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Based on policy review, document review, medical record review, and staff interviews, it was determined the facility failed to ensure patients received care in a safe setting, by not reporting allegations of possible staff abuse, and not investigating reported allegations of abuse, This failure has the potential to cause great physical and psychosocial harm to patients, and staff (See tag A0120 and A0144). As a result of this failure, Immediate Jeopardy (IJ) was identified, and the facility was notified on 08/28/25 at 1:10 p.m. The facility submitted and implemented an acceptable plan to remove the IJ, which was verified by the State Survey Agency on 08/28/25 at 4:37 p.m.

The following interventions were implemented to resolve the IJ: Education: All hospital staff will be educated on the policy "Abuse, Neglect, Exploitation of Patients and Reporting" prior to their next scheduled shift. All staff will receive education on the facility escalation policy prior to their next scheduled shift. Monitoring: The Social Services Director will conduct monthly audits of ten (10) randomly selected patient charts to ensure that any incidents of abuse or neglect are properly identified and reported in accordance with policy for a period of twelve (12) months.

Cross reference:

§482.13(a)(2): Prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.

§482.13(c)(2): The patient has the right to receive care in a safe setting.

Based on policy review, document review, medical record review, and staff interviews, it was determined the facility failed to ensure patients were not injured after an alleged sexual assault. This failure has the potential to cause great physical and psychosocial harm to patients, and staff (See tag A0398). As a result of this failure, Immediate Jeopardy (IJ) was identified, and the facility was notified on 08/28/25 at 1:10 p.m. The facility submitted and implemented an acceptable plan to remove the IJ, which was verified by the State Survey Agency on 08/28/25 at 4:37 p.m.

The following interventions were implemented to resolve the IJ: Education: All Registered Nurses assigned to the Behavioral Health Unit will be educated on the requirement to perform a comprehensive reassessment whenever there is an event reported inappropriate sexual contact between the adolescent patients. Education will be completed prior to the beginning of their next shift.

Cross Reference: §482.23(b)(6): The Director of Nursing must provide supervision of care to all nursing staff.

Based on policy review, document review, medical record review, and staff interviews, it was determined the facility failed to investigate reported allegations of abuse in one (1) reported incident of alleged peer to peer sexual assault, involving patient 1, 2, and 3, and two (2) alleged incidents of possible staff to patient abuse, involving patient 4, out of ten (10) patients reviewed. This failure has the potential to negatively affect all patients receiving care at the facility.

Findings include:

A policy was reviewed titled "Patient Grievance Policy," last adopted 1/2009. The policy states in part, " ...Definitions...Complaints versus Grievance...Patient grievances also include situations where patients or the patients representative phone or right to Appalachian regional health care about concerns related to care services, or with an allegation of abuse or neglect, or failure of the organization to comply with one or more CMS CoPs, HIPAA privacy rules or other CMS requirements...Process for Complaints/Grievances...Any staff member can accept a patient complaint whether expressed verbally or in writing. The complaint or grievance should be documented directly in the incident reporting system...All ARH personnel are responsible for notifying the appropriate management staff concerning any patient complaint or grievance. This would include the department manager when present in the facility. During evening or night shift, the house supervisor should be notified immediately when a complaint has been lodged...Complaints that are allegations of abuse or neglect must be reviewed immediately due to the seriousness of the allegation and the potential for harm to the patient. Established ARH policy concerning abuse and neglect must be initiated when a complaint of this nature is filed..."

The patient grievance log was reviewed for the past three (3) months. No complaint or grievance was filed on behalf of patient 1, 2, 3, or 4.

A policy was reviewed titled, "Chain of Command for Patient Care Issues: Escalation Policy," last adopted 12/28/15. The policy states in part, "...Definitions:...This list Is not comprehensive but provides examples of situations in which the chain of command process should be used...5. if there is unprofessional behavior that jeopardizes patient care...Policy: A. All staff is responsible to advocate for the patient at all times and has the responsibility to implement the chain of command procedure to resolve issues when the safety of the patient becomes affected or the delivery of patient care may result in an adverse patient outcome. This includes employees, contract staff and agency personnel..."

A medical record review was conducted for patient 1. The patient presented to the facility's Emergency Department via Emergency Medical Services (EMS) on 08/17/25 with a chief complaint of violent behaviors and suicidal ideations. The patient was admitted to the facility's adolescent behavioral unit with a diagnosis of Bipolar 1 Disorder, ADHD (attention deficit hyperactivity disorder), and PTSD (post-traumatic stress disorder). A medication regimen was started, and the patient was encouraged to participate in group therapy. The patient was referred to a psychiatric residential treatment facility, as [he/she] had been hospitalized in the acute psychiatric setting several times and still exhibited behavioral problems.

On 08/22/25 at 1:53 a.m. a "Nurse Note" by staff 7 states, "At 2115 (9:15 p.m.) another patient [patient 3] said that while in the lounge [patient 1] was reaching under the table rubbing [his/her] leg and touching [his/her] privates and later [patient 3] said that [patient 1] did give [him/her] a hand job but [he/she] was told to stop and it was not consensual. When [patient 1] was asked what occurred in the lounge [he/she] said, 'I did things with my hand to pleasure some one else". [He/She] also said they both was touching each other. [Patient 1] would not talk much or give many details about the incident. HNC (House Nurse Coordinator) [staff 6] was notified of incident, [Staff 8] on call was called and informed of the incident orders received to make [patient 1] level 2 and have [him/her] to only come out of [his/her] room for needs and place somebody close to [his/her] room for closer observation. Tried to call [his/her] [parent], [parent's name] there was no answer message was left for [him/her] to call about an incident involving [patient 1]."

On 08/22/25 at 8:09 a.m. a "Psychiatry Progress Note" by staff 8, signed by staff 15 states in part, "...The report from staff was that around 2045 (8:45 p.m.) three (3) [gender] patients, including [patient 1], were in the lounge playing cards. It was noted that they were observed on the camera to being close together around the table with their backs to the camera. Another [gender] peer (will be referred to as 3rd (third) [gender] peer) was noted to be moving [his/her] arm consistent with the motion of manual self-stimulation but it was not clear if this was what was happening as [his/her] back was to the camera. This reportedly only lasted a few seconds. [patient 1] then proceeded to get on the floor and went under the table and staff immediately went into the lounge and advised [patient 1] to get out of the floor. [He/she] did comply with this request and stated that [he/she] was picking up cards. Approximately 30 (thirty) minutes later, at around 2115 (9:15 p.m.), one (1) of the peers (will be referred to as second (2nd) [gender]peer) that was in the lounge with [patient 1] expressed concerns to the nursing staff about some things that had happened in the lounge. When [patient 1] was asked for [his/her] side of the story by nursing staff, [he/she] did not provide many details and stated that [he/she] did do "things with my hand to pleasure someone else" and that they both touched each other. When- staff called and reported the incident, I did advise them to ensure the [patients] remained separated and [patient 1] was placed on level 2 and room restrictions. A security guard was also moved onto the unit to help monitor the situation. The nurse did attempt to reach [patient 1]'s parent] but [he/she] did not answer phone and a message was left asking [him/her] to call the unit back. A referral has been made to Round Table at [other facility] and a decision on this is pending. [He/she] does not report any issues with appetite. [He/she] has been cooperative with taking [his/her] medications here. No additional concerns or issues reported at this time ...Assessment and Plan: (1) Bipolar 1 disorder: Continue medications the same. Patient is on room restrictions and level 2. Staff is monitoring any interactions between the [same gender] peers to ensure that they are not alone with each other at any time. Staff is working on a plan to further monitor things and report that they will likely rotate them through the lounge in 30 (thirty) minute increments. There will be extra staff on the unit to monitor the situation. Staff to report any new issues or concerns that may arise ..."

On 08/22/25 at 4:01 p.m. a "Counselor services Note" by staff 4 states, "Patient was seen 1: 1 (one to one) by Counselor and by Treatment Team for reassessment this day. Patient is alert and oriented x3 (times three). Patient reports [he/she] is "okay" this day. When asked about events from last night, Patient reports that "we were all ([patient 1, 2, and3]) in the lounge talking about sexual things and we were touching each other and stuff". Patient is educated on proper behavior while on the Unit and to keep hands to [him/her]self. Patient verbalizes understanding and reports this will not happen again."

The patient remains compliant with medication, occasionally attends group therapy, is cooperative, and has had no further reported inappropriate sexual behaviors. The patient remains hospitalized awaiting approval for placement in a long-term facility.

A medical record review was conducted for patient 2. The patient was admitted to the facility's adolescent behavioral health unit after being transferred from an acute hospital with reports of self-harming behaviors and intermittent psychosis. The patient's diagnosis is major depression recurrence with psychotic features. The patient's medications were adjusted, and a treatment plan was initiated. The patient continued to be manipulative with staff and not focused on treatment. The patient is medication compliant and attends groups.

A "Nurse Note" by staff 7 on 08/22/25 at 2:32 a.m. states, "Addendum: [Patient 2] was accused by [patient 1] of showing [him/her], [his/her] penis and rubbing [his/her] knee, this nurse was watching the camera, saw [patient 2] with [his/her] back to the camera moving [his/her] left arm fast look like [he/she] was masturbating possibly exposing [him/her]self for a few seconds then [patient 1] crawled under the table and I immediately intervened. [He/she] said [he/she] was under the table picking up cards. I don't feel that [patient 2]'s story is credible because [he/she] said there was oral sex and the other two (2) [patient 1, and 3] both said it was a hand job. Original note: Approximately 2200 (10:00 p.m.) [patient 2] was asked about a sexually inappropriate incident in the lounge involving himself [patient 1] and [patient 3]. [He/she] said [patient 1] started telling [patient 3] [he/she] was gay and [patient 3] said [he/she] wasn't, and they started touching each other and then [patient 1] went under the table and gave [patient 3] oral sex. After that, [patient 2] said [patient 3] looked at [him/her] and told [him/her], [he/she's] next, [he/she] then pulled [patient 2's] hand to [patient 3's] privates, [he/she] then said [patient 3] spit on [his/her] own hand and gave [him/her] self a hand job. [He/she] then said [he/she] could see [patient 1's] arm moving under the table giving [him/her] self a handjob then after, [he/she] was done [he/she] licked sperm off [his/her] own hand. HNC [staff 6] notified of incident, on call [staff 8] notified as well. West Virginia DoHS called with info left for a Cabell County case worker [name] about the incident referral number 570-478."

A "Psychiatry Progress Note" by staff 9 via telehealth on 08/22/25 at 11:03 a.m. states in part, "...Subjective...Patient was seen in [his/her] room this morning. [He/she] was placed on room restrictions last night, along with two (2) other peers due to inappropriate sexual behavior. Patient said [he/she] felt pressured to do what [his/her] peers were doing, which Involved masturbating and touching each other's genitals. [He/she] said that [he/she] knows it was wrong and feels disgusting. [He/she] said that life is "excruciating" at times. [He/she] has some thoughts of self harm, but denies any plans or intent. Denies any HI (homicidal ideations). Denies any AVH (audio-visual hallucinations). [He/she] has been compliant with [his/her] medications ...Plan: will need to be on peer restrictions and not sitting near peers involved in this incident ..."

The patient remains compliant with medication, attends group therapy, is cooperative, and has had no further reported inappropriate sexual behaviors. The patient remains hospitalized awaiting approval for placement in a long-term facility.

A medical record review was conducted for patient 3. The patient presented to the facility's ED on 08/20/25 after continued anger outbursts with episodes of self-harm. The patient was admitted to the facility's adolescent behavioral health unit with a diagnosis of major depressive disorder and oppositional defiant disorder. A medication regimen was started, and the patient was encouraged to participate in group therapy.

An "Event Note" by staff 8 on 08/21/25 at 6:31 p.m. states, "At approximately, 2130 (9:30 p.m.), I received a call from the nurse on the unit about an incident that had occurred, which is detailed as follows: The report from staff was that around 2045 (8:45 p.m.) three (3) [gender] (gender) patients, including [patient 3], were in the lounge playing cards. It was noted that they were observed on the camera to be sitting close together around the table with their backs to the camera. Another [gender] peer (who will be referred to as the 3rd (third) [gender] peer) was noted to be moving [his/her] arm consistent with the motion of manual self-stimulation but it was not clear if this was what was happening as [his/her] back was to the camera. This reportedly only lasted a few seconds. Another [gender] peer (who will be referred to as the first [gender] peer) then proceeded to get on the floor and went under the table. Staff immediately went into the lounge and advised the first [gender] peer to get out of the floor. [He/She] did comply with this request and stated that [he/she] was picking up cards. Approximately 30 (thirty) minutes later, at around 2115 (9:15 p.m.), [patient 3] approached the nurses station, requesting to talk to staff privately. [He/she] began crying and reported that the first [gender] peer was reaching under the table and rubbing [his/her] leg, touching [his/her] genitals. The patient reporting this stated that [he/she] asked the first [gender] peer to stop but [he/she] did not. [He/she] also reported that the first [gender] peer also gave [him/her] a hand job. Staff did report that when [patient 3] approached the nurses station, there was a wet spot on the front of [his/her] scrubs that was inconsistent with urine. (Staff was asked to take these scrubs and put them in a bag in case these were needed for anything.) When staff called and reported the incident, I did advise them to ensure the [patients] remained separated. [Patient 3] was placed in a room directly in front of the nurses station. A security guard was also moved onto the unit to help monitor the situation. The nurse was asked to contact [patient 3's parent] to make [him/her] aware of what had happened. They did reach [patient 3's parent] and let [him/her] know about the incident."

On 08/22/25 at 1:18 a.m., a "Nurse Note" by staff 7 states, "Patient approached this nurse and said [he/she] needed to talk in private at approximately 2115 (9:15 p.m.) and reported a patient [patient 1] was reaching under the table in the lounge rubbing [his/her] leg and touching [his/her] privates and would not quit when told to stop. And [he/she] said another patient, [patient 2] would not let [him/her] get up and [patient 2] was showing [his/her] penis to [him/her]. Later at 2230 (10:30 p.m.) [patient 3] said it was not consensual [he/she] had said stop but [he/she] did not try to make them stop because [he/she] was afraid they would hurt [him/her]. [He/she] said that [patient 1] did give [him/her] a hand job. Patients [parent] was called and told about the incident that occurred. [Staff 8] was called about the incident with orders to make [patient 1 and 2] level 2 and have them stay in their rooms for safety and have security to watch all involved to keep them separated. HNC [staff 6] notified of incident as well."

The patient left the facility, discharged by request of parents, on 08/22/25 at approximately 2:40 p.m.

A "Counselor Services Note" by staff 4 on 08/22/25 at 3:27 p.m. states in part, "Patient was seen one to one (1:1) by counselor and by treatment team for reassessment this day. Patient is alert and oriented times three (3). Patient reports [he/she] is not okay this day and wants to go home. Patient asked about events that happened last night and patient reports [he/she] was forced and it really makes me sick to my stomach to even think about it. Patient reports [he/she] was setting in the lounge with two (2) other patients [patient 1] and [patient 2] when they begin talking about how they like having sex with [peers] and stuff. Patient reports [he/she] told them that [he/she] didn't do that and reports they [patient 2] and [patient 1] touching my leg. Patient reports that [he/she] told them to stop, but they did not. Patient reports that [patient 1] got under the table and tried to pull my pants down and I nudged [him/her] with my leg, but [he/she] didn't stop so I did it again. Patient reports that [he/she] was touched and began crying. Patient reports [he/she] said [he/she] had to go to the bathroom so I can leave. If [he/she] did not do what the other [peers] wanted, they would hurt [him/her]. Patient reports [he/she] left to go to the bathroom and reported to staff what had happened..."

A medical record review was conducted for patient 4 on 08/27/25. A "History of Present Illness- Psychiatric Note" dated 05/28/25 at 8:38 a.m. stated in part, "Chief Complaint: Psychiatric Symptoms. Stated Complaint: Thoughts of self-harm...Medical decision-making narrative: Patient here for reported thoughts of self-harm the patient will not divulge to myself. Has no acute medical concerns and no signs of illness, reassuring lab workup exam and vital signs. Disposition per psychiatry and social work."

A "Treatment Plan/Review Note," by staff 4 dated 05/29/25 at 16:41 (4:41 p.m.) stated in part, "..."[Parent] also reports that Patient "really likes being here (BARH)" and reports that Patient "was really focused on a [gender] night shift RN, talking about [him/her] for at least 25 (twenty five) minutes and told me that [he/she] strip-searches [him/her] and that when I [parent] don't answer the phone, [he/she] makes a pouting noise and makes this face ([parent] reports patient showed [his/her] this face and it was like "puppy dog eyes") and says that [he/she] specifically does this to [gender] night shift RN and "they feel bad for me (patient)". Counselor shared [parent's] concern with patient seeming fixated on night shift [gender] RN with current adolescent nursing staff and supervisor."

A "Discharge Note" dated 08/12/25 at 10:46 a.m. stated in part, "Patient status on admission - voluntary. Patient's legal guardian (under age 18) is patient's adoptive [parent], [parent name] [phone number]. Patient will discharge to home on 08/12/2025 and will be transported via [parent]. Follow up has been scheduled with [staff 14] [phone number] [Fax number] on 08/18/2025 at 11:15 AM (a.m.) for continued psychiatric treatment and counseling."

An interview was conducted with staff 4 on 08/27/25 at 1:50 p.m. Regarding patient 4, staff 4 states in part, "...The parent told me about the patient talking about a [gender] nurse that strips search the patient at night shift. The parent doesn't believe what the patient said about the [gender] nurse. [Staff 13] is the [gender] nurse that the patient is talking about. The parent said that it happened on the last admission, but it was not true. After I spoke with the parent, I documented this in the patient's chart, and I spoke with [staff 2 and staff 6] and one (1) or maybe two (2) of them told me not to put the staff ' s name. Nobody mentioned reporting to CPS. The parent doesn't believe it. I spoke to [staff 13] and, [staff 13] said that never happened..."

A telephone interview was conducted with staff 5 on 08/27/25 at 2:05 p.m. Regarding patients 1, 2, and 3, staff 5 states in part, "...We were sitting at the nurses station and [staff 7] was watching them on the monitor. Sometime after that, [patient 3] was in the back room crying...We got [him/her] to calm down and into [his/her] room. When [staff 7] called [staff 8], [she/he] wanted us to keep [his/her] pants bagged up. I went in the room and told [him/her] we need to take [his/her] pants. [He/She] seemed irritated but complied. I sat outside of the door, so [he/she] changed [his/her] pants and then handed them to me. [He/She] went and talked to [staff 7] some more after that. I know [patient 3] left the next day..."

An additional interview was conducted with staff 4 on 08/27/25 at 2:12 p.m. Regarding patients 1, 2, and 3, staff 4 states in part, "The next day we are doing rounds with [staff 15] and [he/she] asked [patient 3] what had happened. [Patient 3] said that they were all sitting in the lounge playing cards [him/her], [patient 1] and [patient 2]. [He/She] said [patient 1 and 2] both started touching [him/her]. [He/She] said [patient 1] went under the table and tried to advance on [him/her] and [he/she] nudged [him/her] away. [He/She] felt if [he/she] didn't let them do something that they would hurt [him/her]. Then [he/she] felt like [he/she] was getting kicked out of here due to [his/her] behavior. I told [him/her] [he/she] wasn't being kicked out, that [his/her] parents requested that [he/she] be discharged. [He/She] said [he/she] was a victim but then said [he/she] was a bad kid and doesn't act right. When [he/she] was telling the doctor what had happened [he/she] put [his/her] head down and was sobbing. [He/She] said it felt like [he/she] wanted to be discharged. The [parent] was approved to come and visit that morning and [he/she] told [him/her] [he/she] wanted to leave. The [parent] said [she/he] thought that [he/she] should be here. After talking with [him/her] though, [she/he] requested that [he/she] be discharged and said [she/he] would be there to pick [him/her] up about 4:30 (p.m.)... [Patient 3] was discharged between 1:30 and 2:00 p.m..."

A telephone interview was conducted with staff 6 on 08/27/25 at 4:11 p.m. Regarding patients 1, 2, and 3, staff 6 states, "I was sitting beside [staff 7] when it happened. We were talking about work and [staff 7] was watching the video. [Staff 7] said did you see that? I couldn't see the screen. [He/She] said [he/she] moved [his/her] hand funny, I'm going to go check. Just then, one [1] of the [patients] got down under the table [staff 7] was already getting up to go into the room and [he/she] walked straight into the day room. [He/She] said they [the patients] were just playing cards and one (1) said [he/she] was picking up the cards. Shortly after that [patient 3] came to the nurse's station and wanted to talk to [staff 7]. [Staff 7] went into the room and talked to [patient 3] and then came and got me about two (2) to three (3) minutes later and I came in the room with [him/her]. [Patient 3] was crying and said I didn't mean for that to happen. [Patient 3] said [he/she] touched me. I asked who and [he/she] said [patient 1]. [He/She] said [patient 2] touched [him/her] on [his/her] knee and exposed [him/her] self to [him/her] but [patient 1] touched [him/her] on [his/her] private area, then [he/she] started crying. I told [him/her] no one is blaming [him/her], it's not [his/her] fault. [He/She] continued to cry, [staff 7] went out of [his/her] room. I stayed in there with [patient 3]. [He/She] said [his/her] [parent] is going to be angry. I told [him/her] something unfortunate happened and you didn't do anything to cause your [parent] to be angry. We separated the [patients] and made them stay in their rooms at that time. We kept someone in the hall to watch them. I wrote up the incident reports and [staff 7] called the parents and the physician. When I came back to the unit, the [patients] were all in their rooms and [patient 3] was in [his/her] room coloring. [Staff 7] was waiting to hear back from one of the parents at that time. [Staff 7] said that [patient 3's] story had changed and they all told a different story. [Patient 3] now said the other patient made oral contact with [him/her]...No, I didn't call the police. I'm not sure of the policy. Normally we just fill out incident reports, call the parents and guardians of everyone involved, and the physician..."

A telephone interview was conducted with staff 7 on 08/27/25 at 6:23 p.m. Regarding the incident on 08/21/25 with patients 1, 2, and 3, staff 7 states, "That night all three (3) [patients] were just being hyper teenagers. They were not misbehaving, just being loud and playing. When the [patients] are in the lounge I keep my distance, but I'm constantly watching on the video feed. I was looking at the camera at that time and saw the three (3) [patients] sitting at the table in the lounge. They were sitting a little close and one (1) [patient] started moving [his/her] left arm. It looked like [he/she] was masturbating. I looked into the camera closer and just then the one (1) [patient], [patient 1] started to get on the floor. I immediately jumped up and ran into the lounge and asked what was going on. [Patient 1] got up and had cards in [his/her] hand and said [he/she] was picking up [his/her] cards. I thought everything was okay. Thirty (30) minutes later, [patient 3] said [he/she] wanted to talk to me. [He/She] said the other [patient], [patient 1], groped [him/her] and was playing with [himself/herself] and touched [patient 3]. I separated them and talked to the other two (2) [patients]. [Patient 1] said [he/she] was playing with [him/her] self and gave [patient 3] a hand job. Said that [patient 1] gave [him/her] a hand job. I called all the legal guardians, the doctors, and the supervisor was there at that time. The doctor ordered to put them in their room and change them to level two (2) observation and put them in a hospital gown. Security came to the unit to help monitor the situation. We moved [patient 3] to room 24, in which the hallway can be locked with double doors so that the other two (2) patients couldn't even come over on that side. We placed [patient 3] in room 24 and that is also in front of the nurses station. I did not contact CPS or call the police. That night I did call [Patient 1's parent] but [she/he] did not return my phone call. I left a message on the DHHR hotline for [patient 2]'s Guardian since [he/she's] a DHHR client. I did speak with [patient 3's parent], [she/he] was upset and said that [she/he] might come the next day to pick [him/her] up. The video feed on the unit is in black and white and it does not record."

An interview was conducted with staff 2 on 08/28/25 at 8:34 a.m. Regarding filing a CPS report for patient to patient abuse, staff 2 states, "We don't ever file a CPS report unless it's abuse by a parent or guardian. We notify the patient's parents or guardian if something happens here and it's up to them if they want to file."

An interview was conducted with staff 15 on 08/28/25 at 9:05 a.m. Regarding the incident with patients 1, 2, and 3, staff 15 states, "I am the physician of [patient 3] and [patient 1] not the other patient. I got the report first thing in the morning from [staff 8]. [She/He] had briefed me as [she/he] had been on call that night. I did not speak with [patient 2] as [he/she] is not my patient. We did speak with [patient 3] and [patient 1] the next morning. We had a long talk with [patient 1]. [He/She] had been having some behavioral issues and had referred [him/her] to long-term placement at a PRTF and was just awaiting acceptance. [Patient 3] was only here for a couple of days, but [he/she] was just released from long-term placement not long before admission. [He/She] had issues with impulsive behavior and there was a question if [he/she] had a high functioning autism. When the incident was reported to [patient 3's parent], [she/he] felt [patient 3] needed to stay for additional treatment. [Patient 3's parent] came to visit. [She/He] didn't initially say anything about discharging [him/her], but a little later after speaking with [him/her], [she/he] had spoken with [his/her spouse] and wanted to take [patient 3] out. [His/her] decision to take [him/her], and it was not [patient 3's] fault or anything. [Patient 3's parent] came in and was very upset. I came out and I offered to talk with [him/her], the staff said there's no use [he/she] is upset and one [1] did not want to talk to anyone. The police came to take a report. I assume that the [parent] had called the police. The police cannot talk to minors without the guardian and I offered to help coordinate this, but the police didn't want to talk to them at that time. We discharged [patient 3] at the request of [his/her] guardians. Prior to the incident, we made sure that the patients were in view at all times. If the nurses weren't in the room with them, they watched them on camera. The cameras don't record. [Patient 3's parent] was upset about this when [he/she] came, but even if they did record, we couldn't share any footage with [him/her]. When this had happened there was a [gender] nurse working, [he/she] watched the incident on camera. The incident was a very short period of time, and the nurse got up and responded immediately. [He/She] intervened as quickly as [he/she] could. The next morning, after speaking to the patients and finishing my rounds, that's when [patient 3's parent] showed up. Initially the [patients] had not said anything that happened directly. All three (3) initially said it was consensual. Then [patient 3] changed [his/her] story and said that the [patients] were talking about sexual stuff and then the touching went on between the other two (2) and then they touched [him/her]. [He/She] admitted [he/she] didn't tell them to stop. [Patient 3] reported that [patient 1] tried to do a blowjob on [him/her] but [patient 3] got up and went to the bathroom. The whole incident upset [patient 3] and caught [him/her] by surprise. [Patient 3] did admit that [he/she] did not tell them to stop or that [he/she] didn't want to, [he/she] just got up and went to the bathroom. [Patient 3] said [he/she] was upset and wanted to leave. I told [him/her] [he/she] wouldn't be targeted or have any negative response from the other [patients]. [Patient 3's] parents agreed and that [he/she] could leave and wanted to discharge [him/her]. For the precautions, [patient 1], if [he/she] is in the day room, [he/she] needs to be with a staff person. That morning [patient 1] was in [his/her] room when we did rounds. If [he/she] came out, staff had to be with [him/her]. As long as staff was with [him/her], [he/she] could come out and interact with the other patients and participate in activities in the day room. [Patient 1] was never confined to [his/her] room. The staff thought that maybe [patient 1] and [patient 2] were trying to exchange blame with each other or intimidate each other so they kept them out of the day room together. There was not an order from me to keep them separated. This is not a punitive environment. I was told initially after the incident happened, the nurses observed the front of [patient 3's] pajamas to be wet, and they kept them. I do not know where they went..."

An interview was conducted with staff 12 on 08/27/25 at 2:22 p.m. Regarding patient 4, staff 12 states, "After the patient was discharged, the insurance company case manager called and said that the parent mentioned underwear and razor not belonging to the patient in [his/her] belongings. The phone call was maybe a week after discharge, not sure. The health insurance case manager never saw it, just what the [parent] said. [He/She] was planning to visit the patient at home. Also, the insurance company case manager mentioned that the [parent] is very religious and might overexaggerate underwear that is not appropriate. The [parent] never called me to tell me anything about the patient's sexy panty's [underwear]. I never heard anything about a razor. I talked very frequently with the [parent], and [he/she] did not mention anything abnormal. The [parent] said that during the previous admission, that the patient had a crush with a [gender] nurse..."

A telephone interview was conducted with staff 13 on 08/27/25 at 6:10 p.m. Regarding patient 4, staff 13 states in part, "I did not have issues with the patient, last time I worked in the kids unit was like six (6) weeks ago. I didn't know that the patient was discharged. Never heard anything about lingerie or razors. The patient never said anything about having a crush on another staff member...When the patient tried to call [his/her parent], most of the time, [he/she] did not answer the phone."

A telephone interview was conducted with staff 14 on 08/27/25 at 6:35 p.m. Regarding patient 4, staff 14 states in part, "...The patient never mentioned anything about a razor or lingerie. No one ever said anything about the patient being infatuated with a [gender] staff..."

An interview was conducted with staff 2 on 08/28/25 at 8:33 a.m. Regarding patient 4, staff 2 stated, "If an incident happens, we call the parent or guardian and the parent or guardian will decide what to do. It is not our process to notify CPS for patient to patient incidents. Abuse is defined as abuse by a parent, guardian, or custodian, not a peer. I never heard anything about [patient 4], having underwear or razor that didn't belong to them. Never heard anything about the patient accusing staff of strip searching them. We do

Based on policy review, document review, medical record review, and staff interviews, it was determined the facility failed to report allegations of abuse to the police in one (1) reported incident of alleged peer to peer sexual assault, involving patient 1, 2, and 3, and failed to report to CPS two (2) alleged incidents of possible staff to patient abuse, involving patient 4, out of ten (10) patients reviewed. This failure has the potential to negatively affect all patients receiving care at the facility.

Findings include:

A policy was reviewed titled, "Chain of Command for Patient Care Issues: Escalation Policy," last adopted 12/28/15. The policy states in part, "...Definitions:...This list Is not comprehensive but provides examples of situations in which the chain of command process should be used ...5. if there is unprofessional behavior that jeopardizes patient care ...Policy: A. All staff is responsible to advocate for the patient at all times and has the responsibility to implement the chain of command procedure to resolve issues when the safety of the patient becomes affected or the delivery of patient care may result in an adverse patient outcome. This includes employees, contract staff and agency personnel. B. Any staff member who implements this policy in good faith will not be penalized or subject to retaliation for acting in accordance with this policy ..."

The policy was reviewed titled "Abuse, Neglect, Exploitation of Patients and Reporting," last adopted 05/17. The policy states in part, "t ...Policy ...Any person, including but not limited to physician, nurse, or social worker, having reasonable cause to suspect that a patient who is a vulnerable adult, as defined above, or child has suffered abuse, neglect, or exploitation shall report or cause report to be made in accordance with ...West Virginia State Law ...F. West Virginia Facilities: Reporting Procedure ...Also, Any person over the age of 18 who receives information from a credible witness or observes any sexual abuse or sexual assault of a child, shall immediately and not more than 48 (forty-eight) hours report the circumstances to the Department of Health and Human Resources and the West Virginia State Police or other law enforcement agency having jurisdiction to investigate the report."

West Virginis State Code: §49-2-803. States in part, "Persons mandated to report suspected abuse and neglect; requirements. (a) Any medical, dental, or mental health professional, Christian Science practitioner, religious healer, school teacher or other school personnel, social service worker, child care or foster care worker, emergency medical services personnel, peace officer or law-enforcement official, humane officer, member of the clergy, circuit court judge, family court judge, employee of the Division of Juvenile Services, magistrate, youth camp administrator or counselor, employee, coach or volunteer of an entity that provides organized activities for children, or commercial film or photographic print processor who has reasonable cause to suspect that a child is neglected or abused, including sexual abuse or sexual assault, or observes the child being subjected to conditions that are likely to result in abuse or neglect shall immediately, and not more than 24 hours after suspecting this abuse or neglect, report the circumstances to the Department of Human Services. In any case where the reporter believes that the child suffered serious physical abuse or sexual abuse or sexual assault, the reporter shall also immediately report to the State Police and any law-enforcement agency having jurisdiction to investigate the complaint. Any person required to report under this article who is a member of the staff or volunteer of a public or private institution, school, entity that provides organized activities for children, facility, or agency shall also immediately notify the person in charge of the institution, school, entity that provides organized activities for children, facility, or agency, or a designated agent thereof, who may supplement the report or cause an additional report to be made: Provided, That notifying a person in charge, supervisor, or superior does not exempt a person from his or her mandate to report suspected abuse or neglect."

West Virginia State Code: §49-2-809 states in part, "Reporting procedures. (a) Reports of child abuse and neglect pursuant to this article shall be made immediately to the department of child protective services by a method established by the Bureau for Social Services:..."

A medical record review was conducted for patient 1. The patient presented to the facility ' s Emergency Department via Emergency Medical Services (EMS) on 08/17/25 with a chief complaint of violent behaviors and suicidal ideations. The patient was admitted to the facility ' s adolescent behavioral unit with a diagnosis of Bipolar 1 Disorder, ADHD (attention deficit hyperactivity disorder), and PTSD (post-traumatic stress disorder). A medication regimen was started, and the patient was encouraged to participate in group therapy. The patient was referred to a psychiatric residential treatment facility, as [he/she] had been hospitalized in the acute psychiatric setting several times and still exhibited behavioral problems.

On 08/22/25 at 1:53 a.m. a "Nurse Note" by staff 7 states, "At 2115 (9:15 p.m.) another patient [patient 3] said that while in the lounge [patient 1] was reaching under the table rubbing [his/her] leg and touching [his/her] privates and later [patient 3] said that [patient 1] did give [him/her] a hand job but [he/she] was told to stop and it was not consensual. When [patient 1] was asked what occurred in the lounge [he/she] said, ' I did things with my hand to pleasure some one else". [He/she] also said they both was touching each other. [Patient 1] would not talk much or give many details about the incident. HNC (House Nurse Coordinator) [staff 6] was notified of incident. [Staff 8] on call was called and informed of the incident orders received to make [patient 1] level 2 and have [him/her] to only come out of [his/her] room for needs and place somebody close to [his/her] room for closer observation. Tried to call [his/her][parent], [parent's name] there was no answer message was left for [him/her] to call about an incident involving [patient 1]."

On 08/22/25 at 8:09 a.m. a "Psychiatry Progress Note" by staff 8, signed by staff 15 states in part, "...The report from staff was that around 2045 (8:45 p.m.) three (3) [gender] patients, including [patient 1], were in the lounge playing cards. It was noted that they were observed on the camera to being close together around the table with their backs to the camera. Another [gender] peer (will be referred to as 3rd (third) [gender] peer) was noted to be moving [his/her] arm consistent with the motion of manual self-stimulation but it was not clear if this was what was happening as [his/her] back was to the camera. This reportedly only lasted a few seconds. [patient 1] then proceeded to get on the floor and went under the table and staff immediately went into the lounge and advised [patient 1] to get out of the floor. [He/she] did comply with this request and stated that [he/she] was picking up cards. Approximately 30 (thirty) minutes later, at around 2115 (9:15 p.m.), one (1) of the peers (will be referred to as second (2nd) [gender]
peer) that was in the lounge with [patient 1] expressed concerns to the nursing staff about some things that had happened in the lounge. When [patient 1] was asked for [his/her] side of the story by nursing staff, [he/she] did not provide many details and stated that [he/she] did do "things with my hand to pleasure someone else" and that they both touched each other. When- staff called and reported the incident, I did advise them to ensure the [patients] remained separated and [patient 1] was placed on level 2 and room restrictions. A security guard was also moved onto the unit to help monitor the situation. The nurse did attempt to reach [patient 1] ' s parent] but [he/she] did not answer phone and a message was left asking [him/her] to call the unit back. A referral has been made to Round Table at [other facility] and a decision on this is pending. [He/she] does not report any issues with appetite. [He/she] has been cooperative with taking [his/her] medications here. No additional concerns or issues reported at this time ...Assessment and Plan: (1) Bipolar 1 disorder: Continue medications the same. Patient is on room restrictions and level 2. Staff is monitoring any interactions between the [same gender] peers to ensure that they are not alone with each other at any time. Staff is working on a plan to further monitor things and report that they will likely rotate them through the lounge in 30 (thirty) minute increments. There will be extra staff on the unit to monitor the situation. Staff to report any new issues or concerns that may arise ..."

On 08/22/25 at 4:01 p.m. a "Counselor services Note" by staff 4 states, "Patient was seen 1: 1 (one to one) by Counselor and by Treatment Team for reassessment this day. Patient is alert and oriented x3 (times three). Patient reports [he/she] is "okay" this day. When asked about events from last night, Patient reports that "we were all ([patient 1, 2, and3]) in the lounge talking about sexual things and we were touching each other and stuff". Patient is educated on proper behavior while on the Unit and to keep hands to [him/her]self. Patient verbalizes understanding and reports this will not happen again."

The patient remains compliant with medication, occasionally attends group therapy, is cooperative, and has had no further reported inappropriate sexual behaviors. The patient remains hospitalized awaiting approval for placement in a long-term facility.

A medical record review was conducted for patient 2. The patient was admitted to the facility's adolescent behavioral health unit after being transferred from an acute hospital with reports of self-harming behaviors and intermittent psychosis. The patient ' s diagnosis is major depression recurrence with psychotic features. The patient ' s medications were adjusted, and a treatment plan was initiated. The patient continued to be manipulative with staff, and not focused on treatment. The patient is medication compliant and attends groups.

A "Nurse Note" by staff 7 on 08/22/25 at 2:32 a.m. states, "Addendum: [Patient 2] was accused by [patient 1] of showing [him/her], [his/her] penis and rubbing [his/her] knee, this nurse was watching the camera, saw [patient 2] with [his/her] back to the camera moving [his/her] left arm fast look like [he/she] was masturbating possibly exposing [him/her]self for a few seconds then [patient 1] crawled under the table and I immediately intervened. [He/she] said [he/she] was under the table picking up cards. I don't feel that [patient 2] ' s story is credible because [he/she] said there was oral sex and the other two (2) [patient 1, and 3] both said it was a hand job. Original note: Approximately 2200 (10:00 p.m.) [patient 2] was asked about a sexually inappropriate incident in the lounge involving himself [patient 1] and [patient 3]. [He/she] said [patient 1] started telling [patient 3] [he/she] was gay and [patient 3] said [he/she] wasn't, and they started touching each other and then [patient 1] went under the table and gave [patient 3] oral sex. After that, [patient 2] said [patient 3] looked at [him/her] and told [him/her], [he/she's] next, [he/she] then pulled [patient 2 ' s] hand to [patient 3's] privates, [he/she] then said [patient 3] spit on [his/her] own hand and gave [him/her] self a hand job. [He/she] then said [he/she] could see [patient 1 ' s] arm moving under the table giving [him/her] self a handjob then after, [he/she] was done [he/she] licked sperm off [his/her] own hand. HNC [staff 6] notified of incident, on call [staff 8] notified as well. West Virginia DoHS called with info left for a Cabell County case worker [name] about the incident referral number 570-478."

A "Psychiatry Progress Note" by staff 9 via telehealth on 08/22/25 at 11:03 a.m. states in part, "...Subjective ...Patient was seen in [his/her] room this morning. [He/she] was placed on room restrictions last night, along with two (2) other peers due to inappropriate sexual behavior. Patient said [he/she] felt pressured to do what [hls/her] peers were doing, which Involved masturbating and touching each other's genitals. [He/she] said that [he/she] knows it was wrong and feels disgusting. [He/she] said that life is "excruciating" at times. [He/she] has some thoughts of self harm, but denies any plans or intent. Denies any HI (homicidal ideations). Denies any AVH (audio-visual hallucinations). [He/she] has been compliant with [his/her] medications ...Plan: will need to be on peer restrictions and not sitting near peers involved in this incident ..."

The patient remains compliant with medication, attends group therapy, is cooperative, and has had no further reported inappropriate sexual behaviors. The patient remains hospitalized awaiting approval for placement in a long-term facility.

A medical record review was conducted for patient 3. The patient presented to the facility ' s ED on 08/20/25 after continued anger outbursts with episodes of self-harm. The patient was admitted to the facility ' s adolescent behavioral health unit with a diagnosis of major depressive disorder and oppositional defiant disorder. A medication regimen was started, and the patient was encouraged to participate in group therapy.

An "Event Note" by staff 8 on 08/21/25 at 6:31 p.m. states, "At approximately, 2130 (9:30 p.m.), I received a call from the nurse on the unit about an incident that had occurred, which is detailed as follows: The report from staff was that around 2045 (8:45 p.m.) three (3) [gender] (gender) patients, including [patient 3], were in the lounge playing cards. It was noted that they were observed on the camera to be sitting close together around the table with their backs to the camera. Another [gender] peer (who will be referred to as the 3rd (third) [gender] peer) was noted to be moving [his/her] arm consistent with the motion of manual self-stimulation but it was not clear if this was what was happening as [his/her] back was to the camera. This reportedly only lasted a few seconds. Another [gender] peer (who will be referred to as the first [gender] peer) then proceeded to get on the floor and went under the table. Staff immediately went into the lounge and advised the first [gender] peer to get out of the floor. [He/she] did comply with this request and stated that [he/she] was picking up cards. Approximately 30 (thirty) minutes later, at around 2115 (9:15 p.m.), [patient 3] approached the nurses station, requesting to talk to staff privately. [He/she] began crying and reported that the first [gender] peer was reaching under the table and rubbing [his/her] leg, touching [his/her] genitals. The patient reporting this stated that [he/she] asked the first [gender] peer to stop but [he/she] did not. [He/she] also reported that the first [gender] peer also gave [him/her] a hand job. Staff did report that when [patient 3] approached the nurses station, there was a wet spot on the front of [his/her] scrubs that was inconsistent with urine. (Staff was asked to take these scrubs and put them in a bag in case these were needed for anything.) When staff called and reported the incident, I did advise them to ensure the [patients] remained separated. [Patient 3] was placed in a room directly in front of the nurses station. A security guard was also moved onto the unit to help monitor the situation. The nurse was asked to contact [patient 3's parent] to make [him/her] aware of what had happened. They did reach [patient 3 ' s parent] and let [him/her] know about the incident."

On 08/22/25 at 1:18 a.m., a "Nurse Note" by staff 7 states, "Patient approached this nurse and said [he/she] needed to talk in private at approximately 2115 (9:15 p.m.) and reported a patient [patient 1] was reaching under the table in the lounge rubbing [his/her] leg and touching [his/her] privates and would not quit when told to stop. And [he/she] said another patient, [patient 2] would not let [him/her] get up and [patient 2] was showing [his/her] penis to [him/her]. Later at 2230 (10:30 p.m.) [patient 3] said it was not consensual [he/she] had said stop but [he/she] did not try to make them stop because [he/she] was afraid they would hurt [him/her]. [He/she] said that [patient 1] did give [him/her] a hand job. Patients [parent] was called and told about the incident that occurred. [Staff 8] was called about the incident with orders to make [patient 1 and 2] level 2 and have them stay in their rooms for safety and have security to watch all involved to keep them separated. HNC [staff 6] notified of incident as well."
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The patient left the facility, discharged by request of parents, on 08/22/25 at approximately 2:40 p.m.

A "Counselor Services Note" by staff 4 on 08/22/25 at 3:27 p.m. states in part, "Patient was seen one to one (1:1) by counselor and by treatment team for reassessment this day. Patient is alert and oriented times three (3). Patient reports [he/she] is not okay this day and wants to go home. Patient asked about events that happened last night and patient reports [he/she] was forced and it really makes me sick to my stomach to even think about it. Patient reports [he/she] was setting in the lounge with two (2) other patients [patient 1] and [patient 2] when they begin talking about how they like having sex with [peers] and stuff. Patient reports [he/she] told them that [he/she] didn't do that and reports they [patient 2] and [patient 1] touching my leg. Patient reports that [he/she] told them to stop, but they did not. Patient reports that [patient 1] got under the table and tried to pull my pants down and I nudged [him/her] with my leg, but [he/she] didn't stop so I did it again. Patient reports that [he/she] was touched and began crying. Patient reports [he/she] said [he/she] had to go to the bathroom so I can leave. If [he/she] did not do what the other [peers] wanted, they would hurt [him/her]. Patient reports [he/she] left to go to the bathroom and reported to staff what had happened ..."

A medical record review was conducted for patient 4 on 08/27/25. A "History of Present Illness- Psychiatric Note" dated 05/28/25 at 8:38 a.m. stated in part, "Chief Complaint: Psychiatric Symptoms. Stated Complaint: Thoughts of self-harm ... Medical decision-making narrative: Patient here for reported thoughts of self-harm the patient will not divulge to myself. Has no acute medical concerns and no signs of illness, reassuring lab workup exam and vital signs. Disposition per psychiatry and social work."

A "Treatment Plan/Review Note" by staff 4 dated 05/29/25 at 16:41 (4:41 p.m.) stated in part, "... "[Parent] also reports that Patient "really likes being here (BARH)" and reports that Patient "was really focused on a [gender] night shift RN, talking about [him/her] for at least 25 (twenty five) minutes and told me that [he/she] strip-searches [him/her] and that when I [parent] don't answer the phone, [he/she] makes a pouting noise and makes this face ([parent] reports patient showed [his/her] this face and it was like "puppy dog eyes") and says that [he/she] specifically does this to [gender] night shift RN and "they feel bad for me (patient)". Counselor shared [parent's] concern with patient seeming fixated on night shift [gender] RN with current adolescent nursing staff and supervisor."

A "Discharge Note" dated 08/12/25 at 10:46 a.m. stated in part, "Patient status on admission - voluntary. Patient's legal guardian (under age 18) is patient's adoptive [parent], [parent name] [phone number]. Patient will discharge to home on 08/12/2025 and will be transported via [parent]. Follow up has been scheduled with [staff 14] [phone number] [Fax number] on 08/18/2025 at 11:15 AM (a.m.) for continued psychiatric treatment and counseling."

An interview was conducted with staff 4 on 08/27/25 at 1:50 p.m.Regarding patient 4, staff 4 states, "The [patient's parent] told me about the patient talking about a [gender] nurse that strips search the patient at night shift. The [parent] doesn't believe what the patient said about the [gender] nurse. [Staff 13] is the [gender] nurse that the patient is talking about. The parent said that it happened on the last admission, but it was not true. After I spoke with the parent, I documented this in the patient's chart, and I spoke with [staff 2 and staff 6] and one (1) or maybe two (2) of them told me not to put the staff 's name. Nobody mentioned reporting to CPS. The parent doesn't believe it. I spoke to [staff 13] and, [staff 13] said that never happened. The patient never told anything to the other social worker. All that information was reported from the parent. The parent did not believe the patient. The parent never mentioned [staff 7]."

An interview was conducted with staff 4 on 08/27/25 at 2:12 p.m. Regarding patients 1, 2, and 3, staff 4 states in part, "The next day we are doing rounds with [staff 15] and [he/she] asked [patient 3] what had happened. [Patient 3] said that they were all sitting in the lounge playing cards [him/her], [patient 1] and [patient 2]. [He/She] said [patient 1 and 2] both started touching [him/her]. [He/She] said [patient 1] went under the table and tried to advance on [him/her] and [he/she] nudged [him/her] away. [He/She] felt if [he/she] didn't let them do something that they would hurt [him/her]. Then [he/she] felt like [he/she] was getting kicked out of here due to [his/her] behavior. I told [him/her] [he/she] wasn't being kicked out, that [his/her] parents requested that [he/she] be discharged. [He/she] said [he/she] was a victim but then said [he/she] was a bad kid and doesn't act right...The police had showed up at some point during that time. We did not call the police. I believe that [patient 3's parent] had called the police and reported what had happened. The police were coming to get information about it, but [he/she] didn't want to talk to any of the kids. I would assume the parents called the police, we didn't. This is the first time I've encountered that, we don't normally call the police..."

An interview was conducted with staff 12 on 08/27/25 at 2:22 p.m. Regarding patient 4, staff 12 states in part, "After the patient was discharged, the insurance company case manager called and said that the parent mentioned underwear and razor not belonging to the patient in [his/her] belongings. The phone call was maybe a week after discharge, not sure.The health insurance case manager never saw it, just what the [parent] said. [He/She] was planning to visit the patient at home. Also, the insurance company case manager mentioned that the [parent] is very religious, and might overexaggerate underwear that is not appropriate. The [parent] never called me to tell me anything about the patient's sexy panty's [underwear]. I never heard anything about razor. I talked very frequently with the [parent], and [he/she] did not mention anything abnormal..."

A telephone interview was conducted with staff 6 on 08/27/25 at 4:11 p.m. Regarding patients 1, 2, and 3, staff 6 states, "I was sitting beside [staff 7] when it happened. We were talking about work and [staff 7] was watching the video. [Staff 7] said did you see that? I couldn't see the screen. [He/She] said [he/she] moved [his/her] hand funny, I'm going to go check. Just then, one [1] of the [patients] got down under the table [staff 7] was already getting up to go into the room and [he/she] walked straight into the day room. [He/She] said they [the patients] were just playing cards and one (1) said [he/she] was picking up the cards. Shortly after that [patient 3] came to the nurse's station and wanted to talk to [staff 7]. [Staff 7] went into the room and talked to [patient 3] and then came and got me about two (2) to three (3) minutes later and I came in the room with [him/her]. [Patient 3] was crying and said I didn't mean for that to happen. [Patient 3] said [he/she] touched me. I asked who and [he/she] said [patient 1]. [He/She] said [patient 2] touched [him/her] on [his/her] knee and exposed [him/her] self to [him/her] but [patient 1] touched [him/her] on [his/her] private area, then [he/she] started crying. I told [him/her] no one is blaming [him/her], it's not [his/her] fault. [He/She] continued to cry, [staff 7] went out of [his/her] room. I stayed in there with [patient 3]. [He/She] said [his/her] [parent] is going to be angry. I told [him/her] something unfortunate happened and you didn't do anything to cause your [parent] to be angry. We separated the [patients] and made them stay in their rooms at that time. We kept someone in the hall to watch them. I wrote up the incident reports and [staff 7] called the parents and the physician. When I came back to the unit, the [patients] were all in their rooms and [patient 3] was in [his/her] room coloring. [Staff 7] was waiting to hear back from one of the parents at that time. [Staff 7] said that [patient 3's] story had changed and they all told a different story. [Patient 3] now said the other patient made oral contact with [him/her]...No, I didn't call the police. I'm not sure of the policy. Normally we just fill out incident reports, call the parents and guardians of everyone involved, and the physician. If there were obvious signs of abuse we would file, but their stories were everywhere, not consistent. The other two (2) said [patient 3] touched them as well. [Patient 3's parent] was upset [he/she] had an incident while [he/she] was there and said that [she/he] would pick [him/her] up the next day when we called [him/her] that night. I usually leave at 8:00 p.m. but that night I stayed until late, probably around 11:00 p.m. to help with the incident."

A telephone interview was conducted with staff 7 on 08/27/25 at 6:23 p.m. Regarding the incident on 08/21/25 with patients 1, 2, and 3, staff 7 states, "That night all three (3) [patients] were just being hyper teenagers. They were not misbehaving, just being loud and playing. When the [patients] are in the lounge I keep my distance, but I'm constantly watching on the video feed. I was looking at the camera at that time and saw the three (3) [patients] sitting at the table in the lounge. They were sitting a little close and one (1) [patient] started moving [his/her] left arm. It looked like [he/she] was masturbating. I looked into the camera closer and just then the one (1) [patient], [patient 1] started to get on the floor. I immediately jumped up and ran into the lounge and asked what was going on. [Patient 1] got up and had cards in [his/her] hand and said [he/she] was picking up [his/her] cards. I thought everything was okay. Thirty (30) minutes later, [patient 3] said [he/she] wanted to talk to me. [He/She] said the other [patient], [patient 1], groped [him/her] and was playing with [himself/herself] and touched [patient 3]. I separated them and talked to the other two (2) [patients]. [Patient 1] said [he/she] was playing with [him/her] self and gave [patient 3] a hand job. Said that [patient 1] gave [him/her] a hand job. I called all the legal guardians, the doctors, and the supervisor was there at that time. The doctor ordered to put them in their room and change them to level two (2) observation and put them in a hospital gown. Security came to the unit to help monitor the situation. We moved [patient 3] to room 24, in which the hallway can be locked with double doors so that the other two (2) patients couldn't even come over on that side. We placed [patient 3] in room 24 and that is also in front of the nurses station. I did not contact CPS or call the police. That night I did call [Patient 1's parent] but [she/he] did not return my phone call. I left a message on the DHHR hotline for [patient 2]'s Guardian since [he/she's] a DHHR client. I did speak with [patient 3's parent], [she/he] was upset and said that [she/he] might come the next day to pick [him/her] up. The video feed on the unit is in black and white and it does not record."

An interview was conducted with staff 2 on 08/28/25 at 8:34 a.m. Regarding filing a CPS report for patient to patient abuse, staff 2 states, "We don't ever file a CPS report unless it's abuse by a parent or guardian. We notify the patient's parents or guardian if something happens here and it's up to them if they want to file."

A telephone interview was conducted with patient 4's Insurance Company Case Manager on 08/28/25 at 8:55 a.m. The case manager states in part, "...When the patient went home, the patient had 7 (seven) pairs of sexy underwear, the [parent] did not know where [he/she] got those underwear. The parent said that the patient said a [gender] nurse purchased the underwear, and gave the patient gifts. The patient said [staff 7] purchased the razor. It is possible that the patient is lying. The [parent] is concerned that a [gender] nurse could have purchased the gifts and underwear. [He/She] might have had the underwear hiding at home, I am not sure. The parent doesn't believe [patient 4]. The parent is very religious. I was at [patient 4]'s house on 08/18/25, I did not ask to see the underwear...I tried to call the facility, and [staff 12] returned my phone call on 08/20/25. I told [staff 12] that the patient said that a [gender] nurse gave [him/her] seven (7) underwear and perfume, I don't remember saying anything about the shaving. The patient was not in the facility anymore."

An interview was conducted with staff 15 on 08/28/25 at 9:05 a.m. Regarding the incident with patients 1, 2, and 3, staff 15 states, "I am the physician of [patient 3] and [patient 1] not the other patient. I got the report first thing in the morning from [staff 8]. [She/He] had briefed me as [she/he] had been on call that night. I did not speak with [patient 2] as [he/she] is not my patient. We did speak with [patient 3] and [patient 1] the next morning. We had a long talk with [patient 1]. [He/She] had been having some behavioral issues and had referred [him/her] to long-term placement at a PRTF and was just awaiting acceptance. [Patient 3] was only here for a couple of days, but [he/she] was just released from long-term placement not long before admission. [He/She] had issues with impulsive behavior and there was a question if [he/she] had a high functioning autism. When the incident was reported to [patient 3's parent], [she/he] felt [patient 3] needed to stay for additional treatment. [Patient 3's parent] came to visit. [She/He] didn't initially say anything about discharging [him/her], but a little later after speaking with [him/her], [she/he] had spoken with [his/her spouse] and wanted to take [patient 3] out. [His/her] decision to take [him/her], and it was not [patient 3's] fault or anything. [Patient 3's parent] came in and was very upset. I came out and I offered to talk with [him/her], the staff said there's no use [he/she] is upset and one [1] did not want to talk to anyone. The police came to take a report. I assume that the [parent] had called the police. The police cannot talk to minors without the guardian and I offered to help coordinate this, but the police didn't want to talk to them at that time. We discharged [patient 3] at the request of [his/her] guardians. Prior to the incident, we made sure that the patients were in view at all times. If the nurses weren't in the room with them, they watched them on camera. The cameras don't record. [Patient 3's parent] was upset about this when [he/she] came, but even if they did record, we couldn't share any footage with [him/her]. When this had happened there was a [gender] nurse working, [he/she] watched the incident on camera. The incident was a very short period of time, and the nurse got up and responded immediately. [He/She] intervened as quickly as [he/she] could. The next morning, after speaking to the patients and finishing my rounds, that's when [patient 3's parent] showed up. Initially the [patients] had not said anything that happened directly. All three (3) initially said it was consensual. Then [patient 3] changed [his/her] story and said that the [patients] were talking about sexual stuff and then the touching went on between the other two (2) and then they touched [him/her]. [He/She] admitted [he/she] didn't tell them to stop. [Patient 3] reported that [patient 1] tried to do a blowjob on [him/her] but [patient 3]

Based on medical record reviews, and staff interviews, it was determined the facility failed to ensure patients were not injured after an alleged sexual assault in three (3) patintes, patient, 1, 2, and 3 out of ten (10) patients reviewed. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

A medical record review was conducted for patient 1. The patient presented to the facility ' s Emergency Department via Emergency Medical Services (EMS) on 08/17/25 with a chief complaint of violent behaviors and suicidal ideations. The patient was admitted to the facility ' s adolescent behavioral unit with a diagnosis of Bipolar 1 Disorder, ADHD (attention deficit hyperactivity disorder), and PTSD (post-traumatic stress disorder). A medication regimen was started, and the patient was encouraged to participate in group therapy. The patient was referred to a psychiatric residential treatment facility, as [he/she] had been hospitalized in the acute psychiatric setting several times and still exhibited behavioral problems.

On 08/22/25 at 1:53 a.m. a "Nurse Note" by staff 7 states, "At 2115 (9:15 p.m.) another patient [patient 3] said that while in the lounge [patient 1] was reaching under the table rubbing [his/her] leg and touching [his/her] privates and later [patient 3] said that [patient 1] did give [him/her] a hand job but [he/she] was told to stop and it was not consensual. When [patient 1] was asked what occurred in the lounge [he/she] said, ' I did things with my hand to pleasure some one else". [He/she] also said they both was touching each other. [Patient 1] would not talk much or give many details about the incident. HNC (House Nurse Coordinator) [staff 6] was notified of incident. [Staff 8] on call was called and informed of the incident orders received to make [patient 1] level 2 and have [him/her] to only come out of [his/her] room for needs and place somebody close to [his/her] room for closer observation. Tried to call [his/her][parent], [parent ' s name] there was no answer message was left for [him/her] to call about an incident involving [patient 1]."

On 08/22/25 at 5:01 a.m. a "Nurse Note" by staff 7 states, "Patient was happy up about unit with peers, appetite was good and compliant with medications. Then was sexually inappropriate and was sent to [his/her] room and quickly went to sleep and slept well throughout the night."

The patient remains compliant with medication, occasionally attends group therapy, is cooperative, and has had no further reported inappropriate sexual behaviors. The patient remains hospitalized awaiting approval for placement in a long-term facility.

A medical record review was conducted for patient 2. The patient was admitted to the facility ' s adolescent behavioral health unit after being transferred from an acute hospital with reports of self-harming behaviors and intermittent psychosis. The patient ' s diagnosis is major depression recurrence with psychotic features. The patient's medications were adjusted, and a treatment plan was initiated. The patient continued to be manipulative with staff, and not focused on treatment. The patient is medication compliant and attends groups.

An "Event Note" on 08/21/25 at 8:51 p.m. by staff 8 states in part, "...At approximately 2130 (9:30 p.m.),I received a call from the nurse on the unit about an incident that had occurred. The report from staff was that around 2045 (8:45 p.m) three (3) [gender] patients, including [patient 2], were in the lounge playing cards. It was noted that they were observed on the camera to be sitting close together around the table with their backs to the camera. [patient 2] was noted to be moving [his/her] arm consistent with the motion of manual self-stimulation but it was not clear if this was what was happening as [his/her] back was to the camera. This reportedly only lasted a few seconds. Another [gender] peer (who will be referred to as the first [gender] peer) then proceeded to get on the floor and went under the table. Staff immediately went into the lounge and advised the first [gender] peer to get out of the floor. [He/she] did comply with this request and stated that [he/she] was picking up cards. Approximately 30 (thirty) minutes later, at around 2115 (9:15 p.m.), another [gender] peer (who will be referred to as the second [gender] peer) approached the nurses station, expressing concerns about some things that had happened in the lounge. [patient 2] was asked about what happened and [he/she] reported that they were all talking and joking about being gay, but the second [gender] peer maintained that [he/she] was not gay, and this turned into sexual behaviors initially between the first [gender] peer and the second [gender] peer. [He/she] reported that the first [gender] peer: [Patient 1] performed oral sex on the second [gender] peer. Afterwards [patient 2] reported that the second [gender] looked at [him/her] and told [him/her] [he/she] was next, and then reportedly grabbed [his/her] hand and put it over [his/her] genitals. [Patient 2] reported that at this point both the second [gender] peer and the first [gender] peer begin masturbating and that after the first [gender] peer finished [he/she] "licked the sperm off of [his/her] hand." When staff called and reported the incident, I did advise them to ensure the [patients] remained separated and [patient 2] was placed on a level 2 (two) and room restrictions. A security guard was also moved onto the unit to help monitor the situation. The nurse reported that [he/she] did not see how there could have been any oral sex performed as [he/she] was in the lounge as soon as [he/she] saw the first [gender] peer going under the table. The nurse was asked to contact the parents/guardians of each child to make them aware of what happened. They did contact the Cabell County DoHS as that is [patient 2]'s legal guardian and left messages that they were advised would be passed on to [patient 2] ' s worker."

A "Nurse Note" by staff 7 on 08/22/25 at 2:32 a.m. states, "Addendum: [Patient 2] was accused by [patient 1] of showing [him/her], [his/her] penis and rubbing [his/her] knee, this nurse was watching the camera, saw [patient 2] with [his/her] back to the camera moving [his/her] left arm fast look like [he/she] was masturbating possibly exposing [him/her]self for a few seconds then [patient 1] crawled under the table and I immediately intervened. [He/she] said [he/she] was under the table picking up cards. I don't feel that [patient 2] ' s story is credible because [he/she] said there was oral sex and the other two (2) [patient 1, and 3] both said it was a hand job. Original note: Approximately 2200 (10:00 p.m.) [patient 2] was asked about a sexually inappropriate incident in the lounge involving himself [patient 1] and [patient 3]. [He/she] said [patient 1] started telling [patient 3] [he/she] was gay and [patient 3] said [he/she] wasn't, and they started touching each other and then [patient 1] went under the table and gave [patient 3] oral sex. After that, [patient 2] said [patient 3] looked at [him/her] and told [him/her], [he/she ' s] next, [he/she] then pulled [patient 2 ' s] hand to [patient 3 ' s] privates, [he/she] then said [patient 3] spit on [his/her] own hand and gave [him/her] self a hand job. [He/she] then said [he/she] could see [patient 1 ' s] arm moving under the table giving [him/her] self a handjob then after, [he/she] was done [he/she] licked sperm off [his/her] own hand. HNC [staff 6] notified of incident, on call [staff 8] notified as well. West Virginia DoHS called with info left for a Cabell County case worker [name] about the incident referral number 570-478."

The patient remains compliant with medication, attends group therapy, is cooperative, and has had no further reported inappropriate sexual behaviors. The patient remains hospitalized awaiting approval for placement in a long-term facility.

A medical record review was conducted for patient 3. The patient presented to the facility's ED on 08/20/25 after continued anger outbursts with episodes of self-harm. The patient was admitted to the facility's adolescent behavioral health unit with a diagnosis of major depressive disorder and oppositional defiant disorder. A medication regimen was started, and the patient was encouraged to participate in group therapy.

An "Event Note" by staff 8 on 08/21/25 at 6:31 p.m. states, "At approximately, 2130 (9:30 p.m.), I received a call from the nurse on the unit about an incident that had occurred, which is detailed as follows: The report from staff was that around 2045 (8:45 p.m.) three (3) [gender] (gender) patients, including [patient 3], were in the lounge playing cards. It was noted that they were observed on the camera to be sitting close together around the table with their backs to the camera. Another [gender] peer (who will be referred to as the 3rd (third) [gender] peer) was noted to be moving [his/her] arm consistent with the motion of manual self-stimulation but it was not clear if this was what was happening as [his/her] back was to the camera. This reportedly only lasted a few seconds. Another [gender] peer (who will be referred to as the first [gender] peer) then proceeded to get on the floor and went under the table. Staff immediately went into the lounge and advised the first [gender] peer to get out of the floor. [He/she] did comply with this request and stated that [he/she] was picking up cards. Approximately 30 (thirty) minutes later, at around 2115 (9:15 p.m.), [patient 3] approached the nurses station, requesting to talk to staff privately. [He/she] began crying and reported that the first [gender] peer was reaching under the table and rubbing [his/her] leg, touching [his/her] genitals. The patient reporting this stated that [he/she] asked the first [gender] peer to stop but [he/she] did not. [He/she] also reported that the first [gender] peer also gave [him/her] a hand job. Staff did report that when [patient 3] approached the nurses station, there was a wet spot on the front of [his/her] scrubs that was inconsistent with urine. (Staff was asked to take these scrubs and put them in a bag in case these were needed for anything.) When staff called and reported the incident, I did advise them to ensure the [patients] remained separated. [Patient 3] was placed in a room directly in front of the nurses station. A security guard was also moved onto the unit to help monitor the situation. The nurse was asked to contact [patient 3's parent] to make [him/her] aware of what had happened. They did reach [patient 3's parent] and let [him/her] know about the incident."

On 08/22/25 at 1:18 a.m., a "Nurse Note" by staff 7 states, "Patient approached this nurse and said [he/she] needed to talk in private at approximately 2115 (9:15 p.m.) and reported a patient [patient 1] was reaching under the table in the lounge rubbing [his/her] leg and touching [his/her] privates and would not quit when told to stop. And [he/she] said another patient, [patient 2]
would not let [him/her] get up and [patient 2] was showing [his/her] penis to [him/her]. Later at 2230 (10:30 p.m.) [patient 3] said it was not consensual [he/she] had said stop but [he/she] did not try to make them stop because [he/she] was afraid they would hurt [him/her]. [He/she] said that [patient 1] did give [him/her] a hand job. Patients [parent] was called and told about the incident that occurred. [Staff 8] was called about the incident with orders to make [patient 1 and 2] level 2 and have them stay in their rooms for safety and have security to watch all involved to keep them separated. HNC [staff 6] notified of incident as well."

On 08/22/25 at 5:15 a.m., a "Nurse Note" by staff 7 states, "Patient has good appetite ate all of HS (bedtime) snack appears happy, no anxiety or agitation observed. For safety patient was placed in room 124 due to peers being sexually inappropriate. Patient went to sleep around 2300 (11:00 p.m.) and slept well throughout the night."

The patient left the facility, discharged by request of parents, on 08/22/25 at approximately 2:40 p.m.

May it be noted, no physical assessment was documented in patient 1, 2, or 3's chart after the alleged incident on 08/21/25.

A telephone interview was conducted with staff 5 on 08/27/25 at 2:05 p.m. Regarding patients 1, 2, and 3, staff 5 states, "That evening I didn't see anything happening. The [patients] were acting like they were up to something all evening but did not have any inappropriate behaviors. We were sitting at the nurses station and [staff 7] was watching them on the monitor. Sometime after that, [patient 3] was in the back room crying. [Staff 7] went to speak with [patient 3]. After [patient 3] reported what had happened, [he/she] made sure that [patient 1] was separated from the group. [He/She] called security onto the unit. I went to [patient 3's] room and [he/she] told me that [he/she] was a bad person. We offered [him/her] some medication to calm [him/her] down. We got [him/her] to calm down and into [his/her] room. When [staff 7] called [staff 8], [she/he] wanted us to keep [his/her] pants bagged up. I went in the room and told [him/her] we need to take [his/her] pants. [He/She] seemed irritated but complied. I sat outside of the door, so [he/she] changed [his/her] pants and then handed them to me. [He/She] went and talked to [staff 7] some more after that. I know [patient 3] left the next day. We're still keeping the [patients] separated. Someone sits in the hall constantly watching to ensure that the [patients] don't go into each other's rooms."

A telephone interview was conducted with staff 6 on 08/27/25 at 4:11 p.m. Regarding patients 1, 2, and 3, staff 6 states, "I was sitting besides [staff 7] when it happened. We were talking about work and [staff 7] was watching the video. [Staff 7] said did you see that? I couldn't see the screen. [He/She] said [he/she] moved [his/her] hand funny, I'm going to go check. Just then, one of the [patients] got down under the table [staff 7] was already getting up to go into the room and [he/she] walked straight into the day room. [He/She] said they [the patients] were just playing cards and one (1) said [he/she] was picking up the cards. Shortly after that [patient 3] came to the nurse's station and wanted to talk to [staff 7] . [Staff 7] went into the room and talked to [patient 3] and then came and got me about two (2) to three (3) minutes later and I came in the room with [him/her]. [Patient 3] was crying and said I didn't mean for that to happen. [Patient 3] said [he/she] touched me. I asked who and [he/she] said [patient 1]. [He/She] said [patient 2] touched [him/her] on [his/her] knee and exposed [him/her] self to [him/her] but [patient 1] touched [him/her] on [his/her] private area, then [he/she] started crying. I told [him/her] no one is blaming [him/her], it's not [his/her] fault. [He/She] continued to cry, [staff 7] went out of [his/her] room. I stayed in there with [patient 3]. [He/she] said [his/her] [parent] is going to be angry. I told [him/her] something unfortunate happened and you didn't do anything to cause your [parent] to be angry. We separated the [patients] and made them stay in their rooms at that time. We kept someone in the hall to watch them. I wrote up the incident reports and [staff 7] called the parents and the physician. When I came back to the unit, the [patients] were all in their rooms and [patient 3] was in [his/her] room coloring. [Staff 7] was waiting to hear back from one of the parents at that time. [Staff 7] said that [patient 3 ' s] story had changed and they all told a different story. [Patient 3] now said the other patient made oral contact with [him/her]. I don't know how that could have happened in the short amount of time, it was less than a minute. I didn't interview the kids myself, [staff 7] did. There's such a short amount of time it happened in. [Staff 7] had gotten up immediately and the [patients] kept changing their story. The doctor ordered someone to sit between them that night. The doctor also ordered [patient 3] to be moved to a separate area that's not accessible to the other two (2) [patients]. [His/Her] room was originally between the other two (2) [patients] and we moved [him/her] to the room that could be locked on the other side of the unit. The next day, [patient 3] left. After that we made sure that each child would have time in the lounge but not together. That night when it all happened, and we called the Physicians there was nothing ordered for an exam or an assessment. They weren't saying anything happened at that time with actual contact. Since the [patients] were separated, we did not see we needed to take any additional action..."

A telephone interview was conducted with staff 7 on 08/27/25 at 6:23 p.m. Regarding the incident on 08/21/25 with patients 1, 2, and 3, staff 7 states, "That night all three (3) [patients] were just being hyper teenagers. They were not misbehaving, just being loud and playing. When the [patients] are in the lounge I keep my distance, but I'm constantly watching on the video feed. I was looking at the camera at that time, and saw the three (3) [patients] sitting at the table in the lounge. They were sitting a little close and one (1) boy started moving [his/her] left arm. It looked like [he/she] was masturbating. I looked into the camera closer and just then the one (1) boy, [patient 1] started to get on the floor. I immediately jumped up and ran into the lounge and asked what was going on. [Patient 1] got up and had cards in [his/her] hand and said [he/she] was picking up [his/her] cards. I thought everything was okay. Thirty (30) minutes later, [patient 3] said [he/she] wanted to talk to me. [He/She] said the other [patient], [patient 1], groped [him/her] and was playing with himself and touched [patient 3]. I separated them and talked to the other two (2) [patients]. [Patient 1] said [he/she] was playing with [him/her] self and gave [patient 3] a handjob. Said that [patient 1] gave [him/her] a hand job. I called all the legal guardians, the doctors, and the supervisor was there at that time. The doctor ordered to put them in their room and change them to level two (2) observation and put them in a hospital gown..."

An interview was conducted with staff 15 on 08/28/25 at 9:05 a.m. Regarding the incident with patients 1, 2, and 3, staff 15 states, "...Prior to the incident, we made sure that the [patients] were in view at all times. If the nurses weren't in the room with them, they watched them on camera. The cameras don't record...The incident was a very short period of time, and the nurse got up and responded immediately. [He/She] intervened as quickly as [he/she] could. The next morning, after speaking to the patients and finishing my rounds, that's when [patient 3's parent] showed up. Initially the [patients] had not said anything happened directly. All three (3) initially said it was consensual. Then [patient 3] changed [his/her] story and said that the [patients] were talking about sexual stuff and then the touching went on between the other two (2) and then they touched [him/her]. [He/She] admitted [he/she] didn't tell them to stop. [Patient 3] reported that [patient 1] tried to do a blow job on [him/her] but [patient 3] got up and went to the bathroom. The whole incident upset [patient 3] and caught [him/her] by surprise. [Patient 3] did admit that [he/she] did not tell them to stop or that [he/she] didn't want to, [he/she] just got up and went to the bathroom...I was told initially after the incident happened, the nurses observed the front of [patient 3's] pajamas to be wet, and they kept them. I do not know where they went. I was not told if the nurses did a physical exam and there was not one ordered. They were asked to preserve the evidence, but I do not know what happened to it. There was no question that something happened. Neither myself or [staff 8] did a physical exam the next day. The patients kept having a change of stories, and it kept changing..."