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Based on observation, interviews, current and discharged record reviews, and policy reviews, the facility failed to have a systemic practice in place to prevent sexual abuse and harassment for one eligible adult psychiatric patient (#5) of one patient abused in the inside waiting room designated as 2E-041, of the Behavior Health Emergency Department (BHED).

The facility:
- Failed to identify the opportunities for abuse and harassment;
- Failed to take proactive measures that may have prevented abuse and harassment;
- Failed to report an incident of sexual abuse in accordance with applicable State law; and
- Failed to respond in a timely manner after an incident of sexual abuse and harassment to prevent recurrence.

The severity and cumulative effect of the systemic practice resulted in substantial non-compliance with 42 CFR 482.84 - Condition of Participation: Patient's Rights.
The facility census was 188.

Based on observation, interview, record review and policy review the facility failed to protect one eligible adult psychiatric Patient (#5) of one patient reviewed from sexual abuse and harassment in the Behavior Health Emergency Department (BHED). The facility also failed to report the incident/event to the Department of Health and Senior Services (DHSS) as required by State Statute.

Findings included:

1. Record review of the Missouri Revised Statute, Chapter 208, Section 208.912 dated 08/28/12 showed the following direction:
-When any adult day care worker; chiropractor, Christian Science practitioner, coroner, dentist, embalmer, employee of the departments of social services, mental health, or health and senior services; ... ....hospital and clinic personnel engaged in examination, care, or treatment of persons; ... ....mental health professional; minister; nurse; nurse practitioner; optometrist; other health practitioner; ... ....physician; physician's assistant; podiatrist; probation or parole officer; psychologist; vendor as defined in section 208.900; personal care attendant; or social worker has reasonable cause to believe that a consumer has been abused or neglected as defined in section 660.250 as a result of the delivery of or failure to deliver personal care assistance services, he or she shall immediately report or cause a report to be made to the department.

Record review of the facility's policy titled, "ABUSE AND NEGLECT" dated 06/12/13, showed the following:
- Policy: The facility will screen the patient for history of abuse, neglect, or harassment, train work force members on related reporting, ensure a timely and thorough investigation of an incident where reasonable cause to suspect abuse, neglect or harassment is present, and report and analyze in accordance with applicable Missouri or Federal law.
- Purpose: To provide a safe environment and to provide guidance for staff regarding their responsibilities in investigating and reporting suspected abuse or neglect.
- Preventing Abuse and Neglect: All workforce members are trained on components necessary for abuse protection in order to effectively prevent, identify, and protect patients at risk of abuse or neglect in accordance with applicable Missouri or Federal Law.
- Mandatory Reporters of Child Abuse or Neglect or Disabled Adult/Elderly Abuse or Neglect shall make reports of suspected abuse or neglect required by Missouri law to the government agency with statutory responsibility to investigate such reports.
- Social Work Services or the Behavior Health shall coordinate follow up activities between the hospital and investigating government agency.

Record review of the facility's document titled, "OBSERVATION STATUS POLICY" dated 10/27/11, showed the following:
-Universal Psychiatric Precautions: All patients by their need to be evaluated and/or admitted for any psychiatric condition will be seen as having the potential for harm to self and/or others throughout their stay and will be monitored regularly.
- Sexual Behaviors: Any patient who exhibits poor control of non-aggressive sexual impulses and who is not verbally redirectable will be placed on 1:1/constant observation status by nursing staff immediately until further face to face evaluation by psychiatrist/APRN (Advanced Practice Registered Nurse).

2. Record review of the facility's undated document titled, "Timeline from Incident [a definite and separate occurrence; an event] Occurring in BHED on 06/17/13" showed a sexual abuse and harassment incident occurred during a period of nine minutes while the perpetrator (Patient #3) and the victim (Patient #5) were in the BHED inside waiting room while unattended and out of staff view.

3. Record review of Patient #5's medical record showed that the patient was brought to the BHED by her mother for suicidal ideation. She had the following psychiatric diagnoses:
- Axis I: Adjustment disorder with disturbance of mixed emotions and conduct;
- Axis II: Mild mental retardation: (three criteria must be met for a diagnosis of mental retardation: an IQ below 70, significant limitations in two or more areas of adaptive behavior (as measured by an adaptive behavior rating scale, i.e. communication, self-help skills, interpersonal skills, and more), and evidence that the limitations became apparent before the age of 18).
- Axis III: Asthma;
- Axis IV:Relationship issues; and
- Axis V: Global Assessment of Functioning 50 (a numeric scale zero through 100 with a rating of 41-50 is for symptoms that lead to antisocial behavior (kleptomania) or social dysfunction. (Psychiatric Diagnoses are categorized by the Diagnostic and Statistical Manual of Mental Disorders [DSM-IV]) categorized by Axis, a five-level diagnostic system to classify illnesses):


4. Record review of Patient #3's medical record showed the following psychiatric diagnoses:
- Axis I: 1. Mood disorder; 2. History of schizoaffective disorder, bipolar types (schizoaffective disorder can include-but are not limited to-hopelessness, helplessness, guilt, worthlessness, disrupted appetite, disturbed sleep, inability to concentrate, and depressed mood (with or without suicidal thoughts); 3. Attention deficit (a combination of problems, such as difficulty sustaining attention, hyperactivity and impulsive behavior).
- Axis V: Current Global Assessment of Functioning 40.
The patient was a self-admit to BHED for suicidal ideation (thoughts about how to kill oneself, which can range from a detailed plan to a fleeting consideration).

5. Record review of the facility's document titled, "Patient Safety Event Interview Form" dated 06/17/13, showed the following statements by Patient #5 the night of the event:
- We were alone in the waiting room. He tried to get me to sit on his lap and I would not. He pulled down his pants and shook his butt at me. He grabbed my hand and made me touch his private parts; white stuff came out of his private part. After that he played with my breasts and kissed my chest, kissed my stomach and put [his] hand down my pants, then underwear and played with my private parts. He then put his face down there. After that he kissed my chest again.
- I am not sure how long all of this lasted. I told the nurse what happened. I do want to press charges against him.
- Yes, I would like to have a nurse examine me if it will help me press charges against him.
- The only thing that he said to me was that he could get me again and other women back here and have sex with them.

6. Record review of the facility's document titled, "Adverse Event Response Checklist, First "10" Minutes" dated 06/17/13, showed the following information for Patient #5 immediately after the event: Non-consensual sexual interactions: e.g. sexual harassment, sexual coercion, sexual assault. Indicator of potential failure to prevent neglect.

7. Record review of the facility's document titled, "BEHAVIOR OBSERVATION RECORD" dated 06/17/13, showed that the staff completed observation rounds on all patients between 15 and 20 minutes according to the facility's rounding policy and procedure.

8. Record Review of the facility's document titled, "Event Summary" dated 06/17/13 showed that Patient #3 and Patient #5 came separately to BHED both presenting with suicide ideation. They were interviewed by the attendant in the outside waiting room and then taken to the inside waiting room (2E-041) where they were unattended and out of view from staff. At this time Patient #3 began to sexually harass and assault Patient #5 creating an incident of abuse.

9. Record review of the facility's document titled, "Behavioral Health ED Assignment Sheet" dated 06/17/13 (the date of the sexual abuse event), showed: Three Registered Nurses (RNs) and three Mental Health Technician's (MHTs) were on duty and the patient census on the date of 06/17/13 was six, which included Patients #3 and #5.

10. During an interview on 06/20/13 at 5:12 PM, Staff G, Corporate Accreditation Officer, Quality Resources, stated that the ED SANE (Sexual Assault Nurse Examiner) called the incident into the Social Services hotline (direct telephone line in constant operational readiness so as to facilitate immediate communication) and as an employee that would be considered as self-report to the proper investigating government agency. He stated administrative staff were aware of the incident and he did not call the DHSS (Department of Health and Senior Services) because he thought it was already self-reported when the SANE Nurse called.

During an interview on 06/24/13 at 1:45 PM, Staff G stated that DHSS had already investigated the sexual abuse event.

11. Record review showed that a representative from Social Services for Adult Protection Services was called and not DHSS by the SANE Nurse .

12. During an interview on 06/24/13 at 3:15 PM, Staff T, RN, Director of BHED, stated that Staff G was responsible to report all abuse and neglect events to DHSS.

13. During an interview on 06/27/13 at 9:45 AM, Staff NN, RN, SANE Nurse, stated that her policy and procedure directs her to call Social Services for Adult Protection Services to report events of abuse/neglect.

14. During an interview on 06/27/13 at 10:15 AM, Staff G stated that he should have made the call to report the sexual abuse event as directed by policy and procedure and wasn't aware that the SANE policy and procedure directed her to contact social services.

15. During an interview on 06/20/13 at 5:30 PM, Staff GG, RN, Chief Operating Officer (COO) of the BHED stated that the BHED had separated males and females in the inside waiting room to two separate areas. Now males wait in one area and females in another area and they are no longer together.

16. During an interview on 06/20/13 at 5:45 PM, Staff S, RN, Administrator for Inpatient BHED, stated the area where the incident happened is now separated between male and female patients. She stated staff completed 15 minute rounds in the BHED inside waiting room. She stated the facility is in the process of putting video cameras in each room, so a camera will be located in the male waiting room and one in the female waiting room.

17. The first observation on 06/20/13 at 5:48 PM in the BHED, showed that male patients were waiting in the waiting room on the North end and female patients were located at the South end waiting room.

The second observation on 06/24/13 at 3:15 PM showed that the male and female waiting rooms were separated but no increased monitoring of the patients had been put into place such as increased patient observations, video cameras or dedicated clinical staff.

18. Observation on 06/24/13 at 03:45 PM in the BHED, showed three distinct patient waiting areas. Entrance from the front entrance of the BHED showed:
-The first waiting area was located directly to the right beyond an open doorway approximately 40 inches wide. Chairs were located against the walls. The room layout was somewhat square with one entry and exit point. Beyond the waiting room doorway was a walk through metal detector and a security guard desk. When positioned behind the desk, staff were not able to see into the waiting room. No video camera or surveillance monitoring was present in the waiting room.
-The second (room 2E-041) and third (room 2E-051) waiting rooms were located beyond the metal detectors, down a hallway and beyond secure double doors in a distinct patient care area. Staff areas were located on one side of the hall and patient care rooms were located across the hall from the staff areas. Each of the rooms had one doorway approximately thirty six inches wide located at the front of the rectangular shaped rooms. No staff or video monitoring surveillance was present in either of the waiting rooms. Patient activity could not be monitored from the staff desk or hallway.
-These waiting rooms(2E-041 and E2-051) are where patients at high risk wait to be interviewed by the psychiatrist.
-Staff must physically enter the waiting rooms through the doorway from the hallway to visualize patients.

19. During an interview on 06/24/13 at 3:45 PM, Staff R, Director of Nursing (DON), stated that clinical staff are not assigned to the security staff area or the waiting room but respond when notified by security staff when needed to triage patients. She verified that the video cameras at the entrance to the facility and at the double doors beyond the metal detectors did not provide surveillance into the waiting room.

20. During an interview on 06/24/13 at 3:55 PM, Staff T verified Patient #5 was wearing a hospital gown while in the waiting room (2E-04) at the time of the sexual assault. Staff T stated that after being triaged by the Mental Health Tech (MHT) all patients are given a hospital gown to wear while in the waiting room before being evaluated by the nurse or psychiatrist.

21. During an interview on 06/24/13 at 3:40 PM, Staff S, RN, stated that the cameras were to be installed into each waiting room. She stated that the head of security was looking at cameras to be purchased but first they needed to free up DVR (digital video recorder) space and that they were looking at the possibility of using cameras they already have that are not being utilized anymore.

22. During an interview on 06/24/13 at 3:30 PM, Staff T, stated that the facility's response to the sexual assault of Patient #5 (a female patient) by Patient #3 (a male patient) while in the facility BHED waiting room was to separate the male patients from the female patients and place video cameras in the waiting rooms.

23. During the same interview, Staff T stated that the planned video camera installation in the BHED waiting rooms was a problem due to the unavailable DVR plug in ports and that the additional equipment wasn't available and that she didn't know when the equipment would be available. Staff T verified patients were currently left unmonitored in waiting rooms and stated that she is aware of the risks of same sex sexual assaults and that video monitoring would not prevent sexual assaults from occurring but would only verify that an event took place after the occurrence.

24. During an interview on 06/25/13 at 10:50 AM, Staff V, Medical Doctor (MD), BHED Medical Director, stated that he felt the waiting room separation was a start (in the prevention of future occurrences of sexual assaults) but thinks the installation of video cameras in each room and making sure rounding was done every 15 minutes, plus or minus five minutes, will help (to ensure that this type of assault doesn't happen again).

25. During an interview on 06/24/13 at 3:30 PM, Staff R, RN, Director of Nursing (DON) of the Behavior Health facility stated that administration had a meeting on 06/21/13 to look at possible changes in the unit to prevent another sexual abuse and harassment event in the inside BHED waiting room. She stated that installation of a camera in the waiting room was at a standstill.

During an interview on 06/24/13 at 3:45 PM, Staff R, did not have a response when asked how same sex patients were being protected from abuse/neglect in the waiting rooms. She stated that there were 15 to 20 minute observations on those patients. She stated that there was no plan to place a clinical staff monitor in the waiting rooms and no plan to have the video cameras monitored by a dedicated clinical staff member after installation.

26. Record review of the facility's undated document on 06/24/13 titled, "Action Items from 06/26/13 [this is an incorrect date and should have been dated 06/21/13] Alleged Sexual Assault Event RCA (root cause analysis)" for Patient #5 showed the following:
- Develop electronic trigger for evaluating/identifying vulnerable person risk early in the process with a target completion date of 08/01/13 [45 days from the sexual assault event];
- Improve the ability to monitor waiting area activities (cameras, structural changes) with a target completion date of 07/17/13 [30 days from the sexual assault event];
- EQUIPMENT: No cameras in waiting area. Screening tool for patients regarding vulnerabilities (victim precautions) - with a target completion date of 08/01/13 [45 days from the sexual assault event].
- Implement process to allow patients' choice of street clothes or gowns once contraband screening has been conducted. Conduct pertinent policy reviews with a target completion date of 08/01/13 [45 days from the sexual assault event].

27. During an interview on 06/27/13 at 8:45 AM, Staff HH, MHT, stated that Patient #3 had made sexual comments to her before the event with Patient #5. She stated that she reported the inappropriate remarks to Staff MM, RN.

28. During an interview on 06/27/13 at 9:00 AM, Staff MM stated that Staff HH did report the inappropriate sexual comments made by Patient #3. She stated that most of the staff was involved with two other combative patients and there was so much going on at the time she could not recall if Staff HH reported to her before or after the sexual abuse event took place.









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