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Based on observation , record, review, and interview, the hospital failed to ensure a safe environment was provided for nine of 15 patients (Patients #1, #2, #3, #5, #6, #7, #10, #11, #12) between 05/05/23 and 05/08/23 when the local police department was notified of inappropriate inter-patient sexual behavior on at least three occasions.

1. Patient #1's Initial Assessment reflected his sexually acting out behavior prior to admission. The 7-year-old was not placed on special precautionary status or staff observation for his behavior. Five days into his treatment, Patient #1 inappropriately touched Patient #12, a 5-year-old patient who had suffered a two-year sexual trauma prior to admission. Police were notified on 05/08/23.

2. Patient #10 was admitted on 04/28/23 to the adolescent unit. A day later, the patient was placed on sexually acting out precautions and staff supervision due to inappropriately touching another patient. Staff was unaware of Patient #10's special precautions for the following eight days. The patient was then again accused by her peers of sexually inappropriate physical and verbal behavior on 05/07/23.

3. Patient #3 was staff noticed on 05/06/23 with a dark skin blemish suspected from a bite or sucking of skin on her right upper neck. The patient accused Patient #2 of sexual abuse. Police were notified on 05/06/23.

4. Patient #11 had been admitted to the adolescent unit after a suicide attempt. The patient was physician noted to benefit from a therapeutic milieu. Six days into her hospitalization, Patient #11 sought consolence from nursing staff after she reported to be inappropriately touched by another patient. Patient #11 required medicinal intervention for her anxiety after the incident.

5. Patients #5, #6, #7 were allowed to congregate in a patient room on 05/05/23 and kissed. The patients required education regarding respecting personal boundaries. Police were notified.



Findings included:


1. A group of preadolescent boys were surveyor observed on 05/11/23 at or around 1127 lining up to get their lunch meal in the hospital cafeteria. The patients were close to each other while in line. Patients included Patient #1 and Patient #12.

Patient #1's Face Sheet reflected his admission on 05/03/23 at 1403. Admission diagnoses included Disruptive Mood Dysregulation Disorder. The patient's age was seven years.
Patient #1's Assessment and Referral Evaluation dated 05/03/23 at 1330 reflected sexually acting out (SAO) behavior at age seven when he removed his "diapering pants to show his behind." The patient was enuretic.

Physician Preadmission examination orders and Preliminary Plan of Care dated 05/03/23 at 1406 reflected the patient was placed on 15-minute staff supervision with precautions for Aggression, Elopement, and Self-harm.

Multidisciplinary Progress Notes dated 05/08/23 at 1630 reflected Patient #1 was "removed from Cafeteria ...was flicking other pt [patient] in peri area ...notified Police ..."
Hospital Staff N acknowledged the above findings during an interview on 05/10/23 at 1250 and stated the patient received more one-on-one therapy.

Hospital Staff K confirmed during an interview on 05/10/23 at 1635 that Patient #1 pinched Patient #12 in the private area that day.

Multidisciplinary Progress Notes dated 05/08/23 reflected Patient #12 told staff that Patient #1 "tickle[d] his private part ...pushing it in." Multidisciplinary Progress Notes dated 05/08/23 at 1730 reflected that Patient #12 "was touch[ed] inappropriately in cafeteria while lining up ..."

Patient #12's Assessment and Referral Evaluation dated 05/04/23 at 1120 reflected the 5-year-old had a two-year history of sexual trauma prior to admission.




2. Patient #10's Face Sheet reflected the 15-year-old patient's admission date of 04/28/23. Admission diagnoses included Major Depressive Disorder.

Physician Orders dated 04/29/23 at 1430 reflected Patient #10 was to be on SAO (Sexual Acting Out) precautions and staff supervision due to Patient #10 "inappropriately touched peer."

Patient #10's Physician Orders dated 04/30/23, 05/01/23, 05/02/23, 05/03/23, 05/04/23, 05/05/23, 05/06/23, 05/07/23, 05/08/23, 05/09/23, 05/10/23 did not evidence that the patient was on SAO precautions.

Patient #10's Observation Form dated 04/30/23, 05/01/23, 05/02/23, 05/03/23, 05/04/23, 05/05/23, 05/06/23, and 05/07/23 at 1844 did not evidence that the patient was on SAO precautions.

Nursing Shift Note dated 05/07/23 at 1000 reflected Patient #10 "was accused by other peers of inappropriate sexual behavior (physically and verbally)..."

Patient #10's medical record was reviewed with Hospital Staff K during an interview on 05/10/23 at 1635. Hospital K confirmed the above findings.



3. Patient #3 was hospital admitted on 04/26/23 at 0907 with diagnoses that included Major Depressive Disorder according to the patient's Face Sheet. She was discharged on 05/07/23 at 1240.

Patient #3's Multidisciplinary Progress Notes dated 05/06/23 at 0853 reflected staff accompanied a group of patients to the dining room and "noticed that ...[Patient #30] had a mark on her right upper neck ...told me that ...[Patient #2] had come into her room and grabbed her and put it there on her neck and she told her to stop ...this is something that happened on 05/05[23] ...[Patient #3] reported sexual abuse by ...[Patient #2] ...looks like a hickey on the right side of her neck ...contacted Police ..."

Patient #2 was hospital admitted on 04/17/23 at 1248 with diagnoses that included Major Depressive Disorder according to the patient Face Sheet.

Patient #2's Comprehensive Psychiatric Evaluation dated 04/17/23 at 1600 reflected the patient was admitted with suicidal ideation with a plan. The 15-year-old patient had experienced childhood physical abuse and suffered from auditory hallucinations where voices in her head told her to harm herself or others.

Nurse Progress Notes dated 05/06/23 at 0904 reflected Patient #2 was anxious and depressed, requiring medication intervention. The patient reported "thoughts of harming self with plan to use anything."



4. Patient #11 was admitted to the adolescent acute unit on 05/02/23 at 0930 according to the patient's Face Sheet. Admitting diagnoses included Major Depressive Disorder.

Patient #11's Comprehensive Psychiatric Evaluation dated 05/02/23 at 1442 reflected the patient tried to commit suicide by overdosing on Ibuprofen. Therapeutic concerns included to address the patient's poor coping skills, provide the benefit of a therapeutic milieu.

Multidisciplinary Progress Notes dated 05/08/23 at 1255 reflected Patient #11 "reported that another patient had grabbed her butt [and] patient was crying ...nurse consoled patient."

Nursing Shift Assessment dated 05/08/23 (night shift) reflected the patient was anxious and required administration of anti-anxiety medication at 2015.

Physician Progress Note dated 05/09/23 at 0716 reflected Patient #11's behavior was guarded; the mental status exam reflected anxious mood with a labile affect.



5. During an interview on 05/10/23 at or around 1300 Hospital Staff K identified three patients involved in an incident dated 05/05/23 at 0730. Patients #5, #6, #7 were kissing.


a) Record review of Patient #5's Face Sheet reflected the patient had been admitted on 04/25/23 at 2149 and discharged on 05/07/23 at 1833. Admitting and discharge diagnoses included Major Depressive Disorder, recurrent.

Patient #5's Comprehensive Psychiatric Evaluation dated 04/26/23 at 0906 reflected a childhood trauma history of sexual, emotional, and physical abuse by a family member.

Patient #5's Nurse Shift Progress dated 05/05/23 at 1300 reflected the patient "was reported to have been kissed by another pt [patient] in the room ...Arlington PD [Police Department] notified ... education regarding boundaries was provided ..."

b) Patient #6's Face Sheet reflected the patient's admission on 04/26/23 at 1805 and discharge on 05/06/23 at 1225. Admitting and discharge diagnoses included Major Depressive Disorder, single episode.

Patient #6's Comprehensive Psychiatric Evaluation dated 04/27/23 at 0820 reflected the 12-year-old patient had suicidal intentions with a specific plan to hang herself or jump off a building. The patient had suffered from emotional abuse during childhood. Therapeutic concerns included the patient's poor coping skills. The document noted that the patient was able to "benefit from therapeutic milieu."

Patient #6's Nurse Shift Report dated 05/05/23 at 1200 reflected "the patient went into another pt [patient]'s room and kissed the pt ...Arlington Police notified ...education on maintain proper boundaries was done ..."

c) Patient #7 was hospital admitted on 05/03/23 at 0855 and discharged on 05/07/23 according to the patient's Face Sheet. Admitting and discharge diagnoses included Major Depressive Disorder, Generalized Anxiety Disorder.

Patient #7's Comprehensive Psychiatric Evaluation dated 05/04/23 at 0809 reflected. The 11-year-old patient was admitted for suicidal ideation with the plan to overdose. She had suffered from childhood emotional abuse and had poor coping skills. Psychiatric diagnoses included Major Depressive Disorder, severe, recurrent.

Nursing Shift Progress Note dated 05/05/23 at 1330 reflected Arlington PD had been notified after a kissing incident in peer's room and "boundaries education was provided."

Hospital Policy #1013 titled Patient Rights dated 07/07/19 reflected the patients receiving the hospital's mental health services "will be granted ...the right to a humane treatment environment that that ensures protection from harm, provides privacy ...with regards to personal needs and promotes respect and dignity for each individual" (p. 2).