HospitalInspections.org

Based on medical record review, review of hospital policy, observation and staff interviews, the hospital's administrative staff failed to ensure there was appropriate nursing staff available to meet the safety needs of patients receiving services from the inpatient pediatric behavioral health (BH) units (see A0144).

The cumulative effect of these deficient practices resulted in the hospital's inability to ensure the nursing staff provided safe and appropriate care in accordance with the hospital's policies and acceptable standards of practice for patients receiving services from the inpatient pediatric behavioral health unit. The hospital's administrative staff identified a total capacity potential of 15 patients for the inpatient pediatric behavioral health unit at the time of the investigation.

Based on document review, staff interviews, and observations the hospital's administrative staff failed to ensure there were appropriate nursing staff available to the inpatient pediatric behavioral health (BH) unit, and that nursing staff appropriately supervised 4 of 8 patients reviewed (Patient #11, #16, #17, and #18). The effects of the failures and deficient practices resulted in the hospital staff's inability to ensure that patients received care in a safe setting resulting in allegations of Patient #16 having sexual acting out behaviors with Patient #11, #17, and #18 while hospitalized in the inpatient pediatric BH unit.

Findings include:

1. Review of Patient #11's medical record revealed:

a. On 10/25/23 at 12:10 AM, Patient #11 was admitted to the inpatient pediatric BH unit.

b. On 11/2/23 at 10:00 PM, Patient #11 reported a peer was making them uncomfortable by their comments earlier in the day. Patient #11 reported the peer told Patient #11 they were going to "come into [Patient #11's] room at night to rape [Patient #11]." The nurse talked with the peer regarding the alleged statement, the peer denied the statement, and reported Patient #11 was trying to get them into trouble. Nursing failed to provide any additional safety interventions or precautions after Patient #11 reported a peer threatened to rape them.

c. On 11/3/23 at 7:55 AM, Patient #11 reported to the psychiatric provider they were feeling unsafe due to a comment reportedly made by a peer. The provider increased Patient #11's Sertraline (medication used to treat depression) to 125 mg starting on 11/4/23. The provider failed to address Patient #11's concern of feeling unsafe and to provide any additional safety interventions or precautions.

d. On 11/15/23 at 8:00 PM, Patient #11 was observed to be visibly agitated by a male peer that Patient #11 accused of making inappropriate statements, and exhibiting inappropriate actions. Patient #11 and other patients were relocated as a de-escalation strategy. Nursing staff educated and relocated the patient and peers, but again failed to put additional safety precautions in place to maintain patient safety on the inpatient pediatric BH unit.

e. On 11/16/23 at 10:53 AM, Physician N noted Patient #11 reported sexual relations with another patient on the unit, when the other patient came to her room Monday night. Physician N noted that Patient #11 reported the sexual relations with the patient on multiple occaisions. Physician N noted they would consider repeat pregnancy testing and sexually transmitted infection (STI) prevention, and would notify Patient #11's parents. The provider noted they would follow up with Patient #11 on how they wished to disclose the information, and offer a SANE (sexual assault exam) exam. Patient #11 reported the encounter with the peer was non-consensual, nursing spent time processing with Patient #11, and collecting additional information. When the team went back to offer a SANE examination, and STI testing, Patient #11's parent was present, but hospital staff had not yet discussed with Patient #11 their preferences to disclose the incident to their parent, and the psychiatric provider did not want to broach the subject without Patient #11's input. The psychiatric provider noted they would discuss further tomorrow. A safety report was filed and leadership was notified. Patient #11 was placed on sexual acting out precautions.

f. On 11/16/23 at 1:15 PM, nursing staff documented during physician rounding Patient #11 shared with their team that on Monday, a peer was in their room, and there was sexual contact.

g. On 11/16/23 at approximately 1:52 PM, RN E (Registered Nurse) documented they interviewed Patient #11 regarding their allegation about Patient #16. RN E asked Patient #11 multiple questions. During the interview Patient #11 confirmed that Patient #16 was in Patient #11's room, and Patient #16 and Patient #11 had sex. Patient #11 reported Patient #16 learned the routines, and figured out that sometimes there was a gap between 11:15 PM and 11:45 PM, during shift change lots of nursing assistants left, and Patient #16 would sneak into a room and close the door. Patient #11 then reported that Patient #16 did this before, and identified Patient #17 and Patient #18.

h. On 11/16/23 at 6:49 PM, Patient #11 was moved to another room.

i. On 11/16/23 at 8:53 PM, Patient #11's parent/legal guardian requested discharge of Patient #11 upon disclosure of potential abuse. After nursing elicited further details from Patient #11 in the late afternoon, a report to the Police Department (PD) was completed, and Patient #11's parent was notified.

j. On 11/16/23 at 10:30 PM, Patient #11 was 1:1 (one staff to one patient at all times) supervision.

k. On 11/16/23 at 11:30 PM, Patient #11 was discharged from the hospital.

l. On 11/16/23 at 11:50 PM, Patient #11 arrived to Hospital B's ED for a SANE examination. Patient #11 was transported by law enforcement, and accompanied by Detective FF. Patient #11's parent was present at Hospital B, but Patient #11 refused to allow their mother to accompany them for the examination.

m. On 11/17/23 at 12:58 AM, MD EE completed the sexual assault examination on Patient #11. MD EE noted it would be possible that an examination could be normal even if there was a sexual assault. Patient #11 reported being raped by another patient on Monday night around midnight. Patient #11 reported the incident in detail including the identity of the other patient (Patient #16). Patient #11's examination did not reveal any injuries or bruising related to a sexual assault. A sexual assault kit was collected.

n. On 11/22/23 at 9:30 AM, MSW with Child Protection Center completed a forensic interview with Patient #11. During the interview, Patient #11 reported that Patient #16 had sex with them without consent. Patient #11 reported that Patient #16 would ask weird questions, and would inappropriately touch over their clothes while they watched movies at the hosptial BH unit. Patient #11 reported they would sit with Patient #16 at the back of a table where it was darker, and no one saw them, but there were other people in the room and at the table. Patient #11 reported that Patient #16 kept looking in her room, and when no one was around, he came into their room. Patient #11 reported they were on their bed when Patient #16 came in, and closed the door. Patient #11 reported that staff were in the hallway, but taking breaks. Patient #11 reported Patient #16 told her to perform sexual acts, and Patient #11 did not want to, but Patient #16 forced her to. Patient #11 continued to report the details of the sexual encounter. Patient #11 reported Patient #16 stopped and left her room. When Patient #11 was asked for more details, Patient #11 reported that staff walked in, and told Patient #16 to leave the room. Patient #11 reported that when staff walked into Patient #11's room, Patient #11 was unclothed. Patient #11 reported that staff were aware she was taking a shower.

2. During an interview on 12/6/23 at 3:00 PM, RN G recalled Patient #11 reported Patient #16 told Patient #11 during lunch time that day (on 11/2/23), they were going to come into Patient #11's room and rape Patient #11. RN G recalled having the nursing assistant sit outside Patient #11's room between 15-minute checks, to monitor Patient #11 and Patient #16's rooms to make sure neither patient came out of their room. RN G recalled asking Patient #16 about Patient #11's report, and Patient #16 denied it, and reported Patient #11 was trying to get Patient #16 into trouble. RN G recalled reporting the threat to the day shift staff, and Patient #11's room was moved away from Patient #16's room, but may not have been for a couple days, due to the unit being full. RN G then recalled Patient #11 and Patient #16 were placed in separate groups the next day.

3. During an interview on 12/7/23 at 11:00 AM, Physician N recalled during morning rounding (on 11/16/23) with a resident and a medical student, Patient #11 out of nowhere said they needed a pregnancy test. Physician N recalled Patient #11 reported Patient #16 snuck into their room, and they had sex, but then Patient #11 refused to talk anymore about it. Physician N recalled they reported the allegation to RN E, who follow up with Patient #11 to obtain more information. Physician N recalled the nurse manager for the unit was present during rounding that morning, and was aware of the incident. Physician N recalled filing a report. Physician N recalled they sent an email regarding the allegation to the chair of the pediatric BH unit and the medical director of the unit, and the head of the pediatric BH unit became involved in the incident. Physician N denied any other female patients asking them specifically for a pregnancy test or birth control. Physician N reported since Patient #11 made their report about having sex, Physician N feels it could have been possible for patients on the inpatient pediatric BH unit to have sex.

4. During an interview on 1/4/23 at 9:15 AM, Unit Manager JJ recalled the provider mentioned Patient #11 made an allegation, and Unit Manager JJ asked the provider to ask Patient 11 for additional information, but the provider was not comfortable with that, because they had a resident and a student working with them, and felt it would be three staff to the one patient. The provider went to the nurse on duty, and asked them to talk with Patient #11 about the allegation made. Unit Manager JJ reported after the nurse talked with Patient #11, they found there may have been validity to the report, Unit Manager JJ reported the allegation to the director of the inpatient pediatric BH unit. Unit Manager JJ reported they did not receive any staff report that Patient #16 was found in Patient #11's room, and there were not any witnesses to the allegation.

5. During an interview on 12/6/23 at 12:00 PM, RN E recalled doing an interview with Patient #11 after they reported being sexually assaulted by Patient #16. RN E recalled Patient #11 reported it to Physician N during rounds, and Physician N did not take it further, because there were 3 adults present at the time, and Physician N did not feel it was appropriate to question Patient #11 further about the report. RN E recalled interviewing Patient #11 in two sessions, asked Patient #11 specific questions related to their interaction with Patient #16. RN E recalled Patient #11 reported two other patients being sexually assaulted by Patient #16, and identified Patient #17 and Patient #18.

6. During an interview on 1/3/24 at 9:35 AM, Patient #11's parent/legal guardian recalled Patient #11 made a comment during their visit on 11/16/23 about hoping they were not pregnant, but then told their parent to leave. After Patient #11's parent got home from visiting Patient #11, the parent received a call from a nurse reporting that something happened, and a detective was coming to talk with Patient #11. Patient #11's parent returned to the hosptial. Patient #11's parent made the decision to have Patient #11 discharged, and taken to Hospital B for a SANE exam. Patient #11's parent reported Patient #11 did not have a history of making up stories, and that Patient #11's parent and the hospital staff were agreeable that something happened between Patient #11 and Patient #16. Patient #11's parent reported she talked with Patient #11 about the allegation, and Patient #11 remains consistent with her initial report of what happened.

7. During an interview on 12/6/23 at 9:30 AM, Detective FF recalled the police department was contacted at 7:22 PM on 11/16/23, two uniformed officers responded. Detective FF arrived around 8:30 PM. Detective FF recalled talking with RN E, Patient #11's parent, the two uniformed officers, and the security supervisor, and explained to Patient #11's parent there was a potential that Patient #11 was sexually assaulted, then RN E explained what happened, and read the questions Patient #11 was asked by RN E. Detective FF recalled Patient #11 reported the incident happened on Monday, 11/13/23. Detective FF recalled specifically asking RN E and Patient #11's parent, if Patient #11 would have made up the allegation to be discharged from the hosptial, and both said no. Detective FF recalled they started the process of emergency contact, and calling Hospital B, and CPC (Child Protective Services) to arrange a child sexual assault examination. Detective FF reported when Patient #11's made the initial report, they did not report any staff coming into their room during or after the alleged sexual assault, but during Patient #11's interview with CPC, they learned of a staff person coming into Patient #11's room while Patient #16 was still in there. Patient #11 identified the staff person from a lineup of staff photos.

8. During a follow up interview on 12/28/23 at 1:00 PM, Detective FF reported having an interview with Staff LL. Staff LL reported remembering two specific incidents on 11/13/23. The first incident Patient #16 was found standing outside of Patient #11's room. Patient #16 was told by Staff LL to go back to their room, and Staff LL then walked with them back to their room. Staff LL reported both patients were fully clothed. The second incident Staff LL reported they found Patient #16 inside Patient #11's room, just inside the threshold of the bedroom door, and Patient #11 was across the room standing against the wall. Staff LL reported telling Patient #16 to get out of Patient #11's room, then again walked Patient #16 back to their room. Staff LL reported both patients were wearing clothing. Detective FF reported Staff LL did not go back to Patient #11's room after walking Patient #16 back to their room. Detective FF reported Staff LL denied telling Patient #11 to take a shower, get cleaned up in any way, or wash their clothing. Detective FF then reported that Staff LL reported they did not report to anyone else they found Patient #16 in Patient #11's room. Detective FF reported Patient #16 also made omissions to Detective FF that Patient #16 had kissed and made out with Patient #11, and had been in Patient #11's room several times, but never overnight and was only caught one time when Staff LL caught them in Patient #11's room. Detective FF reported that both Patient #11 and Patient #16 disclosed that 15-minute checks are not always done appropriately, all the patients know the routines and schedules of the unit and staff, and they all know when they can get away with things, such as passing notes.

9. During an interview on 1/3/24 at 7:15 PM, Staff LL reported they found Patient #16 in Patient #11's room, Patient #16 was told to go back to their room, and when Staff LL went back to check on Patient #16 they were sleeping. Staff LL recalled Patient #16 was standing just inside the door of Patient #11's room, and Patient #11 was across the room against the wall. Staff LL reported both Patient #11 and Patient #16 were wearing clothing. Staff LL denied checking on Patient #11 after Patient #16 was sent back to their room. Staff LL reported telling other staff they were working with to watch Patient #16, because he was not acting normal. Staff LL then reported telling her boss that comes in at 11:00 PM they found Patient #16 in Patient #11's room and to watch Patient #16.

10. During a follow up interview on 1/8/24 at 8:30 AM, RN D acknowledged that Staff LL just reported a few days ago they had found Patient #16 just inside Patient #11's bedroom, in front of the bathroom, talking to Patient #11, but RN D was not notified at the time the incident occurred. RN D reported Staff LL did not report whether it happened during the evening shift or night shift, or how long ago it occurred.

11. During an interview on 12/6/23 at 8:00 AM, RN CC recalled Patient #11 reported being sexually assaulted by a peer, sometime around 11 PM on 11/13/23. Patient #11 reported staff did 15-minute checks, but at shift change the routine might have been off. Patient #11 reported the peer knew staff routine, during shift change the checks may have longer periods of time between them, and that was when the peer entered Patient #11's room to sexually assault them. RN CC recalled Patient #11 reported the peer came into their room right after 15-minute checks were done, assaulted them, and left Patient #11's room before staff did their next rounds. Patient #11 also reported there may have been other girls that were sexually assaulted by the peer.

12. During an interview on 12/5/23 at 9:00 AM, MD EE recalled Patient #11 reported being sexually assaulted by Patient #16 on Monday. MD EE explained their exam of Patient #11 was negative, but that did not mean an assault had not happened. MD EE recalled Detective FF had reported another patient on the inpatient pediatric BH unit at the hosptial had asked for birth control, but did not receive it because the patient was in the hospital, and the staff did not think anything happened.

13. During an interview on 12/6/23 at 12:45 PM, Educator B recalled finding a sheet of paper in Patient #11's school tub, that was written by Patient #11, and had a few sentences that talked about Patient #11 and Patient #16 having sex. Educator B reported she reported the note to RN E, then handed the note off to RN E. Educator B recalled finding the note on the day Patient #11 reported the allegation of sexual assault by Patient #16 (11/16/23).

14. During an interview on 12/7/23 at 9:00 AM, RN F recalled Patient #11 was flirty with Patient #16. RN F recalled Patient #11 and Patient #16 sitting in the day room and RN F told them they needed more space between them. RN F denied witnessing any further interactions.

15. Review of Patient #16's medical record revealed:

a. On 10/27/23 at 10:36 PM, Patient #16 was re-admitted to the inpatient pediatric BH unit.

b. On 11/3/23 at 8:00 AM, a psychiatric provider noted staff were monitoring Patient #16's comments to peers. Patient #16 was guarded about conversations about his behaviors on the unit. Patient #16 did not voice insight into making any verbal threats toward others. Expectations of the unit were reviewed with Patient #16. The psychiatric provider and nursing staff failed to increase Patient #16's safety precautions or add interventions to assure the safety of Patient #16 and others.

c. On 11/3/23 at 3:27 PM, Patient #16 continued with inappropriate behavior and statements, and resulted in time away from peers.

d. On 11/5/23 at 9:37 AM, Patient #16 continued to require frequent redirection due to inappropriate comments.

e. On 11/5/23 at 9:53 PM, Patient #16 required several reminders of appropriate space between peers, and reminded not to pass notes. Patient #16 became upset when the nurse told the unit they would not have movies in a dim room for the remainder of the day due to multiple observations of patients getting cozy with each other.

f. On 11/14/23 at 10:43 AM, a psychiatric provider noted Patient #16 made several inappropriate comments to peers in group activities, and was placed on room restriction. Further action for a behavioral plan to be discussed at rounds. The psychiatric provider noted the plan for the day was discussed at Interdisciplinary Team (IDT) rounds, focused on behavioral goals, reinforcements, and actions. Patient #16 will remain on room restriction at this time, with cognitive worksheet completion required to earn out-of-room time. Patient #16 may be moved to a different room, and standards for peer interaction continue to be discussed.

g On 11/14/23 at 4:08 PM, Patient #16's room was moved to another room.

h. On 11/15/23 at 8:57 AM, a psychiatric provider noted Patient #16 was upset about the room change. IDT met to discuss a new behavioral plan for Patient #16, a new behavioral plan was developed, and put into place, but failed to increase Patient #16's safety precautions.

i. On 11/15/23 at 8:00 PM, Patient #16 was observed to be interacting inappropriately with peers.

j. On 11/16/23 at 12:42 PM, -Patient #16 made a derogatory comment toward a peer and was told they needed to complete 30 minutes in their room for the behaviors. Patient #16 was made a 1:1 for safety concerns. Patient #16 had allegedly sexually assaulted a peer. Patient #16 was told they had 1:1 supervision due to accusations by several others that Patient #16 was sneaking into their peers' rooms at night. Patient #16 reported the female peer was lying. Later requested a PRN and told their 1:1 staff "I want a PRN before I go beat her up."

k. On 11/16/23 at 5:20 PM, Patient #16 was redirected from telling a peer they were assigned a 1:1, for making acusations in a derogatory manner regarding another patient.

l. On 11/16/23 at 6:23 PM, Patient #16 heard the female peer down the hallway, and told the 1:1 staff, "If I hear [Patient #11's] voice one more time, I am going to walk out of my room, and beat her up."

m. On 11/16/23 at 10:20 PM, Patient #16 verbalized that a female peer was lying. Patient #16 stated "I know who it was. It was [Patient #11]" Patient #16 stated the peer warned them on 11/16/23 that they would tell lies about them, because Patient #16 had been bullying Patient #11's friend. Patient #16 also reported Patient #11 had previously warned Patient #16, they would tell lies about them to nurses, to make another peer mad, because Patient #11 thought it "was funny" when the other peer got mad.

n. On 11/16/23 at 10:39 PM, Patient #16 had sexual acting out precautions added.

o. On 11/17/23 at 12:24 PM, Patient #16 was 2:1 (two staff to one patient) supervision following peer accusation of sexual acting out (SAO) behavior.

16. During an interview on 12/6/23 at 12:00 PM, RN E reported Patient #16 would develop relationships with other peers, and was "always looking for the next relationship." RN E recalled Patient #16 would pick a female peer, develop a relationship with them, flirt with them, and as soon as they discharged, Patient #16 would move on to another female peer. RN E recalled staff were always redirecting Patient #16 for whispering with female peers, for sitting too close, touching under the table, or sliding really low in their chair to touch their leg against a female peer's leg. RN E reported they had to split up male and female patients for entire shifts, because of flirtation, and Patient #16 was always involved. RN E reported Patient #16 would make a lot of sexually inappropriate comments. RN E recalled witnessing Patient #16 calling Patient #11 by a derogatory name with sexual connotations.

17. During an interview on 12/6/23 at 1:30 PM, RN H recalled Patient #16 would make sexually inappropriate comments to Patient #11. RN H reported Patient #11 would get upset, but Patient #16 was flirting with Patient #11. RN H reported Patient #16 would require redirection for being intrusive and verbally inappropriate with their peers, making sexual comments toward peers and staff. RN H reported that female patients have reported being scared of Patient #16, and that staff were trying to keep Patient #16 away from peers they wanted to flirt with.

18. During an interview on 1/2/24 at 10:05 AM, Staff HH reported that Patient #16 made a lot of sexually inappropriate comments, and would act out to get the attention of female peers. Staff HH reported Patient #11 and Patient #16 did not get along at all, and Patient #16 would make comments to Patient #11 with derogatory sexual connotations.

19. During an interview on 1/2/24 at 3:45 PM, Staff GG reported Patient #16 would make sexual comments to female peers, would touch their leg against a peer's leg under the table, or would sit too close to female peers. Staff GG reported they had to remind Patient #16 about personal space, but they would just say "I don't care." Staff GG recalled Patient #16 and Patient #11's rooms were close to each other at one time, like 3 doors away from each other, but Patient #11 was moved due to their negative interaction, and negative comments toward each other. Staff GG recalled Patient #16 would call Patient #11 derogatory names.

20. During an interview on 1/3/24 at 3:25 PM, Staff KK recalled receiving emails regarding sexually inappropriate behaviors demonstrated by Patient #16, but Staff KK did not directly see or hear anything. Staff KK reported the emails said to be careful of Patient #16, and another patient, because sexually inappropriate remarks were made, but the email did not have anything specific. Staff KK could not recall the other patient identified in the email.

21. During an interview on 1/4/23 at 3:45 PM, Patient #16's family member reported that Patient #16 told him about the allegations of sexual assault, but has denied it, and would not discuss anything about it. Patient #16's family member recalled finding Patient #16 one other time, about four or five years ago, where Patient #16 was demonstrating sexually inappropriate behavior toward another person. Patient #16's family member reported the hospital staff was not aware of the incident. Patient #16's family member reported Patient #16 was given repeated warnings for getting too close to female peers, and felt hospital staff would do more to intervene.

22. During an interview on 12/6/23 at 12:45 PM, Educator B recalled a lot of female peers were uncomfortable around Patient #16.

23. During an interview on 12/6/23 at 1:00 PM, RN L recalled Patient #11 and Patient #16's interactions with each other became challenging to redirect and hospital staff would do their best to limit their interactions with each other by separating them in groups when programming for the day.

24. During an interview on 12/6/23 at 4:00 PM, Staff M recalled Patient #11 and Patient #16 would demonstrate flirty behavior when together in group, and they would be split up. Staff M also recalled Patient #11 and Patient #16 would exchange dergogatory coments to each other. Staff M reported they do not feel the inpatient pediatric BH unit is observed as closely at night as it could be.

25. During an interview on 12/7/23 at 8:15 AM, RN D recalled that Patient #11 did not get along with Patient #16. RN D recalled Patient #16 would not take no for an answer, and if Patient #16 was told no, their behaviors would escalate, and it would take a lot to calm them down. RN D reported seeing a "very bad" interaction with Patient #11 and Patient #16. Patient #16 would call Patient #11 inappropriate names and deragatory statements and Patient #11 would get upset. RN D recalled Patient #11 and Patient #16 had to be separated. RN D reported that Patient #16's interaction with other female peers on the unit was a big concern when working on the weekend. RN D recalled witnessing Patient #18 and Patient #16 sitting close to each other, and Patient #16 touched their knee to Patient #18's leg. RN D reported they felt uncomfortable with Patient #16 touching a female peer like that, and acknowledged that Patient #16 could probably touch anyone like that. RN D reported that when staff saw Patient #16 touch female peers or making inappropriate verbal comments, they would take immediate action, redirect Patient #16, and separate them, but Patient #16 was never made a 1:1 prior to the allegation of sexual assault.

26. During an interview on 12/7/23 at 11:00 AM, Physician N recalled Patient #16 demonstrated flirtatious behaviors toward female peers, and staff felt like they were often redirecting Patient #16 for this behavior. Physician N reported that Patient #16 was not place on 1:1 supervision prior to the allegation, because the unit had at least a dozen teenage patients, flirtation were typical behaviors demonstrated, and Patient #16's flirtation was not above the level of flirtation for their age group for appropriate flirtation. Physician N then verbalized that most teenagers would end up on 1:1 supervision if they did that for every teenager who was flirtatious.

27. Review of Patient #17's medical record revealed:

a. On 10/12/23 at 3:00 PM, Patient #17 was admitted to the inpatient pediatric BH unit.

b. On 10/25/23 at 2:34 PM, Patient #17 received a warning for whispering to another peer and was caught getting too close with physical touch. Patient #17 was reprimanded multiple times about behavior and continued to disobey.

c. On 10/26/23 at 1:46 PM, Patient #17 required redirection about personal space and flirty comments.

d. On 10/26/23 at 2:57 PM, Patient #17 was passing notes with a peer that had sexual content and was inappropriate. Patient #17 was to fill out another CRP and would remain in their room the remainder of the shift other than for activity, meals, and group. Staff failed to increase safety precautions.

e. On 10/27/23 at 1:59 PM, Patient #17 was discharged from the hospital.

28. During an interview on 12/6/23 at 12:00 PM, RN E recalled a full sheet of paper being found in Patient #16's room that had notes written on it between Patient #16 and Patient #17 that were sexual in nature.

29. Review of Patient #18's medical record revealed:

a. On 11/2/23 at 10:31 PM, Patient #18 was admitted to the inpatient pediatric BH unit.

b. On 11/3/23 at 8:23 AM, Patient #18 was being monitored for boundaries with a male peer.

c. On 11/4/23 at 7:32 AM, Patient #18 was continuing to be monitored for boundaries with a male peer.

d. On 11/4/23 at 1:41 PM, Patient #18 appeared distracted and flirty with a peer.

e. On 11/5/23 at 8:53 AM, Patient #18 reported a male peer continued to do things Patient #18 asked him to stop. It was noted that this same male peer was who Patient#18 had been struggling to maintain boundaries with. Patient #18 continued to require observation for boundaries with the male peer. Education was provided to Patient #18, and were asked if they were being made to feel uncomfortable by the male peer, but then reported they were not. Staff failed to increase safety precautions.

f. On 11/9/23 at 2:00 PM, Patient #18 was discharged from the hospital.

30. During an interview on 12/6/23 at 9:30 AM, Detective FF reported Patient #17 and Patient #18 were identified as having sexual interaction with Patient #16. Detective FF reported having two hospital providers, and the Director of the BH units present when Detective FF notified the parents of the two additional patients identified, and informed them of the allegations made. Detective FF reported they have not talked to Patient #17 or Patient #18 regarding the allegations. Detective FF also recalled RN E reported a 17-year-old patient asked for a pregnancy test and emergency birth control when they were discharged from the hospital.

31. During an interview on 1/10/24 at 5:00 PM, Patient #18's family member reported they talked with Patient #18 regarding the allegation made about Patient #18 and Patient #16 having sexual contact. Patient #18 reported Patient #16 would try to be sexual with female peers, would grab Patient #18 and made sexual advances toward Patient #18, but Patient #18 and Patient #16 did not do anything more than that. Patient #18 reported Patient #16 never went into their room. Patient #18 reported other female peers would say Patient #16 was "creepy", but did not report Patient #16 going into the rooms of their peers.

32. During an interview on 12/6/23 at 12:00 PM, RN E reported the day shift was fully staffed, but as the day went on, staffing became shorter on the night shift. RN E reported the inpatient pediatric BH unit was staffed with two nurses after 11:00 PM. RN E reported a few nursing assitants did not know how to redirect problematic pediatric patients. RN E reported that staff floated from other units of the hospital and lacked experience working with pediatric patients.

33. During an interview on 12/6/23 at 1:30 PM, RN H reported that during the day staffing was adequate, but after 7:00 PM, they usually had the wrong kind of staff that were not appropriately trained. RN H reported shifts changed every 4 hours, and a different staff would come and go, which made it difficult to keep a routine on track. RN H recalled when they started working for the hosptial on the inpatient pediatric BH unit, staff received a "stern" discussion, and were told that staff have to physically lay eyes on each patient when doing 15-minute checks, because in the past, staff would call to the location of the patient, asking if the patient was there.

34. During an interview on 12/6/23 at 2:15 PM, Educator A reported the inpatient pediatric BH unit did not have enough adequately trained staff taking care of the patients on the unit, and the quantity and quality of staff were both lacking. Educat

Based on medical record review, review of hospital policy, observation and staff interviews, the hospital's administrative staff failed to ensure there was appropriate nursing staff available to meet the safety needs of patients receiving services from the inpatient adult behavioral health (BH) units (see A0395).

The cumulative effect of these deficient practices resulted in the hospital's inability to ensure an RN supervised and evaluated the nursing care-including patient care needs, patient health status/conditioning, and response to interventions-for each patient upon admission and when appropriate on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy. The hospital's administrative staff identified a total capacity potential of 15 patients on the inpatient adult behavioral health unit at the time of the investigation.

Based on a review of patient medical records, review of hospital policies and procedures, interviews with hospital staff (including 9 Registered Nurses (RNs) and 4 Psychiatric Nurse Assistants (PNAs), and observations of nursing services, the hospital failed to ensure an RN supervised and evaluated the nursing care-including patient care needs, patient health status/conditioning, and response to interventions-for each patient upon admission and when appropriate on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy. Despite hospital staff observing inappropriate behaviors between Patient 2 and Patient 5 on 9/13/23, UIHC staff failed to implement necessary precautions in a timely manner to prevent further inappropriate behaviors and to maintain the safety and wellbeing of the Adult Psychiatric Unit patient population. This inaction culminated in a credible allegation of sexual activity involving Patient 2 and Patient 1 on the evening of 9/13/23.

The cumulative effect of this deficient practice resulted in the hospital's inability to ensure the nursing staff provided safe and appropriate care in accordance with the hospital's policies and acceptable standards of practice for patients receiving services from the inpatient Adult Psychiatric Unit. The hospital's administrative staff identified a total capacity potential of 15 patients for the inpatient Adult Psychiatric Unit.

Findings include the following:

1. Review of the hospital's incident report regarding the alleged sexual encounter between Patient 1 and Patient 2 on 9/13/23 revealed the following:

a. On 9/14/23 at 6:50 PM, Patient 3 reported having witnessed a sexual encounter between Patient 1 and Patient 2 in Patient 2's room on 9/13/23. Patient 3 reported the incident to Staff K (PNA) who subsequently reported the incident to Staff J (RN). the hospital placed Patient 2 on 1:1 monitoring at this time until 8:20 PM.

b. On 9/14/23 at an unspecified time, per instruction by Staff J (RN), Staff G (RN) and Staff H (RN) spoke to Patient 1 and Patient 2 separately about the alleged sexual encounter on 9/13/23. Staff G and Staff H reported that both Patients (1 and 2) indicated that they had previously engaged in sexual acts.

c. On 9/14/23 at 8:20 PM, the hospital staff transferred Patient 2 to another patient unit.

d. On 9/15/23 at an unspecified time in the morning, the hospital nursing staff discussed the alleged sexual encounter during the morning nursing report. The hospital nursing staff received encouragement to remain hypervigilant of Patient 1's behaviors and interactions.

e. On 9/15/23 at 10:00 AM, Staff H (RN) attempted to contact Patient 1's legal guardian to provide notification of the alleged sexual encounter. At 11:00 AM, Staff H received a return phone call and notified the legal guardian, who then expressed skepticism that the incident actually occurred.

f. On 9/15/23 at 1:00 PM, the hospital staff relocated Patient 1 to a room closer to the nurse's station to facilitate closer monitoring of the patient and preclude further inappropriate interactions from occurring with other patients on the unit.

2. Review of the hospital's internal investigation report regarding the alleged sexual encounter between Patient 1 and Patient 2 on 9/13/23 revealed the following:

a. On 9/13/23 at 3:00 PM, per Staff I, the hospital evening staff observed Patient 1 and Patient 2 touching each other inappropriately.

b. On 9/15/23 at 10:30 AM, Staff L (Public Safety Officer (PSO) and Staff N (PSO) spoke to Patient 2 to inquire about the incident. Patient 2 stated that she hugged Patient 1 but denied any sexual activity occurring between them. Patient 2 admitted that she slept in Patient 1's room while he worked on a computer in the dayroom. Staff L and Staff N then spoke to Staff I who reported being previously notified by evening staff that they had observed Patient 1 and Patient 2 touching each other inappropriately on 9/13/23 at 3:00 PM. Additionally, Staff I reported observing Patient 1 and Patient 5 laying together in an inappropriate manner on multiple occasions within the previous few days. Staff I redirected the Patients (1 and 5) and reminded them that this behavior did not comport with the patient behavior guidelines in the unit.

c. On 9/15/23 at an unspecified time, Staff L (PSO) and Staff N (PSO) spoke to Staff H (RN) and Staff J (RN) regarding the incident. Both Staff (H and J) reported receiving notification of the incident from Staff K (PNA) who received notification of the incident from Patient 3.

d. On 9/15/23 at an unspecified time, Staff L (PSO) and Staff N (PSO) spoke to Patient 1 to inquire about the incident. Patient 1 reported that he had previously engaged in a consensual kiss with Patient 2 but did not admit to engaging in other sexual activities.

e. On 9/15/23 at an unspecified time, Staff L (PSO) and Staff N (PSO) spoke to Patient 3 to inquire about the incident. Patient 3 reported that she observed Patient 1 and Patient 2 engaging in sexual activity on 9/13/23. Patient 3 stated that Patient 2 spent much of the day in Patient 1's bed but stated that she did not believe any additional sexual activity occurred between the Patients (1 and 2). Patient 3 stated that she hesitated to report the incident due to fearfulness of Patient 1.

3. Review of Patient 1's medical records revealed the following:

a. On 9/14/23 at 7:18 PM, Staff H documented overhearing Patient 3 discussing with another patient that she witnessed Patient 2 engage in sexual activity with Patient 1.

b. On 9/15/23 at 10:16 AM, restricted activity order was entered until 9/18/23 at 10:54 AM.

c. On 9/15/23 at 10:19 AM, sexual acting out (SAO) precautions were entered until 9/18/23 at 9:59 AM.

d. On 9/15/23 at 2:18 PM, Patient 1 relocated from room 2779 on 2JPW Unit to 2784 on 2JPW Unit.

e. On 9/18/23, SAO precautions were removed.

f. On 9/18/23 at 10:54 AM, restricted activity order was removed.

4. Review of Patient 2's medical records revealed the following:

a. On 9/13/23 at 9:54 AM, Staff I documented in a nursing note that she observed Patient 2 laying closely with Patient 5 in the day room with the lights off while fully clothed. Staff I turned on the lights, instructed the Patients (2 and 5) to leave the room, and locked the door to the day room. Staff I reminded Patients (2 and 5) not to touch each other and to keep a modest distance.

Review of Patient #5's medical record lacked documentation of any inappropriate encounter with Patient #2 on 9/13/23.

b. On 9/14/23 at 7:45 PM, Staff S placed an order for transfer of Patient 2 to another unit within the hospital.

c. On 9/14/23 at 7:52 PM, the hospital staff entered the incident report for the alleged sexual activity between Patient 1 and Patient 2 on 9/13/23.

d. On 9/14/23 at 8:18 PM, Staff G documented in a nursing note that the patient's roommate (Patient 3) observed Patient 2 leaving a male patient's (Patient 1) room the previous night.

e. On 9/14/23 at 8:34 PM, Patient 2 relocated to another unit within the hospital.

f. On 9/15/23 at 8:15 AM, SAO (sexually acting out) precautions were entered until 9/18/23 at 2:30 PM.

g. On 9/18/23 at 2:30 PM, SAO precautions were removed.

5. Interview with Staff H (RN) revealed the following:

a. On 11/29/23 at 12:35 PM, Staff H stated that she did not witness Patient 2 engage in any sexual activity with other patients, but the Patient (2) did attempt to hold hands with other patients, which would warrant redirection by staff. Staff H recalled that Staff K previously stated that Patient 3 informed her (Staff K) that she (Patient 3) observed Patient 2 engaging in sexual activity. Staff H stated that Patient 1 does not always reliably tell the truth about events.

6. Interview with Staff T (RN) revealed the following:

a. On 11/29/23 at 2:45 PM, Staff T stated that he never saw Patient 1 or Patient 2 in each other's rooms and he (Staff T) never witnessed any inappropriate behaviors between them; however, Staff T indicated that Patient 1 and Patient 2 appeared to be flirting with each other in the day room on the day prior to the allegation. Staff T stated that Patient 1 fabricates and hyperbolizes stories and indicated that he (Staff T) was skeptical that Patient 1 and Patient 2 engaged in sexual activity. Additionally, Staff T stated that Patient 2 was believed to manufacture information on occasion.

7. Interview with Staff K (PNA) revealed the following:

a. On 11/29/23 at 1:06 PM, Staff K reported that she observed Patient 2 and Patient 5 sitting in the day room together with the lights off, which did not comport with the expectation of patients in the unit. Staff K recalled that a table separated the Patients (2 and 5) so she did not witness any touching, and she (Staff K) did not see any clothing removed from either patient.

8. Interview with Staff V (RN) revealed the following:

a. On 11/29/23 at 3:25 PM, Staff V reported that she did not witness any inappropriate behaviors between Patient 1 and Patient 2, and she (Staff V) stated that Patient 2 appeared to gravitate toward men to converse; however, she (Patient 2) did not appear to be motivated by sexual interests. Staff V stated that Patient 3 (Patient 2's roommate) did not think highly of Patient 2 and indicated that Patient 3 often told stories that were not based in fact. Staff K also indicated that Patient 1 could not be relied upon for accurate portrayals of situations due to an inclination to lie. Staff V indicated that she did not believe that Patient 1 possessed sufficient intelligence to calculate when to engage in sexual activity between 15-minute checks, but could not rule out Patient 2 having this capability due to limited interactions with the Patient (2). Staff K did not observe Patient 1 or Patient 2 in each other's rooms at any time.

9. Interview with Staff W (PNA) revealed the following:

a. On 11/30/23 at 8:12 AM, Staff W stated that she was not made aware of any sexual activity between Patient 1 and Patient 2, she did not witness any sexually inappropriate behaviors exhibited by either patient, and she did not observe either patient in the other's room.

10. Interview with Staff X (RN) revealed the following:

a. On 11/29/23 at 2:00 PM, Staff X stated that Patient 3 periodically changed details, including the date of occurrence, of the alleged sexual activity between Patient 1 and Patient 2-even outright denying that she (Patient 3) reported the incident at one point. Staff X stated that Patient 3 could not be relied on to be truthful and had a patent motivation to lie about the incident because she did not want to remain roommates with Patient 2. Staff X indicated that Patient 3 knew that manufacturing the alleged incident would likely result in Patient 2's relocation. Staff X also indicated that Patient 1 frequently manufactured stories to represent himself in a good light and that Patient 2 could be characterized as a poor historian and 'storyteller'.

11. Interview with Staff G (RN) revealed the following:

a. On 11/30/23 at 12:00 PM, Staff G reported that, to his knowledge, no UIHC staff witnessed any sexual activity between Patient 1 and Patient 2, and he (Staff G) expressed skepticism that the incident actually occurred. Staff G indicated that Patient 1 often lied or made delusional statements and was motivated to maintain an appearance of toughness. Staff G stated that he had limited interactions with Patient 2, but he recalled that Patient 3 treated other patients and staff poorly and frequently complained about trivialities.

12. Interview with Staff Z (PNA) revealed the following:

a. On 11/29/23 at 1:30 PM, Staff Z did not recall any inappropriate interactions between Patient 1 and Patient 2, but reported that Patient 1 very commonly lied in an attempt to appear wealthy or famous. Per Staff Z, Patient 1 did not appear to be motivated, however, by a desire to project sexual prowess to other patients.

13. Interview with Staff J (RN) revealed the following:

a. On 11/30/23 at 10:30 AM, Staff J stated that Staff K informed her of the alleged sexual activity between Patient 1 and Patient 2 on 9/13/23. She then proceeded to speak with Patient 3 to confirm details of the allegation. Per Staff J, Patient 3 informed her (Staff J) that she (Patient 3) witnessed Patient 1 and Patient 2 kissing in Patient 1's room but that did not mention witnessing any sexual acts. The following day, Staff K accompanied Staff L (PSO) and Staff M (PSO) to speak to Patient 1 about the incident. Patient 1 stated that Patient 2 pushed him against the wall and kissed him, but Patient 1 did not mention sexual acts occurring during the interaction either.

14. Interview with Staff AA (RN) revealed the following:

a. On 12/7/23 at 11:50 AM, Staff AA reported that he only recalled one observation of Patient 1 and Patient 2 together, which he characterized as strictly verbal and social, but not inappropriate. Staff AA indicated that Patient 1 exhibited behavioral issues, including impulsivity, but was not known to be sexually inappropriate with other patients or staff.

15. Review of the policy "Psychiatric Nursing Precautions/Observation," Last Revised 10/20, revealed in part:

a. "Purpose: To provide the level and type of precautions/observation necessary to meet the safety needs of a patient."

b. " ...A patient will be placed on the precaution/observation procedure based on a RN and/or Licensed Independent Practitioner (LIP) Admission Assessment or risk related to ... sexual acting out ... RN initiated precaution/observations based upon patient needs with the exception of 1:1 for history of sexually acting out behavior in a hospital ..."