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Based on interview and document review, the hospital failed to ensure patient rights were protected when a minor patient assaulted another minor patient.

See A 0144.

An IJ was identified 12/08/20 at 9:06 a.m., related to patients receiving care in a safe setting. The IJ was removed 12/09/20, at 5:37 p.m., but the hospital remained out of compliance at the Condition of Patient Rights.

Based on interview and document review, the hospital failed to provide adequate supervision for 1 of 11 patients (P1) who was allegedly sexual assaulted by P2. This deficient practice resulted in an immediate jeopardy (IJ).

The IJ began on 11/22/20, when during the night shift, P2 was able to avoid staff notice, entered P1's bedroom, and allegedly sexually assaulted her. The chief nursing officer, the director of patient care, and the risk manager were notified of the IJ finding on 12/8/20, at 9:06 a.m.

Findings include:

P1's History and Physical dated 11/20/20, identified P1 was admitted to the hospital's adolescent psychiatric unit on 11/20/20, with diagnoses which included mild intellectual disability, depressive disorder, history of sexual trauma, and a history of making allegations of sexual assault and abuse toward peers, staff, and community members. P1's admission assessment dated 11/20/20, indicated P1 was placed on 1:1 specialized supervision for active hours, and routine monitoring during the night hours (15 minute checks). P1 was also to be placed in a room located across from the nursing station to maintain safety.

P2's History and Physical dated 9/16/20, identified P2 was admitted to the hospital's adolescent psychiatric unit on 9/16/20, with diagnoses which included history of acting out sexually toward others, mild intellectual disability, disruptive mood disorder, agitation and aggression, and problems with respecting boundaries of others. P2's admission assessment dated 9/16/20, identified P2 had been assessed to require specialized monitoring (1:1) due to his behavior, and need for frequent redirection and staff intervention. Following a COVID-19 outbreak, P2's specialized supervision was decreased because of patients remaining in their rooms with no peer interaction. Following resolution of the outbreak and resumption of admissions to the unit on 11/19/20, P2 was placed on 2:1 supervision, but continued to require very frequent staff intervention and redirection.

P2's undated care plan listed a history of agitation and aggression, and failure to respect personal boundaries. The care plan interventions included continue to monitor boundaries, and P2 needed firm limits and breaks away from activity.

On 11/22/20, at 1:03 p.m. a security report indicated P1 reported P2 had entered her bedroom on 11/22/20, between 5:30 a.m. and 6:00 a.m., woke her up, forced her to have oral sex, then forced her onto the floor, and sexually assaulted her. P1 stated P2 had also made threats of acts he was going to perform against P1 when he was discharged. During P1's statement to security, P1 stated P1 and P2 knew each other outside of the facility, and this was known to facility staff. Following the alleged assault, P2 told P1 he was going to "do it again tonight." A request was made to MD-A for a Sexual Assault Nurse Examination (SANE), and following delay with the provider deciding to order the examination, the SANE exam was completed for P1. Security officer (SO)-A was interviewed on 12/3/20, at 11:12 a.m. and verified the security report.

On 11/23/20, an investigation document from the licensed social worker (LSW)-A, indicated P1 was overheard telling a peer that P2 had given her a "hickey." The report indicated P1 told the peer P2 had crawled into her room during the night, woke her up, took off his pants, made her suck his penis, and put it inside her vagina. P1 stated P2 had given her a hickey, and he hid in the bathroom when RN-B entered the room. When RN-B left the room, P2 snuck out of the room, and went to the nursing station pretending he was there for a drink of water. P1 initially identified the sex as consensual, but then changed her story, stating P2 had raped her, and she requested to file a police report. P1 stated she had not called out during the assault because was afraid P2 would hit her.

The police and SANE both reports dated 11/23/20, indicated P1 was examined at 9:20 p.m. and detailed a sexual assault by P2 which took place between 5:00 a.m. - 6:00 a.m. on 11/22/20, in P1's room. Marks detailed in the SANE report included a 2 x 2 circular hematoma on the left side of P1's throat, in addition to a 4.5 centimeter abrasion located slightly above the naval area. According to the police report and SANE document, P2 refused the complete examination, but did allow swabbing of his cheek and finger nails. The police report indicated P2 stated P1 had invited him to come to her room. P2 stated he had waited until staff were not performing routine rounding, and had sneaked into P1's room. P2 stated they had removed their pants and "did it." P2 stated he had hid in the bathroom when staff entered the room, and when they left he had snuck out of her room.

On 12/3/20, at 12:49 p.m. mental health assistant (MHA)-A was interviewed, and stated she was in attendance during a group activity on the evening of 11/21/20, when P1 and P2 were observed playing "footsie" while seated at a table. P1 was escorted to her room by MHA-A, where she became upset claiming that she and P2 were boyfriend and girlfriend, and had a relationship prior to this admission. P1 was counseled by MHA-A regarding boundaries, and reminded there was no personal contact with peers.

On 12/3/20, at 9:15 p.m. registered nurse (RN)-B was interviewed, and stated she was the charge nurse on the night shift of 11/22/20. RN-B stated she had not noticed P2 in the hallway on the morning of 11/22/20, and was unaware of the incident until her next shift. RN-B stated she had taken her paperwork and sat in the patient lounge area to be able to observe both hallways which was her usual practice. RN-B stated the usual pattern for over night staffing was to have one staff located behind the nursing station, and one staff working at a table in the lounge area. RN-B stated this was in addition to staff who were assigned to provide 1:1 specialized supervision. RN-B stated rounds were assigned, and staff alternated performance of making the rounds on the unit. RN-B stated that on previous admissions, P2 had 1:1 over night supervision, but since he had been sleeping more on this admission, the IDT had felt it was safe to decrease the level of supervision to routine 15 minute checks on the overnight shift. RN-B stated P2 had a history of boundary issues with both staff and peers, and she was not surprised that he would act out.

On 12/3/20, at 9:23 a.m. RN-C was interviewed, and stated all adolescent patients were placed on routine 15 minute checks on a 24/7 basis, in addition to any specialized supervision ordered. RN-C stated 1:1 supervision was assessed to be indicated when there was a risk of self harm or harm to others. RN-C stated all patients were reviewed according to their individual assessment of need, with input from unit staff and medical providers occurring on a 5 day/week basis at the Interdisciplinary team (IDT) meeting. On the days IDT meetings did not take place, RN-C stated there was a provider on-call that would make the determination of need for level of supervision. RN-C stated P2 had been a patient on the unit for two plus months at the time of P1's admission. RN-C stated P1 and P2's rooms were located one alcove apart or a distance of 20 - 30 feet. RN-C stated P2 was on 1:1 special monitoring until about 3 weeks previously, when a COVID-19 outbreak had resulted in patients on the unit remaining in their rooms. RN-C stated P2 did not require 1:1 supervision while he was in his room. RN-C stated once the unit was open to taking new admissions again. P2 was determined to require 2:1 specialized supervision during waking hours. RN-C stated safety was a primary concern on the unit, and new admissions were not accepted unless they had adequate staff to meet their care needs.

On 12/3/20, at 9:49 p.m. RN-A was interviewed, and stated she had worked the night shift on 11/22/20, but was not the primary nurse assigned to P1 or P2. RN-A stated she had performed the 15 minute unit rounds for the hours of 12 a.m., 3 a.m., and 5 a.m. RN-A stated up until the 5:45 a.m. rounds, P1 was observed sleeping in her bed. P2 was awake at 5:00 a.m. and in and out of his room, sitting in the chair located in the alcove of his room. RN-A stated at 5:30 a.m. P2 was seated on the floor with his back against the wall, knees drawn up, hood of his sweatshirt pulled up, and his head resting against his knees. RN-A stated this was not unusual behavior for P2, and when he had 1:1 specialized supervision that person would engage and redirect P2 back to his room. RN-A stated P2 was aware of the unit policy that patients were to retire to their rooms from 10:00 p.m. until 7:00 a.m., and they were not be hanging out in the hall or the lounge. RN-A stated special circumstances in which a patient needed to remain with staff were allowed, but that patient and staff were together in the lounge area. RN-A stated she had requested P2 to return to his room a couple of times, and he had refused. RN-A stated P2 could quickly become agitated and aggressive, and due to the limited number of staff on the unit, had decided to stop attempts to redirect P2. At 5:45 a.m. RN-A stated she opened the door to P1's darkened room, and discovered P1 seated on the floor between the main room door and the bathroom door. P1 was dressed, and the bathroom door was closed with the light on. P1 immediately stood up and asked for a glass of water, then requested to stand in the door while RN-A finished rounds and retrieved a glass of water for her. RN-A stated the room was dark, and she did not notice anything unusual when she was in the room. RN- A stated she proceeded to the next room, which was room P2's room. Upon entering the room, P2 was not visible, but the bathroom door was closed and the light was on. RN-A stated she called out his name a couple of times, and when there was not a response, opened the bathroom door to observe no one in the bathroom. RN-A stated she had looked around the room, and when P2 was not found, she had exited the room to see him standing by the nursing station. Upon completion of rounds, RN-A returned to P1's room with the water to find P1 lying in bed, and when asked what had woken her, P1 responded she had had a nightmare. P1 denied wanting to talk, was settled in bed, and RN-A left the room, and stated she had no cause to be concerned.

On 12/3/20, at 10:20 a.m. RN-D was interviewed, and stated P2 had a history of displaying inappropriate sexual behavior toward others prior to his admission, and peers had voiced discomfort related to him making sexual comments and attempting to touch them. RN-D stated P2 had poor boundaries, and was not always easily redirected. RN-D stated staff on the unit had been advocating for resuming 1:1, 24/7 supervision for P2 for an extended period of time, due to behaviors around peers, and requirement of excess staff interventions and redirection. RN-D stated these concerns had been communicated to both the medical provider and administration on multiple occasions, but were not followed up on.

On 12/3/20, at 12:00 p.m. RN-E was interviewed, and stated P1 was on 1:1 specialized supervision during "active" hours (days and evenings), but routine 15 minute checks were felt to be appropriate during night hours. RN-D stated she was not certain why the 1:1 was not continued during the night for P1, as it had been in place with previous admissions. RN-E stated P2 was on specialized supervision 1:1 for the majority of his stay, and it was decreased to 2:1 supervision related to staffing on the unit. RN-E stated she had contacted MD-A on 11/17/20, following an incident in which P2 had made sexual comments to a peer, and refused to allow her to leave her room. In addition, RN-E stated P2 required almost constant staff intervention and redirection, and she had communicated the 2:1 supervision was not working. RN-E stated she had been told by MD-A she would need to take this request to upper management. RN-E stated staff were pressured to remove 1:1 supervision, even when multiple unit staff felt it was indicated to protect both the patient and peers.

On 12/3/20, at 12:49 p.m. MHA-A was interviewed, and stated she was familiar with P1 and P2 from both the current and previous admissions. MHA-A stated P1 had been placed on 1:1 specialized supervision during active hours, but routine monitoring (15 minute checks) during the night shift. MHA-A stated she thought it could have been due to being housed in the room across from the nursing station. MHA-A stated she was working with P1 performing specialized 1:1 supervision on 11/20/20, when P2 entered the area and P1 became excited at seeing him. MHA-A stated P1 was smiling and waving, and stated she knew P2 from before when they were in the same home situation and would meet in a park. On 11/21/20, MHA-A stated P1 had been exhibiting poor boundaries, and had required frequent staff redirection and reminders as she and P2 attempted to interact with each other during the day. MHA-A stated on that evening, P1 and P2 were separated with P1 escorted to her room following attempting to play footsie with P2 during a group activity. MHA-A stated on the afternoon of 11/22/20, P1 had told her another patient had come into her room during the night, and turned her head to show the hickey on the left side of her neck. MHA-A stated she escorted P1 to her room, and MHA-A questioned further about the incident. P1 told MHA-A P2 had entered her room during the night, and gave her the hickey. MHA-A stated P1 told her P2 had touched her down here, and pointed to her genital area. MHA-A stated she reported the incident to the charge nurse, RN-F, and P1's primary nurse RN-G, who escorted P1 to the conference room for interview about the incident. MHA-A stated P2 had been on 1:1 supervision up until a couple of weeks ago, and following the COVID-19 outbreak was changed to 2:1 supervision. MHA-A stated this was a challenging situation for both staff and P2, as he required constant supervision and intervention from staff. MHA-A further stated on the Tuesday or Wednesday before the alleged incident (unit was still on quarantine), she had caught P2 in his bathroom with the laptop used for school work. MHA-A stated she had taken the laptop to the unit social worker who checked the history, and discovered P2 had been attempting to search for inappropriate sexual topics. MHA-A stated P2 had additional documented incidents of attempting to touch other female peers, had prevented a female peer from leaving her room as he made sexual comments to her, and demonstrated poor boundaries with both staff and peers on the unit. MHA-A stated she had been aware of RN-E requesting 1:1 special supervision for P2 after incidents of agitated behavior, and the need for excessive staff attention. MHA-A stated the request was denied, and RN-E stated she had been told to take it up with upper management. MHA-A stated there were multiple staff on the unit who had voiced concerns with P2's behavior and the need for additional supervision. MHA-A stated no changes in supervision occurred for P1 or P2 until after the alleged incident on 11/22/20, when they were both placed on 1:1 24/7 supervision, and transferred to rooms a greater distance apart.

On 12/3/20, at 1:40 p.m. MD-B was interviewed, and stated she was familiar with both P1 and P2. MD-B stated P2 had been a repeat patient on the unit several times, had a low IQ, and was difficult to maintain placement in the community related to agitation and aggressive behavior toward others. MD-B stated the usual procedure was to reduce overnight supervision on patients if they usually slept during the night. MD-B stated patients return to their bedrooms at 10:00 p.m. through 7:00 a.m., unless there was a need for a drink or medication. MD-B stated with routine checks, camera monitoring, and a staff person monitoring the halls from the lounge and desk area, staff should have been able to intervene or prevent P2 from entering P1's room on 11/22/20.

P1's discharge summary dated 11/23/20, at 7:30 p.m. indicated P1 was transferred to a different facility who had a psychiatric unit due to safety concerns and threats of repeated assault from P2 toward P1.

A policy on supervision was requested, but not provided.

The IJ was removed on 12/9/20, at 5:37 p.m. when it was verified through staff interviews and document review the hospital had submitted and implemented an acceptable removal plan, education and training was provided to all psychiatric unit staff on both the adult and adolescent units, and competency documentation of policy revisions for continuous monitoring of halls on the night shift and rounding with documentation.