HospitalInspections.org

Based on record review, observations, and interview, the facility failed to protect a patient's right to be free from all forms of abuse when the facility failed to report a credible allegation of a sexual assault for one out of three patients reviewed for allegations of a sexual assault, according to the State law. (Patient #1)

Findings include:

Review of the facility provided policy "Title: RRI 025 Abuse, Neglect, Abandonment of Patients" (last revised dated 6/2024) reflected, "Upon evidence of reasonable cause to believe that a child, or an elderly or disabled person is in a state of abuse, exploitation or neglect, staff are obliged to report the circumstances to the appropriate state agencies ..."

Review of the facility provided, Risk Management Policy (revised 12/2023) reflected, "it is also important the Risk Manager report credible allegation of abuse or neglect of patient to the appropriate State agency, UHS Management Department, the patient's guardians, insurance company, when appropriate, and local authorities."

Review of Patient #1's Therapist note dated, 11/5/24 reflected, " ...it happened on the unit with another patient during movie time at night shift at the back rectangle table ...she was sexually assaulted by a pt on unit 3 different times, 1 time listed in prior sentence, 2 time in the lunchroom, 3 time in the big group room sitting at the table."

Review of Patient #1's facility provided behavioral health progress note dated 11/7/2024 reflected, "Therapist called pt (patient's) parent and informed her of the allegations that Patient #1 had stated to me about being touched several times inappropriately by another pt who was male. Mother was sad and upset and did say she wanted to press charges ..."

Review of Patient #1's "Investigation Tool Checklist: Abuse/Neglect Response Plan" (dated 11/6/24) reflected, "Alleged incident Type: Sexual Assault, Date Reported: 11-5." The report was completed by Staff #11, RN and signed by Staff #4, Risk Manager.

An observation made on the morning of 7/1/25, in a facility conference room revealed a video recording of patient #1 and Patient #2 interacting in the adolescent units day room. Patient #1 and Patient #2 are not seen making physical contact during the recording. Further video review revealed Patient #2 touching Patient #17 between her legs, over her pants. The facility was unable to provide the video recordings for the movie night and the lunchroom videos.

During a tour of the facility's adolescent's lunchroom on the afternoon of 6/30/25 revealed one lunchroom table that is blocked from the camera view by a large support wall that is approximately 3 feet wide.

When asked if Patient #2 had been interviewed as part of the sexual assault investigation, Staff #4 stated, he (Patient #2) had already been discharged.

Review of Patient #2's medical record dated 11/7/2025 reflected the therapist contacted adolescent's father and reported allegation of sexual assault and suggested intense counseling with someone who specialized in addiction and or sexually acting out.

During an interview, on the morning of 7/1/25, in the facility conference room, Staff #4, Risk Manager stated in part, the facility had conducted an investigation. When asked if the facility had reported the incident to Health and Human Services, Staff #4 stated in part, "No, it was not substantiated. We investigate all allegations, three staff (administrative staffs) participated in reviewing the video; we didn't see anything." However, the facility failed to consider the camera's blind spots in the lunch room and patient #2's inappropriate touching of patient #17. Staff #4, Risk Manager confirmed the facility had not considered the incident of patient #2 being video recorded touching another female patient in the same manner, making patient #1's reported incident more credible.