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Based on a review of medical records, Governing Body Bylaws, governing body meeting minutes, incident log, incident reports, staff interviews, and facility policies, it was determined that the facility failed to have an effective Governing Body that provided oversight and was responsible for the quality assessment and performance improvement plan and safety of patients for 13 (P) (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#22, P#23) of 23 sampled patients involved in allegations of inappropriate sexual behavior or sexual assault.
The facility's Governing Body failed to ensure that policies on incident reporting were adhered to when allegations of inappropriate sexual behavior or sexual assault were not included on the facility's incident log, were not investigated, and results were not reported through the facility's established quality assessment and performance improvment processes. In addition, incident reporting policies were not adhered to when staff failed to document allegations in patient medical records.

Findings included:

A review of the Governing Body Bylaws, last approved 1/15/25, revealed Article III, Governing Board, Section 3.1: General Powers. The affairs of the facility are managed by the Governing Board. The Board is ultimately accountable for the quality of patient care, treatment and services. The Governing Board ensures the safety of patients, staff and others. The Governing Board upholds the Medical Staff By Laws, Rules and Regulations, the Credentialing Process and the policies that have been approved by the Governing Board. The Governing Board has oversight to ensure an ongoing program for performance improvement and risk management at the facility.

A review of the Governing Body meeting minutes dated January 2024 through January 2025 failed to reveal a review or discussion of incidents/allegations of sexual assault.

An interview was conducted with Chief Executive Officer (CEO) BB on 2/25/25 at 9:30 a.m. in the administration conference room. CEO BB stated that he came on board with the facility on September 1, 2024. He continued to explain that he was made aware of the alleged sexual assaults soon after coming aboard as the CEO. He continued to say that he did review reports that were documented in 2024 through 2025 thus far. CEO BB stated that he is a part of the Governing Body and attends the meeting every other month. He continued to explain that all serious assaults result in a thorough investigation including police reports and are reported through the Performance Improvement (PI) manager, then reported through the Medical Executive (MED Exec) Committee and then up to the Governing Body. CEO BB stated that he agrees with the current process for documenting and investigating each allegation that is reviewed by the Risk Management Director and her team.

Cross refer to A-0043 as it relates to the facility's failure to develop, implement, and maintain an effective quality assessment and performance improvement program.

Based on review of the facility's incident log, policy and procedures and staff interviews it was determined that the facility failed to develop, implement and maintain an effective quality assessment and performance improvement program when it was determined that allegations of inappropriate sexual behavior and sexual assault were not tracked, were not investigated, and were not reported to the Governing Board. Seven incidents that involved 10 (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10) of 23 sampled patients were identified that were not included on the facility's incident log and was not investigated by the facility. One incident that involved one (P#11) of 23 sampled patients was not investigated.

Findings included:

Cross -refer to A-0286 as it relates to the facility's failure to track, trend, investigate and report to the Governing Body, allegations of inappropriate sexual behavior and sexual assault.

Based on review of the facility's incident log, policy and procedures and staff interviews it was determined that the facility failed to ensure that adverse patient events were tracked and/or investigated for 11 (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11) of 23 sampled patients. Specifically,

On 4/22/24, P#1 and P#2 were alleged to have a sexual encounter that was not included on the facility's incident log and an investigation was not conducted.
On 7/28/24, P#4 allegedly raped P#3 that was not included on the facility's incident log and an investigation was not conducted.
On 11/18/24, P#6 allegedly groped P#5 that was not included on the facility's incident log and an investigation was not conducted.
On 12/25/24, P#8 allegedly sexually assaulted P#7 that was not included on the facility's incident log and an investigation was not conducted.
On 12/27/24, P#8 allegedly sexually assaulted P#9 that was not included on the facility's incident log and an investigation was not conducted.
On 7/21/24, P#10 observed having inappropriate sexual activity with an unknown peer that was not included on the facility's incident log and an investigation was not conducted.
In December 2024, P#11 reported being raped by an unnamed person. The allegation was not investigated by the facility.

Findings included:
A review of the facility's incident log for 1/1/24 through 2/28/25 failed to reveal the following:
An entry involving P#1 and P#2 on 4/22/24.
An entry involving P#3 and P#4 on 7/28/24.
An entry involving P#5 and P#6 on 11/18/24.
An entry involving P#7 and P#8 on 12/25/24.
An entry involving P#8 and P#9 on 12/27/24.
An entry involving P#10 on 7/21/24.

A review of an incident report that involved P#11 failed to reveal that an investigation including witness statements was conducted.

A review of the facility's "Incident Reporting" policy, no policy number, last reviewed 1/2025 revealed I. Policy. The Incident Report is a mechanism for informing Administration of the occurrences of circumstances surrounding untoward events. An "Incident" is defined as any happening that is not consistent with the normal or usual operation of the hospital and/or department. Injury does not have to have occurred. The potential for injury and/or property damage is sufficient for an event to be considered an incident. III. Procedure. 1. Only the employee who is directly involved in the occurrence or incident, either through witnessing the event or being told by a visitor that an event has occurred, should initiate and document on the Incident Report form. This should be done immediately after the incident occurs (if witnessed) or as soon as one becomes aware of such an occurrence (receiving information from another person). 4. Instructions for completing the Incident Report form: E. The fully completed form should be signed, dated, timed, and forwarded immediately to the staff member's supervisor for review and signature. 5. All occurrences involving patients should be charted in the patient's medical records; no mention of the occurrence report should be made in the medical record. 6. The legal guardian must be notified of all unusual incidents. The information should be shared by the charge nurse unless a decision is made that it would be more appropriate by the therapist or physician. The report should be made ASAP and consent requested for any necessary follow-up.

A review of the facility's policy titled "Protection of Evidence from Assault," Policy #RNP101, last reviewed/revised 1/2025, revealed the following:
I. Policy.
It is the policy of Ridgeview Institute-Smyrna (RIS) to ensure that evidence from assault is protected from destruction or tampering.
II. Procedure.
C. If a patient reports sexual assault, the unit RN will arrange to transfer patient to the ER as per physician orders.
G. The patient's legal guardian is to be notified of the allegation (if applicable) and the patient being sent to the ER.
H. Documentation of the allegation, intervention to ensure the safety of the patient, and all notifications need to be placed in the medical record and a separate incident report is to be completed.

A review of the facility's policy titled "Grievances and the Patient Advocate," Policy #RNP069, last revised 1/2025 revealed the following:
It is the policy of the facility to encourage responsive and open communication with patients at all levels in the facility with the objective of resolving complaints and grievances through appropriate problem-solving actions.
II. Procedure.
2. It is the responsibility of each staff member to respond promptly to any concern or grievance voiced by patients and others no matter how trivial the complaint may appear to be. The staff member receiving the complaint should notify his/her supervisor when the issue cannot be immediately resolved, or if there is an allegation of abuse or neglect, or patient right violation allegation. The Supervisor must respond immediately to ensure that the patient and /or patients are safe.
5. The patient has a right to the following:
H. Be free from all forms of abuse and harassment.

An interview was conducted with Risk Manager (RM) AA on 2/24/25 at 12:30 p.m. in the administration conference room. RM AA stated that she has been in her role for approximately three months and her responsibilities include managing the Patient Advocate role which reports up to her. She continued to explain that she is responsible for receiving and reviewing all incident reports. RM AA stated that the Patient Advocate will review and log all complaint and grievances reported and she will review and investigate all incidents that are serious in nature, such as sexual assault. RM AA stated that apart of her investigation includes pulling video footage from all the common areas as well as the hallways. She continued to explain that there are no cameras in the bedrooms or bathrooms however she will develop a timeline from video footage and interview staff as well as some residents, if the resident feels comfortable in speaking with her. She continued to explain that many of the assault cases are peer-to-peer and in these instances the peers have been able to be separated from one another to different units. She continued to explain that if a resident displays sexual aggression or sexually acting out (SAO) than the resident will be placed on SAO precautions with no roommate.

An interview was conducted with Chief Executive Officer (CEO) BB on 2/25/25 at 9:30 a.m. in the administration conference room. CEO BB stated that he came on board at the facility on September 1, 2024. He continued to explain that he was made aware of the alleged sexual assaults soon after coming aboard as the CEO. He continued to say that he did review reports that were documented in 2024 through 2025 thus far. CEO BB stated that he is a part of the Governing Body and attends the meeting every other month. He continued to explain that all serious assaults resulting in a thorough investigation including police reports are reported through the Performance Improvement (PI) manager, then reported through the Medical Executive (MED Exec) Committee and then up to the Governing Body. CEO BB stated that he agrees with the current process for documenting and investigating each allegation that is reviewed by the Risk Management Director and her team.

An interview was conducted with Regional Director (RD) CC on 2/25/25 at 9:45 a.m. in the administration conference room. RD CC stated that she was involved in the allegations of assault from August of 2024 through the present. She continued to explain that prior to August 2024 when a new process and procedure was implemented the previous Chief Operating Officer (COO) was expected to document and investigated each allegation and the expectations were not being met and therefore he was relieved of his duty at the facility as of August 2024. RD CC stated that when the recent news story was reported she was personally involved in the investigation and communication with the local police department for the seven allegations reported of sexual assault. RD CC confirmed that there was one male patient who was named in an alleged sexual assault arrested on site and his case is still open and under investigation. RD CC confirmed that all serious allegations of assault requiring a thorough investigation and police involvement is reported to the Medical Executive Committee and the Governing Body. RD CC stated that she is in the process of attempting to find any investigative documentation left by COO prior to his termination.