HospitalInspections.org

Based on interview and record review, the facility failed to protect three Patient's (P) right to be free from all forms of abuse and harassment, specifically sexual harassment, by a staff member. The facility failed to conduct a thorough investigation when notified of misconduct by a staff member that was sexual in nature and failed to identify other patients that may have been at risk for similar harassment. As the patients were minors receiving behavioral health treatment services, with previously diagnosed psychological and/or psychiatric issues, the psychosocial harm and potential for negative effects as a result of this deficient practice cannot be fully determined, however, it is known that this deficient practice has the potential to affect all the patients participating in the program.

Findings include:

On 05/13/22 at 12:27 PM, the Office of Health Care Assurance (OHCA) received an e-mail from the facility reporting a "staff to outpatients" Abuse incident/investigation. The Event Report from the Vice-President of Behavioral Health and Pharmacy Services (VPBHP) outlined an investigation completed on 04/15/22 by the facility, of the following allegations against a Van Transporter/alleged perpetrator (AP), responsible for driving male and female minors to and from their Day Treatment Services Program:

The AP "was observed making a remark that could be construed as sexual in nature to one of the [female minor] patients in front of other patients."

The AP had " ...several inappropriate, unwelcome, or sexual conversations with the [minor-aged] patients ..."

The AP " ...took one [female minor] patient's temperature by scanning her thigh instead of her forehead ..."

The AP " ...admitted to stopping to buy the patients coffee at Starbuck's."

On 08/03/22, the State Agency entered the facility to investigate the abuse allegations. Upon review of the facility's investigation notes, it was revealed that on 03/30/22, three of the female program patients (P1, P2, and P4), all minors, reported to an Associate Instructor (AI) that the AP had sat in P1's seat at a table in the courtyard when she got up and left it for a period of time. Upon her return, when she asked for her seat back, the AP responded " ...you can sit on my lap ..." P1 is a 15-year-old female with depression and a history of sexual assault/trauma from September 2021. In response, the facility questioned the AP, initiated an investigation, arranged for direct supervision of the AP's van transport that afternoon, and then removed the AP from the transportation schedule at the end of that day. A record review of P1's electronic health record (EHR) for 03/30/22 revealed two phone notifications made that day to P1's mother by her Primary Counselor (PC1). The first notification was to inform her that P1 may have been exposed to COVID-19. The second to inform her that "the facility would not be able to provide program transportation for tomorrow [03/31/22]." There was no documentation found that P1's mother had been informed of any problems with the AP, or of the incident that had occurred that day.

On 03/31/22, during a scheduled "family therapy session" that P1 chose not to attend, P1's mother expressed concerns about the AP to PC1. P1's mother reported that during the week of 03/21/22, the AP had not brought P1 directly home after Program but had stopped to buy coffee drinks for his two female minor passengers [P1 and P2]. P1's mother also reported the AP asked her daughter questions that she found inappropriate. A record review of P1's EHR documenting the family therapy session revealed no documentation of these concerns expressed about the AP, nor was there documentation that P1's mother was informed of the incidents of the previous day involving her daughter and the AP.

On 04/08/22, as part of the investigation, PC1 interviewed P1, P2, and P3, who were the usual passengers on the AP's van transport schedule. A review of PC1's handwritten notes revealed P1 reporting that the AP had "asked to take a picture [of P2 wearing a dress]," confirming that the AP stopped to buy the female passengers coffee drinks, and expressing that she was uncomfortable being in the van alone with the AP. A review of P2's interview revealed P2 expressing she was uncomfortable having the AP driving her, and reporting that the AP once checked her temperature on her thigh instead of her forehead, took her to a coffee shop to buy her coffee drinks, asked P3 [a male passenger] "if he eats ass", and talked about his penis size, " ...he mentioned like he was going to pull down his pants ..." A review of P3's interview revealed P3 reporting that the AP questioned his sex life (asked about his "body count" and if he had sex with "boys and girls"), made comments about P2's body, and asked to take a picture of her when she was wearing a dress.

Although P4 was one of the three female minors that witnessed and first reported the incident with the AP in the courtyard on 03/30/22, there was no documentation found in the investigation notes that she had been interviewed. Despite having access to any of the Day Treatment Program patients in the courtyard, a review of the investigation notes did not reveal that any other Day Treatment Program patients were interviewed about the AP.

A review of P1, P2, P3, and P4's EHR's noted no documentation found of any problems reported or investigated regarding the AP, nor was there documentation of any assessments of or follow-up discussions with the patients regarding the incident(s).

On 08/04/22 at 11:30 AM, a phone interview was done with AI. AI stated that on 03/30/22, P1, P2, and P4 had approached her and reported to her that they were feeling uncomfortable because of the AP. AI detailed the following allegations were reported to her:

1. While picking her up for Program one morning, the AP had used the thermal thermometer on P2's inner thigh instead of her forehead.

2. That day, P1 was sitting in the courtyard, and she left, when she came back, P1 told the AP "You're in my spot." The AP responded, "something about sitting on my lap."

3. The AP spoke to them about alcohol in the courtyard, asking them what their preferences were.

AI reported these allegations to PC1, who informed the Program Manager (PM). AI confirmed that she did not make a written report, nor was she asked to document any of this in writing.

On 08/04/22 at 12:00 PM, a phone interview was done with PC1. PC1 stated that as the Licensed Mental Health Counselor, he performed the initial investigation. PC1 confirmed that he interviewed P1, P2, and P3, and was present for the Fact-Finding Meeting with the AP. PC1 stated that during the course of his orientation, he provided basic competency information to the AP, and "reviewed verbally" with him what types of things he should refer to clinicians, such as discussions about sex, alcohol, or drugs. During the Fact-Finding Meeting held with the AP on 04/12/22, PC1 stated that the AP confirmed he had made the comment to P1 about sitting on his lap, had stopped several times to buy the female passengers food and coffee drinks with his own money without authorization, made comments to P2 about wearing a dress, participated in discussions about alcohol and/or sex with the patients without reporting it, and pointed a thermal thermometer at P2's thigh instead of her forehead.

When asked, PC1 confirmed and acknowledged that he did not document any of the concerns reported to him in the clinical records even though all of the patients on the van transport with the AP had histories of substance abuse and sexual trauma. PC1 also confirmed that he did not notify any of the parents about the allegations against or investigation of the AP, nor were any of the parents interviewed about changes in behavior in their children, or their own observations of the AP.

In a follow-up phone interview with PC1 on 08/05/22 at 11:59 AM, PC1 confirmed that although they monitor all patients daily in the Program, there were no assessments or documentation made in their EHRs that would indicate monitoring specifically in relation to the incident(s) with the AP.

On 08/05/22 at 10:14 AM, a phone interview was done with the Director of Behavioral Health (DBH). The DBH stated that the PM had reported the 03/30/22 and 03/31/22 allegations to her at one of their "one-to-one weekly sessions." When she heard about it, she immediately stopped the session and began the process of notification for reporting allegations of abuse. She ensured the AP had been suspended and pulled in Risk Management. When asked, the DBH stated that she expected and thought the families were notified of the investigation, findings, and resolution and that the Program had ensured no other patients had been affected.