigation.

The findings include:

Review of the facility's policy/procedure, Reporting of Suspected Abuse and/or Neglect of a Patient by Hospital Employees (dated as reviewed 10/24/11), Reporting and Investigating Unusual Incidents (dated as revised June 2007), Suspected Abuse/Neglect/Exploitation (dated as revised October 2002), and Rape or Attempted Rape; Psychiatric Center (dated as revised August 2005) revealed no component in the policy/procedure for the protection of other patients during the facility's investigation of an alleged sexual abuse.

Review of the medical record of Patient #1 revealed the facility had admitted the patient on 03/29/12, with diagnoses of Schizophrenia and Mental Retardation. Review of the nursing notes for Patient #1 dated 05/29/12, at 9:00 PM, revealed a noise was heard from the patient's room. The patient was found lying on the floor and stated Patient #2 punched the patient with a fist and knocked the patient down. Patient #1 then informed staff that Patient #2 had "raped" the patient every night. The nursing notes documented staff had notified the Nursing Supervisor, the patient's guardian, and the patient's physician of the allegation.

Review of the medical record of Patient #2 revealed the facility had admitted the patient on 05/23/12, with diagnoses of Schizophrenia, Opiate abuse, and Hepatitis C. Review of the Initial Treatment Plan for Patient #2 dated 05/23/12 revealed the patient had a history of aggressive behavior toward others and the goals for the initial treatment plan were to reduce and manage the patient's problematic behavior to maintain safety. Further review of the nursing notes on 05/29/12, at 9:00 PM, revealed Patient #2 had exited the room that he/she shared with Patient #1 after a loud noise was heard coming from the room. Patient #2 informed staff that the roommate, Patient #1, had thrown "pop" on the patient and he/she knocked Patient #1 down with his/her elbow. The nursing notes documented Patient #2 was moved to another room at 9:30 PM, and staff was to continue to observe the patient every 15 minutes. Documentation in the nursing notes at 9:55 PM on 05/29/12, revealed the Nursing Supervisor notified staff Resident #2 was to be "within eye sight" when out of the room. Review of the Patient Monitoring Record for Patient #2 dated 05/29/12, 05/30/12, and 05/31/12, revealed although staff had documented observations of Resident #2 were conducted every 15 minutes, there was no documentation on 05/29/12 or 05/30/12, that the patient had been "within eye sight" when the resident was out of the room.

Review of the medical record of Patient #3 revealed the patient was admitted to the facility on 05/30/12, at 1:15 AM, had a diagnosis of Schizophrenia, had not been taking prescribed medications, and had become delusional. Documentation revealed facility staff placed Patient #3 in the same room with the alleged perpetrator, Patient #2, four hours and fifteen minutes after the allegation had been reported to staff that Patient #2 allegedly raped Patient #1 and prior to completion of an investigation of the allegation.

Interview with Patient #1 on 05/31/12, at 10:15 AM, revealed a patient "got ahold of my head and punched it about 14 times." In addition, Patient #1 stated on "Friday night" (date unknown) the patient's roommate sexually abused the patient. According to Patient #1, staff placed him/her into a private room after the incident.

Interview with Patient #2 on 05/31/12, at 10:55 AM, revealed the patient had been involved in an altercation with his/her roommate (Patient #1) "two to three days ago." According to Patient #2, Patient #1 "spit" on his shirt and Patient #2 hit Patient #1 with the elbow. The patient stated about 30 minutes after the altercation facility staff moved the patient to another room and "that was it." Patient #2 stated he/she shares a room with another patient.

Interview on 05/31/12, at 11:05 AM, with Patient #3 revealed the patient had been in the facility "a few days." Patient #3 confirmed he/she had been a roommate of Patient #2 since admission to the facility.

Interview with RN #1 on 05/31/12, at 5:45 PM, revealed on 05/29/12 the RN was walking into the nursing station and heard a noise in Patient #1's room. RN #1 entered the room and found Patient #1 lying on the floor. According to RN #1, Patient #1 stated Patient #2 had hit him/her and, during the RN's examination of Patient #1, the patient reported Patient #2 had raped him/her every night. RN #1 stated she notified the Nursing Supervisor, the psychiatrist, and Patient #1's guardian of the incident. RN #1 stated that after a police officer and the Nursing Supervisor had spoken to Patient #1 and Patient #2 both patients were moved to different rooms. The RN stated the Nursing Supervisor instructed her to place Patient #2 on "within eye sight" level of supervision when he/she was out of the room. RN #1 was not aware of any provision in the facility policy/procedure related to protection of the other patients.

An interview was conducted on 05/31/12, at 4:35 PM, with Registered Nurse (RN) #2. RN #2 stated she was on duty on 05/29/12, when Patient #1 made the allegation of rape. According to RN #2, if a patient reported they had been abused staff was to report to the Nursing Supervisor. RN #2 stated Patient #1 was moved to a private room and Patient #2 was moved to another semi-private room. According to RN #2, the staff had been instructed by the Nursing Supervisor to place a new patient into the room with Patient #2, the alleged perpetrator. RN #2 stated staff requested to place Patient #2 on one to one supervision but the Nursing Supervisor denied their request. RN #2 stated Patient #2 was on "within eye sight" level of supervision when out of the room and staff had conducted observations of the patients every 15 minutes the night of the alleged incident.

Interview with the Nursing Supervisor on 05/31/12, at 12:54 PM, revealed she had been on duty on 05/29/12. The Nursing Supervisor stated she had been notified by staff of the allegation of rape made by Patient #1. According to the Nursing Supervisor, she went to the unit and spoke with Patient #1 who was in a room by him/herself. Patient #1 informed the Nursing Supervisor that Patient #2 had "raped" the patient several nights in a row. The Nursing Supervisor stated staff was ready to send Patient #1 to the Emergency Department, but the Emergency Physician told her to wait until the local Police Department had spoken with the patient. Further interview with the Nursing Supervisor revealed she had been present on the unit when the local police officer interviewed Patient #1 and Patient #2. According to the Nursing Supervisor, the police officer informed her that he did not feel a rape kit was necessary. At that time, the Nursing Supervisor notified the facility's legal liaison and he instructed her to read and follow the facility policy/procedure. The Nursing Supervisor stated the facility policy/procedure only talked about what to do with the victim and, based on the police officer's decision, the Nursing Supervisor acknowledged she did not send Patient #1 to the Emergency Department per facility policy/procedure. The Nursing Supervisor was not aware of any provision in the policy/procedure related to protecting other patients. The Nursing Supervisor stated Patient #2, the alleged perpetrator, was placed on "within eye sight" when out of the room level of supervision after the incident.

Interview with the facility's Director of Community Liaison on 05/31/12, at 2:05 PM, confirmed the Nursing Supervisor had notified him on 05/29/12, of Patient #1's allegation of rape. The Director stated he informed the Nursing Supervisor to obtain the rape policy/procedure and to notify the local Police Department. The Director stated he was unaware another patient had been placed in the room with the alleged perpetrator (Patient #2).

Interview with the on-call psychiatrist on 05/31/12, at 4:15 PM, revealed the psychiatrist had been notified on 05/29/12, of the allegations made by Patient #1. According to the Psychiatrist, she had given orders for Patient #1 to be sent to the Emergency Department (ED) for a rape kit. The psychiatrist was not aware the rape kit had not been obtained or that the patient had not been sent to the ED. The psychiatrist stated she ordered laboratory tests for Patient #2 and that it would be prudent to place Patient #2 in a room alone and not with a vulnerable patient.

Interview with the facility's Legal Liaison on 05/31/12, at 1:30 PM, revealed he had been assigned to the investigation of Patient #1's allegation of rape. The Legal Liaison stated staff was to obtain a rape kit for the victim and to keep the alleged perpetrator on one to one supervision or within eye sight supervision. According to the Legal Liaison, he was conducting an investigation of the allegation and would also determine if facility staff had acted in accordance with facility policy/procedure to ensure all patients were protected. The Legal Liaison stated he had spoken to Patient #1 and Patient #2 about the allegation but had not completed his investigation. Additionally, the Legal Liaison stated he was under the impression that Patient #2 did not have a roommate.

Interview with the Director of the Psychiatric Center on 05/31/12, at 3:27 PM, revealed all allegations were treated as true until the investigation had been completed. According to the Director, when an allegation had been made staff was required to keep the victim and other patients safe. The Director was unaware another patient had been placed in the room with Patient #2. The Director was unaware the facility's policy/procedure had no provision for protection of other patients.