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Based on observation, interview and record review, the facility failed to protect the rights of one patient (P-3) of 4 patients reviewed for allegations of abuse resulting in an incident of patient to patient sexual abuse.
Findings include:

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0145- Failure to protect patients from abuse.

Based on interview and record review the facility failed to follow policy to prevent patient to patient sexual abuse for one patient (P-3) of four patients reviewed for abuse allegations, and failed to follow policy to prevent further occurrence of abuse, resulting in the potential of reoccurrence and harm to all patients exposed to the abuser. Findings include:

Record review on 10/2/2023 at 1350 for P-9 revealed a Psychiatric Admission Assessment dated 9/23/2023 at 1605 with reason for admission documented as worsening psychotic symptoms. The Assessment listed diagnoses to include schizophrenia spectrum and other psychotic illness and bipolar disorder. Behavioral medicine progress note dated 9/23/2023 revealed P-9 had flashed his penis to female psychiatric technician in the conference room during admission and talked about his "caterpillar" (referencing his penis) with a female nurse during the skin check.

Record review on 10/3/2023 at 1032 for P-3 revealed a Case Management note dated 9/27/2023 which documented the reason for admission as confusion, decline in functioning, hallucinations and suicidal ideation. The note indicated overnight on 9/26/2023 at 0038 a male peer (P-9) had P-3 sitting on his lap and was rubbing her private parts and her back and staff separated them. Documentation revealed the male peer told P-3 he was her father/daddy and that P-3 was confused to the point she thought he was her father. Review of orders from P-9's medical record revealed no Sexual Precaution Order was not placed until after the incident on 9/26/2023 at 0641.

On 10/3/2023 at 1450 review of facility Incident Report from 9/26/2023 documented that Staff O observed P-3 sitting on P-9's lap, clothed with her legs slightly open. P-3 was rubbing her genital area, thigh and then her back while saying "its [sic] ok honey. I am your father." P-9 was noted to be masturbating during safety checks after the incident occurred. The RN spoke with P-3 who was confused and thought blocked and did not appear to understand what was happening and asked the RN "is he my dad?".

During an interview on 10/4/2023 at 1214 with Staff O it was revealed that Staff O was working in the Aspen Unit on 9/25/2023 and at approximately 2300-2330 noticed there were still 7 patients awake in the patient lounge, Staff O stated P-9 and P-3 were seated at a table across from each other talking. P-9 was in his wheelchair at that time. Staff O stated that she told the patients that "lights out in 10 minutes". Staff O stated she returned to the patient lounge area and found P-9 sitting in a regular chair with P-3 on his lap, P-9's leg was propped up off to the side and P-3 was "straddling his leg". Staff O stated she heard P-9 tell P-3 "it's ok, I'm your father" and "I love you" while he was using his left hand to rub P-3's back and his right hand to rub P-3's genitalia, outside of P-3's clothes. Staff O stated she asked them what they were doing, and P-3 looked confused and was not connecting what was happening. Staff O took P-3 to her room and told her to stay there and asked a psychiatric technician to make sure P-3 did not leave her room. Staff O stated she went back to the patient lounge and spoke with P-9 about the facility policies regarding males and females touching. Staff O stated P-9 stated, "I am her father and I work for the FBI". P-9 was asked to go to his room. Staff O stated the technician later reported to her that P-9 had been masturbating in his room for the last 2 hours. Staff O stated she went back to P-3's room and asked her if she was ok and P-3 stated, "I'm really confused and I thought I was at work" and eventually came back to the nurse's station and asked if P-9 was her father. Staff O stated she contacted the nursing supervisor and social worker for each patient approximately one hour after the incident and sent a Teams message to the psychiatrist on call but cannot remember if she spoke with that physician. No new orders and/or precautions were implemented during her shift. Staff O stated she contacted the all-male unit and asked them to hold a bed for P-9 when one becomes available. Staff O stated she put on her handoff sheet for the oncoming nurse to monitor P-9 for sexual behaviors and did not see anything further.

Document review from Staff P on 09/26/2023 at 1317 revealed P-3 and P-9 attended group therapy together on 09/26/2023, the morning after the incident.

Document review revealed P-9 was not separated from P-3 and/or transferred to an all male unit until 09/26/2023 at 1427.

In an interview with Staff A on 10/2/2023 at 1515 she stated P-3 was confused and unable to give consent.

In an interview on 10/2/2023 at 1608 Staff L (manager of the unit) stated per policy P-9 should have been placed on sexual precautions.

Per facility policy "Patient Observations and Precautions-Behavioral Health, HRS 10/362" dated 8/2023 "sexual acting out precautions: applies to the patient whose behavior, verbalizations, or history indicates that sexual preoccupation may be acted upon by inappropriate touching, exposing themselves, or other overt sexual behaviors."