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On the days of the Complaint Investigation based on record reviews, interviews, and review of the hospital's policies and procedures, the hospital's governing body failed to ensure the hospital's adolescent psychiatric unit operated in a responsible manner to ensure the safety of 2 of 3 adolescent psychiatric patients who alleged sexual abuse. (Patient #1 and #4)

The findings are:

Cross Reference to A 0049: The governance of the hospital failed to ensure the oversight and monitoring of psychiatric patients assigned to the hospital's adolescent unit who alleged sexual abuse received care and services by the hospital's medical staff that ensured clear expectations for the patients' safety were established for 2 of 3 psychiatric patients who alleged sexual abuse. (Patient #1 and Patient #2)

Cross Reference to A 0063: The governing body in accordance with hospital policy failed to ensure that specific patient care requirements of the adolescent psychiatric unit were met for 2 of 3 patients who alleged sexual abuse. (Patient #1 and Patient #4)

Cross Reference to A 0145: The hospital failed to ensure psychiatric unit patients' right to receive care in a setting free from all forms of abuse for psychiatric patients assigned to the adolescent psychiatric unit for 2 of 3 patients who alleged sexual abuse. (Patient #1 and Patient #4)

Cross Reference to A 0385: The hospital failed to ensure that psychiatric patients received nursing care and services in accordance with the hospital's policies and procedures and Standards of Practice for patients assigned to the hospital's psychiatric unit for 2 of 3 patients who alleged sexual abuse. (Patient #1 and Patient #4)

Based on record reviews, interviews, and review of the hospital's policies and procedures, the governance of the hospital failed to ensure the hospital's medical staff assured clear expectations for the patient's safety were established for 2 of 3 adolescent psychiatric patients who alleged sexual abuse during the patient's hospitalization. (Patient #1 and Patient #2)

The findings are:

On 12/21/2020 at 12:00 PM, review of Patient #1's chart revealed an 11 year old male admitted to the psychiatric hospital on Thursday, 11/19/2020 at 1543 (3:43 PM) under the care of Psychiatrist #1. Patient #1 was admitted on voluntary commitment that revealed the patient exhibited "explosive outbursts, SI (Suicidal Ideation) Attempt to cut wrist, and ADHD (Attention Deficit Hyperactive Disorder)". Patient #1's admission diagnosis was major depressive disorder. Review of the "Standardized Intake Assessment" form in Patient #1's chart, dated 11/19/2020 at 1600 (4:00 PM) revealed the patient had no "Sexually Aggressive Behaviors" in the last 6 months or over the patient's lifetime. In the section of the Patient #1's intake form, labeled, "Potential for Sexual Victimization" showed "no" for the last 6 months and "no" over the patient's lifetime. On 12/21/2020 at 12:00 PM, review of Patient #1's physician orders dated 11/19/2020 at 2000 (8:00 PM) revealed "Level of Observations Every 15 Minutes". Review of Psychiatrist #1's progress notes dated 11/21/2020 at 10:50 AM reads, "...... Staff reports possible inappropriate behavior with another peer." Review Physician #1's orders for Patient #1 dated 11/22/2020 at 1700(5:00 PM) revealed, "Nursing Order- General Block Patient Room". On 12/21/2020 at 12:00 PM, continued review of Patient 1's chart revealed there was no update in the patient's initial admission treatment plan dated 1/19/2020 at 1930 (7:30 PM) related to the patient's allegation of sexual abuse. Review of a hospital form, dated 11/24/2020 at 0830 (8:30 AM), labeled, "Physician Discharge Order/Progress Note", revealed "Medical/Psychiatric Follow Up: ER (Emergency Room) evaluation for allegations of sexual assault." Review of Physician #1's discharge note dated 11/24/2020, in the section, labeled, "Hospital Course", revealed "..... Client subsequently reported sexual assault by a male peer. He was sent out to the Emergency Room for evaluation of sexual assault".

Review of a hospital form, titled, "Healthcare Peer Review Report", 11/23/2020, revealed Patient #1 reported sexual assault by the roommate occurred at 2200 (10:00 PM) on 11/19/2020. In Section J. of the form, labeled, "Notification of Physician" showed Psychiatrist #1's name. In Section N. of the form, labeled, "Physician Response", was documented, "No Response Required".

Interview Licensed Practical Nurse #1
On 12/21/2020 at 11:08 PM, Licensed Practical Nurse (LPN) #1 verified he worked the first shift(0700 - 0300) on 11/20/2020 as the medication technician. LPN #1 reported .....(Patient #1) notified the day shift nurse manager on 11/20/2020 that his"roommate was touching him." LPN #1 reported that on 11/20/2020, at an unknown time in the morning, he answered a telephone call from .....(Patient #1's) mother who stated she was returning a call that she received from the hospital. LPN #1 revealed he instructed .....(Patient #1's) mother that an incident had been reported concerning .....(Patient #1) and the roommate .....(Patient #2). LPN #1 revealed Patient #1's mother reported the patient had called her earlier on 11/20/2020 to report his/her roommate had forced him to perform oral sex and had penetrated him twice anally during the night......"

Interview Psychiatrist #1
On 1/13/2021 at 8:22 AM, during an interview with Psychiatrist #1 in the conference room , Psychiatrist #1 verified that she was the physician for .....(Patient #1) and .....(Patient #2) who was .....(Patient #1's) roommate on 11/19/2020. Psychiatrist #1 stated she remembered talking to Patient #2's (alleged perpetrator) foster mom about the alleged sexual contact between the roommates. Psychiatrist #1 stated Patient #2's "foster mom did not want the patient to return to her home, and the foster mom was upset because the Department Social Services had not given her the patient's history of sexually acting out in the past". Psychiatrist #1 stated she "recalled a few talks with .....(Patient #1) who never described what happened." Psychiatrist #1 reported ".....( Patient #1) said something had happened, and we offered to send him out immediately for a rape kit, but we wanted his (foster) mom to go to the ER(Emergency Room) with him. The foster mom wasn't available to immediately take him even though an appointment had been made for him on 11/23/20, so we discharged him the next day (11/24/20), sent him by ambulance to the ER so his mom could be present also." Psychiatrist #1 reviewed the progress notes with the surveyor in .....(Patient #1's) chart and stated she "had written a note on 11/23/20 at 8:34 AM when she had first been made aware of some sort of sexual contact between the two roommates". Psychiatrist #1 reported .....(Patient #1) had told her he had made a bad decision and felt ashamed". Psychiatrist #1 reported that she did not know anything about Patient #1 saying he had been raped or anally penetrated".

Psychiatrist #1 said it(the assault) had been reported to her that in group therapy, .....(Patient#1) reported that he had been forced to perform oral sex on ..... (Patient #2)". Psychiatrist #1 said, "After reviewing .....(Patient #2's) Admission report, she had noted the patient had sexual trauma in the past". Psychiatrist #1 reported "..... (Patient #2) was violating boundaries with other patients, getting into other people's personal space, touched a nurse's breast which the patient (#2) said was an accident". Review of another progress note with the surveyor, Psychiatrist #1 verified that she had documented "a pattern of sexually inappropriate behavior based on what ..... (Patient #2's) behavior was in the milieu". Psychiatrist #1 stated "they had put ..... (Patient #2) on 1:1 due to his sexualized behavior, but she could not recall when this had been started". When asked if she had been notified on Friday, 11/20/20 about the patient's allegation of sexual contact between the roommates, Psychiatrist #1 said "I do not recall anything was said." When asked if anyone had contacted her on Saturday, 11/21/20 about any sexual contact between the two patients, Psychiatrist #1 stated "They wouldn't call me on a Saturday. Nursing staff would just remove the person from contact with the other, and notify the parents". When asked about when the rape allegation surfaced, Psychiatrist #1 stated, "I was not sure when detailed information was been reported about the sexual contact. In this environment, kids are doing things. We deal with it regularly. Girls kiss each other or someone slaps them on the butt. There is ambiguity where sexual assault occurs, and when the police needs to be notified versus when it is a boundary violation. I think here, there is ambiguity, and being very specific as to what would warrant the emergency protocol. Also with patient safety, removing a patient and notifying parents is another thing. I don't think we have a sexualized behavior protocol." Psychiatrist #1 reported that she is not sure who informed her of the alleged sexual abuse or when she had been initially been informed, but thought it was on 11/23/20. Psychiatrist #1 reported that she had been told that "the patient had shouted out that something happened in his room. I talked to the patient. I didn't do an interrogation. I didn't have a clear picture of what was being alleged, just that it was sexually related." Psychiatrist #1 stated she had talked to the patient on 11/23/20 at 8:35 AM. and he said "I feel ashamed." I asked the nurse manager what had happened, and she said "It was was oral". When I asked why they did not immediately send the patient out for an exam, I was told that the "evidence wouldn't be any different if sent out on 11/23/20 or 11/24/20. It was okay to wait since the alleged incident happened over the weekend. The mom couldn't go at the time, and they didn't want to traumatize the patient by having him go without his mom".

Based on record reviews, interviews, and review of the hospital's policies and procedures, the governing body in accordance with hospital policy failed to ensure that specific patient care requirements of the adolescent psychiatric unit were met for 2 of 3 adolescent psychiatric patients who alleged sexual abuse. (Patient #1 and Patient #4)

The findings are:

On 12/22/20 at 7:00 AM, during an interview, the Director of Quality (DQ) reported, "The governing body met on 12/16/2020 to discuss the hospital's Quality Quarter 3 reports. Any abuse incidents for Quarter 4 would not have been discussed during that governance meeting. If a trend in abuse or neglect issues are discovered, the governing body would receive an overview of how many incidents and which nursing unit(s) the abuses occurred on. Prior to this quarter, the focus of Quality was on training, rounding, and the identification of precursor risk factors. This information may not be included in the governing body meeting minutes."

On 12/22/20 at 10:00 AM, review of the hospital's Governing Body Meeting Minutes dated 1/30/2020, 5/20/20, 8/25/2020, and 12/16/2020 revealed there was no documentation related to a review of abuse/neglect incidents by the governing body.

During an interview on 12/22/20 at 2:00 PM with the Chief Executive Officer (CEO) and the Director of Quality, the CEO revealed oversight for allegations of abuse is provided by the governing body related to quality and risk data. The CEO revealed the governing body ensures the hospital's policies are in place and training is provided for the clinical staff."

Based on record reviews, interviews, and review of the hospital's policies and procedures, the hospital failed to ensure the psychiatric adolescent unit patients' right to receive care in a safe setting that protects and promotes a safe environment free from any form of abuse or neglect and failed to follow the hospital's own policies and procedures when patients report allegations of sexual abuse for 2 of 3 patients who reported allegations of sexual assault. (Patient #1 and Patient #2)

The findings are:

Cross Reference to A 0145: The hospital failed to ensure its nursing staff and administrative staff completed and documented patient assessments and interventions when patients allege sexual abuse, failed to ensure nursing staff notify and document notification of on duty administrative staff of the alleged sexual abuse, failed to ensure nursing and administrative staff notified and documented notification of physician(s) and parents/guardians of the allegation, failed to ensure nursing staff completed occurrence reports per the hospital's policies (timelines), and failed to ensure victims and the perpetrator are separated and/or monitored at a higher level of observations to ensure the safety of the victim and the safety of other potential victims from further potential abuse or coercion. The hospital failed to ensure Administration notified all pertinent outside agencies of allegations of sexual abuse and completed a thorough investigation of the incident(s) that included interviewing all witnesses and potential witnesses that included staff and others in the close vicinity of the incident when the incident occurred. (Patient #4 and #1)

Based on record reviews, interviews, and review of the hospital's policies, the hospital failed to ensure adolescent psychiatric patients' right to receive care and services in a safe setting free from sexual abuse in accordance with the hospital's policies and procedures for responding to 2 of 3 patients alleged sexual abuse. (Patient #1 and Patient #2)

The findings included:

Cross Reference to A 0392: The hospital's nursing services failed to provide nursing care to patients on the hospital's adolescent psychiatric unit who alleged sexual abuse in accordance with the hospital's policies and procedures and standards of practice for 2 of 3 patients who alleged sexual abuse. (Patient #1 and Patient #4)

On 12/21/2020 at 11:30 PM, review of the hospital's "Incident Report Log" showed an incident report was completed on 11/19/2020 at 2200(10:00 PM) for an allegation of sexual abuse by ....(Patient #1) against Patient #2 who was the roommate. Patient #1(alleged victim) was 11 years old with no documentation of sexual abuse in the chart. Patient #2 (alleged perpetrator) was 14 years old with a history of aggression and sexual abuse. On 12/21/2020 at 11:30 AM, review of an incident report for Patient #1 revealed the 11 year old patient alleged sexual assault/ rape by his roommate(Patient #2) on Thursday, 11/19/2020 at 2200 (10:00 PM). In an interview with the Director of Quality on 11/12/2020 at 2:22 PM, the Director reported the date of the incident report defaulted to 11/19/20, but the incident report was created on 11/23/20 by the Adolescent Unit Manager. On 12/21/2020 at 12:00 PM, review of Patient #1's chart revealed there was no documentation in the patient's nursing progress notes dated 11/19/20, 11/20/20, 11/21/20 , or 11/22/2020 of the patient's alleged sexual abuse by the patient's room mate which was alleged to have occurred per the incident report on 11/19/2020. There was no documentation of a physician's medical or psychological assessment, no physician ordered interventions, or further treatment to address Patient #1's allegation of sexual abuse on 11/19/2020 until a physician telephone order dated 11/22/20 at 17:27 (5:27 PM) for "Block patient room". There was no documentation Patient #1 received a physical or psychological assessment for evaluation of the patient's alleged sexual abuse until a telephone order dated 11/22/20 at 17:27 (5:27 PM) to Block patient room and for a medical evaluation for sexual abuse on 11/24/2020 after the patient's discharge. There was no documentation of a nursing psychological assessment of the patient or any interventions implemented for protection and safety of Patient #1 after his alleged sexual assault on 11/19/2020 until the patient's room was blocked on 11/22/2020 at 5:27 PM. Patient #1 reported an allegation of sexual abuse/rape by his room mate on the second shift on 11/19/2020 per an incident report. There is no documentation in the patient's chart related to the allegation of sexual abuse of notification of all pertinent parties to include the the administrative supervisor on duty or the police department. Patient #1(victim) and Patient #2(alleged perpetrator) (Room 214) were not separated until the evening shift on 11/20/2020.

Review of the staffing for based on the Nurse Assignment Sheets revealed on the evening shift on 11/19/20 1 Registered Nurse(RN), 1 Licensed Practical Nurse(LPN), and 3 Mental Health Technicians(MHTs) were on duty. Review of the staffing for based on the Nurse Assignment Sheets on 11/19/2020 - 11/20/20(night shift) revealed 1 RN and 3 MHTs on duty. On 11/20/2020, the Nurse Assignment Sheets for the day shift showed Patient #1 and Patient #2 were still in Room 214. Review of the Nurse Assignment Sheet for 11/20/2020 for the evening shift revealed Patient #1 was assigned to Room 212 and Patient #2 remained in Room 214 and Room 214 was now designated as No Room Mate (NRM). There was no documentation in either patients' chart as to why the separation of the patients was done. There was no documentation why separation of the patients was not done after Patient #1 submitted his allegation of sexual assault.





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Patient #4
On 12/21/2020 at 11:30 PM, review of the hospital's "Incident Report Log" showed an incident report was completed on 12/10/2020 at 12:08 AM for the alleged sexual assault reported by Patient #4 against her roommate(Patient #5) that occurred on the 7 PM to 7 AM shift on 12/08/2020 - 12/09/2020 that "involved an alleged incident of sexual misconduct on 12/8/20 at 11:15 PM". The electronic Incident Report for Patient #4 dated 12/10/2020 at 12:08 AM revealed Patient #4 alleged unwanted sexual contact by Patient #5. Review of the electronic Incident Report dated 12/10/2020 at 12:30 AM for Patient #5 revealed "When confronted with Patient #4's allegation of sexual assault, Patient #5 reported that "she was a victim of unwanted sexual contact" by Patient #4. The Incident Report log/Incident Report, dated 12/10/2020 revealed Patient #4 was "placed on unit restriction" and Patient #5 had an increased observation level as a result of the incident. There was no documentation in either patient's chart related to any physician ordered interventions or nursing interventions implemented for either patient related to Patient #4's alleged sexual abuse.

Director of Quality
During an interview on 12/22/20 at 8:15 AM, a copy of the hospital's written/typed investigation of the patient's allegation of sexual abuse was reviewed with the Director of Quality (DQ). According to the DQ, she is responsible for documenting the hospital's investigation into the alleged incident of sexual misconduct between Patient #4 and #5. The DQ verified there was no separate investigation for Patient #5, but just one investigation conducted under Patient #4's name. The investigation revealed the date of the incident, Sexual Misconduct Pt/Pt (Patient to Patient), was 12/8/20 at 11:15 PM. Under the section of the investigation report, labeled, "Description of Incident" was documented, "...(Patient #4) is a 14 year old female who reported her roommate, (Patient #5), was sexually inappropriate. The two girls were in the bathroom at the same time and the tech(technician) could not find them when she rounded. At the time, both girls denied that anything happened. However, later, (Patient #4) reported her room mate touched herself while she watched. Later, Patient #4 reported that she and her room mate touched each other. She denied any penetrative sex to the nurse." Under the section of the investigation report, labeled "Camera Review", completed on 12/14/20, revealed, "On 12/8/20 at 22:39, MHT #5 gets RN #4." In the section of the investigation report, labeled, Investigation Under, reads,"Family/Guardian Notification and Response", an entry dated 12/18/20, revealed, "Patient (#4's) parents were very upset and made a police report regarding the alleged incident. Patient #5's (guardian) was not upset at the time of the phone call." When asked when the physician was notified of the incident, the DQ stated she didn't know, but thought it was done on 12/9/20 by one of the nurses. The DQ stated she did not know who notified the parents of the incident, but stated the Nurse Manager would know. When asked, the DQ stated RN (#4) and the Nurse Manager spoke with Patient #4 and #5 about the incident. The DQ stated that she had not interviewed either of the patients and had no documentation related to any patient interviews. The DQ verified she had not interviewed any staff besides the Adolescent Unit Manager about the incident. When asked if the Social Worker was involved, the DQ stated, "The social worker only reviewed the notes for any issues or concerns, but there had been nothing noted about the incident in the notes of any activity or social work groups." When asked if anyone had interviewed the social worker, the DQ stated, "no". When asked if anyone had interviewed the physician(s) for the investigation, the DQ said, "no" but a review of physician progress notes was done, and nothing was documented in the physician progress notes related to the incident." Review of the Recommendations section in the Investigation Report revealed in part,"..... mental health technicians are to receive corrective action, and review the hospital's policy related to every 15 minute rounds, due to rounds were not completed every 15 minutes per hospital policy." Review of the corrective action reports for the Mental Health Technicians, provided by the hospital, related to not completing rounds per hospital policy for RN #4, MHT #2, and #4 revealed none of the corrective action reports had signatures of the staff.

Registered Nurse #1
On 12/22/2020 at 6:30 AM, RN #1 verified she was the charge nurse on the night shift 11/19/2020 through 11/20/2020 working 11:15 PM to 9:15 AM. RN #1 stated, "The last one(sexual abuse) I heard about was at the end of second shift on 11/19/2020. Second shift was having more 'sex' issues. We really need more staff. This staffing is not normal." RN #1 stated that after a patient alleges sexual abuse, "We call the Medical Doctor (MD), and then we call the supervisor. The supervisor notifies risk management and the incident gets reported in the HPR. In all instances, we call the parents." When asked about recent training on sex abuse, RN #1 stated, "We received some messages about doing our rounds correctly."

Chief Executive Officer
During an interview on 12/22/20 at approximately 9:00 AM, the Chief Executive Officer (CEO) and DQ were present. The DQ reported she found out about the alleged incident of sexual abuse on the morning of 12/9/20 when her assistant overheard the nurses report about the allegation of sexual assault during shift change on 12/09/2020, and then, the DQ's assistant reported the information to her. The DQ reported that she was not sure if the Charge of Building/Nursing Supervisor was notified immediately when the alleged unwanted sexual contact was reported, and she did not know who was Charge of Building during the time of the alleged incident on 12/08/2020 - 12/09/2020. When asked, both the CEO/DQ verified law enforcement was not notified by the hospital of the allegation of sexual abuse. The CEO stated, "Both patients kissed and both patients pressured each other." The CEO reported, "If someone had said they were touched forcefully and clarified it as either against their will or forcefully, the hospital would notify law enforcement." The CEO and DQ revealed that when allegations of sexual abuse occur, patients are to be separated and parents are notified. When asked if the patients involved in this incident were separated or what interventions were done related to the incident, the DQ stated the Unit Manager would know. The DQ stated "interventions would be documented in the patient's record." The DQ reported the patient had been kept at the nursing station".

Assistant Director of Nursing
On 12/22/20 at 10:12 AM, the Assistant Director of Nursing (ADON) verified she had been Charge of Building for the 7 PM to 7 AM shift on 12/8/20 - 12/09/2020 when the incident of the sexual abuse allegedly occurred. The ADON reported that she was not notified by nursing during the shift of Patient #4's alleged sexual abuse. When asked what staff responsibilities are when patients allege sexual abuse, the ADON stated staff are to separate the patients, ask both parties what happened, notify the physician, and call everybody. The nurse notifies the Charge of Building after regular hours, and the Charge of the Building notifies Administration. When asked when she was notified of the alleged sexual abuse, the ADON reported she thought RN #7 reported the incident to her on the morning shift on 12/09/20. There was no documentation of this notification or any notifications listed above in either patient's chart by nursing nor was the incident report completed on 12/09/2020.

Unit Manager #2
During an interview on 12/22/20 at 11:15 AM, the Adolescent Unit Manager was asked about what interventions were put in place for Patient #4 and #5 related to the alleged unwanted sexual contact. The Unit Manager reported that she thought Patient #5 was removed from the room and placed in the Observation Room, but she wasn't sure as it may have been Patient #4. Review of the of the every 15 minute observation check sheets in the medical records for both patients revealed that on the morning of 12/9/20, initially Patient #5 was in the bedroom while Patient #4 was in the Day Room. Further review revealed Patients #4 and #5 were both in the cafeteria at the same time for lunch and both attended therapy group together in the afternoon on 12/9/20 after the alleged incident had been reported. The Unit Manager verified the patients' records and stated Patient #4 and #5 would have been accompanied/supervised by staff during those times together. When asked about the interventions listed for Patient #4 and #5 on the Incident Report/log, for unit restriction and increased observations, the Unit Manager stated there was not a sheet for staff to document more frequent checks than 15 minutes, and you would just keep patients closer like in the day room for increased observation. The Unit Manager stated Patient #4 would not have been placed on unit restriction as this is done for patient safety, and the patient is not able to leave the unit. After reviewing the record, the Unit Manager verified there were no physician orders or documentation of increased observations or unit restriction for either patient. When asked, the Unit Manager stated that if sexual abuse occurs, they automatically move the patient from the room and keep patients separated. Staff are to complete an incident report. The Unit Manager stated the physician for both patients was notified of the alleged incident the on the morning of 12/09/20 during treatment team meeting, and both physicians spoke with their patient. Review of the physician progress notes with the Unit Manager, the Unit Manager verified there was no documentation of the incident in the either physician's notes. There was no documentation in the patient's records of notification of either of the physicians. When asked who notified the patients' parents, the Unit Manager stated she would have notified them for her follow up, and thought she had done this after interviewing the patients. The Unit Manager reported she was not aware of any nursing staff who notified the Charge of Building of the allegation of sexual abuse on the 7 PM - 7 AM shift on 12/08/2020 - 12/09/2020.

Adolescent Unit Manager
On 12/22/20 at 11:45 AM, the Adolescent Unit Manager stated, "On 12/09/20, around the time of the morning shift report, I was notified that the patient (#4) alleged she was sexually assaulted during the night shift on 12/08/2020 - 12/09/2020. I do not remember who notified me or the exact time I was notified." When asked which Mental Health Technicians were involved in the incident, the Unit Manager reported she did not know. The Unit Manager stated, "There was some confusion over which staff was involved in the incident. I did not interview RN #4 or MHT #5 who were assigned to the patients (Patient #4) and (Patient #5) on the 7 PM - 7 AM shift on 12/08/2020 - 12/09/2020. The Adolescent Unit Manager stated, "I spoke with RN (#7) who was the 7 AM -3 PM nurse on 12/09/2020, and two of the 3 PM-11 PM Mental Health Technicians who worked 12/8/2020, but those technicians had no knowledge of the incident." When asked what time the alleged incident occurred, the Adolescent Unit Manager stated, "It was early in the morning on 12/9/20 around 1:00 AM -2:00 AM." The Adolescent Unit Manager (UM) reported she interviewed the patient (Patient #4) on 12/9/20 at approximately 8:30 AM, and the patient (Patient #4) told her that the patient (Patient #5) asked her to kiss her, but she didn't want to, and the patient (Patient #5) touched herself inappropriately and the patient (Patient #4) did not like it. The Adolescent Unit Manager stated she asked the patient (Patient #4) if the roommate (Patient #5) touched her? The Adolescent Unit Manager reported the patient (Patient #4) pointed to her breast and pelvic area and said the patient (Patient #5) touched her there over her clothes. The Unit Manager stated she spoke with the patient (Patient #5) who accused patient (Patient #4) of the exact same thing. The Unit Manager stated that she did not have documentation of any interviews she conducted with Patient #4 and #5 or any staff. When asked who she had notified and when, the Unit Manager stated she had informed only the Director of Quality (DQ). There was no documentation or interview that verified the hospital's Administrative staff reported the alleged sexual abuse to the authorities with jurisdiction such as law enforcement minutes, and you would just keep patients closer like in the day room for increased observation." The Unit Manager stated, "The patient (#4) would not have been placed on unit restriction as this is done for patient safety, and the patient is not able to leave the unit." On 12/22/20 at 11:15 AM, the Adolescent Unit Manager was asked what interventions were put in place for the patients (Patient #4 and #5) related to the alleged unwanted sexual contact. The Unit Manager reported, "I thought the patient (#5) was removed from the room and placed in the Observation Room, but I am not sure as it may have been the other patient (#4)." Review of the of the every 15 minute observation check sheets in the medical records for both patients revealed that on the morning of 12/9/20, initially Patient #5 was in the bedroom while Patient #4 was in the Day Room. Further review revealed Patient #4 and #5 were both in the cafeteria at the same time for lunch and both attended therapy group together in the afternoon on 12/9/20 after the alleged incident had been reported. The Adolescent Unit Manager verified the observational documentation in both patients' records and stated, "The patients would have been accompanied/supervised by staff during those times together." When asked about the interventions listed for both patients on the Incident Report/log for unit restriction and increased observations, the Unit Manager stated, "There is not a sheet for staff to document more frequent checks than 15 here were no physician orders or documentation of increased observations or unit restriction for either patient. The Unit Manager stated, "If sexual abuse occurs, they automatically move the patient from the room and keep patients separated. Staff should complete an incident report. The physician for both patients was notified of the alleged incident on the morning of 12/09/20 during treatment team meeting, and both physicians spoke with their patient." Review of the physician progress notes with the Adolescent Unit Manager for 12/09/2020 revealed there was no documentation of the incident in either patient's record in the physicians' progress notes. The finding was verified by the Adolescent Unit Manager on 12/22/2020 at 11:15 AM. There was no documentation in either patient's record that the physician was notified of the allegation of sexual abuse. When asked who notified the patients' parents, the Adolescent Unit Manager stated she would have notified them for her follow up, and thought she may have done this after interviewing the patients.

Director of Quality(DQ)
An interview with the Director of Quality (DQ) was conducted on 12/22/20 at 1:00 PM in the conference room. The DQ was asked when she became aware of incident and what actions were taken. The DQ explained, "We have a system called MIDAS that includes incident reports with names on them. This incident report was a little different since it was vague related to when the incident happened. The patient did not report the sexual assault until the weekend. We were not sure if the incident happened on 11/20/2020 or 11/21/2020. On Monday (11/23/2020), I called and made a police report and the detective came out that day. The weird thing is the MHT reported noticing the room mate acting weird on 11/19/20. The MHT reported when the MHT went to the room, the MHT could see the room mate was aroused. The MHT stated he/she talked with both patients who said nothing happened. The timeline is very murky. LPN #1 reported receiving a call from the mom on 11/20/20 at 8:45 AM stating the patient called her claiming the room mate assaulted him. The patient also reported the sexual assault in the group session on 11/21/2020. The roommate denied anything happened. I notified the roommate's Department of Social Services (DSS) worker. I called the patient's mom again on Monday 11/23/2020. The patient, for whatever reason, did not get a medical check after the allegations until he was discharged on 11/24/20. Mom wanted to be at the hospital so that is why the patient was sent to the Emergency Department (ED) on 11/24/20 so mom could be present. We do not substantiate sexual abuse. We call Out of Home Abuse and Neglect (OHAN) unit of DSS."

Register Nurse #4
During an interview on 12/22/20 at 3:15 PM, RN #4 verified she worked the 7 PM - 7 AM shift on 12/08/2020 - 12/09/2020 when Patient #4 reported the alleged incident of sexual abuse to her. RN #4 stated, "Patient #4 came out of her room saying she was hitting her head on the closet. I asked the patient why, and the patient said she does it when she is upset. So I had her move into a recliner at the nursing station to watch her closer. Her mental status was intact, and she just had a red area on her head, but she was not disoriented." RN #4 stated, " I increased her observation level by moving her into a recliner." RN #4 reported, "An hour after that, the patient told me that she and her roommate did have sex, but she didn't want to, and it was against her will." RN #4 said, "The patient was not emotional, and had the same flat affect. She went into her history of sexual abuse and stated she was scared and that's why she did not say anything before". On 12/22/20 at 3:30 PM, review of the documentation on the observation sheets in Patient #4's and Patient #5's chart revealed the patients were not physically separated from possible contact with each other on 12/09/2020 which was the day after Patient #4's allegation of sexual abuse. Documentation in both patients' medical records of the every 15 minute observation checks as well as the patient's therapy notes revealed Patient #4 and #5 were in the cafeteria during meals and in therapy group together on 12/9/20. On 12/22/20 at approximately 3:40 PM, review of an electronic copy of the Incident Report for Patient #5 revealed the incident report was completed by RN #4 on 12/10/20 at 12:10 AM. When asked why the delay in writing the incident reports for the allegation of sexual abuse, RN #4 stated she had been tired because she had worked a double shift from 12/8/20 3 PM-11 PM shift and 12/9/20 11 PM -7 AM shift. RN #4 reported she came back the next evening (12/10/2020) to complete the report. RN #4 stated "Anything severe would just be documented in Incident reports." When asked why there were no nursing notes related to allegation of abuse in either Patient #4's chart or Patient #5's chart, RN #4 stated, "You could do one, but usually the daily nursing notes are done on the day shift or evening shift." When asked if she had assessed Patient #4 or #5 related to the alleged sexual contact, RN #4 stated "No nursing/medical assessments are done for sexual abuse, only for injuries for things like a cut or skin conditions." When asked why the patients were not placed in separate rooms when informed of the allegation of sexual abuse, RN #4 stated, "There were no rooms available to change, and the patients had already been separated, and there was no reason to do it." RN #4 stated "On 12/09/2020, the patient (#5) was designated a "No Room Mate" and placed in a separate room." RN #4 stated, "I did not report the alleged sexual abuse to the nursing supervisor/charge of building who was on duty on the 7 AM - 7 PM shift 12/08/2020 - 12/09/2020 when the patient alleged sexual abuse."

Hospital Policies
Hospital's policy, entitled, "Prevention of Alleged Sexual Familiarity Incidences Among Minors, Adolescent Services", reviewed November 2018, revealed "...When a sexual assault occurs among patients, the assaulting patient should be placed in a secluded area, and the assaulted patient should be removed to a safe place. Following are some guidelines: 1. Notify the attending physician, Nurse Manager and/or Supervisor immediately. 2. Have the assaulting patient examined by the in-house physician in order to conduct lab work...3. The assaulted patient should be transported to the emergency room for examination and treatment...4. Notify the parents/guardian of the incident and counseled regarding the possibility of sexually transmitted diseases, as well as, pregnancy and the need for medical follow-up. Parents and guardians will also be counseled regarding their rights to initiate criminal proceedings and their right to press charges. E. Sexual contact between consenting partners: 1. Notify the attending physician, CNO(Chief Nursing Officer), DCS, CEO(Chief Executive Officer), parents, and guardians. 2. Have both parties examined by the house physician for lab work. 3. Both parties placed within eyesight of staff at all times. 4. HPR (Incident Report) must be completed on each patient."

Hospital policy, entitled, "Incident Reporting", reviewed November 2020, revealed under "Procedure: A. Any facility employee or staff member who discovers, is directly involved in or is responding to an event/occurrence is to complete or direct the completion of a Healthcare Peer Review (HPR) form...C. Completing the HPR: a. The HPR is to be completed at the time of event..e. The event is documented in the medical record by the person most closely associated with the event and includes: A concise statement of the facts of the event, statements are non-judgmental and objective. Clinical condition of patient (as a result of immediate examination by physician if indicated). Names, times of notification of physician, supervisory personnel, family members as necessary...".

Hospital policy, provided by the hospital, entitled, "Risk Management Investigation and Interview Guidelines", reviewed November 2020, revealed "It is the policy ..... to provide an effective mechanism for conducting and documenting investigations and interviews of staff, patients, and/or others as appropriate, as part of risk management follow-up of reported occurrences. These investigations and interviews should be conducted in an objective, systematic manner. Procedure: 1. When an occurrence requires a follow up investigation, a coordinator should be selected to lead the investigation. 2. Prior to initiating interviews regarding an occurrence involving a patient, review the patient's medical record and any other documentation of the situation about which the interview is taking place. Note any inconsistencies, missing information, and unclear handwriting for clarification during the interview.... (Related to staff interviews) 8. Probe for specific details and attempt to find out...time, place and date of occurrence; witnesses to occurrence, and physical or other supporting evidence. 9. The interview should be thorough... Listen carefully to answers and take notes of the important details..Following the interview, document the interview in a memo format...".

Hospital policy, entitled, "Alleged patient Abuse, Neglect, Exploitation, Clinical Services", Reviewed January 2018, revealed "It is the policy of the (hospital) to report all incidents of patient abuse, neglect, and exploitation within twenty-four working hours of the time the incident occurred....3. Any person who reasonably believes or knows of information that would reasonably cause a person to believe that a person has been, is, or will be adversely affected by abuse or neglect, shall as soon as possible report the information to the Department of Social Services...6. The duty to report to an outside agency is separate from a duty to report to the facility administrator. 7. Should a question occur as to whether an incident rises to the level of reportable conduct, the facility should, upon inquiry by a staff person, call the Risk Manager and seek advice...11. Allegations regarding sexual misconduct by non-professionals are controlled by the above referenced laws and protocols..
Procedure: The following actions shall be taken if any staff member identifies or suspects patient abuse, neglect, or exploitation. 1. Report findings immediately to the CNO(Chief Nursing Officer), Nurse Manager, or Nursing Supervisor (after hours and on weekends). 2. Document information on an Incident Report Form. 3. The Nursing Management Representative Notified shall immediately contact the CEO(Chief Executive Officer) and/or Administrator on Call, Patient Representative, and the Director of Nursing. 4. The facility director or designee must make a verbal report to the Department of Social Services and/or the Ombudsman's Office within 24 hours. If the incident occurs on the weekend or holiday, the report must be made immediately on the next business day...".

World Health Organization (WHO)
Review of the document, titled,"Responding to Children And Adolescents Who Have Been Sexually Abused", WHO Clinical Guidelines, ISBN 978-92-4-155014-7, World Health Organization, revealed the following definitions:
"Adolescent: Any person aged between 10 and 19 years, in accordance with United Nations/
World Health Organization definition (1). The definition of an adolescent overlaps with that of
a child, below. "Young adolescents" are defined as those aged between 10 and 14 years and
"older adolescents" as those aged between 15 and 19 years.

"Child sexual abuse: The involvement of a child or an adolescent in sexual activity that he
or she does not fully comprehend and is unable to give informed consent to, or for which
the child or adolescent is not developmentally prepared and cannot give consent, or that
violates the laws or social taboos of society. Children can be sexually abused by both adults
and other children who are - by virtue of their age or stage of development - in a position
of responsibility or trust or power over the victim. It includes incest which involves abuse by
a family member or close relative. Sexual abuse involves the intent to gratify or satisfy the
needs of the perpetrator or another third party including that of seeking power over the
child (3). Adolescents may also experience sexual abuse at the hands of their peers, including
in the context of dating or intimate relationships. Three types of child sexual abuse are
often distinguished: (i) non-contact sexual abuse (e.g. threats of sexual abuse, verbal sexual
harassment, sexual solicitation, indecent exposure, exposing the child to pornography); (ii)
contact sexual abuse involving sexual intercourse (i.e. sexual assault or rape - see below);
and (iii) contact sexual abuse excluding sexual intercourse but involving other acts such as
inappropriate touching, fondling and kissing. Child sexual abuse is often carried out without
physical force, but rather with manipulation (e.g. psychological, emotional or material). It may
occur on a frequent basis over weeks or even years, as repeated episodes that become more
invasive over time, and it can also occur on a single occasion (4). .....".

"First-line support: This refers to the minimum level of (primarily psychological) support and validation of their experience that should be received by all children and adolescents who
disclose sexual abuse to a health-care (or other) provider. It shares many elements with what
is called "psychological first aid" in the context of emergency situations involving traumatic
experiences (10)."

"Sexual assault: Use of physical or other force to obtain or attempt sexual penetration. It
includes rape, defined as physically forced or otherwise coerced penetration of the vulva,
vagina or anus with a penis, other body part, or object. It also includes oral penetration (12).
The legal definition of rape may vary and this may have implications for the medico-legal
aspects of care and for survivors to be brought to health facilities. The perpetrator can be
anyone (i.e. an adult or another child or adolescent, known to the victim or a stranger). Sexual
assault including rape of children or adolescents is a specific form of child sexual abuse. The
latter has a broader d

Based on record reviews, interviews, review of the hospital's video recording, and review of the hospital's policies and procedures,
the hospital failed to ensure a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care in the adolescent psychiatric unit and failed to ensure that patients on the adolescent psychiatric unit received care and services in accordance with the hospital's policies and procedures and Standards of Practice for 2 of 3 patients who reported allegations of sexual abuse. (Patient #1 and Patient #4)


The findings are:

Cross Reference to A 392: The hospital's nursing services failed to provide nursing care to patients on the hospital's adolescent psychiatric unit who alleged sexual abuse in accordance with the hospital's policies and procedures and standards of practice for 2 of 3 patients who alleged sexual abuse. (Patient #1 and Patient #4)

Based on record reviews, interviews, and review of the hospital's policies and procedures, the hospital's nursing services failed to provide nursing care and services in accordance with the hospital's policies and procedures and standards of practice for 2 of 3 to patients receiving care and services in the hospital's adolescent psychiatric unit who alleged sexual abuse during their hospitalization. (Patient #1 and Patient #4)

The findings are:

Incident Report
On 12/21/2020 at 11:30 AM, review of an incident report for Patient #1 revealed the 11 year old patient alleged sexual assault/ rape by his roommate(Patient #2) on Thursday, 11/19/2020 at 2200 (10:00 PM). In an interview with the Director of Quality on 11/12/2020 at 2:22 PM, the Director reported the date of the incident report defaulted to 11/19/20, but the incident report was created on 11/23/20 by the Adolescent Unit Manager.

Patient #1(Alleged Victim)
On 12/21/2020 at 12:00 PM, review of Patient #1's chart revealed the patient was 11 years old and admitted to the psychiatric hospital on 11/19/2020. Review of the form, titled, "Notification Of Child Emergency Admission Appointment Of Designated Examiners" dated 11/19/2020 showed Patient #1 exhibited "explosive outbursts, SI (Suicidal Ideation) Attempt to cut wrist, and ADHD (Attention Deficit Hyperactive Disorder)". Patient #1's was admitted to Room 214 at 15:43 (3:43 PM) on 11/19/2020 with an admission diagnosis of major depressive disorder. Review of Patient #1's "Standardized Intake Assessment" dated 11/19/2020 at 1600 (4:00 PM) showed the patient had "no" sexually aggressive behaviors in the last six months or over the patient's lifetime. In the section of the form, labeled, "Potential for Sexual Victimization" was documented "no" for the last 6 months and "no" over the patient's lifetime. On 12/21/2020 at 12:00 PM, review of physician orders dated 11/19/2020 at 2000 (8:00 PM) revealed "Level of Observations Every 15 Minutes". There were no further physician orders in the patient's chart changing the patient's level of observation during the patient's admission.

On 12/21/2020 at 12:00 PM, review of physician orders in Patient #1's chart dated 11/19/20 at 20:00 (8:00 PM) revealed orders for admission, Psychiatric Groups(Therapy), Medication Management and Recreational/Activity Therapy, Involuntary Status, Consults for Medical Problems and Laboratory Findings, regular diet, weight, and suicide precautions. Review of physician telephone orders dated 11/19/2020 at 19:21(7:21 PM) for Corona Virus Screening, vital signs, and weight, and physician telephone orders on 11/19/20 at 22:53(10:53 PM) for TSH (Thyroid). Review of a physician telephone order dated 11/22/20 at 17:27 (5:27 PM) for Block patient room.

Physician Progress Notes
On 12/21/2020 at 12:00 PM, review of physician progress note dated 11/21/20 at 1050 (10:50 AM) revealed "Patient seen on rounds and discussed with staff. Staff reports possible inappropriate behavior with another peer." Review of physician progress notes dated 11/22/20 and 11/23/20 showed no documented references to the patient's sexual assault by a peer. There was no progress note related to why Patient #1's room was blocked on 11/22/2020 at 5:27 PM. Review of the physician's discharge summary dated 11/24/2020 at 08:36 (8:36 AM) revealed "Hospital Course: ..... Client subsequently reported sexual assault by a male peer..... He was sent out to emergency room for evaluation of sexual assault". Patient #1's chart showed the patient was sent to the Emergency Room after the patient's discharge. There were no other references in the physician progress notes referencing the patient's alleged sexual abuse by Patient #2 on 11/19/2020. There was no documentation of a physician medical or psychological assessment, no physician ordered interventions, or further treatment to address Patient #1's allegation of sexual abuse on 11/19/2020. The patient did not receive a physical evaluation for alleged sexual abuse until 11/24/2020 after the patient's discharge.

Treatment Plan
On 12/21/2020 at 12:00 PM, review of Patient #1's initial treatment plan dated 11/19/2020 at 1930 (7:30 PM) revealed "Danger to Self" was the only problem identified. The patient's treatment plan had no documentation related to the patient's allegation of sexual assault.

Nursing Progress Notes
On 12/21/2020 at 12:00 PM, review of Patient #1's chart revealed there was no documentation in the patient's nursing progress notes dated 11/19/20, 11/20/20, 11/21/20 , or 11/22/2020 of the patient's alleged sexual abuse by the patient's room mate which was alleged to have occurred per the incident report on 11/19/2020. Review of a nursing progress note dated 11/23/2020 at 11:43 AM, reads, "B: can be intrusive at times and requires frequent redirections for boundaries and volume of language. He has alleged over the weekend that a former roommate had sexually inappropriately touched him and this was reported to risk management and family." Review of an "Interdisciplinary Progress Note", dated 11/23/2020 at 1200 (12:00 PM) revealed, "Nurse discussed with .....(Patient #1) about his allegations about another patient sexually assaulting him, mother was notified and requested she be present with patient during a hospital medical exam at children's hospital. She agreed to meet patient at hospital in the morning for an evaluation so that she could be present. She was cooperative and understanding and concerned about .....(Patient #1's)) health." The Interdisciplinary Progress Note dated 11/23/2020 had no signature of the person who authored the note. There was no documentation in Patient #1's nursing progress notes of the patient's reported allegation of sexual abuse on 11/19/2020, no documented nursing assessments of the patient after the patient's allegation of sexual abuse, no reporting of the patient's allegation of sexual abuse to on duty supervisors at the time of the patient's allegation, and delay of reporting the patient's allegation of sexual assault to other other authorities, and no nursing interventions were documented except for blocking Patient #1's room per physician orders dated 11/22/20 at 17:27 (5:27 PM) which was 3 days after the alleged sexual assault occurred.

Social Worker
On 12/21/20 at 12:00 PM, review of a group therapy progress note dated 11/22/2020 at 4:06 PM, reads,"Social Worker informed administrative and nursing staff of Patient (1's) disclosure of sexual activity with patient in group. Social worker was informed that staff was aware of Pt's(Patient's) disclosure and were separating the two to avoid further fraternization." The social work progress note dated 11/22/2020 at 4:06 PM stated, ".....(Patient #1) shared in group that he had a sexual encounter with other group members and expressed feelings of regret. .....(Patient #1) reported that he/she had informed staff as well. Progress made."

Patient #2 (Alleged Perpetrator)
On 12/22/2020 at 2:00 PM, review of Patient #2's chart revealed the patient was transferred to the psychiatric hospital on 11/18/2020 via involuntary emergency admission with diagnoses of Major Depressive Disorder and Suicidal Ideation. Patient #2 was admitted to the hospital's flex unit on 11/18/2020 with physician orders, stating, "11/18/2020 for observation every 15 minutes". Patient #2 was transferred to Room 214 on the adolescent unit on 11/19/2020 at 5:00 PM. On 12/22/2020 at 2:00 PM, review of the hospital's "Standardized Intake Assessment" form, dated 11/18/2020 with no time documented, revealed "Sexually Aggressive Behavior" had "No" checked for "Sexual Aggression in last 6 months" and "History of Sexual Aggression (over lifetime)". In the section labeled, "Potential For Sexual Victimization Behavior" revealed, "No" was checked for "Sexual victimization in the last 6 months", but "yes" was checked for "History of Sexual Victimization (over lifetime)". Documentation in the assessment showed Patient #2 was a "victim of sexual abuse" by his grandmother who sold the patient for money starting when the patient was 6 years old.

On 12/22/2020 at 2:00 PM, review of Patient #2's chart revealed physician telephone orders dated 11/18/2020 for admission, Level of Observations Every 15 Minutes, Suicide Precautions, Psychiatric Group Therapy, involuntary status, regular diet, consult for medical management, Corona Virus screening, weight, and vital signs. Physician telephone order dated 11/19/2020 at 1700 (5:00 PM) revealed "Transfer In - House Transfer Adol (Adolescent) Transfer Pt. (Patient) to AA." Physician telephone order dated 11/20/2020 at 8:00 AM revealed "Nursing Orders - General Block patient room". Physician telephone orders dated 11/22/2020 at 16:30 (4:30 PM) revealed, "Transfer In House Transfer Flex. Level of Observation One on One". Physician telephone order dated 11/24/2020 at 2344 (11:44 PM) revealed "Level of Observation every 15 minutes", and "General Other Nursing Orders Unscheduled: NRM (No Room Mate)." Review of physician telephone orders dated 11/27/2020 at 10:00 (10:00 AM) revealed "Precautions Sexual Aggression Risk." Review of physician orders dated 11/28/2020 revealed "Level of Observation One on One".

On 12/22/2020 at 2:00 PM, review of the physician progress notes dated 11/20/2020 and 11/21/2020 in Patient #2's chart had no documentation related to the patient's alleged sexual assaulting behaviors by Patient #1. Review of physician progress note dated 11/22/20 at 11:10 AM reads "..... staff reports boundary issues /peers, poor Insight, appears to sleep on floor in room, trash all over floor. aggression.....". Review of the physician progress note dated 11/24/2020 at 10:30 AM revealed,"..... He states that he has a prior hx (history) of sexual trauma, but has difficulty acknowledging his pattern of sexually inappropriate behaviors.....". Review of the physician progress note dated 11/27/2020 at 11:20 AM revealed "..... He was tussling with female staff about changing sheets and made contact with her breasts on his hands. He reports it was an accident.....". Review of the physician's discharge summary dated 12/01/2020 reads, "Hospital course: ..... Client exhibits significant behavioral dysregulation. He was aggressive towards staff and peers. He required frequent redirection for intrusive behaviors. ....He was sexually inappropriate with several peers and staff in the milieu and allegedly coerced a male peer to perform oral sex. He was placed on 1:1 for behavior and impulsive aggression until day of discharge."

On 12/22/2020 at 2:00 PM, review of the "24 Hour RN Progress Note &(and) Once A Day Suicide Risk Assessment" dated 11/20/2020 at 10:42 AM revealed "B.....has been hyperactive and inappropriate. He can violate boundaries frequently and does need limits for his behaviors. He got irritable this morning after told to stay back due to inappropriate behavior with peers. Patient has suspected sexual boundaries violation with peer. He needs multiple redirection for his behavior and language with peers and staff. He shows no insight and takes no responsibility for his actions and behavior. ....I. Continue to monitor every 15 minutes;.....".

Review of the Nurse Assignment Sheets for the psychiatric adolescent unit revealed the evening shift staffing on 11/19/2020 was Registered Nurse (RN), 1 Licensed Practical Nurse(LPN), and 3 Mental Health Technicians(MHT). Review of the Nurse Assignment Sheet dated 11/19/2020 -11/20/2020 for the psychiatric adolescence unit revealed 1 RN and 3 MHTs. Review of the 11/20/2020 Nurse Assignment Sheet for the day shift for the psychiatric adolescent unit showed Patient #1 and Patient #2 were still in Room 214. Review of the Nurse Assignment Sheet dated 11/20/2020 for the psychiatric adolescent unit for the evening shift revealed Patient #1 was in Room 212 and Patient #2 was in Room 214 which was designated as No Room Mate (NRM). There was no documentation in either patients' chart as to why separation of the patients was not done immediately after Patient #1 submitted his allegation of sexual assault.

Interviews
MHT #1
On 12/21/2020 at 10:54 PM, Mental Health Technician (MHT) #1 verified working the evening shift on 11/21/2020, and reported receiving information during shift change that .....(Patient #1) was re-assigned to a new room and .....(Patient #2) was under orders for No Room Mate (NRM) due to .....(Patient #1) reported he was forced to have anal sex with .....(Patient #2) on 11/19/2020 or 11/20/2020. MHT #1 reported that she/he did not know the exact date of the incident or who the incident was reported to.

Licensed Practical Nurse #1
On 12/21/2020 at 11:08 PM, Licensed Practical Nurse (LPN) #1 verified working the day shift on 11/20/2020 as the Medication Technician. LPN #1 reported the day shift nurse manager was notified by .....(Patient #1) that his "roommate was touching him." LPN #1 reported that on 11/20/2020, at an unknown time in the morning, LPN #1 answered a telephone call from .....(Patient #1's) mother who was returning a call from the hospital. LPN #1 revealed he instructed the mother that an incident had been reported concerning .....(Patient #1) and the roommate(Patient #2). LPN #1 revealed the mother reported the .....(Patient #1)called her earlier on 11/20/2020 to report his/her roommate had forced him to perform oral sex and had penetrated him twice anally during the night."

RN #1
On 12/22/2020 at 6:30 AM, RN #1 verified she was the charge nurse on the night shift 11/19/2020 through 11/20/2020 working 11:15 PM to 9:15 AM. RN #1 stated, "The last one(sexual abuse) I heard about was at the end of second shift on 11/19/2020. Second shift was having more sex issues. We really need more staff. This staffing is not normal." RN #1 stated that after a patient alleges sexual abuse, "We call the Medical Doctor (MD), and then we call the supervisor. The supervisor notifies risk management and the incident gets reported in the HPR. In all instances, we call the parents."

Nurse Manager - Adolescent Unit
On 12/22/2020 at 10:07 AM, the Nurse Manager (NM) explained, "It was initially brought up on day shift on 11/21/20 on the 7:30 AM-400 PM shift, but from what I can tell nothing was reported. On Monday, 11/21/2020, I learned .....(Patient #1) reported sexual contact on the second shift on 11/19/2020." The NM stated, "Staff should have handled it on the weekend. After an incident, parents are called, and the patients are separated. The Charge of Building (COB) should be notified immediately and begin the risk management paperwork and obtain a rape kit, if needed. From what I understand, this incident was not brought to the COB and follow up was not done until Monday, 11/23/2020. ......(Patient #1) was discharged Tuesday morning and went to the hospital by ambulance to be checked out." When the NM was asked to explain the process that determines if a patient should be designated "No Room Mate (NRM)", the NM said. "So my thing about inpatient history is all our patients have some sort of trauma and sexual trauma. They don't know what to do with these feelings. Unless it is specifically stated, and they admit they have been assaulted, we don't always know to make the patient a NRM. The doctors are good with NRM orders, but Corporate is not happy when we have so many NRM patients." The Nurse Manager reported, "The room mate was not identified as a NRM patient on his initial admission, but later more information from the Department of Social Services (DSS) indicated a history of touching peers." The NM stated, "I am not aware of any substantiated sexual abuse. The Director of Quality has never come to me with reports of substantiated abuse."

Assistant Director of Nursing
On 12/22/20 at 10:12 AM, the Assistant Director of Nursing (ADON) verified she had been Charge of Building for the 7 PM to 7 AM shift on 12/8/20 - 12/09/2020 when the incident of the sexual abuse by Patient #4 allegedly occurred. The ADON reported that she was not notified by nursing during the shift of Patient #4's alleged sexual abuse. When asked what staff responsibilities are when patients allege sexual abuse, the ADON stated staff are to separate the patients, ask both parties what happened, notify the physician, and call everybody. The nurse notifies the Charge of Building after regular hours, and the Charge of the Building notifies Administration. When asked when she was notified of the alleged sexual abuse, the ADON reported she thought RN #7 reported the incident to her on the morning shift on 12/09/20. There was no documentation of this notification in the patients' charts by nursing.

DOQ
An interview with the Director of Quality (DQ) was conducted on 12/22/20 at 1:00 PM in the conference room. The DQ was asked to explain when she became aware of incident of Patient #1' allegation of sexual abuse and what actions were taken. The DQ explained, "We have a system called MIDAS that includes incident reports with names on them. This incident report was a little different since it was vague related to when the incident happened. We were not sure if the incident happened on 11/20/2020 or 11/21/2020. On Monday, 11/23/2020, I called and made a police report and the detective came out that day. The weird thing is the MHT reported noticing the room mate acting weird on 11/19/20. The MHT reported when she went to the room, she could see the room mate was aroused. The MHT stated she talked with both patients who said nothing happened. The timeline is very murky. LPN #1 reported receiving a call from the mom on 11/20/20 at 8:45 AM stating the patient called her claiming the room mate assaulted him. The patient also reported the sexual assault in the group session on 11/21/2020. The room mate denied anything happened. I called the patient's mom again on Monday 11/23/2020. The patient, for whatever reason, did not get a medical check after the allegations until he was discharged on 11/24/20. Mom wanted to be at the hospital so that is why he was sent to the Emergency Department (ED) on 11/24/20 so mom could be present. I have tried to follow up with the ED for the records but they refused. We do not substantiate sexual abuse. We call Out of Home Abuse and Neglect (OHAN) unit of DSS."

Interview Psychiatrist #1
On 1/13/2021 at 8:22 AM, during an interview with Psychiatrist #1 in the conference room , Psychiatrist #1 verified that she was the physician for .....(Patient #1) and .....(Patient #2) who was .....(Patient #1's) roommate on 11/19/2020. Psychiatrist #1 stated she remembered talking to Patient #2's (alleged perpetrator) foster mom about the alleged sexual contact between the roommates. Psychiatrist #1 stated Patient #2's "foster mom did not want the patient to return to her home, and the foster mom was upset because the Department Social Services had not given her the patient's history of sexually acting out in the past". Psychiatrist #1 stated she "recalled a few talks with .....(Patient #1) who never described what happened." Psychiatrist #1 reported ".....( Patient #1) said something had happened, and we offered to send him out immediately for a rape kit, but we wanted his (foster) mom to go to the ER(Emergency Room) with him. The foster mom wasn't available to immediately take him even though an appointment had been made for him on 11/23/20, so we discharged him the next day (11/24/20), sent him by ambulance to the ER so his mom could be present also." Psychiatrist #1 reviewed the progress notes with the surveyor in .....(Patient #1's) chart and stated she "had written a note on 11/23/20 at 8:34 AM when she had first been made aware of some sort of sexual contact between the two roommates". Psychiatrist #1 reported .....(Patient #1) had told her he had made a bad decision and felt ashamed". Psychiatrist #1 reported that she did not know anything about Patient #1 saying he had been raped or anally penetrated". Psychiatrist #1 said it(the assault) had been reported to her that in group therapy, .....(Patient#1) reported that he had been forced to perform oral sex on ..... (Patient #2)". Psychiatrist #1 said, "After reviewing .....(Patient #2's) Admission report, she had noted the patient had sexual trauma in the past". Psychiatrist #1 reported "..... (Patient #2) was violating boundaries with other patients, getting into other people's personal space, touched a nurse's breast which the patient (#2) said was an accident". Review of another progress note with the surveyor, Psychiatrist #1 verified that she had documented "a pattern of sexually inappropriate behavior based on what ..... (Patient #2's) behavior was in the milieu". Psychiatrist #1 stated "they had put ..... (Patient #2) on 1:1 due to his sexualized behavior, but she could not recall when this had been started". When asked if she had been notified on Friday, 11/20/20 about the patient's allegation of sexual contact between the roommates, Psychiatrist #1 said "I do not recall anything was said." When asked if anyone had contacted her on Saturday, 11/21/20 about any sexual contact between the two patients, Psychiatrist #1 stated "They wouldn't call me on a Saturday. Nursing staff would just remove the person from contact with the other, and notify the parents". When asked about when the rape allegation surfaced, Psychiatrist #1 stated, "I was not sure when detailed information was been reported about the sexual contact. In this environment, kids are doing things. We deal with it regularly. Girls kiss each other or someone slaps them on the butt. There is ambiguity where sexual assault occurs, and when the police needs to be notified versus when it is a boundary violation. I think here, there is ambiguity, and being very specific as to what would warrant the emergency protocol. Also with patient safety, removing a patient and notifying parents is another thing. I don't think we have a sexualized behavior protocol." Psychiatrist #1 reported that she is not sure who informed her of the

MHT #6
On 1/12/21 at 12:46 PM, Mental Health Technician(MHT) #6, in Conference Room, reported the Social Worker came out of group therapy on 11/21/2020 at about 2:00 PM and informed staff that ..... Patient #1 said his room mate .....(Patient #2) asked him to give him a blow job. MHT #6 reported he is not sure of the name of the social worker, and reported the first time that he was made aware of sexual allegations between the two boys was that Saturday (11/21/20) after the group session, and it was about a blow job, and nothing else was alleged.

Nurse Manager - Flex Unit
On 1/12/21 at 1:15 PM, in a interview with the Nurse Manager for the Flex unit in the Conference Room, the Nurse Manager revealed .....(Patient #2) was admitted on 11/18/20 at 7:46 PM to the hospital's flex unit, and then transferred to the Adolescent unit on 11/19/20 sometime before 4:00 PM. The Nurse Manager stated when the hospital gets new patients, they get information about any history of abuse or trauma. After reviewing Patient #2's chart, the Nurse Manager verified ..... (Patient #2) had a no room mate order placed on 11/20/21 at 8:56 AM and verified there was no documentation as to why .....(Patient #1) was designated no room mate. The Nurse Manager verified .....(Patient #2) was transferred back to the flex unit on 11/22/20 at about 4:30 PM. The Nurse Manager reported she was off the weekend of 11/21/20 and 11/22/20, and when she returned on Monday, 11/23/2020, .....(Patient #2) was back on the flex unit. The Nurse Manager reported she was "unable to get a straight answer" on what the issues were between him(Patient #2) and another child. When asked, Lauren stated she had reviewed the incident report related to alleged sexual contact between .....(Patient #1) and .....(Patient #2) and signed it off because at the time of the incident report, she was the Unit Manager.



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Patient #4 (Alleged Victim) Patient #5 (Alleged Perpetrator) Incident Report
On 12/21/2020 at 1:30 PM, review of the hospital's "Incident Report Log" showed there was no incident report(s) completed for the alleged sexual assault reported by Patient #4 against her roommate(Patient #5) that occurred on the 7 PM to 700 AM shift on 12/08/2020 - 12/09/2020 until 12/10/2020 at 12:30 AM. Review of the hospital's Incident Report log revealed Patient #4 and Patient #5 were "involved in an alleged incident of sexual misconduct on 12/8/20 at 11:15 PM". The electronic Incident Report for Patient #4 dated 12/10/2020 at 12:08 AM revealed Patient #4 alleged unwanted sexual contact by Patient #5. Review of the electronic Incident Report dated 12/10/2020 at 12:30 AM for Patient #5 revealed "when confronted with Patient #4's allegation of sexual assault, Patient #5 reported that "she was a victim of unwanted sexual contact" by Patient #4. The Incident Report log/Incident Report, dated 12/10/2020, revealed Patient #4 was "placed on unit restriction" and Patient #5 had "increased observation level" as a result of the incident. There was no documentation in either patient's chart related to any interventions implemented by nursing for either patient on 12/08/2020 - 12/09/2020.

Patient #4 (Alleged Victim)
On 12/21/20 and 12/22/20, review of Patient #4's chart revealed the 14 year old patient was admitted to Room 210 A on 12/4/20 with diagnoses that included Psychoses, Major Depressive Disorder, and Personal History of Physical and Sexual Abuse. Review of the social services intake record from the acute care hospital's ED dated 12/03/2020 at 1700(5:00 PM) revealed, "Pt's (Patient's) presented to the ED (Emergency Department) after taking Flomax in an attempt to harm, and Pt reported that she was sexually assaulted in the orphanage...". Patient #4 was admitted to the psychiatric hospital, and review of the psychiatric hospital's intake assessment dated 12/04/2020 at 1528 (3:28 PM) revealed, in the section labeled, Sexual Aggression, that the patient has no history of sexual aggression over the patient's lifetime and no sexual aggression in the last 6 months. Based on review of an incident report dated 12/10/2020 at 12:30 AM, during the 7 PM - 7 AM shift on 12/08/2020 - 12/09/2020, Patient # 4 reported allegations of sexual abuse by her roommate(Patient #5) to Registered Nurse #4. Review of Patient #4's chart revealed there was no nursing, physician, therapy, or social service documentation related to the alleged incident of sexual abuse dated 12/08/2020 - 12/09/2020 on the 7 AM - 7 PM shift. Review of the patient's records revealed the patient continued on the every 15-minute checks that were ordered by the physician on the patient's admission. Review of "Nursing Progress Notes"/ "Once a Day Suicide Risk Assessments", dated 12/9/20, for Patient #4 revealed the patient continued on the every 15 minute observation checks after the reported incident of alleged sexual abuse. There was a place to mark on the form, labeled, "Sexual Victimization, Sexual Aggression, Other" on the nursing assessment, but the areas were not checked to indicate inappropriate sexual contact had occurred. There was no documentation to indicate either unit restriction or increased level of observations were implemented for the patient as indicated on the filed incident report. Review of the observation logs where staff documented the every 15 minute checks for Patient #4 revealed the patient had not been kept separate from Patient #5 after the reported incident to ensure the potential for continued abuse or intimidation would not occur. Documentation on the observational sheets for Patient #4 dated 12/9/20 revealed Patient #4 and Patient #5 were in the Day Room at 10:45 AM, both patients were in the cafeteria from 11:00 AM to 11:30 AM, and review of the Process Group notes dated 12/9/20 at 1:00 PM revealed Patient #4 and #5 attended the same Group therapy. Patient #4 was discharged on 12/9/20 at 4:00 PM, and subsequently taken to the acute care hospital's emergency room by the patient's mother related to the allegation of sexual abuse when hospitalized in the psychiatric hospital. On 12/22/2020, review of a Police Report dated 12/11/2020 revealed the police responded to the "local hospital emergency room for a female who expressed she was sexually assaulted by her roommate while hospitalized." The patient's mother reported her daughter notified her of the incident of sexual assault on 12/09/2020. The mother stated "Her daughter told her she was digitally penetrated in the vagina, rectum, and mouth."

Patient #5(alleged Perpetrator)
On 12/21/2020 and 12/22/2020, review of Patient #5's chart revealed the 12 year old patient was admitted to Room 210 B on 12/8/20 in the psychiatric hospital for suicidal threats, self harm, homicidal ideation, and running away. The patient's diagnoses included Major Depressive Disorder and Personal History of Physical and Sexual Abuse. Review of the patient's intake form dated 12/08/2020, with no time recorded, showed in the section labeled, Sexually Aggressive Behavior, that the patient had no aggressive sexual behavior in the last six months and no sexually aggressive behavior over the patient's life time. Review of the admission physician orders for Patient #5 12/8/20 revealed 15 minute observation checks. O 12/08/20 - 12/09/20 on the 7 PM - 7 AM shift, Patient #4 alleged Patient #5 sexually abused her. There was no documentation to indicate either physician orders or nursing orders had been written for increased supervision of the patients after Patient #4's alleged alleged sexual abuse by Patient #5. There was no nursing, physician, therapy, or social service documentation related to Patient #4's alleged incident of sexual abuse that occurred on the 7 PM - 7 AM shift on 12/08/20 - 12/09/2020 in Patient 5's chart. There was no documentation of physician orders for increased observations or unit restriction. Review of the patient's records revealed the patient continued on the every 15-minute checks that were ordered on the patient's admission. Patient #5 was discharged on 12/14/20.

On 12/22/20 at approximately 3:15 PM, review of the Incident Report completed by Registered Nurse (RN) #4 dated 12/10/2020 at 12:08 PM for Patient #4 revealed "...Nurse continued to ask questions and patient proceeded to tell nurse that her roommate was touching her own body and private area and that she was just standing there watching. Later, the patient reported to staff that she and her roommate touched each other but she didn't want to do it and that she was scared and was crying inside". On 12/22/20 at approximately 3:40 PM, review of an electronic copy of the Incident Report for Patient #5 completed by RN #4 on 12/10/20 at 12:10 AM revealed "...A peer of the above patient (Patient #5) reported to staff that the above patient(Patient #5) told her that she (Patient #5) and her roommate (Patient #4) had just had sex. When asked about it, Patient (#5) denied saying it. When the day shift nurse asked Patient (#4), she stated that Patient (#5) asked her to kiss her and that she didn't want to but did kiss her and allowed the other patient to touch her. She denied forcing the roommate to engage in any inappropriate behaviors."

Interviews
Mental Health Technician(MHT) #5
On 12/22/20 at 7:20 AM, an interview was conducted with Mental Health Technician (MHT) #5 who verified she worked the 11 PM - 7 AM shift on 12/8/20 and was knowledgeable of the alleged incident of sexual misconduct. MHT #5 confirmed that she and RN #4 were made aware of the patient's (Patient #4's) allegation of sexual abuse on the 7 PM - 7 AM shift on 12/08/2020 - 12/09/2020. MHT #5 reported that after the alleged incident occurred, the patient (Patient #4) exhibited head banging and expressed that she was afraid. MHT #5 reported "I observed the patient (#5) getting some water and going back into her room a few minutes before starting shift rounds. MHT #5 reported she started rounds, and when she got to that room, she assumed the patient (Patient #5) was in the bathroom, and the room mate (Patient #4) was elsewhere on the unit. MHT #5 reported she checked the observation room but Patient #4 was not in the observation room so she went back to the patients' room and found the patients (Patient #4 and #5) in bed. MHT #5 stated she asked both patients if they were okay, and then she informed the nurse (RN #4) that she thought the patients (Patient #4 and Patient #5) had been in the bathroom together. MHT #5 reported the nurse (RN #4) went to the room to talk to the patients. MHT #5 stated RN