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Based on record review, staff interview, patient interview, document review, and policy review, the facility failed to ensure that services performed under contract for Patient #1, one (1) of two (2) patients reviewed, were provided in a safe and effective manner.

Findings include:

On 6/22/2018 the State Agency received an Entity Reported Incident which stated:
"On 6/20/18 at 3:00 p.m. Pt. Advocate... spoke with (Patient #1 and Patient #2). (Patient #2) stated: He stated that he and a female patient were picked up by ....transport on the coast. They stopped along the way and the driver allowed the female patient to by (buy) some alcohol. She became intoxicated and she and the (company) driver began to flirt. They stopped in Waynesboro to get gas. The driver told (Patient #2) that he was going to "get some" (or words to that effect) and told (Patient #2) to drive for him. He did and saw them in the back of the vehicle removing clothing and fondling each other. While he could not see perfectly, he believed she was performing oral sex on the driver and he was "fingering her". The driver then said that she did not smell right and stopped. No intercourse was observed by (Patient #2) but when they stopped they were out of sight for a short amount of time. (Patient #2) was informed that given the seriousness of the clain that we would have to report this to the licensing and legal authorities. He became upset at the prospect of telling the story again but understood that it would be the right thing to do. (Patient #1) was asked what she remembered of the ride. She stated she only remembered getting on the transport and stopping to get the alcohol then she doesn't remember much of anything else until she woke up here at the hospital. She was informed that her peer had reported the above and she became very upset stating she did not remember any of it. She stated that if her family found that she was with a black man they would be extremely upset. She requested some STD testing be done. She stated that she was thankful that the peer had reported it given that she could not remember any of it. (Patient #1's) therapist was called into the meeting and was told of the event and will offer her more thrapy time as needed. She stated she did not want to press charges or have anyone know about this incident. (Patient #1) was informed that we had no proof of events only one person's account but that this would have to be reported to licensing and legal authorities." The report went on to state that the owner of the transport company had been spoken to . He gave the driver's name. The driver had stopped going to work the day after the events. The owner was requested to provide video of the ride and contact information for the driver. The contact information was received.


On 06/26/18 at 8:30 a.m. an unannounced visit was made to the facility. An interview was held with the Director of Clinical Services regarding the complaint/incident of 6/20/18. Information was requested and received regarding the complaint/incident. At 8:40 a.m. the Director stated,"The alleged event happened on 6/7/18, but we were not made aware of the incident until 6/20/18 when male patient (#2) reported the incident. At 11:45 a.m. the Director stated that the arrival time at the facility for Patient #1 and #2 on 6/7/18 was 11:30 p.m.

Review of a 6/8/18 0230 (2:30 a.m.) nursing assessment revealed "Patient #1 is a 51 year old female, appropriately dressed, has flat affect, is confused at times and tries to wonder off requiring re-direction. Pt admits depression and anxious. Pt. admits to suicidal ideation with plan to take pills. Pt admits to substance abuse of tequila one gallon a day... medical history of HTN and diabetes... reported by admissions that patient fell downstairs and has a bruise to her left knee. Pt also fell on Pathways Unit in her room...rolled off bed and fell on right side. Patient is intoxicated with breathalyzer of 0.293. (Physician) notified of intoxication and falls."


On 6/26/18 at 1:00 p.m. an interview was held with the owner of the transport company used to drive Patient #1 and Patient #2 to the facility. During the interview he stated, "(Employee #1) worked on June 6 and 7 (2018) and he did not report back to work. I tried to call him multi times and he did not answer the phone. He showed up on 6/15/18 to collect his payroll check and I asked him why he quit without telling me. He became nervous and agitated stating "I have my reasons." The owner stated that the cameras were not working. He stated, "I have bought over 20 cameras in the last 6 months. They are either stolen or the SD card is taken out. I texted (Employee #1) on 6/21/18 at 10:22 a.m. regarding some gas receipts. He called me back that evening denying stealing gas from me, but said that if I can come up with an amount he would pay me back. He denied anything sexual happening or letting the patent drive the van." The owner reported that there were no complaints filed against this employee during his employment.

Review of the Service Agreement between the facility and the transport company revealed it was signed and dated 1/31/2018. The agreement stated, "....6. Vendor represents that each person performing the services under this agreement (1) has been educated and trained consistent with applicable regulatory requirements and facility policy: (2) is appropriately licensed...; and (3) has appropriate knowledge, experience and competence as are appropriate for his or her assigned responsibilities as required by facility..."

Review of the vendor's records revealed the driver's Background Screeening Report, County Criminal Records Search, National Criminal Search, Sex Offender Records Search and Drug Screen were all negative. The driver was oriented by the facility and signed a Confidentiality Requirements Acknowledgement on 3/22/18.


Interview on 6/26/18 at 1:30 p.m. with Patient #2 revealed, "(Patient #1) was already in the van when the driver picks me up. She was tipsy and slumped down in her seat. (Patient #1) and the driver were flirting with each other and touching each other. The driver stopped at a couple of stores and one store he bought (Patient #1) two Bahama Mamas to drink. He told me he was going to get some. At the store in Waynesboro he stopped and told me to drive. He and (Patient #1) went to the back and he dropped his pants and she gave him oral sex. (Patient #1's) clothes were coming off when he stopped. He told me to pull over. He stated driving again and stated "I could not hit that. She smelled." When we arrived at the facility I caught (Patient #1) when she was falling out of the van and then she walked into the glass door."

On 6/26/18 at 2:00 p.m. the incident was discussed with Patient #1. She stated, "We stopped at a store and I brought two Bahama Mamas and drunk them. I don't remember anything else until I woke up the next morning in detox."

Multiple attempts were made to telephone and interview the transport driver without success.

Review of the facility's Patient Rights document revealed, "As a patient, your rights shall include, but not be limited: ...7. Receive care in a safe setting, free from verbal or physical abuse or harassment..."

Review of the facility's "Patient Rights and Responsibilities" policy, last review date 5/2018, revealed: " We will strive to abide by and respect all patient rights without regard to race, religion, creed, ethnicity, gender, age, sexual orientation or handicap. The facility shall support and protect the fundamental human, civil, constitutional, and statutory rights of the individual patient and recognize and respect personal dignity of the patient at all times ...3... 3.1.2. Each patient's personal dignity shall be recognized and respected in the provision of all care and treatment..."

Based on record review, staff interview, patient interview, document review, and policy review, the facility failed to ensure one (1) of two (2) patients reviewed, Patient #1, had the right to receive care in a safe setting.

Findings include:


Cross Refer to A0084 for the facility's failure to ensure Patient #1 had the right to receive care in a safe setting.

Based on record review, staff interview, patient interview, document review, and policy review, the facility failed to ensure Patient #1, one (1) of two (2) patients reviewed, had the right to be free from all forms of abuse or harassment.

Findings include:

Cross Refer to A0084 for the facility's failure to ensure Patient #1 had the right to be free from all forms of abuse or harassment.