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Based on record review, observation and interviews, the facility failed to ensure 2 of 2 (Patient #1 and Patient #2) recieved care in a safe setting. Patient #1. was able to enter into Patient #2's room without staff knowledge or supervision, Patient #1 entered another patient room Patient #2's and claimed she was sexually assaulted by Patient #1.


Findings included:
During record review the hospital Sexually Acting Out (SAO) - Allegation Response Form 02/23/2025 at 9:45 PM, "Patient #1 was found laying down on the floor of the restroom of a male Patient #2 naked and Patient #1 verbalized that she was raped by the male patient."

In observation of hospital video footage, the video footage is started at 8:31 PM. At 8:31:58sec Patient #1 enters into Patient #2's assigned room directly across the hallway. Patient #1 did have a shirt on at that time. At 8:39 male Staff #7 comes over to assist Staff #6 open Patient #2's room door. At 8:40 PM male Patient #2 exits assigned room. At 8:31 PM Staff #6 was observed walking up and down the hallway checking Patients on her clip board. As well as going to door to door searching for Patient #1. Staff #6 was also witnessed walking behind the MHT Desk, and overlooking the milieu and other patients approaching her and Patient #1 ran into the Patient #2's room at that time. This was one incident just a different angle of observation from video footage.

During interview conducted on 03/20/2025 at 4:20 PM with Staff #3 was asked about the Continued Plan of Corrections presented to the Surveyor. Staff #3 indicated having no knowledge of said Plan of Correction and no employee has been reprimanded in reference to this incident.

During Interview conducted on 03/20/2025 at 4:00 PM with Staff #6, RN reported on the day in question admits to working the unit as a Mental Health Tech indicating Staff #6 not as a nurse as which Staff #3 is trained for. However, Staff #6 should be trained to over see the MHT's on the unit as well. Staff #6 indicated not seeing the Patient #1 in assigned room. Stating she did not see Patient #1 in any other room. Staff #6 indicated noticed the room door was closed directly across from Patient #1's assigned room. Staff #6 indicated approaching Patient #2's room door but felt the pressures on the opposite side of the door holding the door closed. Staff #6 stated Staff #7 assisted in opening the door. The door came open when the Staff #7 opened it. Once the door was open Patient #2 was seated on assigned bed putting pants on. Staff #6 then went into the shower and found Patient #1 laying on the shower floor without any clothing on. When Patient #2 was questioned, it was reported while in assigned room, Patient #1 entered room and bent over in face and then they engaged in sexual activity (intercourse). Staff #6 indicated not being able to figure out how Patient #1 entered the room. Staff #6's reports this was the main concern, Staff #6 had as Staff #6 had been monitoring the hallway and milieu. Staff #6 indicated this was the first time working as a Tech, Staff #6 indicated I am not trained as a Tech, I am a nurse.

During interview was conducted on 03/20/2025 at 5:40 PM with Staff #3 informed that there is concern of all the sexual allegations listed on the hospital incident report. Staff #3 was informed this was due to the lack of Patient supervision and being short staffed. Staff #3 agreed with the finding. Staff #3 was surprised that the Staff #6 reported not knowing what to do as a Tech being a regular nurse on the unit. Staff #3 agreed that they should manage unit as well as the MHT's working the unit. Staff #3 reported all nursing staff are trained on the MHT and operating systems.

During Record Review presented by Staff #1 the training record did not reflect Staff #3 signed in as attending the training.

During Record Review the hospital incident log was reviewed from January 1, 2025 through March 20, 2025 (79 days). There were 65 Incidents in the 79 days that involved Sexually Acting Out Behavior. This reflects 3 out of 4 incidents were sexual boundary issue.

Policy
The hospital Policy on Patient Rights 10/2022, "University Behavioral Health of Denton shall protect the rights of patients as per the Patient Bill of Rights and Texas Law. The staff shall be trained on the 'Patient Bill of Rights' and upon admission, patients will be fully informed of their rights as outlined below. Restriction of patient rights is done only in those situations where the safety, security and welfare of the patient mandates such restriction."

The hospital Policy on Abuse, 12/2022, "University Behavioral Health Of Denton promotes respect, dignity, and safety to all its patients and their rights. Therefore, allegations of patient abuse or neglect will be investigated in accordance with the aforementioned law. Threats or restrictive actions in response to patient's request for discharge shall be considered abuse and are prohibited."

The hospital Policy on Nursing Services 10/2023, "The delivery of nursing care at University Behavioral Health of Denton shall be understood as a purposeful and perpetual application of diversified talents with the common goal of positively impacting the health status of those entrusted to our care. Therapeutic use of self shall be the central treatment of the health status of those entrusted to our care."

The Hospital Policy on Quality Care and Treatment 'Plan for Patient Care and Professional Services' 08/2023, "University Behavioral Health of Denton is committed to the provision of quality behavioral health services to our community. This commitment is demonstrated through the facility's mission and supported through effective strategic and budget planning efforts. Resources are utilized to meet individual patient, family, and staff goals most effectively and efficiently possible."

The hospital Policy on Observation 09/2024, "It is the policy of University Behavioral Health of Denton (UBH-Denton) to provide a safe and secure environment for patients during their hospitalization. To ensure patient safety and to provide a process for observing and documenting patient location and behavior. Staff will conduct observation rounds on each patient as ordered while in treatment. The primary staff who are conducting rounds will be the MHT and nurses, but any staff can be utilized to complete patient rounds per the patient observation procedures."