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Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.13 PATIENT RIGHTS was out of compliance.

A-0144 CARE IN SAFE SETTING The patient has the right to receive care in a safe setting. Based on interviews and document review, the facility failed to ensure patients received care in a safe setting after allegations of sexual abuse were reported.

Based on interviews and document review, the facility failed to ensure patients received care in a safe setting after allegations of sexual abuse in two of four patient charts reviewed (Patients #1 and #4).

Findings include:

Facility policies:

According to the policy Patient Abuse or Neglect, the facility assessed the conditions of potential physical and sexual abuse. Assessment and Referral (A&R) staff would question regarding abuse during the Evaluation of Risk. A&R staff would document data in the Evaluation of Risk, as well as the Comprehensive Psychosocial Assessment. Any reports to authorities would be documented in the Legal section of the Comprehensive Psychosocial Assessment.

According to the policy, Incident Reporting and Severity Classification, Acute, any facility staff member who witnesses, discovers or has direct knowledge of an incident should complete an incident report as soon as practical after the incident is witnessed or discovered and/or before the end of the shift/work day. All occurrences involving patients should be documented in the patient's treatment record. Sexual Assault Allegations (patient to patient) is defined as any allegations in which patients have engaged in sexual behavior with each other, without consent.

1. The facility failed to ensure care in a safe environment by failing to immediately separate patients after allegations of abuse, in accordance with facility expectations.

A. Medical record and document review revealed patients were not separated immediately after reports of sexual assault.

a. Record review of Patient #1's medical record revealed the patient was admitted on 7/6/22 on an M1 hold (involuntary psychiatric hospital admission) for treatment of major depressive disorder. According to a nurse's note documented on 7/9/22 at 9:30 a.m., Patient #1 stated she was assaulted on 7/8/22 and "nothing was done." On 7/11/22 at 1:20 p.m., a physician progress note documented Patient #1 reported an allegation of a sexual assault by Patient #4 and the patient called the police to discuss the issue.

i. Review of patient census reports revealed after the 7/8/22 allegations, Patient #1 and Patient #4 remained in the same patient care unit. The census reports showed that on 7/9/22, Patient #4 was moved in closer proximity in the unit to Patient #1. The census reports further revealed Patient #4 was not relocated to a different unit until 7/10/22, which was two days after Patient #1 reported the assault.

This was in contrast with a staff training slide presentation on abuse titled Abuse and Neglect which was provided by the quality director, who stated all nurses received this training during the onboarding process. The staff training read, the facility was to prevent further harm to the patient while the investigation was in progress. This included separation of the patient from the individual accused of the offense.

B. Interviews with staff revealed patients were expected to be separated immediately after an allegation of abuse was reported.

a. On 8/3/22 at 3:59 p.m., an interview with registered nurse (RN) #1 was conducted. RN #1 stated patients were expected to be separated after any allegations of sexual abuse. RN #1 stated the reason for separating patients was to protect their safety.

b. On 8/4/22 at 8:42 a.m., an interview with the quality director (Director) #2 was conducted. Director #2 stated patients should have been separated immediately after allegations of sexual abuse were reported. He said the reason for separating the patients was to avoid contact between the accuser and the accused patient.

2. The facility failed to ensure reports of abuse were reported and included in the patient's medical record.

a. Record review of Patient #1's medical record revealed she was admitted on 7/6/22 on an M1 hold (involuntary psychiatric hospital admission) for treatment of major depressive disorder. According to a nurse's note documented on 7/9/22 at 9:30 a.m., Patient #1 stated she was assaulted by Patient #4 the day before and "nothing was done." The nurse's note further read the police were contacted.

i. Upon review of the Incident Log, there was no incident report created regarding Patient #1's allegation of assault. This was in contrast to the policy Incident Reporting and Severity Classification, Acute, which read, any facility staff member who witnessed, discovered or had direct knowledge of an incident should complete an incident report as soon as practical after the incident was witnessed or discovered and/or before the end of the shift/work day.

ii. Upon review, Patient #1's medical record did not include a checklist titled Evaluation of Risk or an updated Comprehensive Psychosocial Assessment. This was in contrast with the policy Patient Abuse or Neglect, which read, assessment and referral (A&R) staff would question the patient regarding abuse during the Evaluation of Risk and document the data in the medical record. The policy further read, any reports to authorities would be documented in the Comprehensive Psychosocial Assessment.

b. Record review of Patient #4's medical record revealed he was admitted on 7/5/22 for treatment of schizoaffective disorder (hallucinations or delusions combined with mood disorder symptoms, such as depression or mania). Review of Patient #4's medical record revealed an undated, untimed, and unsigned nurse's note located between 7/8/22 and 7/10/22 in the medical record, which documented Patient #4 was placed on a room block (keeping the patient in his room) due to inappropriate behavior with his roommate.

i. Upon review of the Incident Log, there was no incident report created regarding Patient #4's room block due to inappropriate behavior with his roommate. This was in contrast to the policy Incident Reporting and Severity Classification, Acute, which read, any facility staff member who witnessed, discovered or had direct knowledge of an incident should complete an incident report as soon as practical after the incident was witnessed or discovered and/or before the end of the shift/work day.

ii. Upon review of Patient #4's medical record, there was no documentation regarding details of the allegation reported by Patient #1 or the details of the safety precautions taken. This was in contrast with the policy Incident Reporting and Severity Classification, Acute, which read, all occurrences involving patients should be documented in the patient's treatment record.

iii. Upon further review, the medical record did not include a checklist titled Evaluation of Risk or an updated Comprehensive Psychosocial Assessment. This was in contrast with the policy Abuse or Neglect, which read, assessment and referral (A&R) staff would question regarding abuse during the Evaluation of Risk. A&R staff would document data in the Evaluation of Risk. The policy further read any reports to authorities would be documented in the Comprehensive Psychosocial Assessment.

c. On 8/3/22 at 3:59 p.m., an interview with registered nurse (RN) #1 was conducted. RN #1 stated the purpose of an incident report was to document something unexpected, such as contraband or patient aggression. RN #1 stated she did not know if there was a risk to the patient if an incident report was not filled out, but that an incident report should have been filled out for anything unexpected or out of the ordinary.

RN #1 explained she did not create an incident report regarding Patient #1's allegation of abuse because she was waiting for the quality director to review the security camera footage around the time of the allegation. RN #1 stated an incident report was not required because the allegation was not substantiated. This was in contrast with the Incident Reporting and Severity Classification, Acute policy which defined sexual assault allegations as any allegation in which patients have engaged in sexual behavior with each other, without consent. The policy further read any staff who had direct knowledge of an incident should complete an incident report as soon as practical.

d. On 8/4/22 at 8:42 a.m., an interview with the quality director (Director) #2 was conducted. He stated the reason the facility required incident reports was to document any occurrence that was outside of the usual norm. Director #2 explained the purpose of incident reports was to document errors, opportunities for training, and facility trends. Director #2 stated there was not a specific procedure for filling out incident reports for abuse allegations.

Director #2 was asked about the Evaluation of Risk and Comprehensive Psychosocial Assessment. He stated an Evaluation of Risk was a checklist that the facility no longer used. He stated that the Comprehensive Psychosocial Assessment was completed at admission for each patient. Director #2 stated according to the way the policy read, the Comprehensive Psychosocial Assessment should have been updated in Patient #1's medical record after the police were contacted.

Review of Patient #1 and #4's medical record revealed no evidence of a checklist titled Evaluation of Risk or an updated Comprehensive Psychosocial Assessment documented after authorities were notified of an event in accordance with policy.

e. On 8/5/22 at 11:20 a.m., an interview with the chief executive officer (CEO) #3 was conducted. CEO #3 stated the policies and procedures regarding the Evaluation of Risk and the Comprehensive Psychosocial Assessment were unclear. CEO #3 said that if administrators were confused by policies and procedures, staff would also be confused.