The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

NIX HEALTH CARE SYSTEM 414 NAVARRO, SUITE 600 SAN ANTONIO, TX 78205 Aug. 10, 2015
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review and interview, the facility failed to ensure specific patient rights were protected and promoted, and implement their written policy and procedures that protect and promote each patient's rights for 1 of 1 patients (Patient #1) reviewed with a rights violation complaint.

Specifically, the facility failed to ensure Patient #1's rights to be free from all forms of abuse or harassment by failing to prevent, protect, investigate, and report/respond to a sexual assault allegation made by Patient #1 against another Patient (#2); as a result of facility neglect.

On 04/27/15, Patient #1 reported to the unit's Registered Nurse (RN) an allegation of sexual assault from another Patient, (#2); who had a history of inappropriate sexual behaviors. The allegation was reported to the Medical Doctor, the Nursing Manager, and local Police Department (PD). However, this allegation was not reported to the state health care regulatory agency by any facility employees, in accordance with their policy. In addition, this allegation was not thoroughly investigated by the facility for the identification of neglect and/or a corrective action plan to prevent repeat incidence in accordance with the facility's policy.

Refer to A 0145 for evidence of specific findings.


The effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Patient Rights.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, the facility failed to ensure the patient's rights to be free from all forms of abuse or harassment by failing to prevent, protect, investigate, and report/respond to an allegation of neglect in accordance with their policy, for 1 of 1 patients reviewed (Patient #1) with a complaint allegation of sexual assault against another patient (Patient #2).

On 04/27/15, Patient #1 reported to the unit's Registered Nurse (RN) an allegation of sexual assault from another Patient, (#2); who had a history of inappropriate sexual behaviors. The allegation was reported to the Medical Doctor, the Nursing Manager, and local Police Department (PD). However, this allegation was not reported to the state health care regulatory agency by any facility employees in accordance with their policy. In addition, this allegation was not thoroughly investigated by the facility for the identification of neglect and/or a corrective action plan to prevent repeat incidence; in accordance with the facility's policy.

This deficient practice could affect the prevention of possible unidentified abuse, neglect, or mistreatment for all patients in the facility; by compromising their safety.

Findings Included:

Review of Patient #1's Complaint Form dated 05/15/15, indicated the following in part:

On 04/27/15 at approximately 11:30 AM, Patient #1 was admitted to the facility's "Psychiatric Emergency Services (PES) unit and received medication to help her sleep and calm down. Patient #1 reported shortly after she received the medications; she was asleep in her bed when she "felt someone touching my vagina and butt. I felt a hard pressure. I jumped up and another male patient [#2] jumped out from under my covers." Patient #1 stated she went to find a staff member (Mental Health Worker-A), to report what had happened. Patient #1 indicated she noticed her entire "crotch area [paper gown] was torn exposing her "vagina and butt." Patient #1 indicated the facility staff called the Police Department (PD) for Patient #1 to make a report. Patient #1 reported the staff apologized to her for the incident; "but they had an emergency on another floor and they were short staffed, so every staff member had left." Patient #1 indicated she was "so upset and scared; so they gave me more meds to put me to sleep." Patient #1 stated the facility had done nothing more to help her; there were no witnesses but she believed there were cameras in the hall. Patient #1 stated she found out that Patient #2 had done this before and the Police Officer who responded stated that "he [Patient #2] has a history of doing this, why was he unsupervised?"

Review of the facility's Policy titled, Abuse Reporting-External and Internal, last reviewed January 2012 revealed the following definitions:
Psychological Abuse included; humiliation and harassment.
Sexual Abuse included; sexual harassment, sexual coercion, and sexual assault.

Review of the facility's Policy titled, Assessment and Reporting of Abuse and Neglect, last reviewed February 2013 revealed Neglect included the failure to provide for one's self the goods or services including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caretaker to provide the goods or services. The policy indicated the facility "prohibits neglect, mental or physical abuse or misappropriation of property, of patients by staff, visitors, or other patients." The facility "will report allegations and release information to the proper authorities, according to federal regulations, state specific rules and regulation and [facility] practice guidelines."

Further review of the policy indicated, in part:

1. Reporting allegations of abuse and/or neglect occurring while the patient is under the care in the facility: All alleged violations concerning abuse and neglect while the patient is under the care of the facility will be reported to the Compliance Officer or designee, who will advise the on-call administrator/designee. As appropriate, the facility will report the incident to appropriate state, federal and protective/regulatory agencies, and/or law enforcement agencies and conduct an internal investigation within a maximum of five working days of the incident. The Texas Department of state Health Services (DSHS) is the regulatory body for reporting concerns of hospitals, psychiatric hospitals (including private psychiatric facilities), and various other medical facilities.

2. Investigations are always prompt, comprehensive and responsive to the situation, well conducted, and contain founded conclusions. The investigation may include, but are not limited to the following:
-Interviews conducted with individuals having first-hand knowledge of the incident.
-Follow-up resolution
-Corrective action plan to prevent repeat incidence.
-Reports made to appropriate state health care regulatory agency.


Review of the facility's Original Event report dated 04/27/15 at 12:15 PM completed by the unit RN revealed Patient #1 reported, "She was lying in bed asleep, when she felt Patient [#2] putting pressure around her buttocks area, and then touching her perineal area. Patient [#1] reported sitting up in bed shock and scared, and found Patient [#2] was up in her face with his finger to his mouth telling her to be quiet not to tell. She found her paper scrub button torned on the outer left side. MD [Medical Doctor], Nurse Manager notified, Patient made a police complaint." PD interviewed Patient #1 and accused, Patient #2. "Patient visible distraught, but no other physical problems noted at this time." Further review of the Original Event indicated the Event was documented as "Attempted Rape/Rape/Sexual Assault." Factors included; "Unit busy code greens called on other unit, and high acute of unit." The Original Event report did not include any documentation that this allegation was reported to the state health care regulatory agency by any facility employees, in accordance with the facility's policy. The Original Event report did not include documentation that this allegation was thoroughly investigated by the facility for the identification of neglect and/or a corrective action plan to prevent repeat incidence; in accordance with the facility's policy. The Compliance Officer/Director of Risk Management (RM) acknowledged receipt of the Original Event report dated 04/27/15 at 12:15 PM electronically on 05/06/15 documenting Patient #1 made a Police Report.

Review of the local PD report dated 04/27/15 at 12:45PM revealed Patient #1 wanted to report that, "she was a sleep in her room, when she awaken and felt pressure around her buttock and vaginal area. When she fully awaken, she observed [Patient #2] in bed with her." Patient #1 further stated that Patient #2 told her "Don't tell anyone," before he left her room. Patient #1 did not feel Patient #2 penetrate her at any time, but the hospital [paper gown] pajama that she was wearing had a tear between the leg area. Patient #2 denied being in bed with Patient #1, or touching her. The report was deemed as "Disorderly Conduct" and Patient #1 was advised to contact the special victim's unit to file charges against Patient #2. "The Hospital staff was advised to monitor [Patient #2's] movement more closely."

Record review of the medical record of Patient #1 revealed she was a [AGE] year-old female admitted on [DATE] at 0830 under Emergency Detention (ED) when she cut her wrist and called a friend to call Police. Patient #1 has a history of Depression with Anxiety.

Further review of Patient #1's permanent records revealed no documentation following the sexual assault allegation that she made on 04/27/15 against Patient #2. There was no documentation in her record that she received a physical and/or psychological assessment following her allegation on 04/27/15. There was a Telephone Physician Order (PO) on 04/27/15 at 12:30 PM (following the allegation) for Ativan (an anti-anxiety) 2 milligrams by mouth "now" without documentation of the reason for the emergency medication. The only documentation in Patient #1's record regarding her allegation against Patient #2 was a Behavioral Team Progress Note dated 05/01/15 at 12:28 completed by Licensed Social Worker- A that indicated "Patient discussed being sexually assaulted by Patient [#2] in the [facility's] PES unit.

Review of Patient #1's Daily Observation Notes for 04/27/15 revealed the following:
At 11:30-MHW-A documented 1Q (1=On unit, and Q=Quiet/Calm).
At 11:45-MHW-A documented 1B (On unit, and B=In Bed Awake).
At 12:00-MHW-A documented 1BA (On unit, In Bed Awake, and A=agitated/restless).
At 12:15 MHW-A documented 1BA.
At 12:30, 12:45, 13:00, 13:15, 13:30, and 13:45- MHW-A documented 1A (On Unit and agitated/restless).

Record review of Patient #2's medical records revealed the following:

Patient #2's Psychiatric Evaluation dated 04/24/15 revealed he was a [AGE] year old male admitted on [DATE] with a history of schizoaffective disorder and traumatic brain injury (TBI). Patient #2 was admitted on an ED basis with a history of aggressive behaviors requiring emergency medications to calm him. Patient #2 had recently been discharged from this facility 4-5 weeks prior and has had multiple inpatient treatment episodes over the years (7 inpatient admissions in the previous 5 months). Patient #2 was documented with a known history of aggression and a "history of inappropriate sexual behavior on the unit (masturbating)."

Patient #2 had documented borderline intellectual functioning with poor insight, poor judgment, and poor impulse control.

A Behavioral Nursing Shift Assessment completed by the unit RN on 04/27/15 at 18:08 that Patient #2 was found by a female patient touching on her body while she was asleep in bed. MD, and Nurse Manager notified.

A Telephone PO dated 04/27/15 at 2015 for Patient #2 to be transferred to a higher acuity; sister facility.

A Behavior Team Progress noted dated 04/27/15 at 1855 revealed Patient #2 was transferred to a sister facility by the Sheriff's Department.

Review of the facility's Incident Event dated 04/27/15 at 11:37 AM confirmed a Code Green was called for another Patient [#3] in the Child/Adolescent Unit requiring Restraints/Seclusion. Patient #3 required physical restraint at 11:36 AM, and emergency medications at 11:46 AM. Patient #3 was released from restraint at 12:26 PM. This Code Green occurred during the same time frames of Patient #1's allegation on 04/27/15.

Review of the facility's Policy titled, Psychiatric Emergencies-Code Green, last reviewed January 2012 revealed a Code Green was a Psychiatric Emergency. Code Green will be implemented by any unit personnel in the event of unmanageable behavior of an individual to prevent harm to that individual, patients, hospital personnel and/or others the general hospital area. D. Individuals responding to Code Green will meet in announced area. Available personnel is necessary to control atmosphere through a show of strength and caring or to assist in physical management.

Interview on 08/06/15 at 12:35 PM with the PES unit RN revealed she completed Patient #1's admission assessment to the PES unit on 04/27/15. The unit RN indicated Patients were provided with paper scrubs to wear without other undergarments. The unit RN stated that on 04/27/15 at approximately 11:30 AM to 12:00 PM, "Code Greens" were going on; and "staff were busy". The unit RN stated there was a Code Green on another unit (child/adolescent) and a Code Green was called in the lobby; due to a patient needing to be "put in a [restraint] chair" because they were tearing up the lobby. The unit RN stated she left the unit to respond to the Code Green in the other unit (child/adolescent) and when she arrived; there was another RN responding, so she went to the Code Green in the lobby because they needed an RN to assist with "putting the patient in the [restraint] chair." The unit RN stated she returned to the PES unit following the Code Greens to "something else going on at the end of the unit" that she responded to. The unit RN stated she could not remember if it was LVN-A or LVN-B working on 04/27/15; but that she thought the LVN stayed back in the PES unit when she left and responded to the two Code Greens. The unit RN stated she was notified that during the Code Greens Patient #2 went into Patient #1's bedroom; and Patient #1 made an allegation of sexual assault. The unit RN stated she spoke with Patient #1 who reported that she was asleep in her bedroom and "she felt pressure" causing her to awake to Patient #2 touching her in the buttock and perineal area. The unit RN stated that Patient #1's paper pants were "torn on the side." The unit RN stated the local PD was called. The unit RN stated she spoke to Patient #2 and he said, "I touched her, but didn't do anything else." The unit RN stated he admitted that he "touched her and ripped her paper pants." The unit RN stated that Patient #2 knew that the unit was "chaotic" and knew what Code Green meant; and that is when he "took advantage" of the situation. The unit RN stated she believed that Patient #2 sexually assaulted Patient #1 given the facts, and his own admission. The unit RN stated she notified the MD, Social Worker, and Nursing Manager of the allegation. The unit RN indicated she documented the sexual assault allegation made by Patient #1 on the facility's Event Report; however, confirmed she did not document the sexual assault allegation in Patient #1's record following the incident. The unit RN stated she offered for Patient #1 to have a Sexual Assault Nurse Examination (SANE) completed at another facility if she wanted; but Patient #1 declined, stating she did not believe Patient #2 actually raped her.

Interview on 08/06/15 at 04:45 PM with MHW-A revealed she was the only MHW working on 04/27/15 in the PES unit; along with the unit RN and a Licensed Vocational Nurse (LVN). MHW-A stated she was pulled to the PES unit at 9:15 AM and was unfamiliar to the PES unit; but was told by the leaving MHW to "watch it" for Patient #2, however, she did not know the specific reason why. MHW-A stated the females were assigned rooms on one side, and males on the other side. MHW-A stated during the morning on 04/27/15 at approximately 11:30 AM-12:00 PM it was a "hectic/busy" day with "Code Green's being called." MHW-A stated that security was usually on the PES unit; but on 04/27/15 at the time of the allegation; "security could not be found." MHW-A stated on 04/27/15 at around 11:30-12:00 PM she stayed in the unit when the Code Greens were called and was "getting something out of the supply closet." MHW-A indicated the unit RN "responded to the Code Green" leaving the unit; telling her she [unit RN] would be back. MHW-A did not remember if LVN-A or LVN-B was working on 04/27/15; but further stated she did not remember any LVN being in the unit during the time of the allegation made by Patient #1. MHW-A stated shortly after this Patient #1 "flagged her [MHW-A] down" to her bedroom, and into the restroom of the bedroom where she reported that Patient #2 came into her room and touched her buttocks and vaginal area while she was sleeping in her bed. MHW-A stated that Patient #1's gown was torn around the buttock area and she offered to call the local PD for Patient #1 to make a report. MHW-A stated she then reported the incident/allegation to the unit RN. MHW-A stated she was later told that Patient #2 had been an inpatient to the facility many times before, and he "knows the system; knows what Code Green means." MHW-A stated she had seen Patient #2 "walking out of her [Patient #1] room a few times" and further stated "right before she flagged me down, he had walked out of her room". MHW-A indicated she told Patient #2 "not to go in to other people's rooms." MHW-A confirmed she had not documented the allegation reported by Patient #1 against Patient #2; but that she "told [unit RN]."

Interview on 08/10/15at 1:20 PM with Patient #1 revealed on 04/27/15 at approximately 11:30-11:45 AM she was in her assigned bedroom sleeping after she received multiple medications following her admission. Patient #1 stated she awoke after she "felt pressure" in her buttock and vaginal area. Patient #1 stated that Patient #2 was present telling her not to tell anyone. Patient #1 stated that she noticed her paper pants were ripped and she was not actually aware what all Patient #2 actually did because she "was conked out" after taking multiple medications. Patient #1 stated she knows he touched her because that was what woke her up. Patient #1 stated she was very upset, "freaked out," and asked the MD for an "AIDS" test. Patient #1 stated the unit RN indicated to the nursing staff (LVN) to "give her more meds" because she was "upset, crying, and freaking out." Patient #1 stated she then received the Ativan for her anxiety, to "help me calm down." Patient #1 stated the local PD came and she made a report. Patient #1 stated she was told by the unit RN that "Code Green's" were called and "everyone had to leave the unit" which allowed the opportunity for Patient #2 to go into her room unsupervised.


Interview on 08/10/15 at 2:20 PM with Security Guard-A revealed he was employed by the facility to maintain security and the safety of patients. The Security Guard-A stated Patient #2 had a history of inappropriate sexual behavior of "masturbating in front of females." The Security Guard-A stated he assisted with "viewing the video" footage for evidence following the allegation on 04/27/15 made be Patient #1 against Patient #2. The Security Guard stated the video footage from 04/27/15 showed a total of "four times" that Patient #2 went into Patient #1's room; and the last time Patient #2 came out of Patient #1's room; she was observed to come out of the room a few minutes later. The Security Guard stated that Patient #2 had already been assigned to the front "seclusion room" of the PES unit as his bedroom due to his history of masturbating. The Security Guard stated on the video footage Patient #2 could be seen coming from his room; "looking side to side" down the hallway, and then going into Patient #1's room. The Security Guard stated that female and male patient rooms were separated and that Patient #2 was not supposed to be going into Patient #1's room for any reason.

Interview on 08/10/15 at 2:50 PM with MD-A revealed he was notified of Patient #1's sexual assault allegation against Patient #2 on 04/27/15. MD-A stated he discussed with Patient #1 the option of a "Rape Kit" but she "declined." MD-A stated he understood the allegation made by Patient #1 to be "only touching with no penetration." MD-A stated that Patient #1 was "distressed" about the incident and he ordered Ativan for Patient #1's anxiety following the incident. MD-A stated Patient #1 had already been distressed emotionally because of her ED inpatient admission; and really did not even want to take the Ativan. MD-A stated he recalled there was a Code Green called where staff left the unit in response to the Code Green; which left less staffing in the unit. MD-A confirmed that he did not document in Patient #1's records his contact or discussion with Patient #1 following her allegation.


Interview on 08/10/15 at 3:00 PM with the facility's Risk Manager (RM) indicated that she was aware of the alleged sexual assault allegation made by Patient #1 on 04/27/15 against Patient #2'; however, she had not been notified until 05/06/15 via the facility's Incident/Event electronic system because there had not been any harm documented in order to elevate the notification. The RM stated the staffing ratio on the PES unit was 1 staff to 4 patients. The RM indicated on 04/27/15 the patient census in the PES unit was 11; requiring 3 staff. The RM stated the first required staff is an RN, and then second could be a LVN, and/or MHW. The RM confirmed for 11 patients the required staffing would be 3. The RM stated the PES unit was to always have a licensed nurse present and available in the unit. The RM confirmed that she had not reported the sexual assault allegation made by Patient #1 on 04/27/15 against Patient #2 to the state health care regulatory agency, Department of State Health Services (DSHS); which was determined to have occurred as a result of insufficient staffing in the PES unit during episodes of Code Green's. The RM further confirmed the facility had not completed a thorough investigation with documented findings specific to this allegation for the determination of Neglect and/or a corrective action plan to prevent repeat incidence; in accordance with the facility's policy. The RM stated she had not seen or viewed the video footage following this allegation due to the video being unavailable after 05/06/15; following her electronic notification.


Interview on 08/10/15 at 3:15 PM with Licensed Social Worker (LSW)-A stated she assisted Security Guard-A in viewing the video footage on 04/27/15 after Patient #1 made a sexual assault allegation against Patient #2. LSW-A stated that during the allegation on 04/27/15; Patient #2 could be seen on the camera "looking both ways" and then would go into Patient #1's bedroom. LSW-A stated they were able to count this event occurring a "couple of times" where Patient #2 would go into Patient #1's bedroom and remain there "a couple of minutes" each time. LSW-A stated she saw on the video where MHW-A had been in the "Patient evaluation room" during these time periods; where a supply closet was located. LSW-A stated Patient #2 had a history of "exposing his self, public masturbation, and talks sexually to other women." LSW-A stated that Patient #2 has publically masturbated in front of her during an assessment interview.


Interview on 08/10/15 at 4:15 PM with LVN-A stated he was present and worked the PES unit on 04/27/15. LVN-A stated that on 04/27/15 there were Code Greens called on another unit, and in the facility's lobby about the same time. LVN-A stated he responded to the Code Green in the lobby to assist due to a "fight." LVN-A indicated he had left the unit for approximately 15 minutes.


Interview on 08/10/15 at 4:30 PM with the Vice President (VP) of Clinical Services confirmed that she was notified of the sexual allegation made by Patient #1 against Patient #2 on 04/27/15; however, she had not been notified until 05/06/15 via the facility's Incident/Event electronic system because there had not been any harm documented in order to elevate the notification. The VP of Clinical Services indicated that on 04/27/15 the Nursing Clinical Director (Nurse Manager) had been notified immediately following Patient #1's allegation and she had not obtained information that indicated Patient #1's allegation had occurred due to insufficient staffing in the PES unit when Code Green's had been called; leaving the unit without a RN available. The VP of Clinical Services stated that the unit RN was not supposed to leave the unit and there should always be a Licensed Nurse in the unit during a Code Green; that "it is a judgement call." The VP of Clinical Services stated she had not seen or viewed the video footage following this allegation due to the video being unavailable after 05/06/15; following her electronic notification.


Interview on 08/10/15 at 4:40 PM with the Nursing Clinical Director (Nurse Manager) stated she was immediately notified by the PES unit RN on 04/27/15 of Patient #1's sexual allegation against Patient #2. The Nursing Clinical Director indicated she "separated" the Patients, talked to both of them, and Patient #1 saw the Doctor. The Nursing Clinical Director stated she spoke to the unit RN about the allegation but had not been notified or received information that the RN and LVN had left the PES unit to respond to Code Greens which left the unit without a RN and/or licensed nurse available. The Nursing Clinical Director stated she had not seen or viewed the video footage following this allegation.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the facility failed to ensure there were sufficient numbers of licensed registered nurses (RN), licensed vocational nurses (LVN), and other personnel immediately available at all times in the unit to ensure the provision of care and supervision for patients (Patient #1 and #2) as required; resulting in an allegation of Neglect.

Specifically, on 04/27/15, Patient #1 reported to the unit's Registered Nurse (RN) an allegation of sexual assault from another Patient (#2), who had a history of inappropriate sexual behaviors, after the unit RN and LVN left their assigned unit to respond to "Code Green's" (psychiatric emergencies) in other units/areas of the facility.

This deficient practice affected Patient #1's provision of care and compromised her safety resulting in allegation of Neglect due to insufficient staffing in the unit.

Findings Included:

Review of Patient #1's Complaint Form dated 05/15/15 indicated the following in part:
On 04/27/15 at approximately 11:30 AM Patient #1 was admitted to the facility's "Psychiatric Emergency Services (PES) unit and received medication to help her sleep and calm down. Patient #1 reported shortly after she received the medications; she was asleep in her bed when she "felt someone touching my vagina and butt. I felt a hard pressure. I jumped up and another male patient [#2] jumped out from under my covers." Patient #1 stated she went to find a staff member (Mental Health Worker-A), to report what had happened. Patient #1 indicated she noticed her entire "crotch area [paper gown] was torn exposing her "vagina and butt." Patient #1 indicated the facility staff called the Police Department (PD) for Patient #1 to make a report. Patient #1 reported the staff apologized to her for the incident; "but they had an emergency on another floor and they were short staffed, so every staff member had left." Patient #1 indicated she was "so upset and scared; so they gave me more meds to put me to sleep." Patient #1 stated the facility had done nothing more to help her; there were no witnesses but she believed there were cameras in the hall. Patient #1 stated she found out that Patient #2 had done this before and the Police Officer who responded stated that; "he [Patient #2] has a history of doing this; why was he unsupervised?"

Review of the facility's Policy titled, Abuse Reporting-External and Internal, last reviewed January 2012 revealed the following definitions:
Psychological Abuse included; humiliation and harassment.
Sexual Abuse included; sexual harassment, sexual coercion, and sexual assault.

Review of the facility's Policy titled, Assessment and Reporting of Abuse and Neglect, last reviewed February 2013 revealed Neglect included the failure to provide for one's self the goods or services including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caretaker to provide the goods or services. The policy indicated the facility "prohibits neglect, mental or physical abuse or misappropriation of property, of patients by staff, visitors, or other patients." The facility "will report allegations and release information to the proper authorities, according to federal regulations, state specific rules and regulation and [facility] practice guidelines."

Review of the facility's Original Event report dated 04/27/15 at 12:15 PM completed by the unit RN revealed Patient #1 reported, "She was lying in bed asleep, when she felt Patient [#2] putting pressure around her buttocks area, and then touching her perineal area. Patient[ #1] reported sitting up in bed shock and scared, and found Patient [#2] was up in her face with his finger to his mouth telling her to be quiet not to tell. She found her paper scrub button torned on the outer left side. MD [Medical Doctor], Nurse Manager notified, Patient made a police complaint." PD interviewed Patient #1 and accused, Patient #2. "Patient visible distraught, but no other physical problems noted at this time." Further review of the Original Event indicated the Event was documented as "Attempted Rape/Rape/Sexual Assault." Factors included; "Unit busy code greens called on other unit, and high acute of unit."


Record review of the medical record of Patient #1 revealed she was a [AGE] year-old female admitted on [DATE] at 0830 under Emergency Detention (ED) when she cut her wrist and called a friend to call Police. Patient #1 has a history of Depression with Anxiety.

Further review of Patient #1's permanent records revealed no documentation following the sexual assault allegation that she made on 04/27/15 against Patient #2. There was no documentation in her record that she received a physical and/or psychological assessment following her allegation on 04/27/15. There was a Telephone Physician Order (PO) on 04/27/15 at 12:30 PM (following the allegation) for Ativan (an anti-anxiety) 2 milligrams by mouth "now" without documentation of the reason for the emergency medication. The only documentation in Patient #1's record regarding her allegation against Patient #2 was a Behavioral Team Progress Note dated 05/01/15 at 12:28 completed by Licensed Social Worker- A that indicated "Patient discussed being sexually assaulted by Patient [#2] in the [facility's] PES unit.

Review of Patient #1's Daily Observation Notes for 04/27/15 revealed the following:
At 11:30-MHW-A documented 1Q (1=On unit, and Q=Quiet/Calm).
At 11:45-MHW-A documented 1B (On unit, and B=In Bed Awake).
At 12:00-MHW-A documented 1BA (On unit, In Bed Awake, and A=agitated/restless).
At 12:15 MHW-A documented 1BA.
At 12:30, 12:45, 13:00, 13:15, 13:30, and 13:45- MHW-A documented 1A (On Unit and agitated/restless).

Record review of Patient #2's medical records revealed the following:

Patient #2's Psychiatric Evaluation dated 04/24/15 revealed he was a [AGE] year old male admitted on [DATE] with a history of schizoaffective disorder and traumatic brain injury (TBI). Patient #2 was admitted on an ED basis with a history of aggressive behaviors requiring emergency medications to calm him. Patient #2 had recently been discharged from this facility 4-5 weeks prior and has had multiple inpatient treatment episodes over the years (7 inpatient admissions in the previous 5 months). Patient #2 was documented with a known history of aggression and a "history of inappropriate sexual behavior on the unit (masturbating)."
Patient #2 had documented borderline intellectual functioning with poor insight, poor judgment, and poor impulse control.

A Behavioral Nursing Shift Assessment completed by the unit RN on 04/27/15 at 18:08 that Patient #2 was found by a female patient touching on her body while she was asleep in bed. MD, and Nurse Manager notified.

A Telephone PO dated 04/27/15 at 2015 for Patient #2 to be transferred to a higher acuity; sister facility.

A Behavior Team Progress noted dated 04/27/15 at 1855 revealed Patient #2 was transferred to a sister facility by the Sheriff's Department.

Review of the facility's Incident Event dated 04/27/15 at 11:37 AM confirmed a Code Green was called for another Patient [#3] in the Child/Adolescent Unit requiring Restraints/Seclusion. Patient #3 required physical restraint at 11:36 AM, and emergency medications at 11:46 AM. Patient #3 was released from restraint at 12:26 PM. This Code Green occurred during the same time frames of Patient #1's allegation on 04/27/15.

Review of the facility's Policy titled, Psychiatric Emergencies-Code Green, last reviewed January 2012 revealed a Code Green was a Psychiatric Emergency. Code Green will be implemented by any unit personnel in the event of unmanageable behavior of an individual to prevent harm to that individual, patients, hospital personnel and/or others the general hospital area. D. Individuals responding to Code Green will meet in announced area. Available personnel is necessary to control atmosphere through a show of strength and caring or to assist in physical management.

Interview on 08/06/15 at 12:35 PM with the PES unit RN revealed she completed Patient #1's admission assessment to the PES unit on 04/27/15. The unit RN indicated Patients were provided with paper scrubs to wear without other undergarments. The unit RN stated that on 04/27/15 at approximately 11:30 AM to 12:00 PM, "Code Greens" were going on; and "staff were busy". The unit RN stated there was a Code Green on another unit (child/adolescent) and a Code Green was called in the lobby; due to a patient needing to be "put in a [restraint] chair" because they were tearing up the lobby. The unit RN stated she left the unit to respond to the Code Green in the other unit (child/adolescent) and when she arrived; there was another RN responding, so she went to the Code Green in the lobby because they needed an RN to assist with "putting the patient in the [restraint] chair." The unit RN stated she returned to the PES unit following the Code Greens to "something else going on at the end of the unit" that she responded to. The unit RN stated she could not remember if it was LVN-A or LVN-B working on 04/27/15; but that she thought the LVN stayed back in the PES unit when she left and responded to the two Code Greens. The unit RN stated she was notified that during the Code Greens Patient #2 went into Patient #1's bedroom; and Patient #1 made an allegation of sexual assault. The unit RN stated she spoke with Patient #1 who reported that she was asleep in her bedroom and "she felt pressure" causing her to awake to Patient #2 touching her in the buttock and perineal area. The unit RN stated that Patient #1's paper pants were "torn on the side." The unit RN stated the local PD was called. The unit RN stated she spoke to Patient #2 and he said, "I touched her, but didn't do anything else." The unit RN stated he admitted that he "touched her and ripped her paper pants." The unit RN stated that Patient #2 knew that the unit was "chaotic" and knew what Code Green meant; and that is when he "took advantage" of the situation. The unit RN stated she believed that Patient #2 sexually assaulted Patient #1 given the facts, and his own admission. The unit RN stated she notified the MD, Social Worker, and Nursing Manager of the allegation. The unit RN indicated she documented the sexual assault allegation made by Patient #1 on the facility's Event Report; however, confirmed she did not document the sexual assault allegation in Patient #1's record following the incident. The unit RN stated she offered for Patient #1 to have a Sexual Assault Nurse Examination (SANE) completed at another facility if she wanted; but Patient #1 declined, stating she did not believe Patient #2 actually raped her.

Interview on 08/06/15 at 04:45 PM with MHW-A revealed she was the only MHW working on 04/27/15 in the PES unit; along with the unit RN and a Licensed Vocational Nurse (LVN). MHW-A stated she was pulled to the PES unit at 9:15 AM and was unfamiliar to the PES unit; but was told by the leaving MHW to "watch it" for Patient #2, however, she did not know the specific reason why. MHW-A stated the females were assigned rooms on one side, and males on the other side. MHW-A stated during the morning on 04/27/15 at approximately 11:30 AM-12:00 PM it was a "hectic/busy" day with "Code Green's being called." MHW-A stated that security was usually on the PES unit; but on 04/27/15 at the time of the allegation; "security could not be found." MHW-A stated on 04/27/15 at around 11:30-12:00 PM she stayed in the unit when the Code Greens were called and was "getting something out of the supply closet." MHW-A indicated the unit RN "responded to the Code Green" leaving the unit; telling her she [unit RN] would be back. MHW-A did not remember if LVN-A or LVN-B was working on 04/27/15; but further stated she did not remember any LVN being in the unit during the time of the allegation made by Patient #1. MHW-A stated shortly after this Patient #1 "flagged her [MHW-A] down" to her bedroom, and into the restroom of the bedroom where she reported that Patient #2 came into her room and touched her buttocks and vaginal area while she was sleeping in her bed. MHW-A stated that Patient #1's gown was torn around the buttock area and she offered to call the local PD for Patient #1 to make a report. MHW-A stated she then reported the incident/allegation to the unit RN. MHW-A stated she was later told that Patient #2 had been an inpatient to the facility many times before, and he "knows the system; knows what Code Green means." MHW-A stated she had seen Patient #2 "walking out of her [Patient #1] room a few times" and further stated "right before she flagged me down, he had walked out of her room". MHW-A indicated she told Patient #2 "not to go in to other people's rooms." MHW-A confirmed she had not documented the allegation reported by Patient #1 against Patient #2; but that she "told [unit RN]."

Interview on 08/10/15at 1:20 PM with Patient #1 revealed on 04/27/15 at approximately 11:30-11:45 AM she was in her assigned bedroom sleeping after she received multiple medications following her admission. Patient #1 stated she awoke after she "felt pressure" in her buttock and vaginal area. Patient #1 stated that Patient #2 was present telling her not to tell anyone. Patient #1 stated that she noticed her paper pants were ripped and she was not actually aware what all Patient #2 actually did because she "was conked out" after taking multiple medications. Patient #1 stated she knows he touched her because that was what woke her up. Patient #1 stated she was very upset, "freaked out," and asked the MD for an "AIDS" test. Patient #1 stated the unit RN indicated to the nursing staff (LVN) to "give her more meds" because she was "upset, crying, and freaking out." Patient #1 stated she then received the Ativan for her anxiety, to "help me calm down." Patient #1 stated the local PD came and she made a report. Patient #1 stated she was told by the unit RN that "Code Green's" were called and "everyone had to leave the unit" which allowed the opportunity for Patient #2 to go into her room unsupervised.


Interview on 08/10/15 at 2:20 PM with Security Guard-A revealed he was employed by the facility to maintain security and the safety of patients. The Security Guard-A stated Patient #2 had a history of inappropriate sexual behavior of "masturbating in front of females." The Security Guard-A stated he assisted with "viewing the video" footage for evidence following the allegation on 04/27/15 made be Patient #1 against Patient #2. The Security Guard stated the video footage from 04/27/15 showed a total of "four times" that Patient #2 went into Patient #1's room; and the last time Patient #2 came out of Patient #1's room; she was observed to come out of the room a few minutes later. The Security Guard stated that Patient #2 had already been assigned to the front "seclusion room" of the PES unit as his bedroom due to his history of masturbating. The Security Guard stated on the video footage Patient #2 could be seen coming from his room; "looking side to side" down the hallway, and then going into Patient #1's room. The Security Guard stated that female and male patient rooms were separated and that Patient #2 was not supposed to be going into Patient #1's room for any reason.

Interview on 08/10/15 at 2:50 PM with MD-A revealed he was notified of Patient #1's sexual assault allegation against Patient #2 on 04/27/15. MD-A stated he discussed with Patient #1 the option of a "Rape Kit" but she "declined." MD-A stated he understood the allegation made by Patient #1 to be "only touching with no penetration." MD-A stated that Patient #1 was "distressed" about the incident and he ordered Ativan for Patient #1's anxiety following the incident. MD-A stated Patient #1 had already been distressed emotionally because of her ED inpatient admission; and really did not even want to take the Ativan. MD-A stated he recalled there was a Code Green called where staff left the unit in response to the Code Green; which left less staffing in the unit.


Interview on 08/10/15 at 3:00 PM with the facility's Risk Manager (RM) indicated that she was aware of the alleged sexual assault allegation made by Patient #1 on 04/27/15 against Patient #2'; however, she had not been notified until 05/06/15 via the facility's Incident/Event electronic system because there had not been any harm documented in order to elevate the notification. The RM stated the staffing ratio on the PES unit was 1 staff to 4 patients. The RM indicated on 04/27/15 the patient census in the PES unit was 11; requiring 3 staff. The RM stated the first required staff is an RN, and then second could be a LVN, and/or MHW. The RM confirmed for 11 patients the required staffing would be 3. The RM stated the PES unit was to always have a licensed nurse present and available in the unit. The RM stated she had not seen or viewed the video footage following this allegation due to the video being unavailable after 05/06/15; following her electronic notification. The RM stated there would not be documentation of the Code Green that may have occurred on 04/27/15 in the facility's lobby waiting area; if the patient had not yet been assessed for care.


Interview on 08/10/15 at 3:15 PM with Licensed Social Worker (LSW)-A stated she assisted Security Guard-A in viewing the video footage on 04/27/15 after Patient #1 made a sexual assault allegation against Patient #2. LSW-A stated that during the allegation on 04/27/15; Patient #2 could be seen on the camera "looking both ways" and then would go into Patient #1's bedroom. LSW-A stated they were able to count this event occurring a "couple of times" where Patient #2 would go into Patient #1's bedroom and remain there "a couple of minutes" each time. LSW-A stated she saw on the video where MHW-A had been in the "Patient evaluation room" during these time periods; where a supply closet was located. LSW-A stated Patient #2 had a history of "exposing his self, public masturbation, and talks sexually to other women." LSW-A stated that Patient #2 has publically masturbated in front of her during an assessment interview.


Interview on 08/10/15 at 4:15 PM with LVN-A stated he was present and worked the PES unit on 04/27/15. LVN-A stated that on 04/27/15 there were Code Greens called on another unit, and in the facility's lobby about the same time. LVN-A stated he responded to the Code Green in the lobby to assist due to a "fight." LVN-A indicated he had left the unit for approximately 15 minutes.


Interview on 08/10/15 at 4:30 PM with the Vice President (VP) of Clinical Services confirmed that she was notified of the sexual allegation made by Patient #1 against Patient #2 on 04/27/15; however, she had not been notified until 05/06/15 via the facility's Incident/Event electronic system because there had not been any harm documented in order to elevate the notification. The VP of Clinical Services indicated that on 04/27/15 the Nursing Clinical Director (Nurse Manager) had been notified immediately following Patient #1's allegation and she had not obtained information that indicated Patient #1's allegation had occurred due to insufficient staffing in the PES unit when Code Green's had been called; leaving the unit without a RN available. The VP of Clinical Services stated that the unit RN was not supposed to leave the unit and there should always be a Licensed Nurse in the unit during a Code Green; that "it is a judgement call." The VP of Clinical Services stated she had not seen or viewed the video footage following this allegation due to the video being unavailable after 05/06/15; following her electronic notification.

Interview on 08/10/15 at 4:40 PM with the Nursing Clinical Director (Nurse Manager) stated she was immediately notified by the PES unit RN on 04/27d/15 of Patient #1's sexual allegation against Patient #2. The Nursing Clinical Director indicated she "separated" the Patients, talked to both of them, and Patient #1 saw the Doctor. The Nursing Clinical Director stated she spoke to the unit RN about the allegation but had not been notified or received information that the RN and LVN had left the PES unit to respond to Code Greens which left the unit without a RN and/or licensed nurse available. The Nursing Clinical Director stated she had not seen or viewed the video footage following this allegation.