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The Hospital was out of compliance for the Condition of Participation for Patient Rights.

Findings included:

The Hospital failed to ensure for one (Patient #1) patient of 10 sampled patients that the Hospital provided care in a safe setting.

Refer to Tag A-0144

The Hospital failed to ensure for one (Patient #1) patient of 10 patients sampled to provide care in a safe setting to prevent an alleged sexual assault on a locked behavioral health unit.

It was reported that Patient #1, who had erratic behavior, auditory and visual hallucinations, paranoid behavior and significantly impaired insight and judgement, was found by a Mental Health Clinician with another male patient (Patient #2) in the Sensory Room. On 9/27/19, (at an undocumented time) a Mental Health Clinician found Patient #2 to be laying on his/her back on a bean bag chair with his/her shirt pulled to his/her mid-abdomen and his/her pants unzipped and open while Patient #1 was lying on top of him/her with his/her face in Patient #2's groin area. The report indicated that Patient #1 was delusional at the time of the sexual assault and believed that Patient #2 was his/her deceased fiance. During this admission, a second female patient reported to a nurse on the evening of 9/27/19 that Patient #2 had propositioned him/her for a sexual favor and he/she declined.

Patient #1 was admitted to the Hospital on the locked behavioral health unit on a Section 12 (involuntary commitment) in 9/2019 due to having grossly impaired insight and judgement. Patient #1 had a diagnosis schizoaffective disorder.

The Surveyor interviewed Charge Nurse #2 on 12/4/19 at 12:15 P.M. Charge Nurse #2 said that, on 9/27/19, the staff had kept a close eye on Patient #2 prior to the sexual assault because Patient #1 thought he/she was his/her deceased fiance and the two patients were getting close. Charge Nurse #2 said that Patient #2 presented as a predator and she wasn't sure what his/her motive was.

Review of a Nursing Patient Care Note, dated 9/27/19 at 9:02 P.M., indicated that Patient #1 was disorganized, confused, forgetful, and repeating questions despite attention from staff. Patient #1 was seen walking in the hall with Patient #2 and noted to be getting close at times with him/her. The Nursing Patient Care Note indicated 15 minute checks were maintained. During the 15 minute checks, Patient #1 and Patient #2 were found in the Sensory Room. Patient #2 was sitting on a bean bag and Patient #1 was kneeling with his/her face in Patient #2's lap.

Review of Patient #2's Psychiatric Progress Note, dated 9/30/19 at 4:09 P.M., indicated that it was reported to the Psychiatrist that another patient, Patient #3, had informed staff that Patient #2 sexually harassed Patient #3 and propositioned him/her for oral sex prior to this event. Patient #3 refused the verbal advances and reported this to a registered nurse.

Review of the medical records for Patient #3 did not indicate that there was any documentation regarding Patient #3's complaint of sexual proposition by Patient #2 on 9/27/19.

Review of the Hospital's incident report logs did not indicate that an allegation of sexual harassment was reported as a result of Patient #3 reporting that Patient #2 propositioned him/her for oral sex prior to the sexual assault on Patient #1 that took place on 9/27/19.

The Surveyor interviewed the Risk Manager on 12/2/19 at 11:30 P.M. The Risk Manager said that the proposition (sexual harassment) did not rise to the level of reporting an incident in the Hospital's reporting system.

The Surveyor interviewed the System Director of Behavioral Health on 12/2/19 at 12:50 P.M. The System Director of Behavioral Health said that he has high expectations and would have expected the unidentified staff member to write a note about Patient #2's sexual harassment of Patient #3 by propositioning him/her for oral sex.

The Hospital failed to identify the potential for sexual assault on Patient #1 by not communicating effectively and not addressing the allegations of sexual harassment that took place between Patient #2 and Patient #3, and subsequently, the later sexual assault on Patient #1.

Based on record review and interviews, the Hospital failed to ensure for one (Patient #1) patient of ten sampled patients, that patients were protected from sexual abuse/assault. In addition, the Hospital failed to investigate allegations of sexual abuse/assault for two (Patient #1 and Patient #3) patients of ten sampled patients.

Findings include:

It was reported that Patient #1, who had erratic behavior, auditory and visual hallucinations, paranoid behavior, and significantly impaired insight and judgement was found by a Mental Health Clinician with another male patient (Patient #2) in the Sensory Room. On 9/27/19, (at an undocumented time) a Mental Health Clinician found Patient #2 to be laying on his/her back on a bean bag chair with his/her shirt pulled to his/her mid-abdomen and his/her pants unzipped and open while Patient #1 was lying on top of him/her with his/her face in Patient #2's groin area. The report indicated that Patient #1 was delusional at the time of the sexual assault and believed that Patient #2 was his/her deceased fiance. During this admission, a second female patient reported to a nurse on the evening of 9/27/19 that Patient #2 had propositioned him/her for a sexual favor and he/she declined.

Review of the Hospital's Abuse and Neglect Policy, dated 12/1993, indicated that patients have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of resident property. Patients should not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the patient, family members or legal guardians, friends or other individuals.

Prevention and identification of abuse/neglect may be accomplished via the following:
-Discussion during staff meetings,
-Review with patients and family,
-Follow-up on complaints,
-Patient and family education of the role of the ombudsman,
-Analyzing performance improvement indicators for trends.

Investigations:
-Complaint forms and variance reports will be filled out by all staff,
-All complaints and variance reports will be investigated by the Chief Nursing Officer, Administrator, Vice President of Quality Improvement,
-Appropriate information will be obtained which includes; staff involved, time of incident, statements form patient and staff, etc.

Protection:
- All attempts to protect patients and staff during an investigation will be made.

Reporting:
-All staff are required to report cases of suspected abuse, neglect or mistreatment.

Definitions:
Sexual Abuse: "includes but is not limited to, sexual harassment, sexual coercion, or sexual assault".

1. Patient #1 was admitted to the Hospital in 9/2019 on the locked behavioral health unit on a Section 12 (involuntary commitment) due to having grossly impaired insight and judgement. Patient #1 had a diagnosis of schizoaffective disorder.

Review of a Nursing Patient Care Note, dated 9/27/19 at 9:02 P.M., indicated that Patient #1 was disorganized, confused, forgetful, and repeating questions despite attention from staff. Patient #1 was seen walking in the hall with Patient #2 and noted to be getting close at times with him/her. The Nursing Patient Care Note indicated 15 minute checks were maintained. During the 15 minute checks, Patient #1 and Patient #2 were found in the Sensory Room. Patient #2 was sitting on a bean bag and Patient #1 was kneeling with his/her face in Patient #2's lap.

The Surveyor interviewed Charge Nurse #2 on 12/4/19 at 12:15 P.M.. Charge Nurse #2 said that, on 9/27/19, the staff had kept a close eye on Patient #2 prior to the sexual assault because Patient #1 thought that Patient #2 was his/her deceased fiance and the two patients were getting close. Nurse #2 said that she contacted the System Director of Behavioral Health via email to inform him of the sexual assault. Charge Nurse #2 said that she contacted the Nursing Supervisor and that the physician was notified but did not come to see either patient. Charge Nurse #2 said that Patient #2 presented as a predator and she wasn't sure what his/her motive was. Charge Nurse #2 said that she thought she submitted an incident report to the reporting system. Record review revealed that Charge Nurse #2 did not submit an incident report in the Hospital's reporting system. Charge Nurse #2 said that the incident was considered a sexual assault. Charge Nurse #2 said that she would not call the police in this instance.

The Surveyor interviewed the Risk Manager on 12/2/19 at 11:30 A.M. The Risk Manager said that the Risk Management Department doesn't have an on-call program and found out about the sexual assault of Patient #1 on 9/30/19. The Risk Manager said that she was not involved in the investigation of the sexual assault but did attend the Root Cause Analysis on 10/7/19. The Risk Manager said that the System Director of Behavioral Health did the investigation.

The Surveyor interviewed the System Director of Behavioral Health on 12/2/19 at 12:50 P.M.. The System Director of Behavioral Health said that he was informed of the sexual assault on 9/27/19 while he was not working. The System Director of Behavioral Health did not say if he reported the incident to the Administrator-on-Call or if he directed the nursing staff to do so.

The Surveyor interviewed the the Associate Chief Nursing Officer on 12/4/19 at 10:45 A.M. The Associate Chief Nursing Officer said that the Nursing Supervisor on 9/27/19 was not notified by Charge Nurse #2 of the sexual assault. The Associate Chief Nursing Officer said he was later able to determine that there was a lapse in nursing supervisor coverage on the evening of 9/27/19 so that could be why the Nursing Supervisor was not notified and chain of command for reporting the sexual assault was not followed as indicated in the Abuse and Neglect policy.

The Surveyor interviewed the Social Worker on 12/4/19 at 10:00 A.M. The Social Worker said that, on 9/28/19 when she arrived to the Hospital around 1:00 P.M., she was told the System Director of Behavioral Health requested the staff to have the Social Worker handle a discharge plan for Patient #2 because of an incident that happened the evening before. The Social Worker said she did not think that discharge was the appropriate plan of action and contacted the Director of Social Work for advice. The Social Worker said she then told the Charge Nurse to notify the Legal Department. The Social Worker said that she filed a telephone report of the sexual assault to the Disabled Persons Protection Commission and, by the time she left for the day on 9/28/19, Patient #1's family and the local police had not been notified by the Hospital of the sexual assault which occurred at an undocumented time on 9/27/19.

Review of Patient #2's Psychiatric Note indicated that, on 9/29/19, the Psychiatrist called Patient #2's emergency contact and informed him/her of the sexual assault that took place on 9/27/19. The emergency contact became very emotional. The Psychiatrist told him/her that he/she may choose to report this to the police. The emergency contact said he/she would do that and within an hour the police showed up and started to ask questions of the staff.

Due to untimely documentation, lack of reporting to the appropriate chain of command and follow-up investigation, the Hospital failed to provide an effective investigation into the sexual assault of Patient #1.
2. Patient #3 was admitted to the Hospital in 7/2019 on the locked behavioral health unit with diagnoses including schizoaffective disorder.

Review of a case study provided indicated that, on the evening of September 27, 2019, Patient #3 had reported to an unidentified nurse that Patient #2 had propositioned him/her for a sexual favor.

Review of a Psychiatric Note, dated 9/30/19, indicated that Patient #2 propositioned Patient #3 for oral sex. Reportedly, Patient #3 refused the verbal advances for oral sex and reported the incident to an undocumented nurse.

Review of the Hospital's incident report logs did not indicate that an allegation of sexual harassment was reported as a result of Patient #3 reporting Patient #2 propositioning him/her for oral sex.

The Surveyor interviewed the Risk Manager on 12/2/19 at 11:30 P.M.. The Risk Manager said that the proposition (sexual harassment) did not rise to the level of reporting an incident in the Hospital's reporting system.

The Surveyor interviewed the System Director of Behavioral Health on 12/2/19 at 12:50 P.M.. The System Director of Behavioral Health said that he has high expectations and would have expected nursing to write a note about Patient #2's sexual harassment of Patient #3 by propositioning him/her for oral sex.

When the Hospital was asked to provide a copy of the investigation surrounding the sexual harassment of Patient #3 by Patient #2 the Hospital was unable to provide an investigation file.

The Hospital failed to properly communicate, report and investigate the sexual harassment allegation reported by Patient #3.

The Hospital was out of compliance for the Quality Assessment and Performance Improvement (QAPI) Condition of Participation.

Findings include:

The Hospital failed for one (Patient #1) patient of 10 sampled patients to ensure an investigation and implementation of preventative actions after Patient #1 was sexually assaulted.

Refer to TAG: A-0286

Based on interviews and records reviewed, the Hospital failed for three (Patient #1, Patient #2 and Patient #3) patients of 10 patients sampled, to ensure investigation and implementation of preventative actions were completed after Patient #1 was sexually assaulted by Patient #2 and after Patient #3 was sexually harassed by Patient #2.

Findings include:

It was reported that Patient #1, who had erratic behavior, auditory and visual hallucinations, paranoid behavior, and significantly impaired insight and judgement was found by a Mental Health Clinician with another male patient (Patient #2) in the Sensory Room. On 9/27/19, (at an undocumented time) a Mental Health Clinician found Patient #2 to be laying on his/her back on a bean bag chair with his/her shirt pulled to his/her mid-abdomen and his/her pants unzipped and open while Patient #1 was lying on top of him/her with his/her face in Patient #2's groin area. The report indicated that Patient #1 was delusional at the time of the sexual assault and believed that Patient #2 was his/her deceased fiance. During this admission, a second female patient reported to a nurse on the evening of 9/27/19 that Patient #2 had propositioned him/her for a sexual favor and he/she declined.

Review of the Hospital's Abuse and Neglect policy, dated 12/1993, indicated that Patients have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of resident property. Patients should not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the patient, family members or legal guardians, friends or other individuals.

Prevention and identification of abuse/neglect may be accomplished via the following:
-Discussion during staff meetings.
-Review with patients and family.
-Follow-up on complaints.
-Analyzing performance improvement indicators for trends.

Investigations:
-All complaints and variance reports will be investigated by the Chief Nursing Officer, Administrator, Vice President of Quality Improvement.
-Appropriate information will be obtained which includes; staff involved, time of incident, statements form patient and staff, etc.

Review of the Hospital's Safety Reporting Policy, dated 10/30/17, indicated that the Hospital will:

1. Establish a method for timely identification, investigation, and reporting of incidents that have an adverse or potentially adverse impact on patients. visitors and colleagues;
2. Identify serious safety events and provide a method for proper analysis and follow-up;
3. Facilitate identification of process issues, trends and opportunities for improvement;
4. Provide a non-punitive, just culture conducive to reporting; and
5. Comply with regulatory and accreditation requirements for reporting.


1. Patient #1 was admitted to the Hospital on the locked behavioral health unit on a Section-12 (involuntary commitment) in 9/2019 due to having grossly impaired insight and judgement. Patient #1 had a diagnosis of schizoaffective disorder.

Review of a Nursing Patient Care Note dated 9/27/19 at 21:02 indicated that Patient #1 was disorganized, confused, forgetful, and repeating questions despite attention from staff. Patient #1 was seen walking in the hall with Patient #2 and noted to be getting close at times with him/her. The Nursing Patient Care Note indicated 15 minute checks were maintained. During the 15 minute checks, Patient #1 and Patient #2 were found in the Sensory Room. Patient #2 was sitting on a bean bag and Patient #1 was kneeling with his/her face in Patient #2's lap.

The Surveyor requested a copy of the Hospital investigation. The Hospital provided a synopsis of the investigation performed by the System Director of Behavioral Health. This synopsis indicated that, on 10/1/19, the Mental Health Specialist that discovered the sexual assault was questioned about what she saw. On 10/1/19, in a telephone interview, the nurse for Patient #1 said that he was not a witness to the events. On 10/3/19, the System Director for Behavioral Health spoke with the Charge Nurse who worked 9/28/19 and asked her why she didn't follow the chain of command and contact the Legal Department to inform them of the sexual assault that took place the day before, instead of notifying the house supervisor. On 10/4/19, the System Director of Behavioral Health met with the Department of Mental Health investigator and discussed the next steps with them. No further interviews or investigation documentation was provided to the Surveyor in relation to the sexual assault.

The allegation of sexual assault on Patient #1 by Patient #2 was reported to the Department of Public Health as a Serious Reportable Event on 10/7/19. The Hospital staff members were aware of the sexual assault on 9/27/19. State regulatory requirements are that all Serious Reportable Events are to be reported to the Department of Public Health within seven calendar days of the date of discovery of an Serious Reportable Event.

The 30-day review of the Serious Reportable Event had inconsistencies with the medical records reviewed in relation to the family being notified of the sexual assault, the police being notified of the sexual assault, the level of supervision provided to Patient #2 after the sexual assault and the timeliness of notification to the Hospital administration and police after the sexual assault occurred.

The Surveyor interviewed the Risk Manager on 12/2/19 at 11:30 A.M. The Risk Manager said that the Serious Reportable Event was not reported to the Department of Public Health until 10/7/19 because the Risk Management Department doesn't have weekend coverage and didn't learn of the event until 9/30/19 and it is their internal policy to submit the Serious Reportable Event within 7 days of the Risk Management Departments identification of the event. The Risk Manager said that the Root Cause Analysis resulted in corrective actions that were not in effect as of 12/2/19. The Risk Manager said that, although the Root Cause Analysis is not dated, she knew that the Root Cause Analysis meeting took place on 10/7/19.

The Hospital provided a copy of the undated Root Cause Analysis. The Hospital identified that Patient #1 was sexually assaulted by Patient #2. The corrective actions were:

1. Video surveillance of sensory room and add lights that don't turn off;
2. Work on chain of command as a result of this case;
3. Would team huddle have helped in this situation?
4. Process for vetting patients for geriatric psychiatric care;
5. Criteria for every 5 minute or 1:1 observation and
6. Criteria for calling a Sexual Assault Nurse Examiner.

At the time of the Survey, the Hospital had not implemented any of their corrective actions. There was no follow up on the Root Cause Analysis that took place on 10/7/19 and no education had been provided to the staff members to address the corrective actions identified in the Root Cause Analysis as of 12/4/19. The Hospital failed to identify the breakdown of the Hospital's own Abuse and Neglect Policy by lack of documentation, investigation and timely reporting to the family, the police and the Department of Public Health.


2. Patient #2 was admitted to the Hospital in September of 2019 with diagnoses which included depression and suicidal ideation.

Review of a Psychiatric Progress Note, dated 9/30/19 at 4:09 P.M., indicated that Patient #2 was found with Patient #1 in the sensory room: Patient #2 was reclined on the bean bag chair, his/her shirt pulled up, his/her pants unfastened, and Patient #1's face in his/her crotch face-down. The Mental Health Specialist who found Patient #1 and Patient #2 told them to stop and get dressed and then reported the incident. Patient #1 was placed on 1:1 constant observation and Patient #2 was placed on five minute observation. It was reported to the Psychiatrist that Patient #3 had informed staff that Patient #2 sexually harassed Patient #3 and propositioned him/her for oral sex prior to this event. Patient #3 refused the verbal advances and reported this to a registered nurse.

The Root Cause Analysis, undated, indicated that another patient had reported to an unidentified nurse that Patient #2 had sexually harassed him/her by requesting oral sex.

The Surveyor interviewed the Risk Manager on 12/2/19 at 11:30 A.M. The Risk Manager said that the proposition (sexual harassment) did not rise to the level of reporting an incident in the Hospital's reporting system.

The Surveyor interviewed the System Director of Behavioral Health on 12/2/19 at 12:50 P.M. The System Director of Behavioral Health said that he has high expectations and would have expected nursing to write a note about Patient #2's sexual harassment of Patient #3 by propositioning him/her for oral sex.

The Hospital did not identify any corrective actions that should have taken place as a result of this sexual harassment report and did not follow their Abuse and Neglect Policy or their Safety Reporting Policy.

3. Patient #3 was admitted to the Hospital in July of 2019 with a diagnosis of schizoaffective disorder.

During the Root Cause Analysis that took place on 9/27/19, the Hospital identified that Patient #3 was sexually harassed by Patient #2. Patient #2 had propositioned Patient #3 for oral sex.

Record review revealed that there was no documentation in Patient #3's medical record to indicate that the report of sexual harassment had be identified, investigated or corrective actions implemented to prevent a like occurrence from happening again.

The Surveyor interviewed the Risk Manager on 12/2/19 at 11:30 A.M. The Risk Manager said that the proposition (sexual harassment) did not rise to the level of reporting an incident in the Hospital's reporting system.

The Surveyor interviewed the System Director of Behavioral Health on 12/2/19 at 12:50 P.M. The System Director of Behavioral Health said that he has high expectations and would have expected nursing to write a note about Patient #2's sexual harassment of Patient #3 by propositioning him/her for oral sex.

The Hospital failed to identify the sexual harassment of Patient #3, failed to properly report, investigate and implement corrective actions for both the sexual harassment of Patient #3 and the sexual assault of patient #1 to prevent like occurrences from happening in the future.