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Based on clinical record review, interviews, review of hospital documentation, and review of hospital policy for 1 of 10 patients reviewed for patient rights (Patient #1) the facility failed to investigate an allegation of sexual abuse in a timely manner. The finding includes:

Patient #1's diagnosis included schizoaffective disorder bipolar type.

Patient #1's psychiatric annual review dated 11/10/2020 identified Patient #1 had a history of delusions, hallucinations and poor impulse control. The treatment plan directed to continue to work with Patient #1 on reality testing of his/her auditory hallucinations and delusional beliefs to improve his/her ability to cope with them.

Review of Patient #1 and Patient #2's clinical records for November and December 2020 failed to identify an allegation of patient-to-patient sexual abuse.

The hospital documentation dated 7/15/21 identified that Patient #1 reported that last November (2020), Patient #2 raped him/her. Patient #1 reported that Patient #2 told him/her to perform oral sex in the comfort room at 12:00 PM, and again at 3:00 PM in the female bathroom, again at 7:00 AM the next day, and that they had intercourse in the male dormitory. Patient #2 denied ever having any sexual behavior with Patient #1 or any other patients.

Interview with Patient #1 on 11/1/21 at 11:18 AM identified that in November 2020 while in the comfort room, Patient #2 pulled down his/her pants and threatened to punch Patient #1 if he/she did not perform oral sex. Patient #1 identified that he/she complied because he/she did not want to get punched. Patient #1 identified that approximately one week later he/she reported it to Psychologist #1, but nothing was done until after Patient #2 was readmitted. At that time, Patient #1 re-stated concerns about Patient #2 being on the same unit. Patient #1 was unable to recall the specific dates of the alleged sexual assault or the dates he/she reported it to hospital staff.

Interview with MD #2 on 11/8/21 at 9:55 AM identified that she was not aware of Patient #1's allegation of abuse from November 2020 until sometime in July 2021 when Patient #1 reported the allegation again and a full investigation was completed. MD #2 identified that Patient #1 identified that she reported it to Psychologist #1 and MHW #1, but the psychologist and mental health worker did not work on the unit during that time. MD #2 identified that based on staff and patient interviews, and Patient #1's history of delusions, false allegations, and inconsistent story, the hospital did not substantiate the allegations. MD #2 identified that the allegation was also investigated by the hospital police department in July 2021, and they did not substantiate the allegation.

Interview with Psychologist #1 on 11/8/21 at 3:30 PM identified that she returned to work on Patient #1's unit in November 2020 after being temporarily reassigned to another unit. Psychologist #1 identified that after a group session in November 2020 she approached Patient #1 because she felt Patient #1 needed support after she observed Patient #2 reject Patient #1's effort to engage in conversation. Psychologist #1 identified Patient #1 then reported that approximately one week prior while in the comfort room, Patient #2 threatened to harm Patient #1 if he/she did not perform oral sex. Psychologist #1 identified he/she immediately reported it to RN #2, and it was her understanding that RN #2 completed an incident report.

Interview with RN #2 on 11/8/21 at 5:00 PM identified that sometime in the fall of 2020 Psychologist #1 notified her of an allegation of sexual abuse reported by Patient #1. RN #2 identified he/she completed a critical incident report and reported it to MD #2. RN #2 could not recall who she submitted the incident report to for follow up. RN #2 identified she did not document it in the clinical record, did not place either patient on continuous observation for safety, and did not notify the DHMAS police or the patient advocate because Patient #1 was delusional and that she had completed an incident report.

Interview with the Director of Quality on 11/9/21 at 4:00 PM identified the hospital is unable to locate an incident report or evidence of an investigation for the allegation of sexual abuse that was reported to Psychologist #1 in November 2020.

Interview with the Chief Executive Officer on 11/10/21 at 5:00 PM identified if a patient makes an allegation of abuse, it should be documented in the medical record, and an incident report should be completed to initiate the hospital investigation process.

The hospital was unable to provide documentation that the allegation of abuse was investigated from 11/2020 until 7/15/2021.

The hospital abuse policy dated 12/27/18 identified all employees made aware of alleged abuse must report this immediately to their supervisor and complete an incident report by the end of the shift when the alleged violation occurred or was discovered. The patient should be moved immediately to a safe location and a registered nurse and physician must complete a thorough physical assessment of the patient including any psychological effects. The RN supervisor and/or unit director, or manager who is made aware of an allegation of abuse initiates the first phase of the facility's investigation process which must include the collection of witness statements, oral notification to the division director, and notification to the public safety division and the critical incident submission form.

Based on observation, interview, review of hospital documentation, and review of hospital policy, for one of nine shifts reviewed for nursing staffing, the hospital failed to provide staffing according to policy. The finding includes:

Hospital documentation identified that unit Battel 4 north had a patient census of 22 on 10/29/21, 10/30/21 and 10/31/21. Review of staffing schedules identified that only 3 staff members (1 RN and 2 Mental Health Workers) worked on the night shift (11:00 PM to 7:00 AM) on each of the three nights.

Interview with Director of Nursing #1 on 11/8/21 at 3:00 PM identified that all Battel units are required to have 5 staff members on the night shift. The Director of Nurses identified that if there isn't enough staff scheduled to work, the hospital will exhaust all staffing resources including a mass distribution request to hospital employees and any trained staff at other DHMAS facilities to fill the vacancies, and that the Nursing Supervisor and/or Director of Nurses will provide additional support as needed based on the acuity of the patients.

The hospital's plan for providing nursing care identified that staffing patterns are determined utilizing patient to staff ratios. Patient to staff ratios on average are one staff to every four patients on both day and evening shifts and one staff to six patients on the night shift. The staffing plan identified 5 total staff are required on the night shift for Battel 4 north.