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The Hospital failed to ensure for two (Patient #3 and Patient #4) of 11 sampled patients that the Hospital provided care in a safe setting.

Findings included:

Based on interviews and records reviewed, the Hospital failed to ensure that patients were supervised per Hospital protocols/unit rules for two (Patient # 3 and Patient #4) of 11 sampled patients, in response to Patient # 3's allegation of a sexual assault on 12/25/23.

Cross Reference: A-0144

Based on interviews and records reviewed, the Hospital failed to ensure that patients were supervised per Hospital protocols/unit rules for two (Patient # 3 and Patient #4) of 11 sampled patients, in response to Patient # 3's allegation of a sexual assault on 12/25/23.

Findings include:

Review of the Hospital's Patient Rights Policy, revised in 2/2019, indicated that patients have the right to be protected by the Hospital from neglect; from physical, verbal, and emotional abuse.

Patient #3 was admitted to the Hospital in 12/2023 after ingesting 6 Seroquel (an antipsychotic medication) pills. Review of Patient #3's medical record indicated they have a history of self-injurious behaviors, sexually acting out, aggression and elopement. Patient #3 was diagnosed with disruptive mood dysregulation disorder (a condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outburst). Patient #3's physician ordered level of observation on 12/25/23 was for 15 minute safety checks.

Patient #4 was admitted to the Hospital in 12/2023 due to increased aggressive behavior at his/her new group home. The medical record further indicated that Patient #4 was diagnosed with Disruptive Mood Dysregulation Disorder. Patient #4's physician ordered level of observation on 12/25/23 was for 15 minute safety checks.

Review of the Hospital's Internal Investigation, not dated, indicated that Patient #5 reported to staff on 12/25/23 and again on 12/26/23, that he/she witnessed Patient #3 and Patient #4 touching each other's private parts (genitals) with their hands and mouths while in the activity room on 12/25/23. The Hospital's investigation indicated that Patient #3 did not reveal anything further than inappropriate touching over clothing on 12/25/23, but later reported to staff during an interview on 12/26/23 that he/she was experiencing bleeding as a result of digital penetration by Patient #4 that was non-consensual. After the allegation of sexual assault was reported, Patient #3 and Patient #4 were both placed on 1:1 observation and sexually acting out precautions were updated to their records. The Hospital's investigation further indicated that Registered Nurse (RN) #1 was made aware of the allegation of inappropriate touching in the activity room on 12/25/23 by a Behavioral Health Associate (BHA) and Patient #3 and subsequently reported it to a supervisor and Department of Children and Families (DCF). The investigation indicated that there was another patient in the room (Patient #11) who said he/she observed Patient #3 and Patient #4 touching each other over the clothed genital area and did not observe any further touching between Patient #3 and Patient #4. Review of the Hospital's investigation concluded that they did not have enough information to substantiate the allegation of sexual assault.

During an interview on 1/19/24 at 9:47 A.M., the Director of Risk Management indicated that the Hospital investigated the sexual assault allegation made by Patient #3 on 12/26/23 and that the Hospital was unable to substantiate the allegation due to lack of proof as well as conflicting stories. He said although the Hospital was unable to substantiate the allegation, the investigation revealed a system break that was evident. He said at the time of the allegation the activity room was not being monitored by staff and there were male/female patients mixed in the same activity room which goes against the unit rules.

During an interview on 1/22/24 at 9:45 A.M., the Nurse Manager of the Adolescent unit said she had done verbal re-education with staff as a result of Patient #3's allegation of sexual assault and that she tried to capture staff at change of shift or while working. The Nurse Manager further said that a hall monitor had been implemented after this event to serve as an extra set of eyes on the unit as needed per unit acuity. The Nurse Manager was unable to provide documentation regarding any of the re-education that was done with staff in response to this event. The Nurse Manager of the Adolescent units indicated that the following protocols/unit rules were in place and have been standard practice since the opening of the Adolescent Unit in December 2022 including, but not limited to not leaving any patient unattended in any area of the Hospital (group rooms, dining areas, activity rooms, classrooms, outdoor courtyards, and any other recreational spaces on or off-unit). If the unit necessitates extra staffing, the Nursing Supervisor and/or administrator on call is to be notified immediately.

During an interview on 1/22/24 at 11:15 A.M., BHA #1 said that she was working on 12/25/23 but was unable to recall specifics about the day. BHA #1 said the normal process of the unit is at the start of the shift the Charge Nurse from the previous shift verbalizes the rules and expectations to the incoming shift and said that on the unit the male and female patients need to be separated and monitored at all times while in rooms such as the activity room. BHA#1 said that if a room can't be monitored, it should be escalated to the nurse and the nurse will make the decision whether it can go without direct monitoring and the nurse can monitor from the nurse's station based on how many patients are in the room and if there are any concerning behaviors from the patients, conflicting with unit rules.

During an interview on 1/22/24 at 11:53 A.M., BHA #2 indicated the general practice of the unit starts out with rules and expectations verbalized by the Charge Nurse. He said that male and female patients need to be separated into 2 separate activity rooms and they are not supposed to go unmonitored. BHA#2 said if he ever needs to leave to do another task, he notifies the nurse who will take over monitoring the room and further said if there is a group being conducted, he can leave for a short period of time to do checks as the staff member conducting group can monitor the room. BHA #2 said that the hallway is supposed to be monitored but that this is not a scheduled task and optional as staffing allows.

During an interview on 1/22/24 at 12:12 P.M., BHA #3 indicated that the general practice on the unit is that the rules and expectations are verbalized at the start of the shift to include male and female patients needing to be separated. BHA #3 indicated that all rooms like the activity room need to be monitored at all times. BHA #3 further indicated that if there are more than 2 patients in the room staff must be present in the room to monitor, but if there are only 2 patients who are low risk, and the hospital is short staffed, the nurse can watch the room from the nurse's station.

During an interview on 1/22/24 at 12:40 P.M., Licensed Practical Nurse (LPN) #1 indicated that the general practice of the unit is that the Charge Nurse verbalizes to the incoming shift the rules and expectations to include separating male and female patients at all times. LPN #1 further indicated that rooms always need to be monitored and that if staffing is an issue and a room can't be monitored, the room is closed for use or at the discretion of the nurse. LPN #1 indicated that based on the patient's behavior and with no more than 3 patients in the room, the nurse can monitor the room from the nurse's station making sure the lights are on in order to visualize the patients.

During an interview on 1/22/24 at 1:15 P.M., Registered Nurse (RN) #1 said she did not remember specifics about the evening of 12/25/23. RN #1 said that a BHA reported to her that Patient #3 told her that he/she had been touched in the activity room by Patient #4. RN #1 said shortly after reporting this, Patient #3 was sent to the Emergency Department for ingesting bodywash and at the time was her priority. RN#1 did not remember specifics of where staff were that night, but in general, the activity room is always monitored separating male and female patients in different activity rooms. RN#1 said the Hospital did implement a hall monitor after this event, but this is not assigned and is optional.

During a follow up interview on 1/22/24 at 1:56 P.M., the Nurse Manager of the Adolescent units said that if groups are being conducted the expectation is that there is another staff member in the room to monitor the patients while the other staff member conducts the group and interacts with the patients as it is against the rules to do both at the same time. The Nurse Manager further said that it is inappropriate to monitor the patients from the nurse's station as the view is obstructed and that this practice is not allowed, that rooms like the activity room and dining room always need to be monitored and that there is no exception to this rule. The Nurse Manager further indicated that staff do not determine whether a room should be monitored based on the patient's behavior or number of patients in the room.

The Hospital failed to provide care in a safe setting for two (Patient #3 and Patient #4) of 11 sampled patients, in response to Patient # 3's allegation of a sexual assault on 12/25/23.