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BRYNN MARR HOSP 192 VILLAGE DRIVE JACKSONVILLE, NC July 12, 2016
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based upon hospital policy review, facility grievance investigation review, and staff interview; the facility failed to investigate peer to peer sexual harassment, by failing to investigate an allegation of sexual harassment per hospital policy, in 1 of 1 patient (Patient #8).

The findings include:

Review of hospital policy titled, "Patient Abuse, Neglect and Exploitation - Reporting & (and) Investigating", last review date: 11/09/15, revealed, "POLICY STATEMENT: It is the policy of (Named Facility) to prohibit the abuse, neglect or exploitation of patients in any manner from...patients...Employee Reporting Procedure The hospital maintains a proactive approach to identifying events or occurrences that may constitute abuse, neglect or exploitation. Whenever neglect, abuse or exploitation is observed or suspected, the employee should:...j. If the allegation involves a minor or adult, and the suspected abuse occurred at the facility/alleged perpetrator is a peer, employees are required to report to their supervisor, or designee, any information that caused them to suspect the patient may have been abused. If applicable, the supervisor, or designee, will then report the event to the Risk Manager or Administrator-on-Call. The accused patient should immediately be separated from the peer..."

Review of facility grievance investigation, written by the Director of Risk Management (DRM) on 06/01/2016, revealed, "I got called into the Board Room to meet with (Patient #8) and (Named Attorney) on 6-1-16 at approximately 12:30 p.m. (afternoon). (Patient #8) reported to (Named Attorney) that another peer, (Named Peer), now on residential, had been sexually inappropriate with her. She told (Named Attorney) that staff was aware and nothing has been done. (Patient #8) said she is fearful to go to PRTF (Psychiatric Residential Treatment Facility) because this patient is there. (Patient #8) stated she never submitted a grievance, staff never told her about it and she didn't realize it was for patient issues (she thought it was to make a complaint against staff, the food, etc.). (Named Program Manager (PM) #1), Program Manager, and (DRM), Risk Manager, met with (Patient #8) at approximately 1:15 p.m. on 6-1-16. (Patient #8) stated she believes she was in room 309, bed A, and (Named Patient) was in Bed C. She said (Named Patient) told her that she 'gets weird at night'. (Patient #8) said she was lying in her bed and (Named Patient) 'came and got on top of me'. (Patient #8) described it as being straddled... (Named Patient) then came and stood 'beside my bed and was rubbing my leg'. (Patient #8) said (Named Patient) continued moving her hand and was 'rubbing the v'... (Named Patient) said 'I want to kiss you'...'face was in my face'... (Patient #8) said they did not kiss and the rubbing was above the clothing... She (Patient #8) thinks this occurred on the night of May 20 or May 21. She said she told staff and remembers telling (Named Staff) and (Named Staff)....(PM #1) and (DRM) met with (Named Staff) at approximately 1:50 p.m. on 6-1-16. (Named Staff) was told that (Other Named Staff) talked with (Named Accused Patient), and that she admitted that the situation had occurred... (Named Staff) said she didn't know it hadn't been reported until yesterday. She said (Patient #8) brought it up during process group... and (Named Staff) 'said it hadn't been reported'..." Review of facility grievance investigation, written by Patient Representative (PR) #1 on 06/03/2016, revealed "...After interviewing staff and both patients, it was substantiated that (Named Patient) did have poor boundaries toward (Patient #8). Although an investigation was not immediately reported and properly conducted, both patients were kept safe by a room change occurring and the patient being separated...informed management of the need for additional training of all disciplines of staff in regards to allegations of patient abuse and how to report/investigate to ensure prompt intervention and updating of guardians...informed management that allegations were substantiated by both patients meaning that sexually inappropriate boundaries occurred. Both patients were separated as an intervention, however it was not reported properly for immediate investigation. All management agreed to provide re-education and training to their direct staff during departmental staff meetings..."

Staff interview was conducted with the DRM on 07/12/2016 at 1320, which revealed facility policy was not followed with regards to reporting patient to patient inappropriate boundary violations. Interview revealed staff are currently going through re-education of facility policy. Interview revealed 59% of Nursing, and 85% of Mental Health Workers have completed the re-education.