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Based on observation, record review, and interview, the psychiatric hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The psychiatric hospital failed to protect and promote each patient's rights as evidenced by:
1) Failure to provide a written letter describing the steps taken to investigate the patient's claims for 1 (#1) of 1 reviewed patient records with an associated grievance (See Findings Tag A0123);
2) Failure to increase Patient #4's observation level per hospital policy immediately following an incident where Patient #4 was the alleged perpetrator of a sexual assault (See Findings Tag A0144);
3) Failure to obtain a physician order for a physical hold and seclusion for Patient #1 (See Findings Tag A0154); and
4) Failure to document a one-hour face-to-face in 1 (#1) of 1 reviewed for restraint/seclusion initiation (See Findings Tag A0178).

Based on policy review, record review, and interview, the hospital failed to provide the patient with a written notice of its decision regarding the resolution of a grievance that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion. This deficient practice was evidenced by the failure to provide a written letter describing the steps taken to investigate the patient's claims for 1 (#1) of 1 reviewed patient records with an associated grievance.
Findings:

A review of hospital policy No. RTS-04 titled, "Patient Grievance Process," last revised 09/01/2024, revealed in part: "PROCEDURE: Grievance Procedures: 3. If the investigation is ongoing on the 7th day, an extension letter should be sent to the grievant with documentation confirming date of issuance. The extension letter should include the date the expected resolution will be completed and sent. 4. The Patient Advocate issues a final written response to the grievant by the 7th day, or no later than the date referenced on the extension letter, from the date of the grievance allegation, and will include: a. The name of the facility contact person. b. The steps taken on behalf of the person reporting to investigate the grievance. c. The results of the grievance process. d. The facility's decision. e. The date of completion. f. The contact information to appeal the offered resolution. Role of the Administrator: 1. Ensure appropriate policies and procedures are followed for grievances alleging abuse and neglect of patients."

A review of the complaint and grievance log revealed a grievance listed involving Patient #1. The nature of the complaint/grievance revealed complaints from DCFS related to safety and treatment after Patient #1 was tased by a police officer while at facility. The grievance investigation was documented as completed on 01/30/2025. Review of the complaint and grievance log failed to reveal documentation that a written grievance letter was provided at the date of completion.

In an interview on 03/25/2025 at 1:50 PM, S4DCS confirmed that a written grievance letter was not provided. S4DCS confirmed that she was "instructed not to send a written grievance letter by corporate quality because it was transparent" and the incident was reviewed in person with DCFS. S1DOQ confirmed that the hospital policy states a final written response is to be sent to the grievant.

Based on record review and interview, the hospital failed to provide care in a safe setting. This deficient practice was evidenced by failure to increase Patient #4's observation level per hospital policy immediately following an incident where Patient #4 was the alleged perpetrator of a sexual assault.
Findings:

A review of hospital policy No. CS-44 titled, "Sexual Acting Out (SAO) Identification and Precautions," effective date 12/19/2022, no last revision date, revealed in part: "PROCEDURE: Management of Sexual Incident: 1. Immediately separate patients involved in the alleged incident. Patients are either placed immediately on separate units if possible or on opposite sides of the same unit with increased observations for the alleged perpetrator until the investigation is completed and provider has completed evaluation. 4. Based on the incident, place the alleged perpetrator on 1:1 or LOS until the Provider completes a face to face evaluation of the patient to determine if the patient's activities or behaviors are appropriate for a lower level of observation. Patients with alleged and observed sexual acting out behaviors will be assessed daily by the Physician to ensure appropriate level of care."

A review of the incident report involving Patient #4, revealed that Patient #4 was identified as the aggressor/perpetrator of a patient to patient sexual assault that occurred on 03/11/2025 at 2:00 PM.

A review of Patient #4's medical record revealed that the patient was admitted on 03/07/2025 and orders for Q15 minute observations were initiated. Patient #4's medical record failed to reveal orders for increased observation levels following the sexual assault incident that occurred on 03/11/2025. Further review failed to reveal that a provider completed a face-to-face evaluation of Patient #4 after being identified as the alleged perpetrator in the sexual assault incident.

Review of the Nursing Assignment Sheets revealed the following:
03/11/2025 for 7:00 AM-7:00 PM, both Patient #3 and Patient #4 assigned to the room a.
03/11/2025 for 7:00 PM-7:00 AM, Patient #3 remained assigned to room a and the second bed was marked as blocked. Patient #4 was reassigned to room b with female Patient #R1.
03/12/2025 for 7:00 PM-7:00 AM, Patient #4 was assigned to room b and the second bed was marked blocked.

In an interview on 03/24/2025 at 1:30 PM, S3ADM confirmed that Patient #4 was identified as the aggressor/perpetrator in the sexual assault incident. S3ADM also confirmed that Patient #4 was moved to room with Patient #R1 with no additional precautions or interventions to prevent Patient #4 from also assaulting Patient #R1.

In an interview on 03/24/2025 at 1:44 PM, S1DOQ confirmed that Patient #4 was placed in room b with Patient #R1 following the sexual assault incident.

In an interview on 03/25/2025 at 2:34 PM, S1DOQ confirmed that there were no observation orders for 1:1 or LOS after Patient #4 was identified as the perpetrator of an alleged sexual assault as per policy. S1DOQ also confirmed that Patient #4 remained on Q15 minute observations until discharge on 03/13/2025.

Based on policy review, record review, and interview, the hospital failed to ensure patients had the right to be free from restraints. This deficient practice was evidenced by the hospital failing to obtain a physician order for a physical hold and seclusion for Patient #1.
Findings:

A review of hospital policy No. NSG-71, titled, "Seclusion and Restraints- LA/MS/OK," last revised 05/01/2024, revealed in part: "Definitions:
Restraint: Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Physical Holding for Forced Medications: The application of force to physically hold a patient, in order to administer a medication against the patient's wishes, is considered a restraint. The use of force in order to medicate a patient must have a physician's order prior to the application of restraint (use of force). If physical holding for forced medication is necessary with a violent patient, the 1-hour face-to-face evaluation requirement would also apply.
Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior.
PROCEDURE: 1. Initiation: The physician/NPP will be notified as soon as possible after the initiation of seclusion and/or restraint. The RN will document physician/NPP contact and physician order on Physician Order for Seclusion and Restraint Form. For facilities with electronic medical record (EMR), the physician or NPP will directly enter the physician's order into the EMR. Any verbal orders for initiation of seclusion or restraint will be authenticated within the timeframe specified by state requirements."

Review of Patient #1's medical record revealed an admission date of 01/17/2025 with an admitting diagnoses of Intermittent Explosive Disorder, ADHD, and Autism Spectrum Disorder/Intellectual Disability.

Review of Patient #1's Seclusion and Restraint Packet for 01/17/2025 revealed the following:
Seclusion/Restraint Type:
Physical Restraint:
Date/Time In: 01/17/2025 at 4:20 PM; Date/Time Out: 01/17/2025 at 4:20 PM
Seclusion:
Date/Time In: 01/17/2025 at 4:30 PM; Date/Time Out: 01/17/2025 at 5:00 PM

Review of Patient #1's Seclusion and Restraint Packet for 01/18/2025 revealed the following:
Seclusion/Restraint Type:
Physical Restraint:
Date/Time In: 01/18/2025 at 9:00 AM; Date/Time Out: 01/18/2025 at 9:00 AM
Seclusion:
Date/Time In: 01/18/2025 at 1:10 PM; Date/Time Out: 01/18/2025 at 1:30 PM

Review of Patient #1's medical record failed to reveal orders for a physical restraint initiated on 01/17/2025.

Review of Patient #1's medical record failed to reveal orders for seclusion initiated on 01/18/2025.

In an interview on 03/25/3035 at 9:20 AM, S1DOQ confirmed the above mentioned findings.

Based on record review and interview, the psychiatric hospital failed to ensure a one-hour face-to-face assessment was performed with the initiation of restraint/seclusion. The deficient practice is evidenced by failure to document a one-hour face-to-face in 1 (#1) of 1 reviewed for restraint/seclusion initiation.
Findings:

A review of hospital policy No. NSG-71, titled, "Seclusion and Restraints- LA/MS/OK," last revised 05/01/2024, revealed in part: "Definitions:
Restraint: Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Physical Holding for Forced Medications: The application of force to physically hold a patient, in order to administer a medication against the patient's wishes, is considered a restraint. The use of force in order to medicate a patient must have a physician's order prior to the application of restraint (use of force). If physical holding for forced medication is necessary with a violent patient, the 1-hour face-to-face evaluation requirement would also apply.
Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior.
PROCEDURE: 4. Face-to-Face Evaluation: A one-hour face-to-face patient evaluation must be conducted in person by a physician or other NPP, or trained RN in the absence of the physician or NPP. Conduct a one hour face-to-face, if trained to do so, even if patient is no longer in restraint/seclusion and physician is not present."

Review of Patient #1's medical record revealed an admission date of 01/17/2025 with an admitting diagnoses of Intermittent Explosive Disorder, ADHD, and Autism Spectrum Disorder/Intellectual Disability.

Review of Patient #1's Seclusion and Restraint Packet for 01/17/2025 revealed the following:
Physical Restraint: Date/Time In: 01/17/2025 at 4:20 PM
Seclusion: Date/Time In: 01/17/2025 at 4:30 PM
One Hour Face to Face Evaluation: Date/Time: 01/17/2025 at 6:00 PM

Review of Patient #1's Seclusion and Restraint Packet for 01/18/2025 revealed the following:
Seclusion/Restraint Type:
Physical Restraint: Date/Time In: 01/18/2025 at 9:00 AM
Seclusion: Date/Time In: 01/18/2025 at 1:10 PM
One Hour Face to Face Evaluation: Date/Time: 01/18/2025 at 2:30 PM

In an interview on 03/25/3035 at 9:24 AM, S1DOQ confirmed the one-hour face-to-face evaluation was not completed within one hour of the initiation of restraint/seclusion on 01/17/2025 or 01/18/2025 for Patient #1.

Based on record review and interview, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by:
1) failure to accurately self-report an incident which involved 2 juvenile patients being tased by law enforcement; and
2) failure to accurately self-report the actions taken following the sexual assault of a patient.
Findings:

A review of hospital policy No. QAPI-004 titled, "Incident Reporting," last revised 08/01/2024, revealed in part: "Information to Provide in the Incident Report: 1. The Incident Report shall be limited to factual statements (who, what, where, and when) related to the pateitn safety incident and any interventions take to reduce the risk of future incidents and promote safety."

1) Failure to accurately self-report an incident which involved 2 juvenile patients being tased by law enforcement.

Review of the medical record for Patient #1 revealed an admission date of 01/17/2025 with an admitting diagnoses of Intermittent Explosive Disorder, ADHD, and Autism Spectrum Disorder/Intellectual Disability.

Review of the Hospital / Licensed Provider Abuse/ Neglect Initial Report finalized on 01/30/2025 revealed the following documentation:
Incident type documented as: Workplace violence
Date/Time Incident: 01/25/2025 at 10:30 AM

Patient Information documented on report included:
Patient #1 and Patient #2 documented as both being aggressor

Video Surveillance information documented on report included:
Video surveillance at incident site: yes
What was revealed on video? Answer: Patient #1 came out of a room and entered another patient's room. Patient #1 was redirected into the hallway by one of the MHT's. Multiple staff members assisted in medicating the patient. Staff continued to attempt to maintain control of the patient in a safe manner unsuccessfully. Patient #1 then goes into her room briefly before attempting to enter another patient's room. As Patient #1 was guided to the hallway, by multiple staff members, she began running at nurse and swinging her hands at nurse. Multiple staff members attempted to get control of Patient #1. Patient #1 is seen kicking, fighting and biting at staff. After an extended period of exchange, police arrived on the scene and assumed control of the situation with Patient #1.

Incident details revealed in part:
Law enforcement arrived at approximately 11:30 AM. Patient continued to attempt to attack officer, officer then tased Patient #1. Patient #1 went back down hall while officer was dealing with another peer. Patient transferred to ER for medical evaluation.

Comments documented on report included:
The hospital immediately initiated an investigation. The investigations included a review of video, medical records and interview of staff. The investigation found that the patient had made multiple attempts to harm the staff and other patients. Staff made every effort to maintain safe control of the patient despite Patient #1's continuous refusal to comply or to behave safely. No policy violations were discovered and staff worked in accordance with Oceans' workplace violence plan.

Investigation Results:
Was the allegation substantiated, unsubstantiated, or unable substantiate due to lack of evidence? Answer: N/A

The report failed to reveal that Patient #2 was also tased by the officer.

On 03/24/2025 at 1:51 PM, a review of video footage navigated by S1DOQ of the incident involving Patient #1 and Patient #2 on 01/25/2025 revealed in part:
11:22 AM- Officer enters unit.
11:23 AM- Patient #1 swinging arms at officer.
11:23:50 AM- Officer tases Patient #1.
11:24 AM- Patient #2 runs down hall to Patient #1 and starts removing taser prongs from Patient #1.
11:25 AM- Officer deploys his taser at Patient #2 at least 3-4 times.

In an interview on 03/24/2025 at 2:10 PM, S1DOQ confirmed that the video footage revealed that both Patient #1 and Patient #2 were tased by the officer. S1DOQ also confirmed that the self-report was not reported "appropriately" and did not include all the details of the incident.

2) Failure to accurately self-report the actions taken following the sexual assault of a patient.
Review of the Hospital / Licensed Provider Abuse/ Neglect Initial Report finalized on 03/17/2025 revealed the following documentation:
Incident type documented as: Alleged Neglect: Patient to Patient Sexual Assault
Date/Time Incident: 03/11/2025 at 2:00 PM
Location of incident: Patient Room

Patient Information documented on report included:
Patient #3 as Victim
Patient #4 as Aggressor

Video Surveillance information documented on report included:
Video surveillance at incident site: yes
What was revealed on video? Answer: Video review revealed that the patients were in and out of their room numerous times during the time frame of alleged sexual abuse. Although we cannot determine the exact time of the alleged abuse occurring, or substantiate that the alleged abuse occurred, based on video review we can speculate that the alleged incident occurred between 2:11 PM (the time of the MHT round) and 2:22 PM (when Patient #4 exits the bedroom and goes to the bathroom).

Incident details revealed in part:
After the afternoon patient rest period, Patient #3 reported that while in their assigned room, Patient #4 pushed her against the wall and "fingered" her crotch at about 2:00 PM.

Initial Actions Taken:
Patients were separated, and rooms were blocked. Patient #3 was assessed for harm and patients involved in the incident were interviewed.

Comments documented on report included:
The hospital immediately initiated an investigation, which included a review of video, medical records and staff interviews. Based on video review, it was determined that the staff rounded on patients appropriately, based on their ordered level of observation. Medical record review did not indicate a history of sexually inappropriate behavior for either patient, nor did either score as "at risk" for sexually acting out on admission, but did indicate that Patient #4 has a history of reporting sexual abuse. However, Patient #4 is reported to be the aggressor in this case. Patients both maintain their original statements, in which Patient #3 alleged sexual abuse and Patient #4 reports consensual inappropriate sexual behavior.

Investigation Results:
Was the allegation substantiated, unsubstantiated, or unable substantiate due to lack of evidence? Answer: The allegation of abuse is unable to be substantiated due to lack of evidence.

Review of the Nursing Assignment Sheets for 03/10/2025 - 03/12/2025 revealed the following:
03/11/2025 for 7:00 AM-7:00 PM, both Patient #3 and Patient #4 assigned to the room a.
03/11/2025 for 7:00 PM-7:00 AM, Patient #3 remained assigned to room a and the second bed was marked as blocked. Patient #4 was reassigned to room b with female Patient #R1.
03/12/2025 for 7:00 PM-7:00 AM, Patient #4 was assigned to room b and the second bed was marked blocked.

The report failed to reveal that Patient #4 (the aggressor) was moved into a room with another female patient without additional measures to ensure the safety of the other occupant of the room, Patient #R1.

In an interview on 03/24/2025 at 1:30 PM, S3ADM stated that they did not have the availability at the time of the incident to provide separate rooms for both Patient #3 and Patient #4. S3ADM confirmed that Patient #4 was identified as the aggressor in the incident, and confirmed that she was placed in another room with Patient #R1.

In an interview on 03/24/2025 at 1:44 PM, S1DOQ stated the self-report was "misleading" and verified that it was documented in the self-report that the patients were separated and rooms were blocked. S1DOQ confirmed that Patient #4 was placed in room b with Patient #R1, and not in a blocked room as reported in the self-report.

Based on record review and interview, the hospital failed to ensure a registered nurse (RN) supervised the care for each patient. This deficient practice is evidenced by failing to immediately address any clinical assessments on Patient #3 following a sexual assault.
Findings:

A review of hospital policy No. AS-18 titled, "Assessment and Reporting of Abuse, Neglect, Exploitations," last revised 10/01/2024, revealed in part: "PROCEDURE: Procedure to Respond to Alleged or Suspected Abuse, Neglect, Exploitation by Facility staff (employed or contracted) or by another patient: 2. If the allegation involves another patient or an employed or contracted staff member of the facility, the Administrator/Administrator-on-Call are responsible to ensure a thorough investigation is performed and will respond immediately to address any clinical assessments and ensure the provision on any clinical interventions necessitated by the circumstances and perform an investigation to determine if the allegations are substantiated."

A review of hospital policy No. RTS-01 titled, "Patient Rights," last revised 09/01/2023, revealed in part: "Rights of Minors: R. A minor patient admitted to a treatment facility has the right to have available such treatment as is medically appropriate to his condition. S. Each minor patient shall have the right to receive prompt and adequate medical treatment for any physical ailments and for the prevention of any illness or disability. Such medical treatment shall meet the standards of medical practice in the community."

A review of the incident report involving Patient #3, revealed that Patient #3 was identified as the victim of a patient to patient sexual assault that occurred on 03/11/2025 at 2:00 PM.

A review of Patient #3's medical record revealed that she was admitted on 03/05/2025. Patient #3 was placed on a PEC on 03/05/2025 and on 03/07/2025 a CEC was completed. Patient #3 was deemed as dangerous to self and gravely disabled.

A review of Patient #3's progress note from 03/11/2025 at 4:00 PM documented by S2ADON revealed in part the following:
Patient #3 verbalized to S6MHT that her roommate (Patient #4) had sexually assaulted her. Patient #3 was brought to the Nurses desk for privacy to discuss this allegation. Patient #3 states, my roommate, "pushed me against the wall and fingered me." Patient #3 further explains that she did not want this to happen and that she was discussing clothing with her roommate prior to this incident. Patient #3 has no contusions or abrasions and denies any injury. Patient #3 further denies pain or discomfort in any area of her body.
Actions:
Separated Patient #3 from Patient #4.
Notified guardian who does not wish to press charges.
Notified Nursing supervisors.
Notified S13MD- no orders given.

Patient #3 was discharged home on 03/12/2025 at 3:04 PM.

Review of Patient #3's medical record failed to reveal documentation that Patient #3 was evaluated by a provider prior to being discharged home following the sexual assault.

In an interview on 03/25/2025 at 1:05 PM, S1DOQ confirmed that there was no documentation of an evaluation being completed by a provider following the sexual assault incident. S1DOQ also confirmed that there was no documentation by a provider regarding the sexual assault incident prior to discharge the following day.

In an interview on 03/25/2025 at 1:35 PM, S2ADON confirmed that she was the nurse who cared for Patient #3 following the sexual assault on 03/11/2025. When asked if she visualized any contusions or abrasions as documented in her assessment, S2ADON stated that she did not remove Patient #3's clothing to perform an assessment. S2ADON further stated "it was just 2 fingers." S2ADON confirmed that she did not perform an assessment on Patient #3 following the sexual assessment and her findings were based on what she was told by Patient #3 while investigating the incident.