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Based on record review, interview and policy review, the facility failed to ensure alleged abuse was thoroughly investigated and failed to ensure patients were protected from abuse during an investigation. This had the potential to affect all patients. The census was 65.

See A145

Based on record review, interview and policy review, the facility failed to ensure alleged abuse was thoroughly investigated and failed to ensure patients were protected from abuse during an investigation. This affected two (Patients #1 and #2) of 10 records reviewed. This had the potential to affect all patients. The census was 65.

Findings include:

1. Review of the medical record of Patient #1 revealed the patient was transferred from an outside hospital on 11/17/24 at 4:42 PM. An application for involuntary emergency admission dated 11/17/24 at 11:49 AM stated the patient represented a substantial and immediate risk of serious physical impairment or injury to self because of the patient's mental illness and the patient would benefit from treatment in a hospital for mental illness. The psychiatric evaluation, completed on 11/18/24, stated the patient was admitted with concerns for decompensation of psychosis. The patient had a history of psychiatric a diagnosis that included schizoaffective disorder bipolar type. The psychiatric physician stated that upon admission, the patient was very agitated, aggressive, and needed emergency medications of Haldol (medication used to treat nervous, emotional, and mental conditions) 10 milligrams (mg) and Benadryl (antihistamine medication used in mental health to treat extrapyramidal side effects from antipsychotics) 50 mg. According to the Medication Administration Record (MAR), the patient was medicated again with Thorazine (medication used to treat mental health conditions such as schizophrenia and bipolar disorder) 50 mg and Benadryl 50 mg at 3:07 AM.

The physician stated that at the time the psychiatric evaluation was completed on 11/18/24, the patient was on one to one observation for safety. Patient #1 remained under one to one observation until she was transported to an outside hospital with severe stomach pain on 11/25/24.

Review of the outside medical record revealed the patient required an emergency appendectomy for an acute appendicitis. Patient the patient reported a staff member at the transferring facility forced her to have oral sex with him on 11/19/24. The patient requested not to return to facility due to the alleged sexual assault and was transferred to another hospital for psychiatric care.

During an interview on 12/10/24 at 1:20 PM, Staff B stated she received notification of the patient's allegations from referral information that was placed in a county psychiatric bed portal. Staff A confirmed through the facility's investigation that Staff D was identified by the patient as the staff member that sexually assaulted her. Staff A revealed that Staff D remains a current staff member but had been placed on administrative leave from 12/03/24 to 12/06/24. Staff B was asked to provide documentation of their investigation. Staff B stated the investigation is ongoing and is subject to change. Staff B explained that the investigation was not complete as the facility where the patient was transferred was refusing to share any information regarding the patients's allegation of sexual assault. Staff A reported that video footage from 11/19/24 was reviewed, however, no additional information was obtained from the footage. A request was made to view the video footage but Staff A stated that video footage is deleted after 15 days if there is nothing concerning contained in the footage. He stated that video footage is saved on a flash drive if there is anything concerning.

Review of the facility's investigative summary did not indicate when the investigation was started nor did it indicate who completed the investigation. The summary stated after discharge, a patient reported being sexually assaulted by a staff member while inpatient at the facility. Under"Outcome of Investigation", the summary stated, "this investigation is still open, ongoing and not yet been closed out." It stated that a call was scheduled on 12/12/24 in an attempt to gather more information related to the allegation. The summary included the first name of the staff member identified by the patient and that this staff member was immediately placed on administrative leave on 12/03/24. Interviews were conducted with staff members and the medical record was reviewed. Staff D returned to work on 12/06/24 due to the inability to substantiate the allegation. The investigative summary lacked documentation of the details of staff interviews conducted, that video footage was reviewed, that the local police department was contacted, or that patient interviews were conducted.

The facility Daily Staffing Report from 11/17/24 through 12/10/24 revealed Staff D worked on 11/17/24 from 3:00 PM to 11:00 PM; on 11/18/24, from 11:00 PM to 7:00 AM; on 11/19/24, Staff D was the staff member observing patients on one to one observation the entire shift; on 11/20/24, Staff D worked from 3:00 PM to 3:00 AM; on 11/21/24, from 11:00 PM to 7:00 AM; 11/23/24 from 7:00 AM to 3:00 PM, 11/25/24 and 11/26/24, 11:00 PM to 7:00 AM; on 11/27/24 from 3:00 PM to 3:00 AM; on 11/28/24, 11:00 PM to 7:00 AM; 11/29/24 and 11/30/24, 11:00 PM to 7:00 AM. Staff D worked shifts on 12/01/24 and 12/02/24. Although Administrative Staff stated Staff D was placed on administrative leave on 12/03/24, review of the Daily Staffing Report revealed he worked on the Dual Diagnosis unit (DDX) on 12/03/24 from 11:00 PM to 7:00 AM. Staff D did not work at all from 12/04/24 through 12/09/24.


2. Review of the medical record of Patient #2 revealed the patient was transferred from an outside hospital on 09/10/24 where she was pink slipped with homicidal ideations towards her mother. According to the psychiatric evaluation, the patient had a psychiatric history significant for schizophrenia and post traumatic stress disorder (PTSD). A progress note on 09/17/24 stated that the patient reported being raped by three black staff members. The patient was transported to an outside hospital for examination and potential collection of forensic evidence. Review of the outside medical record revealed staff at the outside hospital determined the patient was "too psychotic" to give informed consent for the exam. Additionally, a second attempt was made to perform a forensic exam and the patient refused. At 5:35 PM, the patient requested to be transported back to the facility. The discharge summary noted that the patient met treatment goals and on 10/12/24, was deemed appropriate to be discharged home. At the time of discharge, the patient denied suicidal or homicidal ideations.

Review of the facility's investigative summary did not indicate when the investigation was completed nor did the summary indicate who completed the investigation. Patient #2 reported that the three male staff members were African American, however, there were only two African American staff members that worked on the night of 09/16/24, Staff D and Staff H. According to the investigation, Staff D and Staff H were interviewed regarding the allegations and both staff members denied the patient's allegations. The investigation stated that neither Staff D nor Staff H had any disciplinary actions in their personnel records. Upon camera review, the video footage showed staff conducting rounds on all patients but nothing to support the patient's allegations. The patient was transported to an outside hospital for a forensic examination, however, it was determined the patient was "too psychotic" to give informed consent for the exam. Additionally, a second attempt was made to perform a forensic exam and the patient refused. The investigative summary contained no documentation that either of the two staff members were placed on administrative leave pending completion of the investigation. The investigative report also contained no documentation that any staff members working the night of 09/16/24 were interviewed. The allegation of rape was deemed unsubstantiated.

During an interview on 12/11/24 at 4:00 PM, Staff A stated the patient made the allegation of rape the morning of 09/17/24 and the investigation was completed by the morning of 09/18/24. He stated although the investigative report contained no documentation of the two staff members being placed on administrative leave until the conclusion of the investigation, both had immediately been placed on leave. Because the investigation was completed before both staff members were scheduled to work the night of 09/18/24, both were permitted to work that night.

Review of the Staffing and Census records from 09/16/24 through 09/18/24 revealed both Staff D and Staff H worked during night shift on 09/16/24. Despite the ongoing investigation of the alleged rape by Patient #2, Staff D and Staff H were permitted to work night shift on 09/17/24.

During an interview on 12/18/24 at 2:45 PM, Staff B confirmed both staff worked on 09/17/24.

During an interview on 12/11/24 at 10:30 AM,Staff A, Staff B, Staff C, and Staff E all confirmed an allegation could not be determined to be not substantiated when an investigation has not been completed. It was also confirmed that the investigations remained ongoing while the staff members accused of sexual assault were permitted to care for other patients. It was also confirmed that Staff D cared for other patients on 12/03/24, 12/09/24, 12/10/24, and 12/11/24 without completion of the investigation. It was also confirmed that the current facility policy does not protect patients from abuse during investigation of any allegations of abuse.

The facility policy titled "Alleged Patient Neglect and Abuse by Staff", effective 08/20/24, stated it is the policy of the facility to maintain a safe/therapeutic environment for patients. The policy defines sexual assault as any involuntary sexual act in which a person is threatened, coerced, or forced to engage against their will, or any sexual touching of a person who has not consented. All allegations will be taken seriously accompanied by a thorough investigation. Human Resources will determine if the staff member will be removed from the schedule or reassigned to another unit/position during the investigation. Any employee receiving a substantiated abuse charge (internally or externally) may be placed on suspension and up to termination based on the severity of the incident. The policy states that it will be reviewed within the Annual Education sessions for all staff.