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Based on interview and record review, the facility failed to report inappropriate sexual misconduct of Patient 1 towards Patient 2 to the California Department of Public Health (CDPH, a state agency that regulates health facilities).

This failure had the potential for CDPH to be unaware of the welfare and the safety of the patients at the facility.

Findings:

Patient 1 was admitted to the facility on 12/2/24 with schizoaffective disorder (a mental illness), per the patient's history and physical (H&P, an assessment of the patient by a physician).

Patient 2 was admitted on 11/26/24 with schizoaffective disorder, per the patient's H&P.

An interview and record review was conducted with Nurse Manager (NM) 1 on 12/27/24 at 9:24 A.M. NM 1 stated there was an incident of inappropriate sexual contact from Patient 1 to Patient 2. NM 1 stated staff witnessed Patient 1 naked in Patient 2's bed with Patient 1's genitalia out while in bed with Patient 2. NM 1 stated Patient 1's nakedness in Patient 2's bed was inappropriate behavior.

A review of Patient 1's record was conducted with NM 1. A nursing note, dated 12/14/24, indicated Patient 1 was " ...seen masturbating (touching self for sexual pleasure) naked and holding onto his roommate who was asleep..." A physician's progress note, dated 12/15/24, indicated " ...Per staff, [Patient 1] was sexually inappropriate to his roommate [Patient 2] ..."

A review of Patient 2's record was conducted with NM 1. A significant event note, dated 12/14/24, indicated Patient 2's roommate (Patient 1) was found " ...lying beside [Patient 2] and was hugging him with his [Patient 1's] genitals out ...".

A joint interview and record review was conducted with Regulatory Affairs (RA) 1 and RA 2 on 12/27/24 at 1:07 PM. RA 1 stated that the incident between Patient 1 and Patient 2 was not reported to CDPH. RA 1 stated there were sexual connotations in the interaction of Patient 1 towards Patient 2, but it was not abuse.

A review of the facility's policy titled Patient Sexual Abuse - Identification & Reporting, revised 12/2023, indicated " ...D. Sexual Abuse: means sexual conduct that includes sexual assault or battery (e.g., inappropriate touching of a sexual nature). E. Sexual Misconduct: means inappropriate contact or communication of a sexual nature ...Suspected or alleged Sexual Abuse of a patient shall be reported to CDPH within 24 hours after detection ..."

RA 2 stated the policy titled Patient Sexual Abuse - Identification & Reporting was intended for sexual abuse and sexual misconduct of patients by a workforce member. RA 2 stated the policy for sexual abuse between patients, titled Reporting & Documentation Associated with Alleged Sexual Assault Between Patients, did not have definitions for sexual abuse or sexual misconduct. A review of the policy indicated "...A. Sexual Assault: Sexual Battery...lewd or lascivious acts...Telephone reports of sexual assault must be made immediately or as soon as practicably possible in accordance with [the facility's] HealthCare Abuse Reporting Policies..."

A review of the facility's policy titled Abuse - Reporting of Elder and Dependent Adult, revised 6/2023, indicated " ...It is [the facility's] policy to report suspected adult abuse in accordance with federal, state, and local laws and regulations ..."

A review of Title 22 (California's Code of Regulations), Division 5, Chapter 2: Acute Psychiatric Hospital, indicated " ...unusual occurrence which threatens the welfare, safety or health of patients ...shall be reported as soon as reasonably practical ...to the local health officer and to the Department [CDPH] ..."