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Based on record review, surveillance video review, policy review and interviews, it was determined the facility failed to ensure patients were free of abuse and harassment, as evidenced by failure to thoroughly investigate allegations of sexual misconduct involving Staff A and affecting Patient #1 and Patient #2, and failure to implement corrective action to minimize risk of reoccurrence.

The findings included:

Facility policy, titled, Reporting Allegations of Patient Neglect or Physical or Sexual Assault or Abuse, last reviewed on 02/21, documents in part, 'The purpose of this policy is to ensure the safety of any individual in the Facility and to ensure that the Administrator on Call immediately and effectively reports allegations of sexual or physical abuse, neglect or assault to the appropriate authorities and within Tenet. This policy is intended to cover the reporting of allegations that could involve criminal conduct.

Investigating Allegations:
All internal reviews will be directed by Operations Counsel and, if appropriate, Employment Counsel. Before conducting interviews that are required to complete the root cause analysis indicated by the Sentinel Event Response and Reporting Policy, the Tenet Facility must coordinate with Operations Counsel to ensure that interviews do not conflict with interviews that may need to be conducted by local law enforcement. During the investigation, past event reports may be consulted to determine whether allegations against the same individual have been reported previously.
Documentation:
The Compliance Officer, Patient Safety Officer/Risk Manager and/or Human Resources Director are each responsible, as appropriate under the circumstances, for maintaining complete documentation of all allegations of abuse, neglect or assault; the specifics of the allegations made; the specific steps taken by law enforcement and/or other appropriate authorities and the Facility to review the allegations; and the results of the review including the results of any review by law enforcement or other external agency. Documentation will be made in the Facility appropriate documentation system and maintained according to Administrative policy Records Management and its Record Retention Schedule.
Occurrence Report. Staff shall limit their reports to the pertinent clinical facts and shall avoid assigning blame or responsibility. Staff shall also report any Hazardous Conditions even though the conditions have not yet resulted in a Critical Event, Sentinel Event or Near Miss. Occurrence Reports shall be submitted to and reviewed by the Patient Safety Officer/Risk Manager in accordance with Organization policy.
The Patient Safety Officer/Risk Manager shall evaluate all Critical Events, Sentinel Events, Near Misses and other patient safety matters reported on an Occurrence Report. After evaluation, the Patient Safety Officer/Risk Manager shall determine what action is required or may, given the nature of the Occurrence, determine to take no action. The Patient Safety Officer/Risk Manager shall refer an Occurrence to the Quality Improvement/Patient Safety Committee only if the Occurrence materially impacts a patient's plan of care or had the potential to materially impact a patient's plan of care. The Patient Safety Officer/Risk Manager shall report potential Sentinel Events to the Tenet Patient Safety and begin the Root Cause Analysis pursuant to the Sentinel Event Policy. As required, the Patient Safety Officer/Risk Manager shall contact the Organization's Operations Counsel to determine whether the Critical Event or Sentinel Event is reportable to a state agency, the FDA or other external agency in accordance with applicable law.'


Clinical record review conducted on 04/14/21 revealed Patient #1 presented to the Emergency Department (ED) with chief complaint of suicidal ideation on 10/01/20. The patient was treated and stabilized and subsequently transferred to the psychiatric unit for further inpatient treatment. The physician ordered one to one level of supervision for this patient. The patient was deemed as competent to make own decisions.
Facility records indicated Patient #1 made an allegation of sexual misconduct involving Staff A, a Mental Health Technician, on 10/02/20, while the staff provided one to one level of supervision. The patient complaint included an allegation that the staff touched her breast when removing an electrocardiogram sticker from her chest and other claims of sexual abuse. The facility conducted an immediate investigation and reported the allegations to all required agencies. The corrective action was to suspend Staff A, pending the investigation. The facility investigation deemed the allegation as unfounded as the patient did not want to proceed with charges and recanted her statements.

Review of the Police report, dated 10/13/20, documented there was probable cause for an arrest, but due to the victim not wanting to proceed, the case was closed.

Further review of the facility documents failed to provide evidence of a thorough investigation. The facility did not address the reason why the patient, in the psychiatric unit, had electrocardiogram stickers on her body; the investigation did not include attempts or measures to identify other possible victims after the allegation was made; and there was no evidence of formal education to all staff regarding sexual misconduct related to this incident.

Two months later, the facility records indicated Patient #2 made an allegation of sexual misconduct involving the same staff, Staff A, on 12/20/20.

Clinical record review conducted on 04/14/21 revealed Patient #2 presented to the Emergency Department with chief complaint of suicidal ideation's on 12/18/20. The patient was treated and stabilized and subsequently transferred to the psychiatric unit for further inpatient treatment. The patient was deemed competent to make decisions.
Facility records indicated Patient #2 made an allegation of sexual misconduct involving Staff A, on 12/20/20. The complaint included allegations of sexual intercourse and oral sex on at least two occasions.

Review of the surveillance video, for the date of the incident 12/20/20, showed Staff A and Patient #2 having a conversation in the hallway. Staff A signals, makes a hand gesture towards the room next door. Patient #2 is seen going inside the next room. A minute later, Staff A goes inside the same room. Eight minutes after they went in the room, a staff member (Staff G) is seen walking around with a clipboard, he looked into Patient #2's room, and seems to be searching for the patient. Staff G comes back to the area, checks the room occupied by Staff A and Patient #2, appears to be locked so he does not go in the room. Three minutes later, Staff A is seen leaving the room and going down the hallway. Staff G is then seen walking back towards the nurses' station and sees Patient #2 leaving the room that he previously checked and was locked. Staff A and Patient #2 remained in the room for 11 minutes.

The facility conducted an immediate investigation and reported the allegations to all required agencies. The corrective action was to suspend Staff A, pending the investigation and subsequently, the staff was terminated.

Further review of the facility documents regarding the second allegation of sexual misconduct failed to provide evidence of facility-wide effective and measurable corrective action to minimize re-occurrence. There is no evidence of a root cause analysis of the event.

Interview with the Nurse Manager (NM) conducted on 04/14/21 at 12:23 PM revealed his (NM) recollection of the incidents, regarding Staff A and the allegations of sexual misconduct. The Nurse Manager was asked why Patient #1 had electrocardiogram stickers on her body. The Manager explained the facility does a body search and skin assessment upon admission. Patient #1 went back to the emergency room and the staff does not complete a body check after an emergency room visit. The Manager agreed the electrode stickers should have been removed for safety reasons. Upon inquiry, the NM stated the corrective action for this event was to have a female one to one with Patient #1, to have two staff members present when needed; the staff involved met with human resources; and after the second allegation Staff A was terminated.

Interview with Staff C, a Mental Health Technician, conducted on 04/14/21 at 1:14 PM, revealed he worked on 10/02/20 and recalls the allegations regarding Patient #1. He was not involved in the incident and corrective action was never discussed with him.

Interview with Staff E, a Mental Health Technician, conducted on 04/14/21 at 2:03 PM revealed she was not involved with any of the incidents or investigation and heard about the allegations through other staff members.

Interview with the Director of the Behavioral Health Services conducted on 04/15/21 at 8:55 AM revealed the corrective action plan was education, through huddles and staff meeting. The staff were made aware of not going into rooms alone. The Director confirmed the facility has no policies and procedures governing the two-staff being present when in rooms, and there is no policy addressing body or skin reassessment after an emergency room visit. Regarding the investigation and corrective action, the Director said the risk manager usually follows up and typically law enforcement has a good sense of the resolution. In this case, his total understanding, was that they did not find probable cause during the first event, the patient refused to cooperate and there were some conflicting statements. The Director was very surprised when he read the police report. After the second incident, the facility corrective action was termination of employment.

On 04/15/21 at 10:25 AM, the Director of Quality confirmed the facility did not complete a root cause analysis and the investigation and corrective action was noted in the event tool.

On 04/15/20 at 12:48 PM, the Director of Behavioral Services confirmed after the first and second incident, the facility did not establish or implemented a process to identify other probable victims of sexual misconduct. There is no written evidence of staff education related to the incidents, as the education was verbal.

Telephone interview with Staff G, a Registered Nurse, on 04/15/21 at 3:11 PM, revealed he had no knowledge of the first allegation of sexual misconduct, and heard about it Saturday on a news report. Staff G explained, 'on 12/20/20, he was working as a technician and while doing the safety checks, he was looking for Patient #2. After searching the unit, he checked the empty room and it was locked, then he saw Patient #2 leaving that empty room.' Staff G confirmed all staff on duty have keys to access empty rooms.

Telephone interview with Staff H, a Mental Health Technician, conducted on 04/16/21 at 9:20 AM, revealed he was not on duty during the incidents, does not recall the incidents or corrective action, and recently heard the allegations through the news report.

Telephone interview with the Medical Director conducted on 04/16/21 at 9:56 AM revealed the director was made aware of the incidents recently, as of last Monday, and was not part of the investigation or corrective action plan.

The facility received two allegations of sexual misconduct and failed to conduct a thorough investigation, failed to identify possible factors to the encounters, failed to address the possibility of additional victims, failed to complete a root cause analysis, and failed to implement corrective actions to protect patients from further events.

Based on record review, surveillance video review, policy review and interview, it was determined the facility's Quality Assurance and Performance Improvement Program failed to ensure patients were free of abuse and harassment, as evidenced by failure to identify opportunities for improvement after investigation of allegations of sexual misconduct involving Staff A and affecting Patient #1 and Patient #2 and failure to develop and implement interventions to minimize risk of reoccurrence and failure to measure, assess and monitor for sustained improvement.

The findings included:

Performance Improvement Plan, revised 02/21, documents in part, Organizational leaders have the responsibility to create an environment that promotes performance improvement through the safe delivery of patient care, quality outcomes and high customer satisfaction.
The organization's leaders are responsible to implement the performance improvement policies of the Board.
Leadership includes but is not limited to members of the Quality Improvement I Patient Safety Committee (QIPSC), the Administrative and Management Staff, and the Executive Committee of the Medical Staff. Actions and results of performance improvement activities implemented by the leadership will be shared with the facility community advisory board to assess the effectiveness of the performance improvement program.
Department Directors support the organizational performance improvement program. Directors help to create a culture that enables the organization to fulfill its mission and meet or exceed its goals. Department Directors are responsible for following the 2020 Performance Improvement Reporting Schedule to identify opportunities for improvement within their respective area(s) and plan interventions, measure, assess and monitor for sustained improvement. Department Directors shall evaluate annually the effectiveness of their department specific performance improvement activities.
The Quality Improvement [Patient Safety Committee oversees and coordinates all quality improvement and patient safety activities within the organization. This committee is responsible for evaluating, prioritizing, and supporting performance improvement opportunities. Members may include administrative leaders, medical staff leaders, representation from the community and/or the community advisory board, key department directors, and other staff involved in quality improvement and patient safety activities, The Quality Improvement / Patient Safety Committee reviews requests for chartering performance improvement teams based on identified trends and patterns. Information and requests come from a multitude of sources, which helps inform decision making and utilization of resources. Common areas inquiry and analysis include regulatory, risk, patient safety, clinical practice, and publicly reported data.


Clinical record review conducted on 04/14/21 revealed Patient #1 presented to the Emergency Department with chief complaint of suicidal ideation on 10/01/20. The patient was treated and stabilized and subsequently transferred to the psychiatric unit for further inpatient treatment. The physician ordered one to one level of supervision for this patient and was deemed as competent to make own decisions.
Facility records indicated Patient #1 made an allegation of sexual misconduct involving Staff A, a Mental Health Technician, on 10/02/20, while the staff provided one to one level of supervision. The patient complaint included an allegation that the staff touched her breast when removing an electrocardiogram sticker from her chest and other claims of sexual abuse. The facility conducted an immediate investigation and reported the allegations to all required agencies. The corrective action was to suspend Staff A pending the investigation. The facility investigation deemed the allegation as unfounded as the patient did not want to proceed with charges and recanted her statements.

Review of the Police report, dated 10/13/20, documented there was probable cause for an arrest, but due to the victim not wanting to proceed, the case was closed.

Further review of the facility documents failed to provide evidence of a thorough investigation. The investigation did not include attempts or measures to identify other possible victims after the allegation was made and there is no evidence of formal education to all staff regarding sexual misconduct related to this incident.

Two months later, facility records indicated Patient #2 made an allegation of sexual misconduct involving the same staff, Staff A, on 12/20/20.

Clinical record review conducted on 04/14/21 revealed Patient #2 presented to the Emergency Department with chief complaint of suicidal ideation's on 12/18/20. The patient was treated and stabilized and subsequently transferred to the psychiatric unit for further inpatient treatment. The patient was deemed competent to make decisions.
Facility records indicated Patient #2 made an allegation of sexual misconduct involving Staff A, on 12/20/20. The complaint included allegations of sexual intercourse and oral sex on at least two occasions.

Review of the surveillance video for the date of the incident, 12/20/20, showed Staff A and Patient #2 having a conversation in the hallway. Staff A signals, makes a hand gesture towards the room next door. Patient #2 is seen going inside the next room. A minute later, Staff A goes inside the same room. Eight minutes after they went in the room, a staff member (Staff G) is seen walking around with a clipboard. He looks into Patient #2's room, and seems to be searching for the patient. Staff G comes back to the area checks the room occupied by Staff A and Patient #2, appears to be locked so he does not go in the room. Three minutes later, Staff A is seen leaving the room and going down the hallway. Staff G is then seen walking back towards the nurses' station and sees Patient #2 leaving the room that he previously checked and was locked. Staff A and Patient #2 remained in the room for 11 minutes.

The facility conducted an immediate investigation and reported the allegations to all required agencies. The corrective action was to suspend Staff A pending the investigation and subsequently the staff was terminated.

Further review of the facility documents regarding the second allegation of sexual misconduct failed to provide evidence of facility wide effective and measurable corrective action to minimize re-occurrence. There is no root cause analysis of the event.

Interview with the Director of The Behavioral Health Services conducted on 04/15/21 at 8:55 AM revealed the corrective action plan was education, through huddles and staff meeting. The staff was made aware of not going into rooms alone. The Director confirmed the facility has no policies and procedures governing the two-staff being present when in rooms and there is no policy addressing body or skin reassessment after an emergency room visit. Regarding the investigation and corrective action, the Director said the risk manager usually follows up and typically law enforcement has a good sense of the resolution. In this case, his total understanding, was that they did not find probable cause during the first event, the patient refused to cooperate and there were some conflicting statements. The Director was very surprised when he read the police report. After the second incident, the facility corrective action was termination of employment.

On 04/15/21 at 10:25 AM, the Director of Quality confirmed the facility did not complete a root cause analysis and the investigation and corrective action was noted in the event tool and there is no evidence the incidents were reviewed by the Quality Assurance Performance Improvement Program.

On 04/15/20 at 12:48 PM, the Director of Behavioral Services confirmed after the first and second incident, the facility did not establish or implemented a process to identify other probable victims of sexual misconduct. There was no written evidence of staff education related to the incidents, as the education was verbal.

The facility received two allegations of sexual misconduct and failed to conduct a thorough investigation, failed to identify possible causes to the encounters, failed to address the possibility of additional victims, failed to complete a root cause analysis, and failed to implement corrective actions to protect patients from further events.