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Based on review of Governing Body Bylaws, Quality Assurance Performance Improvement Plan, policy and procedures, video recording, internal incident reports and staff interviews it was determined that the facility's Governing Body failed to:
1. Ensure that patients are monitored/observed per physician orders
2. Ensure that an investigation and corrective actions were completed in response to a reported incident
when it was determined that two (P#1 and P#7) patients engaged in inappropriate sexual activity in a bathroom undetected by facility staff.


Findings:

Cross refer to A0309 as it relates to the Governing Body's failure to ensure that patient incidents are investigated and corrective actions implemented.

Cross refer to A0385 as it relates to the failure of nursing staff to follow facility policies regarding patient observation and monitoring.

Based on Governing Body Bylaws, Quality Assurance Performance Improvement Plan policy and procedures, internal incident reports, personnel files and staff interviews, it was determined that the facility failed to ensure that an investigation and corrective actions were implemented in response to patient safety incidents when it was determined that facility staff failed to adequately observe patients that resulted in two (P#1 and P#7) patients allegedly engaged in inappropriate sexual behavior in a bathroom on 10/17/24 and mitigation actions were not implemented until 11/14/24.

Findings:

A review of the Governing Body Bylaws amended April 1, 2020, revealed in accordance with the operation and management of Peachford Hospital, the following Bylaws are hereby adopted: Article IV. Purpose of the Hospital. The Board shall be accountable for the safety and quality of care, treatment and services of the Hospital. The primary purposes of the Hospital are to own and operate a behavioral health care facility and to perform such other activities for such other purposes as authorized by the Corporate Entity's governing corporate documents and as authorized by the Corporate Governing Body.

A review of the Quality Assurance and Performance Improvement Plan (QAPI) revealed 1. Introduction. The design of the QAPI plan is based on Peachford's Mission, Vision and Values as well as the needs and expectation of our customers, including patients, their families and staff and fosters teamwork and an organization-wide commitment to improvement of patient care.

9. PERFORMANCE IMPROVEMENT TEAM MEMBERS are selected based on their knowledge, experience and involvement with the process targeted for improvement. PI Team members are responsible for:
a. Attending all meetings;
b. Actively participating in team activities including the collection & analysis of data, identifying issues and root causes, defining the process flow and contributing factors for breakdown and identifying the opportunities for improvement.
10. THE ROLE OF THE PERFORMANCE IMPROVEMENT (PI) DIRECTOR
The PI Director assists the leadership, Medical Executive Committee and Performance Improvement Committee in designing, planning, implementing and overseeing a comprehensive and integrated management program. The authority and responsibility of the director includes, but is not limited to, the following:
-Maintain a record of all completed reviews, evaluations and process improvement team activities.
-Review patient surveys and patient complaints to determine the presence or absence of patterns and/or trends or opportunities for improvement in patient care outcomes, as well as the appropriateness of corrective action.
-Attend and participate in appropriate committee and department/service meetings in which quality management activities occur.
-Share data and information with appropriate committees and departments/ services.

A review of policy titled 'Alleged Patient Abuse, Neglect, Exploitation', number RI.018, last reviewed 1/2024 revealed that 6.0 An internal investigation shall be conducted and a report of findings written by the Patient
Advocate or designee. Documentation of all investigations shall be maintained in a central
file by the Patient Advocate. 10.0 Incidents of reporting negative patient treatment shall result in a review of standards/systems designed to prevent such negative occurrences. Systems reviewed may include one or more
of the following:
10.1 New employee orientation relevant to patient rights, abuse, neglect and exploitation
10.2 Annual employee education, pertaining to patient rights, abuse, neglect, and
exploitation
10.3 Level and quality of staff supervision and support.

A review of incident report #24-282036 dated 10/18/24 at 11:45 p.m. revealed that P#1 reported that on 10/17/24 at 11:30 a.m., he had sexually inappropriate behavior with a peer. P#1 denied injury and stated that he failed to report the incident earlier as he was afraid of the peer. P#1's guardian was notified. Physician was notified.

A review of incident report #24-282065 dated 10/19/24 revealed that it was alledged that P#7 had inappropriate sexual activity with P#1 on 10/17/24. P#7 denied that the incident took place. P#7's guardian was notified. The Physician was notified.

A review of an email communication dated 11/14/24 written by CNO LL revealed P#1 was located in room 501 prior to alleged sexual assault and remained located in room 501 after the alleged sexual assault. Continued review revealed P#7 was located in room 506 prion to alleged sexual assault and remained located in room 506 after the alleged sexual assault.

An interview was conducted with Assistant Administrator (AA) FF on 11/12/24 at 1:30 p.m. in the facility library. AA FF stated that when she was notified of the alleged incidents, she discovered that the resident reported the sexual assault the next day and not the same day of the incident. She continued to say that it was reported by the nurse manager that the two residents involved were separated, placed on peer restrictions, and a room block preventing any roommates from being assigned. AA FF continued to say that P#1 and P#7's parents were notified, and the usual investigation procedure was followed. She stated that the investigation procedure included speaking with the residents involved, interviewing the staff that were on duty, and reviewing any camera footage. AA FF stated that her investigation detailed notes as to who she interviewed, what the residents stated in their statements, and the timeline review of the camera footage were protected and considered Patient Safety Work Products (PSWP) and therefore per the facility's legal department will not and cannot be shared with this surveyor. AA FF continued to say that she does not have an alternative document to the PSWP to provide to this surveyor.


An interview was conducted with Staff Development Coordinator (SDC) HH on 11/12/24 at 4:00 p.m. in facility library. SDC HH stated that her responsibilities as SDC include training all facility staff at New Employee Orientation (NEO) and annual training. She continued to explain that she is involved in re-training as needed when issues arise. SDC stated that her responsibilities also include sending staff monthly reminders and reiterating policies and patient safety standards. She stated that it is the facility policy that all personal rooms are to remain locked throughout the day and that residents are not allowed to enter their room without staff and only one resident at a time can be escorted to their room if necessary. SDC HH confirmed that as of the date and time of this interview she had not been made aware of who from the Adolescent Boys Unit #7 needed re-training. She continued to explain that in general, she will review the corporate rounding training video with the staff member being re-trained and then discuss the video afterwards. SDC confirmed that she has not reviewed the corporate rounding training video with any staff member from the Adolescent Boys Unit #7 as of the date of this interview. SDC HH stated that all staff are required to complete competencies annually.



An interview was conducted with Mental Health Assistant (MHA) CC on 11/12/24 at 3:30 p.m. on the Adolescent Boys Unit #7. MHA CC stated that she has worked at the facility for a little over a year and that she is not assigned to Unit #7 and that she comes to the unit when she is on her break. She continued to explain that she is not familiar with P#1 or P#7 from the unit or any of the residents on Unit #7. MHA CC stated that she is assigned to work on the young girls unit ages seven and younger. She continued to say that the general policies as it pertains to all units are the same. She continued the say that all the doors to the personal rooms remain closed and locked at times during the day and that residents are not permitted to return to their rooms without staff present.

An interview was conducted with Mental Health Assistant (MHA) II on 11/13/24 at 11:00 a.m. in the facility's library. MHA II stated that he works on the Adolescent Boys Unit #7 and that he did recall Patient (P) #1 and P#7. MHA II confirmed that P#1 and P#7 have discharged from the facility. He continued to say that he did recall the incident that was reported of a sexual assault that occurred during his shift on 10/17/24. MHA II stated that he was notified by management that an alleged sexual assault occurred on the unit. He continued to say that prior to this incident he did not notice that P#7 had any indications of sexually acting out (SAO). He continued to explain that P#1 did seem as though he may have those tendencies however, he did not witness it. MHA II stated that on the day and approx. time of the incident it was nearing shift change and MHA stated that it's around this time that he likes to have all the boys sit in the dayroom and unwind before the staff change shifts and we can account for all the boys and smoothly shift from one shift to the next. He continued to explain that since the incident more interactive activities have been implemented to keep the boys engaged and active in order to prevent opportunities of doing something wrong. He continued to explain that there is a new activities book that the MHAs on the unit are required to utilize and follow for the boys to participate in. MHA II stated that he takes responsibility for not completing the 15-minute checks and conducting a rollcall and head count to ensure everyone was present and accounted for on the unit. He continued to say that it is facility policy that all personal rooms are to remain locked at all times during the daytime. MHA II stated that the routine is to wake the boys on the unit up at approximately 7:00 a.m. Everyone was allowed time to take of their morning hygiene and remind everyone to gather everything they will need for the day out of their room because they will not be allowed to return to their room until it is time for bed. He continued to explain that because there is no single bathroom on the unit, they have to utilize one room, the closest to the front, for bathroom breaks. He continued to explain that when the boys need to use the bathroom during the day they ask one of the MHAs on the unit and the staff unlock the designated room, and one person will be allowed to use the bathroom at a time. Then the room is locked when the resident is done. MHA II stated that after he was notified of the incident he met with management, and he was given a written warning. He continued to explain that he was not given additional training with the facility trainer, SDC HH, until today 11/13/24. MHA II continued to say that prior to today's training he did not received any retraining regarding observations or implementing additional activities.


An interview was conducted with Mental Health Associate (MHA) JJ on 11/13/24 at 11:30 a.m. in the facility's library. MHA JJ stated that he works on the adolescent boys unit seven and that he did recall P#1 and P#7. He continued to say that he was made aware of the incident involving P#1 and P#7 a few days after it was reported to his supervisor. He continued to say that he found out about the incident during a team meeting and then he did not have any firsthand knowledge of the details. MHA JJ stated that during the team meeting it was stated that there was an alleged sexual assault where on resident forced another resident to perform oral sex on him. He stated that during the meeting it was reiterated that the personal rooms must remain locked at all times and the MHAs are required to complete 15 minute checks and the facility will start having more activities for the kids to do during free time. MHA JJ stated that it is protocol to wake the kids up in the morning, they eat breakfast, and then take of their morning hygiene and then they're done we make sure they take everything out of their rooms that they will need for the day before they leave in the morning. He continued to explain that the kids are not allowed to return to their room during the day unless they are sick, and the nurse approves it. MHA JJ stated that he has not received any recent retraining from the facility.

An interview was conducted with Mental Health Associate (MHA) KK on 11/13/24 at 12:15 p.m. in the facility library. MHA KK stated that he works on the adolescent boys unit seven and recalled P#1 and P#7. He continued to say that he heard a rumor that a resident entered another resident's room and asked for a sexual favor. He continued to explain that he was on break when the alleged incident occurred. MHA KK stated that his responsibilities as an MHA include facilitating group activities and one-on-ones with the youth when needed. He continued to explain that he performs 15-minute checks on the residents and during the day when the residents are out of their personal rooms their doors must remain closed and locked all day until they return to get ready for bedtime. MHA KK stated that management did not include him in a meeting. He continued to say that he thinks management met with only the staff that were directly involved because no one communicated with him regarding the incident. MHA KK stated that he has not received any additional training or re-training.

An interview was conducted with Chief Nursing Officer (CNO) LL on 11/13/24 at 12:30 p.m. in the facility's library. CNO LL stated that she was first made aware of the incident after Risk Management was notified by the nurse manager on 10/18/24. She continued to say that she reviewed the video the following week and was disappointed by what she saw. CNO LL stated that soon after reviewing the video she started meeting with staff about re-educating everyone and then met with risk management about how we should proceed with the staff that were directly involved. She continued to explain that she handled the disciplinary parts of the incident and reviewed the video with MHA II. She stated that she discussed with MHA II what was viewed on the surveillance video that he was obviously distracted and not monitoring the patients properly which gave P#1 and P#7 a four minute opportunity that no one can actually say what did or did not happen. CNO LL stated that she and the director of clinical services came up with a more structured approach to activities on the units. She continued to explain that she has instructed her staff that they can no longer just sit and play music. She stated that the new activities schedule includes activities to be more interactive and engage the residents. CNO LL stated that she reminded the staff that activity time for the residents is not their free time. She continued to explain that an activities notebook was created for the unit and that MHA II assured her that the staff was utilizing it with the residents. CNO LL stated that the nurse manager will make surprise visits to the unit when activities should be happening to verify that the new activities notebook and schedule is taking place, and the nurse manager will make note of her observations on an observation log. CNO LL stated that she also have a conversation with the nurse supervisor who was on duty the day incident took place. She stated that she reiterated what her responsibilities included and that she will need to be more vocal with what the MHAs are or are not doing on the unit and the let MHAs who do not work on the unit to take their breaks in the breakroom. CNO LL continued to explain that she met with the entire staff individually and talked about the expectations of their role and what it means to maintain the milieu, completing their rounds, monitoring the hallways, and closing the bedroom doors because the automatically lock once closed securely. She continued to explain about the ceiling cameras in the personal rooms of the residents. CNO LL stated that the ceiling cameras are for observation only, they are only monitored during the evening shift, and they do not record. CNO LL stated that the general process when assault complaints are reported is to interview all residents involved, interview staff, review any video surveillance, and forward all evidence to risk management. She continued to explain that risk management will then review evidence, enter information in patient safety system and review personnel records to very competencies. CNO stated that to her knowledge re-education of the unit staff has been completed.

An interview was conducted with Quality Manager (QM) MM on 11/13/24 at 12:45 p.m. in the facility's library. QM MM stated that she became aware of the incident involving P#1 and P#7 when AA FF informed her about what happened. QM MM continued to explain that once Risk Management was made aware of a Level 3 or 4 incident had occurred then an event notification to the corporate office, and investigate the incident. She continued to say that the corporate notification is the Patient Safety Work Products (PSWP) that prevents this facility from sharing investigation findings with surveyors. She continued to explain that once the internal investigation begins, they have seven days to report back to the corporate office, and that is what AA FF is responsible for. QM MM stated that she is primarily responsible for more of the quality care complaints that come from payers. QM MM stated that when a Level 3 or 4 investigation is warranted the , medical staff and leadership team are brought in to review the case. She continued to explain that the medical staff reviewed any necessary medication changes and/or change in condition where notifications are required. She continued to explain that leadership will review any available video surveillance, interview staff, and interview residents to include in the PSWP report to corporate. If corrective actions were written this information will be included in the report. QM MM stated that her responsibilities include coordinating with AA FF to ensure all pieces of the investigation are completed before submitting to corporate.


An interview was conducted with Charge Nurse (CN) NN on 12/13/24 at 1:00 p.m. in the facility's library. CN NN stated that she works as a nurse on the Adolescent Boys Unit #7 and was on duty when the incident occurred between P#1 and P#7. She continued to explain that she was notified about the incident a day or two after it occurred. She stated that she was told P#1 was pacing around on the unit floor when P#7 asked him to come to his room and then a sexual act took place. CN NN continued to explain that after the incident Nurse Manager (NM) AA placed both residents on peer restrictions and blocked both room from having a roommate. She continued to say that P#1 was moved to another room on the other side of the unit to maintain distance from P#7. CN NN stated that NM AA have a few meetings with the staff during shift change to incorporate more structured activities for the residents to participate in and to reiterate that the personal rooms must remain locked at all times. She continued to explain that NM AA met with her individually to discuss her responsibilities as charge nurse, to correct the staff when they are not performing their duties as expected, and not to allow the MHAs to hang out at the nurses station and to work more with the residents. CH NN stated that the staff did received some re-education on their expectations on the unit.


An interview was conducted with Mental Health Assistant (MHA) OO on 11/13/24 at 2:45 p.m. in the facility's library. MHA OO stated that he works on the Adolescent Boys Unit #7 and about of his responsibilities as a MHA is to do safety checks and safety sweeps of the unit before each shift change. MHA OO stated that he does recall P#1 and P#7 from Unit #7 and was made aware of the alleged incident that took place on the unit between the two residents. He stated that he did recall the day of the incident that he arrived on Unit #7 a few minutes before the start of his shift at 2:25 p.m. because his shift begins at 3:00 p.m. He continued to explain that what he does is he arrives on the unit prior to shift change and open each personal room, walk in, look around for any objects or items, such as contraband, that does not belong in the residents room. He continued to explain that after performing a safety check and if no unauthorized items are found he will walk out of the room, ensure the door closes completely behind him, and check to ensure the door is lock before moving on to the next room. MHA OO stated that he did recall doing a safety check and sweep of Unit #7 at approximately 2:55 p.m. on the day of the alleged incident. He continued to explain that he did recall ensuring that all the doors remained locked after completing the check before he walked off the unit. MHA OO stated that if the room door was unlocked long enough for a resident to walk in and out of the room then it could be because another MHA unlocked the room after he left the unit to allow a resident to retrieve a personal item from their room or to use the bathroom. MHA OO stated that he did not recall seeing P#1 or P#7 roaming or pacing the hallway during the safety sweep. He continued to explain that the MHAs usually notice if a resident is out of place and redirect them to join the group and there were at least four MHAs on the floor at the time. MHA OO stated that since the incident on Unit #7 he has not received personal counseling, nor has he received re-training on rounding or observations.

Based on review of policy and procedures, medical record review, video surveillance, observations, internal incident reports, and staff interviews, it was determined that the facility staff failed to ensure that patients were monitored/observed as ordered when it was alleged that two (P#1 and P#7) adolescent patients engaged in inappropiate sexual behavior on 10/17/24 while in a bathroom. Video review of the unit dated 10/17/24 revealed that staff were seemingly unaware of patients going into unlocked patient rooms. Facility staff documented observations of P#1 and P#7 every 15 minutes.

Findings:

A review of the facility's "Levels of Observation/Patient Safety Rounds" policy, Policy # EC.034, last revised 4/2024 revealed the purpose is to provide for the safety of the patient through staff presence, supportive care and/or control if the patient is expressing or exhibiting behavior that indicates the potential for injury to self or others and/or the need for frequent, consistent interaction. Q15 MINUTE OBSERVATION - provided on all units. FIFTEEN MINUTE CHECKS are maintained with patients on this level of observation. Patient may be away from staff for approximately 15 minute intervals during waking hours and may sleep in own room during the night (no camera monitoring).

A review of the facility's "Hospital Plan for Provision of Nursing Care" policy, Policy #NR.001, last revised 6/2024 revealed 1.0 Definition. The delivery of nursing care at Peachford Behavioral Health System shall be understood as the purposeful and perpetual application of diversified talents with the common goal of positively impacting the health status of those entrusted to our care. 3.0 Identification of Nursing Care Needs. Nursing care needs of patients shall be identified using the nursing process. The nurse caring for the adolescent will determine nursing care needs based on an understanding of family dynamics, developmental/cognitive stages and capacity for independent activities of daily living of the adolescent.

A tour of the 30-bed Adolescent Boys Unit #7 on 11/12/24 at 3:00 p.m. with Development Coordinator revealed 14 boys sitting in the dayroom talking with one another. There were two Mental Health Assistants (MHA) and one Registered Nurse (RN) on the unit. All patient room doors were locked. Observation of room 504 revealed weighted furniture, bathroom with pull-away curtains, and two ceiling cameras. Observation of room 506, located next to room 504, revealed weighted furniture, bathroom with pull-away curtains, and two ceiling cameras. Further observation revealed that there is a monitoring system located at the nurses station that was unmonitored by staff.

A review of Patient (P) #1 medical record revealed that he was admitted to the facility on 9/21/24 with a diagnosis of Major Depressive Disorder (MDD).

Review nurse progress note dated 10/1/24 at 11:12 a.m. revealed P#1 became upset after staff would not open the door to his room. Patient picked up a chair in the dayroom, threw it at the exit door and began hitting patient room doors. P#1 refused staff redirection. P#1 began to threaten to harm staff, himself, and peers. MD notified. Patient to seclusion. Patient mother notified and voiced understanding.

Review of nursing note dated 10/15/24 at 9:56 a.m. revealed P#1 revealed that he attempted cutting himself, was aggressive, difficult to verbally redirect and was placed in seclusion.
Review nurse progress note dated 10/17/24 at 9:18 a.m. by Charge Nurse (CN) NN revealed that P#1 reports sleeping well; had a good appetite; and good energy level. Denied SI/HI thoughts of self-harm and hallucinations. Denies SI during the last 24 hours. Calm mood; cooperative.

Review of Patient Observation Rounds dated 10/17/24 revealed the following: 10:45 a.m. through 1:00 p.m., P#1 was sitting in the day room; from 1:00 p.m. through 2:00 p.m. P#1 was walking/pacing while in group. Continued review revealed that monitoring was documented every 15 minutes on 10/17/24.

Review of nurse progress note dated 10/18/24 at 12:34 p.m. revealed Assessment: patient denies SI//HI/AH/VH. Patient is medication compliant; patient states his goal for today is "do better." Plan: patient will be monitored for progression in the program, monitored Q15 minutes for safety and monitored for signs of escalating behavior. Patient's present plan of care will be continued per physician orders and treatment plan.

Review of nurse progress note dated 10/18/24 at 11:21 p.m. revealed that P#1 reported that his peer continued to ask him to come to his room on the 10/17/24 around noon. He finally accepted. The peer involved took him to his bathroom, the peer pulled his own pants and also pulled this patient's pants down and performed oral sex on him. Pt stated that, he told no one because of been afraid of his peer. P#1 denied any injury. P#1's mom was called and notified on [sic] the incident. Nurse notified MD. Will continue to monitor.

Review of nurse progress note dated 10/20/24 at 4:10 p.m. revealed that at 4:04 p.m., as instructed from management - outgoing call was made to patient's father by this nurse to inform police will be notified in regards to the incident and alligation on 10/17/24, based on previous documentation. Mom verbalized understanding of the call.

Review of nurse progress note dated 10/21/24 at 10:35 a.m. revealed mom called to inquire about the reported incident and findings. She had P#1's counselor on the line from the Progress Place. Mom gave verbal consent for this writer to speak to her. I informed her that the investigation was on going and could not give specific information without consulting risk management.

Review of treatment plan problem number three. Sexual acting out behavior. As manifested by stated he had oral sex with a peer. 10/22/24 long term goal: 3.1 P#1 will demonstrate absence of sexually inappropriate bx (behavior) while in the hospital. Short term goal 3.1.1 P#1 will maintain appropriate boundaries at all times with no sexually inappropriate comments or behavior. Intervention: 10/22/24 place in a blocked room.

A review of video surveillance of Adolescent Boys Unit #7 dated 10/17/24 revealed the following at timestamp:
01:36 MHA OO enters Adolescent Boys Unit #7
02:13 MHA OO begins safety sweep of the unit
02:14 MHA OO unlocks first personal room
02:46 MHA OO re-locks first personal room
02:54 MHA OO unlocks second personal room
03:25 MHA OO re-locks second personal room
03:38 Youth enter Adolescent Boys Unit #7
04:09 MHA OO unlocks third personal room
04:12 MHA II wearing black hoodie with orange & white strip on sleeve enters unit with youth
04:45 MHA OO walks out of third personal room without relocking
04:45 MHA OO youth walks in unlocked third personal room without supervision
04:48 MHA OO unlocks fourth personal room #504
05:13 MHA OO re-locks fourth personal room #504
05:22 MHA OO unlocks fifth personal room #506
05:58 MHA OO walks out of fifth personal room #506 without re-locking; appears youth are still in the room unsupervised
06:01 MHA OO unlocks sixth personal room
06:23 MHA OO re-locks sixth personal room
06:30 MHA OO unlocks seventh personal room
07:03 MHA OO relocks seventh personal room
07:20 MHA OO exits unit
09:35 MHA CC enters unit
09:37 MHA CC and MHA II engage in conversation
12:55 MHA II exits unit
12:59 MHA OO enters unit
13:06 MHA OO and MHA CC engage in conversation
13:53 MHA II re-enters unit and joins MHA CC and MHA OO at the desk
14:10 MHA OO exits unit
21:04 MHA CC exits unit
22:20 MHA CC re-enters to unit with MHA JJ
22:25 MHA II, MHA CC and MHA JJ engage in conversation
22:27 MHA KK enters unit
22:30 MHA KK, MHA II, MHA CC, and MHA JJ engage in conversation
28:20 MHA KK exits unit
32:12 MHA II exits unit to nurses station; MHA CC and MHA JJ continue conversation
32:28 MHA II re-enters unit
32:51 MHA II joins MHA CC and MHA JJ in conversation
35:53 MHA II exits unit to nurses station

A tour of the 30-bed Adolescent Boys Unit #7 on 11/12/24 at 3:00 p.m. with the Development Coordinator revealed 14 boys sitting in the dayroom talking with one another. There were two Mental Health Assistants (MHA) and one Registered Nurse (RN) on the unit. All personal room doors were locked. Observation of 504 revealed weighted furniture, bathroom with pull-away curtains, and two ceiling cameras. Observation of room 506, located next to room 504, revealed weighted furniture, bathroom with pull-away curtains, and two ceiling cameras. Further observation revealed that there is a monitoring system located at the nurses station that remains unmonitored and unchecked by the day shift.

A review of incident report #24-282036 dated 10/18/24 revealed patient #1, Unit PEA Unit 7A.
A. Date/Time of Incident: 10/17/24, Time: 1130.
B. Incident Type: Sexual Assault Pt/Pt 16.
D. Type of Injury: no injury.
G. Site of Event: Bathroom.
L. Notification: Supervisor.
M. Patient/Family: Patient Attitude After Event: Cooperative. Family Attitude After Event: Cooperative.

Risk Manager (Assistant Administrator): AA Date Reviewed: 10/20/24 3:54 p.m. Comments: 10/18/24 11:45 p.m. pt reported that his peer continued to ask him to come to his room on the 10/17/24 around noon. He finally accepted. The peer involved took him to his bathroom, the peer pulled his own pants and also pulled this patient's pants down and performed oral sex on him. P#1 stated that, he told no one because of been [sic] afraid of his peer. P #1 denied any injury. Pt's mom was called and notify on the incident; P#1 was very cooperative during the phone conversation. Nurse notified physician.

A review of incident report #24-282065 dated 10/19/24 revealed P#7, Unit PEA Unit 7A.
A. Date/Time of Incident: 10/17/24; Time: 1130.
B. Incident Type: Sexual Assault Pt/Pt 16.
D. Type of Injury: No injury.
G. Site of Event: Bathroom.
L. Notification: Supervisor.
M. Patient Attitude After Event: Cooperative. Family Attitude After Event: Cooperative, Understanding;

Reviewed By Supervisor: RN AA Date 10/21/24 2:14 p.m.
By Risk Manager (Assistant Administrator): AA FF Date Reviewed: 10/20/24 3:55 p.m. Comments: P#7 stated that the peer in question was walking back and fort [sic] in the way, came to his room door and said something to him but could not remember what he said to him but did not reply. Pt denied allegations made by his peer (P#1) No injury noted on him. P#7's dad was informed of the incident, he encouraged nurse to do what necessary to take care of it. Physician notified.


A telephone interview was conducted with Nurse Supervisor (NS) GG on 11/12/24 at 2:15 p.m. NS GG stated that she generally works on the weekends or will pick up a shift during the week when needed. She continued to explain that she does recall P#1 and P#7 and the alleged incident that was reported by P#1. NS GG stated that she did recall speaking with P#1 who reported to her the day after the incident had occurred that he was pacing up and down the hallway several times when P#7 continued calling him to his room. She continued to explain that P#1 stated to her that after he kept saying no, he finally gave in and went in P#7's room. NS GG stated that P#1 told her that P#7 performed oral sex on him. NS GG stated that after she took P#1's statement and P#7's statement she reported the incident to Nurse Manager (NM) AA and both patients were placed on peer restrictions, which keeps the two of them separated from each other. She continued to explain that in addition peer restrictions P#1 and P#7 rooms were blocked from having a roommate added to their room. NS GG stated that she completed the incident report and forwarded to Assistant Administrator (AA) FF

An interview was conducted with Staff Development Coordinator (SDC) HH on 11/12/24 at 4:00 p.m. in facility library. SDC HH stated that her responsibilities as SDC include training all facility staff at New Employee Orientation (NEO) and annual training. She continued to explain that she is involved in re-training as needed when issues arise. SDC stated that her responsibilities also include sending staff monthly reminders and reiterating policies and patient safety standards. She stated that it is the facility policy that all personal rooms are to remain locked throughout the day and that residents are not allowed to enter their room without staff and only one patient at a time can be escorted to their room if necessary. SDC HH confirmed that as of the date and time of this interview she had not been made aware of who from the Adolescent Boys Unit #7 needed re-training. She continued to explain that in general, she will review the corporate rounding training video with the staff member being re-trained and then discuss the video afterwards. SDC confirmed that she has not reviewed the corporate rounding training video with any staff member from the Adolescent Boys Unit #7 as of the date of this interview. SDC HH stated that all staff are required to complete competencies annually.

An interview was conducted with Chief Nursing Officer (CNO) LL on 11/13/24 at 12:30 p.m. in the facility's library. CNO LL stated that she was first made aware of the incident after Risk Management was notified by the nurse manager on 10/18/24. She continued to say that she reviewed the video the following week and was disappointed by what she saw. CNO LL stated that soon after reviewing the video she started meeting with staff about re-educating everyone and then met with risk management about how we should proceed with the staff that were directly involved. She continued to explain that she handled the disciplinary parts of the incident and reviewed the video with MHA II. She stated that she discussed with MHA II what was viewed on the surveillance video that he was obviously distracted and not monitoring the patients properly which gave P#1 and P#7 a four minute opportunity that no one can actually say what did or did not happen. CNO LL stated that she and the director of clinical services came up with a more structured approach to activities on the units. She continued to explain that she has instructed her staff that they can no longer just sit and play music. She stated that the new activities schedule includes activities to be more interactive and engage the residents. CNO LL stated that she reminded the staff that activity time for the residents is not their free time. She continued to explain that an activities notebook was created for the unit and that MHA II assured her that the staff was utilizing it with the residents. CNO LL stated that the nurse manager will make surprise visits to the unit when activities should be happening to verify that the new activities notebook and schedule is taking place, and the nurse manager will make note of her observations on an observation log. CNO LL stated that she also have a conversation with the nurse supervisor who was on duty the day incident took place. She stated that she reiterated what her responsibilities included and that she will need to be more vocal with what the MHAs are or are not doing on the unit and the let MHAs who do not work on the unit to take their breaks in the breakroom. CNO LL continued to explain that she met with the entire staff individually and talked about the expectations of their role and what it means to maintain the milieu, completing their rounds, monitoring the hallways, and closing the bedroom doors because the automatically lock once closed securely. She continued to explain about the ceiling cameras in the personal rooms of the residents. CNO LL stated that the ceiling cameras are for observation only, they are only monitored during the evening shift, and they do not record. CNO LL stated that the general process when assault complaints are reported is to interview all residents involved, interview staff, review any video surveillance, and forward all evidence to risk management. She continued to explain that risk management will then review evidence, enter information in patient safety system and review personnel records to verify competencies. CNO stated that to her knowledge re-education of the unit staff has been completed.


An interview was conducted with Charge Nurse (CN) NN on 12/13/24 at 1:00 p.m. in the facility's library. CN NN stated that she works as a nurse on the Adolescent Boys Unit #7 and was on duty when the incident occurred between P#1 and P#7. She continued to explain that she was notified about the incident a day or two after it occurred. She stated that she was told P#1 was pacing around on the unit floor when P#7 asked him to come to his room and then a sexual act took place. CN NN continued to explain that after the incident Nurse Manager (NM) AA placed both residents on peer restrictions and blocked both room from having a roommate. She continued to say that P#1 was moved to another room on the other side of the unit to maintain distance from P#7. CN NN stated that NM AA have a few meetings with the staff during shift change to incorporate more structured activities for the residents to participate in and to reiterate that the personal rooms must remain locked at all times. She continued to explain that NM AA met with her individually to discuss her responsibilities as charge nurse, to correct the staff when they are not performing their duties as expected, and not to allow the MHAs to hang out at the nurses station and to work more with the residents. CH NN stated that the staff did receive some re-education on their expectations on the unit.

An interview was conducted with Nurse Manager (NM) AA on 11/13/24 at 2:10 p.m. in the facility's library. NM AA stated that after learning about the incident involving P#1 and P#7 she immediately notified Risk Management and began to gather information to begin the investigation. She continued to explain that the information she put together was the staffing to determine who was on the schedule and to determine the staffing ration for the unit. She continued to explain that she gathered the rounding sheets, reviewed the levels of observations and then begin interviewing everyone involved. NM AA stated that her role in the investigation process is to gather the pertinent information, place it all in a red folder and turn everything over to Risk Management. She continued to explain that the video review is handled solely by Risk. NM AA stated that she interviewed P#1 and P#7. She continued to explain that she concluded that both accounts as to what happened were conflicting and did not agree as to what happened. NM AA continued to say that one resident stated that it happened, and the other resident stated that it did not happen. She continued to explain that after interviewing the staff on duty they informed her that they were unaware anything had taken place. NM AA stated that she began the re-education process with CN NN and her staff to discuss rounding protocol , being proactive, and being where they need to be. She continued to explain that the rooms on the unit are to remain locked after the youth get up in the morning, complete their morning hygiene, and gather all their personal belongings for the day. She continued to explain that Unit #7 does not have a single bathroom on the unit, so one room is designated as the room to use for bathroom use for the day and youth must be escorted one at a time to use the bathroom during the day. NM AA stated that she has reiterated that no other staff should visit other units for any reason if it is not work related. She continued to explain that she tries to have monthly meetings and to review with the staff the policies and procedures of the unit. She stated that she plans to make unannounced visits to the unit to ensure that the staff is doing what they're supposed to do, and the changes are implemented as discussed. She continued to explain that she plans to use a check-off sheet to keep track of who is complying with the changes and who needs reminding.