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Based on interview and record review, the facility failed to provide care in a safe setting for 2 (#1, 4) of 10 patients resulting in the sexual assault of Patients #1 and #4, and the potential for harm to all patients. Findings include:

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Failure to provide care in a safe setting (See A-0144).

Based on interview and record review, the facility failed to provide care in a safe setting for 2 (#1, 4) of 10 patients on the developmentally delayed psychiatric unit resulting in the sexual assault of Patients #1 and #4, and the potential for harm to all patients. Findings include:

On 10/11/2021 at 1300 a document review of the complaints/grievance/Office of Recipients rights log was conducted. During the review it was noted that during 6/1/2021 and 10/11/2021 there were a total of 5 events documented of "peer to peer sexual allegation" including an 8/21/2021 "peer to peer sexual allegation" for patient #1. On 10/11/2021 at 1305 a request was made for the medical record of patient #1.

On 10/11/2021 at 1330 review of the medical record of Patient #1, the patient of concern for intake MI00123309, revealed the patient was a 28-year-old female, 5' 5" tall, weighing 130 pounds, who was admitted involuntarily to the facility's Developmentally Delayed (DD) unit on 8/20/2021. Patient #1 was noted to have a guardian.

Review of physician progress notes dated 8/21/2021 at 1748 revealed the nurse reported a sexual assault by a male patient on the unit in which "the perpetrator entered (Patient #1's) room and pushed her into the bed. Then, he sexually assaulted her by placing 'his penis inside her'. The encounter was not consensual. There was visible blood on the patient's gown..."

Review of Mental Health Technician (MHT) Staff K progress notes dated 8/21/2021 at 1543 revealed Patient #1 had "episodes of crying, slamming her head on the walls and windows, as well as yelling episodes. (Patient #1) also (accused) a peer of rape, and stated throughout the day that "semen was coming out of her..."

On 10/11/2021 at 1346, the Director of Quality/Risk/Compliance Staff A provided documentation of the facility's review of the incident involving Patient #1 and Patient #2 (the alleged perpetrator) that were pulled from the medical record documentation, medication administration reports, staffing sheets, patient census, and video camera documentation. When queried on 10/11/2021 at 1415 as to if interviews had been conducted with the patients involved as well as with the staff, Staff A stated that interviews had not been done. Staff A was then queried as to if a root cause analysis (RCA) had been conducted by the facility to which he stated that some members of administration and management had sat down on 8/23/2021 and had a table top discussion about what had occurred on 08/21/21. Staff A was unable to provide minutes for the table top discussion. When queried as to if anything had been identified that required change as a result of the incidents, Staff A stated maintaining MHT (Mental Health Technician) staffing levels was discussed and that the angles of the camera needed to be changed for a more comprehensive view of the area under surveillance. Staff A was then queried as to if any policies had been reviewed and identified as needing to be updated as a result of the incidents to which he replied they had not been reviewed.

On 10/11/2021 at 1430 a request was made for policy regarding sexual assault in the facility. On 10/11/2021 at 1640 staff A, the Director of Quality and Risk Compliance and staff B, the Chief Operations Officer stated a policy was not available regarding sexual assault. On 10/12/2021 at 0900 staff A and staff B stated that a policy was located after in-depth searching.

Review of Patient #2's medical record on 10/11/2021 at 1630 revealed he was a 33-year-old male, 6' 0" weighing 280 pounds, who had been admitted involuntarily for aggression and homicidal ideation. No history of sexual aggression was documented in the patient's medical record. Patient #2 was also noted as having a guardian. On 8/21/2021 at 1149 (approximately 1 hour and 19 minutes after the alleged rape was reported), physician orders were noted for Patient #2 to be placed on 1:1 supervision. The implementation/completion of this order was not documented.

A late entry nursing note by Charge Nurse Staff D dated 8/21/2021 at 1733 stated a female patient (Patient #1) reported Patient #2 had come into her room and "forced himself on her, penetrating her and ejaculating inside of her... According to security camera footage, (Patient #2) entered the pt (patient) room at 1027 and walked out at 1033." When confronted, Patient #2 "denied the incident and became very defensive." "When police arrived in the early afternoon" to interview both Patient #1 and Patient #2, Patient #2 "stated he didn't do anything. Shortly after (Patient #2) was escorted back to the unit. He admitted to one of the MHT's that it was his fault and he did it because he loved her. Furthermore, he said to another MHT, 'Yeah, I tried to fuck her.'" The nursing note when on to say that approximately 30 minutes later, Patient #2 and another female patient (Patient #3) walked into the quiet room and closed the door behind them. When they started getting close to each other, they were separated by staff. The nursing note further documents that after being caught in the quiet room with Patient #3, Patient #2 was caught by staff masturbating in the TV (television) room where another female patient (Patient #4) was laying down and sleeping. "He stood up and walked toward her and started masturbating over her...2 sheriffs arrived and took (Patient #2) into custody at 1352..."

Additionally during the review of Patient #2's medical record it was noted by MHT Staff P on 8/19/2021 at 1811 that he was "getting close to female peers; touching them and calling them his girlfriend." He was redirected successfully at that time. On 8/20/2021, Patient #2 was caught having sexual intercourse with Patient #3 when Registered Nurse (RN) Staff O walked in on them. Staff O documented on 8/20/2021 at 1634, "Patient found in room with clothes off on top of a female peer engaged in sexual activity... Patient was educated that sexual intercourse is not appropriate while on the unit..." The physician progress note by Resident Physician Staff E on 8/21/2021 at 1716 indicated the patients were discovered having sexual intercourse "at approx(imately) 1615." Both patients were separately interviewed and agreed that the intercourse was consensual. Both guardians were notified. Staff E further documented, "Pt were separated, and staff were instructed to keep the pt on close observations at this time." When interviewed on 10/12/2021 at 0917, Staff E stated he had conducted Patient #2's admission and "he had no history of sexual misconduct. He did have a history of aggression and he was placed on assault precautions." Staff E was then queried as to what "assault precautions" were, he stated he was unsure.

On 10/11/2021 at 1630 review of the untitled patient rounding documentation form dated 08/21/2021 revealed every 15 minute rounding checks had been completed for Patients #1 and #2 at 1015 and the next set of rounds was in progress at the time of the incident.

During an interview on 10/12/2021 at 1100 MHT Staff I, identified as working on the day Patient #1 reported she was sexually assaulted, stated Patient #1 came into the day room around 1030 on 8/21/2021 and informed her that Patient #2 had "kissed her and gotten on top of her and she didn't want that. The story started coming out more and more... I went and told the charge nurse."

An interview was conducted on 10/12/2021 at 1221 with Charge Nurse Staff D. Staff D stated when Staff I informed her of what Patient #1 had said, that she pulled Patient #1 aside and questioned her. "She (Patient #1) said she was sitting up in her bed. (Patient #2) came into the room, pushed her down on the bed and got on top of her and put his penis inside of her. She managed to kick him off. (Patient #1) stated, 'He came inside me.'" Staff D confirmed that Patient #1 meant Patient #2 had ejaculated. Staff D stated she then notified the Assistant Director of Nursing and the Physician. Staff D was then queried as to what was done with Patients #1 and #2 to which she stated they were separated and "a close eye was kept on them." Staff D stated a short time after Patient #1 had reported the sexual assault, Patient #2 and Patient #3 were visualized via camera entering the quiet room and closing the door. "When they started getting close together, we intervened and separated them... Then we saw him masturbating in the tv room... Patient #4 was asleep and unaware of what he was doing." When asked if Patient #2 was placed in 1:1 monitoring status, Staff D stated he was not. When queried as to why Patient #2 was not placed on 1:1 monitoring immediately following the sexual assault of Patient #1, Staff D reiterated that they were "closely monitoring" both patients. She further stated 1:1 monitoring was later ordered by the physician but she could not "remember if it was due to being short staffed or if (Patient #2) had already left" regarding why the order was not carried out.

When interviewed on 10/12/2021 at 1116, Psychiatrist Staff J, who was also the facility's medical director, stated he was "very upset about the rape." The female (Patient #1) could not defend herself and he (Patient #2) took advantage of her." He stated he was the physician for both patients and interviewed both of them on 8/21/2021. "(Patient #1) didn't want to talk about it. She was quiet. I did notice though that there was a spot of blood on her gown." When queried where on the patient's gown the blood was located, he used his finger and circled an area near his waist/groin and stated, "In this area." Staff J stated when he spoke with Patient #2, "all he would say was 'I love her.'" Staff J went on to say that orders were placed by the resident for the patient to be placed on 1:1 monitoring. "We ordered it, but there was not enough time to implement it... I ordered it, but I don't know why it wasn't carried out." When queried as to if it were his expectation for physician's orders to be implemented, Staff J stated that was his expectation. He explained that in most cases when an incident of assault occurs either the victim or the perpetrator would be moved to another unit. "In this case we couldn't do that because both patients were developmentally delayed. To move either one of them to another unit would be making them even more vulnerable..." Staff J further explained that the DD unit was a specialized unit and was 1 of 2 DD units in the state.

MHT Staff L was interviewed on 10/12/2021 at 1244 and stated he had been working on 4 South, an all-male unit, on 8/21/2021. He stated he was "pulled to the DD unit to do a 1:1 with a male patient. I had worked with him the day before and established a rapport with him, so they thought I would be the best person to be with him. We were dealing with an issue on my unit, so I was unable to leave the unit until that issue was taken care of and it was safe to leave. By the time I got to the DD unit, (Patient #2) had already left the unit. Staff were asking me if I had heard what happened and told me (Patient #2) had been arrested and taken out in handcuffs."

On 10/12/2021 at 1500 review of video documentation dated 08/21/2021 revealed the time stamp on camera in the patient bedroom hallway would freeze for long periods of time and then appear to jump ahead. It was unclear as to if this was deliberate and/or if the video was actually working as the hallway would remain empty from any foot traffic for long periods; although, the video timer continued to accurately advance while the camera clock was frozen. The camera timer froze at 10:26:41 and restarted at 10:33:56. The video showed Patient #2 entered Patient #1's room at 10:26:40 and is next visualized exiting the TV room at 10:34:26.

Facility policies were reviewed on 10/11/2021 and 10/12/2021 and included the following:
#BMD-S-3 titled "Sexual Incident: Recipient" effective 11/1/2012
(No policy number) titled "Precautions and Level of Monitoring" effective 5/10/2021
#BMD-S-2 titled "Sexual Behavior Between Recipients" last revised 5/13/2013
(No policy number) titled "Sexual Assault Emergency Management Plan" effective 10/11/2021

The policies failed to provide definitions for the types of precautions listed and failed to have "close observations" and 1:1 monitoring listed and defined as a type of patient monitoring even though the policies themselves speak of "one on one" (See Policy #BMD-S-3 quoted below). Additionally, the policies did not address steps to take in the event that the perpetrator of an assault/sexual assault was a staff member.

Facility policy #BMD-S-2 titled "Sexual Behavior Between Recipients" last revised 5/13/2013 states, "It is the policy of (facility name), Behavioral Medicine Department, that there be no sexual contact or behavior between Recipients in the Behavioral Medicine Department...Procedure: In the event that sexual contact or behavior of a sexual nature is suspected or occurs, staff shall: Investigate the circumstances, Check for injury, Contact the appropriate physician(s), Notify legal guardian if applicable, Counsel all parties involved, Initiate an 'Incident Report'." The policy fails to address the separation of patients or the level of monitoring required following such incident.

Facility policy #BMD-S-3 titled "Sexual Incident: Recipient" effective 11/1/2012 states, "When a Recipient reports an alleged forced sexual incident, the following steps are to be immediately instituted: Charge Nurse ensures that a staff member stays with the reported victim. The reported victim of the assault and the reported perpetrator be moved to separate areas/units with a staff member assigned (one on one) to each and the aggressor/perpetrator to be put in seclusion/isolation..."

On 10/12/2021 at 1221, an interview occurred with Charge Nurse Staff D from the DD unit. Staff D was queried if she knew where to access facility policies to which she stated she was unsure. When prompted by Director of Operations Staff B, Staff D then stated, "I guess they are online, but I'm not sure how to find them there."

Director of Operations Staff B stated on 10/12/2021 at 1225, "If staff need policy, they ask the nursing director. The policy is online. Staff will need to be educated on how to find out."



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On 10/12/2021 at 1145 an interview occurred with staff nurse N on the 6 South Adult Unit. Staff nurse N was queried about how long she had been working at the facility. On 10/12/2021 at 1146, staff nurse N stated, "About 3 weeks but not a month yet." Staff nurse N was asked if she knew where to locate facility policies. Staff nurse N replied, "I would ask my charge nurse for the policy." Staff nurse was then queried if the charge nurse wasn't available and it was an emergent situation where a policy was needed how would she proceed. Staff nurse N responded, "I would keep calling my charge nurse."