HospitalInspections.org

Based on interview and record review, the facility failed to implement their policy that provided 1 Patient (Pt #2) of 10, a safe setting, from an alleged abuser, Patient #3, resulting in the potential for unsatisfactory outcomes for any of the 131 patients currently being served by the facility. Findings include:
See specific tag A-0144.

Based on interview and record review, the facility failed to report an alleged sexual abuse encounter and protect the rights of one (Pt #1) of ten (Pt's #10, #11, #12, # 13, #14, #15, #16, #17, #18 and #19) patients reviewed for alleging sexual abuse, resulting in the potential for undesirable outcomes for all 131 patients served by the facility. Findings include:

On 04/12/22 at 0900 during the entrance conference, The Director of Quality, Staff B, stated "I bet I know why you are here." Staff B started to tell the story of Patient (Pt) #2, complaining of an alleged sexual abuse incident. Staff B proceeded to tell that they were "not sure it the patient even told anyone in house, but we know he told his mom.". The patient's mom apparently told the Social Worker the day after the incident happened, but he did not report it, he suggested "she tell one of the nurses."

On 04/12/22 at 1206 during review of the document titled "Family Session Note" dated "03/18/22" it was determined that the Social Worker, Staff M, documented under the header "Issue addressed: ...but mom said his new roommate tried to kiss him and did kiss him. Mom became upset, why did he not tell her before this, and why didn't you do to him what you did to me? Apparently, this went on for a few minutes, I empathized with her anger, she said who do I talk to, to make sure that this is investigated. I suggested she tell one of the nurses."

On 04/12/22 at 1400 during an interview with Staff B, it was noted that the Pt's mother never called anyone to report the incident. It was also noted that Staff M, never reported the allegation to nursing staff or any of the appropriates people noted in the facility's policy.

On 03/12/22 at 0930, an interview and review of a Complaint/Grievance investigation was conducted with Staff C, Office of Recipient Rights (ORR) pertaining to Pt #2. According to Staff C, he emptied the ORR Complaint Mailbox on 03/24/22, found the alleged allegation report form filled out by Pt #2 and initiated an investigation. Further review it was noted that during 01/01/22 and 04/12/22 there were a total of 10 events documented of "peer to peer sexual allegation" including a "03/24/24 "peer to peer sexual allegation" for Pt #2.

According to the ORR notes
(Pt #2) stated a nurse named "(Unknown name)" came in to check on them twice, during the approximate 20-minute encounter, he did not yell or try to get staff's attention during this time, but spoke to staff afterwards, who told him to sleep on the bench.

Review of provider notes dated 03/14/22 through 03/24/22 revealed no mention of the patient's inappropriate sexual behavior. There was no evidence that nursing /Behavioral Health Technician (BHT), or the social worker had informed the appropriate people Admin, DON, ORR, of the patient's inappropriate behavior.

On 04/12/22 at 1430 during an interview with the Registered Nurse, Staff G, in charge of the patient's care the night of the alleged abuse (03/17/22), she stated the "He never said anything to me. He did say he didn't want a roommate, but he never alleged a sexual abuse incident ever occurred."

Review of the grievance revealed Pt #2 identified that the incident happened on 3/17/22 and named his roommate, Pt #3, as "kissing him and touching him". The complaint form was filled out and completed on 03/20/22. On 03/24/22 when the ORR was aware of the alleged incident, the physician was notified that Pt #3) was identified as displaying inappropriate sexual behaviors towards his peers and was ordered to be on 5-minute safety checks to help maintain a safe environment for all patients. On 03/24/22 both Pt #2 and Pt #3 were interviewed by phone with their guardians also on the phone, due to them both being "minors". Staff C, ORR, stated that "they both denied anything happened in front of their moms".

On 04/12/22 at 1430, The Director of Nursing (DON), Staff F, was asked to explain why nursing had not documented the anything in regard to the alleged abuse. She stated "We just aren't sure when or where, or who knew. It was noted in the video that Pt #2 approached the nurse's desk, talked to an unidentified person. They point to a bench in the hall, Pt #2 has his pillow and blanket in hand and lays on the bench. According to the "rounding Checks" document it was noted that the Pt #2 never returned to his room.

On 04/13/22 at 1300 during review of the facility's policy "Sexual Contact Policy" number 2.47.02, with a revision date 02/20/19:

It is the policy of (the facility) to take all allegations of sexual contact between patients whether witnessed or unwitnessed very seriously. All allegations of sexual contact including non-consensual contact between adults and all sexual contact between adolescent's patient or patient that have a guardian will be promptly reported to the (local police department).

Procedure:
In the event that sexual intercourse or oral sex between patients does occur or is suspected, the following procedure is required:
1. The Sexual Contact Form will be completed and filled out in its entirety. The completed form will be placed in the patient's medical record. (Exhibit A)
2. The attending physician of both patients must be contacted.
3. The administrator on call, nursing administrator on call and Risk Manager will be immediately notified of the event.
4. The CEO, Director of Patient Care Services, and the Recipient Rights Advisor will be notified ASAP (as soon as possible), but within 24 hours of notification of the event. If the below criteria is present, the listed steps will be completed by the RN (Registered Nurse).

Further review on 04/13/22 at 1500, revealed that a "Sexual Incident Form" was not completed and place in the patient's medical record according to policy. Staff B confirmed at this time there was no completed form in the chart.