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Based on review of Patient #1's medical record, hospital policy review, associated documents, and staff interviews the hospital failed to ensure Patient #1's care was in a safe setting as related to the nonconsensual sexual encounter on 8/28/16 that occurred on the medical/behavioral unit. The inpatient medical/behavioral health unit census was 15 at the time of the incident. The hospital self reported the 8/28/16 incident, and a similar sexual acting out incident on 5/4/15 involving Patient #1.

Failure to ensure care in a safe setting could potentially result in sexual acts between non- consenting patients, acts of violence, and acts of self harm to patients.

Findings include:

Review of Patient #1 medical record revealed 12 hospital admissions from 2/25/15 to present. The record revealed 6 of 12 admissions included 30+ days of hospitalization. Patient #1's admitting diagnosis dated 8/25/16 included: type 1 diabetes, uncontrolled insulin dependent brittle diabetes, depression with major depressive disorder reoccurring, post traumatic stress disorder, distributive behavior disorder, generalized anxiety disorder, psychosis, and mild intellectual disabilities (ID). Physician ordered precautions at admission included self harm, suicide, violence, and elopement. Internal Medicine History and Physical dated 8/26 reads in part...Patient #1 started refusing insulin the night of 8/24, brought to the ED (Emergency Department) and staff identified a blood sugar of 477. Patient #1 received insulin, stabilizing treatment and discharged back to the residential living facility. Staff at the residential living facility expressed concern since Patient #1 continued to refuse insulin, Patient #1 was brought back to the ED on the evening of 8/25 with a blood sugar of 767 and was admitted to the hospital. According to the clinical record Patient #1 stopped taking the insulin because of a disagreement with the roommate. Patient #1 did not want to hurt the roommate, so Patient #1 decided to not take insulin.

Review of Nurses Notes dated 8/29/16 at 2:00 AM, by Staff A, RN (Registered Nurse) reads in part...at approximately 11:40 PM, on 8/28/16 myself and 2 other staff members (Staff B, RN & Staff C, PNA(Psych Nursing Assistant)) entered Patient #1's room to find the patient pulling up underwear and quickly rising from the lap of Patient #2, sitting in a wheel chair. Patient #2 was directed back to Patient #2's room. After confronting both patients regarding the incident, Patient #1 states anxiously "it wasn't my fault..." Patient #1 admits sexual intercourse occurred, "but I told Patient #2 I didn't want to"...Patient #2 just kept touching me. On-call physician and nursing supervisor were notified of the incident. Patient #1 was placed on 1:1, and sexual acting out precautions, a staff member was assigned to Patient #1.

Review of Psychiatric Progress Note dated 8/29/16, no time noted, by Staff D, MD (Medical Doctor) reads in part...Patient #1 was caught sitting on Patient #2's lap, with underwear down, last night on the unit. Patient #1 stated it was not Patient #1's desire to engage in sexual activity. Patient #1 jumped off of Patient #2's lap when staff members entered the room. When Patient #1's guardian was informed of the incident. Patient #1's guardian identified to the unit staff this type of incident had occurred multiple times before.

The facility staff separated Patient #1 and Patient #2, by placing them on different units.
Additional review of Patient #1 past hospital admissions revealed a similar incident occurred on 5/4/15 with sexual acting out behavior on the behavioral health unit at the hospital.

Review of Patient #2 medical record revealed admission on 8/24/16 for suicidal and homicidal ideation with type I diabetes, and hemo-dialysis. Patient #2 was brought to the ED by the police after voicing suicidal ideation and homicidal ideation's toward a spouse. Patient #2 has a left lower leg amputation and uses a wheelchair for mobility. The Physician ordered precautions at admission to include suicide and violence.

Review of Nurses Notes dated 8/29/16 at 6:21 AM, by Staff B, RN reads in part...At approximately 11:40 PM, Staff A performed room safety checks and discovered Patient #2 was not located in Patient #2's room. Staff A notified Staff B and a review of the camera monitors in the nurses station revealed Patient #2 sitting in a wheelchair in Patient #1's room. Three staff (Staff A, RN, Staff B, RN and Staff C, PNA) quickly went to the room and Patient #1 suddenly stood up from Patient #2's lap and pulled up Patient #1's underwear and stated, "It wasn't my fault, I told Patient #2 I didn't want to." Patient #2 was told by staff to return to Patient #2's room. Both patient were placed on room restrictions. the patients were unable to leave the rooms unless supervised. Patient #2 denied sexual intercourse, stating Patient #2 went to Patient #1's room to finish a movie that was started earlier. Patient #2 gave Patient #1 a hug and then Patient #1 sat on Patient #2's lap. The staff informed the On-call MD and nursing supervisor of the incident.

Review of Physician Progress Note dated 8/29/16 at 1:35 AM, by Staff E, MD; reads in part...I spoke with Patient #2 regarding what happened. Patient #2 reports that earlier in the evening both Patient #1 and #2 were watching a movie and the movie was interrupted by another patient's physical altercation. Patient #2 went to Patient #1 room to finish watching the movie. Patient #2 initially reported no physical contact occurred with Patient #1, but later Patient #2 admitted to hugging Patient #1. Patient #2 reports that Patient #1 proceeded to sit on Patient #2's left leg and was told to get off. That's when the nurses came in. Patient #2 denies having intercourse and stated Patient #2 can't have sex because of a medical condition. Patient #2 was instructed to remain in Patient #2's room the rest of the night. Sexual acting out precautions were ordered.

Review of the Daily Assignment Sheet for 8/28/16, revealed an additional RN and PNA was called in at 3:00 AM, Patient #1 was placed on a 1:1 and Patient #2 was placed on sexual acting out restrictions. The 15 minute rounding sheets dated 8/28/16 revealed no gaps. Staff completed all rounds as assigned.

Review of Policy and Procedure Manual titled Nursing-Behavioral Health Services N-BHS-Adult-03.006 Subject/Title: Observation-Adult Units, revised 9/15, reads in part...Purpose: To provide the level and type of observation necessary to meet the safety needs of a patient.
Procedure: A. A patient will be placed on the observation procedure based on an RN and/or MD assessment of risk related to suicide potential, violence potential, self-harm potential, elopement potential, wandering precautions, sexual acting out or other patient safety needs. RN's may independently initiate the observation procedure based upon patient needs.

Procedure: D. 2. 1:1 is a continuous one to one staff observation of the patient. Patients are to be in eyesight at all times.

Procedure: E. Types of Psychiatric Nursing Precautions/Observation patients may be placed on include:
1. Suicide Precautions:
a. Assign patient to room that will provide appropriate level of supervision.
b. May be placed on dayroom restriction or 1:1 at RN discretion for increased monitoring and or safety.
2. Violence Precautions:
a. Assign patient to a private room.
c. Monitor patient behavior closely for indication of potential for violence.
3. Self-harm Precautions:
a. Assign patient to room that will provide appropriate level of supervision.
b. May be placed on dayroom restriction or 1:1 at RN discretion for increased monitoring and or safety.
4. Elopement Precautions:
a. Assign patient to a room away from unit exits.
b. May be placed on dayroom restriction or 1:1 at RN discretion for increased monitoring and or safety.
8. Sexual Acting Out:
a. Assign patient to a room close to the Nurses Station and away from any other patients on sexual acting out precautions.
b. May be placed on dayroom restriction or 1:1 at RN discretion for increased monitoring and or safety.
c. Patient is never to be alone with another patient.

Review of all precaution levels revealed 15 minute monitoring was standard on all patients identified as requiring 1:1 monitoring.

Review of Policy and Procedure Manual Nursing-Behavioral Health Services N-BHS-Adult-03.001 Subject/Title Activity Levels-Adult Inpatient Units, revised date of 12/14, reads in part... Purpose: To provide patients with the least restrictive supervision required to meet their safety and treatment needs.
Policy: A. Activity levels are ordered by the resident physician upon admission and as patient condition changes.
2. Supervised: a) Level 1 (1:1): Patient may go anywhere in the hospital (including Participating in Level 1 activities) providing there is one nursing staff member assigned to be with the patient at all times.

An interview on 10/10/16 at 4:05 PM, with Staff C, PNA, revealed Staff C worked on 8/28/16 from 7:00 PM to 11:00 PM. Staff A was completing 15 minute rounds and could not locate Patient #2. We looked at the camera monitor in the nursing station and observed Patient #2 in Patient #1's room. I went with Staff A and B to Patient #1's room. I saw Patient #2 in the wheelchair with back to the door and Patient #1 was standing facing Patient #2. Patient #1 had a hospital gown on with underwear and Patient #2 was fully clothed. Patient #2 left the room. Patient #1 was questioned by Staff A and Staff B. Patient #1 stated that Patient #2 was trying to pressure Patient #1 into doing things. Patient #1 has been known to exaggerate. Staff C statede she remained 1:1 with Patient #1 after the questioning. Patient #1 and #2 were not on a 1:1 before the incident. I would say Patient #1 flirts, but I am not sure if Patient #1 knows it is flirting due to intellectual disabilities (ID).

A phone interview on 10/11/16 at 9:00 AM, with Staff B revealed; Staff B worked on 8/28/16 and was passing medications at the time of the incident. Staff A alerted us of being unable to locate Patient #2 for 15 minute checks. We identified Patient #2, on the camera monitor in the nurses station was in Patient #1's room. We knocked on the door, entered and found Patient #1 sitting on Patient #2's lap. Patient #2 was in a wheelchair. Patient #1 jumped up and pulled their uderwear up. Patient #1 immediately stated this was not Patient #1's fault. The patients were separated. The on-call MD and house supervisor were notified. Patient #1 stated they had sex. Patient #2 denied having sex. I do not recall what precautions Patient #1 was on that night, I would have to look at the chart for that information. I do recall that Staff A requested in report that Patient #1 be placed on a 1:1, due to Patient #1 having close encounters with patients of the opposite sex.

An interview on 10/11/16 at 2:00 PM, with Staff A, RN revealed; she was assigned to Patient #1 on 8/28/16. Patient #1 was on sexual acting out, violence, and self harm precautions. For sexual acting out and violence precautions we have to be more aware of the patient. Not all sexual acting out patients are put on a 1:1, it depends on their history and background. Patient #1's flirtatious, had a previous history of sexual acting out behavior and was on a 1:1 in the past. Patient #1 had been on the unit a couple of days and was not on a 1:1, when I came to work on 8/27/16, it was the first thing I asked why Patient #1 was not on a 1:1. We discussed it in report, but no one put her on a 1:1, probably because we have less staff on weekend overnight shifts. Patient #1 was not on a 1:1 at the time of the incident. A 1:1 means staff was assigned to a single patient and the staff stay with the patient. Determination of a 1:1 is a group decision, the nurse assigned to the patient is the one that makes the decision, the decision depends a lot on staffing and if staffing is available to provide 1:1 coverage of the patient.

A phone interview on 10/13/16 at 8:55 AM, with Staff F, Internal Resident DO (Doctor of Osteopathy), revealed Staff F admitted Patient #1 to the medical/behavioral unit. Staff F was aware of Patient #1's past medical history that was in the medical record at that time. Staff F was not aware of Patient #1 previous alleged sexual acting out behavior from a past hospital admission. Staff F knew Patient #1 had a manipulative behavior and multiple suicide attempts.

Based on review of Patient #1's medical record, hospital policy review, associated documents, and staff interviews the hospital failed to ensure Patient #1's care was in a safe setting as related to the nonconsensual sexual encounter on 8/28/16 that occurred on the medical/behavioral unit. The inpatient medical/behavioral health unit census was 15 at the time of the incident. The hospital self reported the 8/28/16 incident, and a similar sexual acting out incident on 5/4/15 involving Patient #1.

Failure to ensure care in a safe setting could potentially result in sexual acts between non- consenting patients, acts of violence, and acts of self harm to patients.

Findings include:

Review of Patient #1 medical record revealed 12 hospital admissions from 2/25/15 to present. The record revealed 6 of 12 admissions included 30+ days of hospitalization. Patient #1's admitting diagnosis dated 8/25/16 included: type 1 diabetes, uncontrolled insulin dependent brittle diabetes, depression with major depressive disorder reoccurring, post traumatic stress disorder, distributive behavior disorder, generalized anxiety disorder, psychosis, and mild intellectual disabilities (ID). Physician ordered precautions at admission included self harm, suicide, violence, and elopement. Internal Medicine History and Physical dated 8/26 reads in part...Patient #1 started refusing insulin the night of 8/24, brought to the ED (Emergency Department) and staff identified a blood sugar of 477. Patient #1 received insulin, stabilizing treatment and discharged back to the residential living facility. Staff at the residential living facility expressed concern since Patient #1 continued to refuse insulin, Patient #1 was brought back to the ED on the evening of 8/25 with a blood sugar of 767 and was admitted to the hospital. According to the clinical record Patient #1 stopped taking the insulin because of a disagreement with the roommate. Patient #1 did not want to hurt the roommate, so Patient #1 decided to not take insulin.

Review of Nurses Notes dated 8/29/16 at 2:00 AM, by Staff A, RN (Registered Nurse) reads in part...at approximately 11:40 PM, on 8/28/16 myself and 2 other staff members (Staff B, RN & Staff C, PNA(Psych Nursing Assistant)) entered Patient #1's room to find the patient pulling up underwear and quickly rising from the lap of Patient #2, sitting in a wheel chair. Patient #2 was directed back to Patient #2's room. After confronting both patients regarding the incident, Patient #1 states anxiously "it wasn't my fault..." Patient #1 admits sexual intercourse occurred, "but I told Patient #2 I didn't want to"...Patient #2 just kept touching me. On-call physician and nursing supervisor were notified of the incident. Patient #1 was placed on 1:1, and sexual acting out precautions, a staff member was assigned to Patient #1.

Review of Psychiatric Progress Note dated 8/29/16, no time noted, by Staff D, MD (Medical Doctor) reads in part...Patient #1 was caught sitting on Patient #2's lap, with underwear down, last night on the unit. Patient #1 stated it was not Patient #1's desire to engage in sexual activity. Patient #1 jumped off of Patient #2's lap when staff members entered the room. When Patient #1's guardian was informed of the incident. Patient #1's guardian identified to the unit staff this type of incident had occurred multiple times before.

The facility staff separated Patient #1 and Patient #2, by placing them on different units.
Additional review of Patient #1 past hospital admissions revealed a similar incident occurred on 5/4/15 with sexual acting out behavior on the behavioral health unit at the hospital.

Review of Patient #2 medical record revealed admission on 8/24/16 for suicidal and homicidal ideation with type I diabetes, and hemo-dialysis. Patient #2 was brought to the ED by the police after voicing suicidal ideation and homicidal ideation's toward a spouse. Patient #2 has a left lower leg amputation and uses a wheelchair for mobility. The Physician ordered precautions at admission to include suicide and violence.

Review of Nurses Notes dated 8/29/16 at 6:21 AM, by Staff B, RN reads in part...At approximately 11:40 PM, Staff A performed room safety checks and discovered Patient #2 was not located in Patient #2's room. Staff A notified Staff B and a review of the camera monitors in the nurses station revealed Patient #2 sitting in a wheelchair in Patient #1's room. Three staff (Staff A, RN, Staff B, RN and Staff C, PNA) quickly went to the room and Patient #1 suddenly stood up from Patient #2's lap and pulled up Patient #1's underwear and stated, "It wasn't my fault, I told Patient #2 I didn't want to." Patient #2 was told by staff to return to Patient #2's room. Both patient were placed on room restrictions. the patients were unable to leave the rooms unless supervised. Patient #2 denied sexual intercourse, stating Patient #2 went to Patient #1's room to finish a movie that was started earlier. Patient #2 gave Patient #1 a hug and then Patient #1 sat on Patient #2's lap. The staff informed the On-call MD and nursing supervisor of the incident.

Review of Physician Progress Note dated 8/29/16 at 1:35 AM, by Staff E, MD; reads in part...I spoke with Patient #2 regarding what happened. Patient #2 reports that earlier in the evening both Patient #1 and #2 were watching a movie and the movie was interrupted by another patient's physical altercation. Patient #2 went to Patient #1 room to finish watching the movie. Patient #2 initially reported no physical contact occurred with Patient #1, but later Patient #2 admitted to hugging Patient #1. Patient #2 reports that Patient #1 proceeded to sit on Patient #2's left leg and was told to get off. That's when the nurses came in. Patient #2 denies having intercourse and stated Patient #2 can't have sex because of a medical condition. Patient #2 was instructed to remain in Patient #2's room the rest of the night. Sexual acting out precautions were ordered.

Review of the Daily Assignment Sheet for 8/28/16, revealed an additional RN and PNA was called in at 3:00 AM, Patient #1 was placed on a 1:1 and Patient #2 was placed on sexual acting out restrictions. The 15 minute rounding sheets dated 8/28/16 revealed no gaps. Staff completed all rounds as assigned.

Review of Policy and Procedure Manual titled Nursing-Behavioral Health Services N-BHS-Adult-03.006 Subject/Title: Observation-Adult Units, revised 9/15, reads in part...Purpose: To provide the level and type of observation necessary to meet the safety needs of a patient.
Procedure: A. A patient will be placed on the observation procedure based on an RN and/or MD assessment of risk related to suicide potential, violence potential, self-harm potential, elopement potential, wandering precautions, sexual acting out or other patient safety needs. RN's may independently initiate the observation procedure based upon patient needs.

Procedure: D. 2. 1:1 is a continuous one to one staff observation of the patient. Patients are to be in eyesight at all times.

Procedure: E. Types of Psychiatric Nursing Precautions/Observation patients may be placed on include:
1. Suicide Precautions:
a. Assign patient to room that will provide appropriate level of supervision.
b. May be placed on dayroom restriction or 1:1 at RN discretion for increased monitoring and or safety.
2. Violence Precautions:
a. Assign patient to a private room.
c. Monitor patient behavior closely for indication of potential for violence.
3. Self-harm Precautions:
a. Assign patient to room that will provide appropriate level of supervision.
b. May be placed on dayroom restriction or 1:1 at RN discretion for increased monitoring and or safety.
4. Elopement Precautions:
a. Assign patient to a room away from unit exits.
b. May be placed on dayroom restriction or 1:1 at RN discretion for increased monitoring and or safety.
8. Sexual Acting Out:
a. Assign patient to a room close to the Nurses Station and away from any other patients on sexual acting out precautions.
b. May be placed on dayroom restriction or 1:1 at RN discretion for increased monitoring and or safety.
c. Patient is never to be alone with another patient.

Review of all precaution levels revealed 15 minute monitoring was standard on all patients identified as requiring 1:1 monitoring.

Review of Policy and Procedure Manual Nursing-Behavioral Health Services N-BHS-Adult-03.001 Subject/Title Activity Levels-Adult Inpatient Units, revised date of 12/14, reads in part... Purpose: To provide patients with the least restrictive supervision required to meet their safety and treatment needs.
Policy: A. Activity levels are ordered by the resident physician upon admission and as patient condition changes.
2. Supervised: a) Level 1 (1:1): Patient may go anywhere in the hospital (including Participating in Level 1 activities) providing there is one nursing staff member assigned to be with the patient at all times.

An interview on 10/10/16 at 4:05 PM, with Staff C, PNA, revealed Staff C worked on 8/28/16 from 7:00 PM to 11:00 PM. Staff A was completing 15 minute rounds and could not locate Patient #2. We looked at the camera monitor in the nursing station and observed Patient #2 in Patient #1's room. I went with Staff A and B to Patient #1's room. I saw Patient #2 in the wheelchair with back to the door and Patient #1 was standing facing Patient #2. Patient #1 had a hospital gown on with underwear and Patient #2 was fully clothed. Patient #2 left the room. Patient #1 was questioned by Staff A and Staff B. Patient #1 stated that Patient #2 was trying to pressure Patient #1 into doing things. Patient #1 has been known to exaggerate. Staff C statede she remained 1:1 with Patient #1 after the questioning. Patient #1 and #2 were not on a 1:1 before the incident. I would say Patient #1 flirts, but I am not sure if Patient #1 knows it is flirting due to intellectual disabilities (ID).

A phone interview on 10/11/16 at 9:00 AM, with Staff B revealed; Staff B worked on 8/28/16 and was passing medications at the time of the incident. Staff A alerted us of being unable to locate Patient #2 for 15 minute checks. We identified Patient #2, on the camera monitor in the nurses station was in Patient #1's room. We knocked on the door, entered and found Patient #1 sitting on Patient #2's lap. Patient #2 was in a wheelchair. Patient #1 jumped up and pulled their uderwear up. Patient #1 immediately stated this was not Patient #1's fault. The patients were separated. The on-call MD and house supervisor were notified. Patient #1 stated they had sex. Patient #2 denied having sex. I do not recall what precautions Patient #1 was on that night, I would have to look at the chart for that information. I do recall that Staff A requested in report that Patient #1 be placed on a 1:1, due to Patient #1 having close encounters with patients of the opposite sex.

An interview on 10/11/16 at 2:00 PM, with Staff A, RN revealed; she was assigned to Patient #1 on 8/28/16. Patient #1 was on sexual acting out, violence, and self harm precautions. For sexual acting out and violence precautions we have to be more aware of the patient. Not all sexual acting out patients are put on a 1:1, it depends on their history and background. Patient #1's flirtatious, had a previous history of sexual acting out behavior and was on a 1:1 in the past. Patient #1 had been on the unit a couple of days and was not on a 1:1, when I came to work on 8/27/16, it was the first thing I asked why Patient #1 was not on a 1:1. We discussed it in report, but no one put her on a 1:1, probably because we have less staff on weekend overnight shifts. Patient #1 was not on a 1:1 at the time of the incident. A 1:1 means staff was assigned to a single patient and the staff stay with the patient. Determination of a 1:1 is a group decision, the nurse assigned to the patient is the one that makes the decision, the decision depends a lot on staffing and if staffing is available to provide 1:1 coverage of the patient.

A phone interview on 10/13/16 at 8:55 AM, with Staff F, Internal Resident DO (Doctor of Osteopathy), revealed Staff F admitted Patient #1 to the medical/behavioral unit. Staff F was aware of Patient #1's past medical history that was in the medical record at that time. Staff F was not aware of Patient #1 previous alleged sexual acting out behavior from a past hospital admission. Staff F knew Patient #1 had a manipulative behavior and multiple suicide attempts.