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.


Based on observation, record review, policy and procedure review, review of video surveillance, and staff interview, the Hospital failed to ensure the provision of care in a safe setting for 1 of 1 closed patient record (Patient #1) who reported being sexually assaulted by another patient (Patient #2). Failure to thoroughly identify, investigate, and evaluate all aspects of sexual abuse allegations and implement facility policies does not ensure the patient's right to receive care in a safe setting.

Findings include:

Review of the policy "Level of Observation" occurred on 08/30/17. This policy, dated May 2017, stated, "PURPOSE: To maintain the commitment to service excellence for each patient . . . and providing guidelines for observation and protection of patients exhibiting high risk behaviors. POLICY: It is the policy of Prairie St. John's to support patients who exhibit high risk behaviors by placing them on appropriate precautions. PROCEDURE: Assessment: Patients are assessed upon admission and reassessed throughout their hospitalization , by a interdisciplinary team, for any current or historical behavior that supports the use of high risk precautions. Patients who require increased levels of supervision are placed on precautions through the following process: Early Identifiers: . . . 2. Aggression - history of acts of aggression toward others; current acts of aggression toward others, or verbal threats of violence towards others. . . . 4. Sexual Aggression - history of sexual perpetration or reactivity or acts of touching others in a sexual manner. . . . 6. Sexual Victimization - history of victimization . . . 11. Homicide - threatening others' lives (i.e. [for example] "going to kill the judge") . . . NURSING/CLINICAL SERVICES: . . . 2. The following safety measures will be implemented for each category of high risk behavior. . . . e. Staff must monitor and be aware of all high-risk times such as shower or bath times . . . or when staff members' attention may be diverted. . . . MONITORING LEVELS: 1. All patients on Close Observation or 1:1 level of monitoring will be reviewed by the physician daily. . . . 2. Unit restriction will be reassessed daily, by the physician, to determine continuation of the order. 3. Nursing staff will document patient location and behaving using . . . "24 Hour Nursing Observation Record" during all rounds. . . . 15 Minute Observations . . . 1. Every patient is monitored for safety at a minimum of every 15 minutes upon registration for intake assessment . . . 4. All patient room doors will remain open while the patients sleep. 5. All patient room doors will remain locked during the day, while patients are participating in programming. Close Observation 1. Close Observation is defined as increased monitoring at Q [every] 8 minutes for at risk behaviors. 2. This precaution is used if a patient has active symptoms that impair his/her ability to remain safe as demonstrated by: . . . Sexually acting out (within the last 48 hours touching others, exposing self) . . . High Risk Behavior Precaution Interventions . . .Sexual Aggression . . . 6. The RN [registered nurse] documents all incidents of sexual aggression in the patient's medical record. . . . 9. Response Notification of sexual aggression on hospital grounds: . . . e. The following actions are taken upon notification of sexual assault: . . . ii. Local/state police, state agencies . . . are notified as required by state statues. . . . h. The facility Risk Manager will obtain copies of external reports (ER [emergency room ] record, police report) as applicable. . . ."

Review of the policy "Sexual Aggression & [and] Sexual Victimization Prevention" occurred on 08/30/17. This policy, dated June 2016, stated, ". . . Policy: Provision of a safe environment, intervention and communication to the treatment team, as soon as possible, when patients exhibit boundary violations/high risk behaviors. Observations (sic) levels change as necessary to insure adequate staffing and interventions to maintain safety. Policy: Protocols are in place when there are reported sexual assaults, sexual allegations and/or acts of consensual sex between adult patients . . . Protocols address reporting and documentation requirements, medical interventions, STD [sexually transmitted disease] testing, police contact, etc. . . Response to sexual allegation or actual event: A. Separation of patients: precautions initiated/adjusted based on evaluation of event. B. Evaluation/ER visit . . . C. Incident location and evidence, such as clothing, bedsheets, etc. are secured . . . D. Process following sexual allegation or actual event, including: a. Notifying Psychiatrist, Facility leadership/supervisor . . . b. Local/state police, state agencies . . . as required by state statutes. E. Discussion with alleged victim . . . regarding resident rights to initiate criminal proceedings/press charges F. Facility secures a copy of the video of the alleged event . . . G. Obtaining copies of external reports, (ER record, police report) as applicable."

- Review of Patient #1's medical record occurred on 08/30/17. The record identified an admission date of [DATE] and medical diagnoses of unspecified psychotic disorder and depression.

A "Progress Note" for Patient #1, written by a nurse on 4 East, dated 08/20/17 at 1:27 a.m., stated the following: "At approximately 2215 [10:15 p.m.] on 08/19/17 patient [Patient #1] entered the nurse's station and was tearful. She initially would not tell this writer what was troubling her. This writer then went to her room with her and she reported a number of items. 1. While she was socializing with a peer on 4 west, she decided to follow him into his room on that unit. 2. She then reported to me that this male patient de-robed her top and underwear. 3. She then claims that he had and (sic) orgasm on her underwear. The House Charge Registered Nurse did a camera review and found that the two patients were in his room on 4 West for approximately 10 minutes. Per this camera review, it appears she followed the male patient into his room. After being in his room for 10 minutes, they exited, and socialized in the 4 West day room for approximately 10 more minutes. It is after this, that the pt [patient] then came into the nurse's station. The writer spoke with the pt for approximately 20 minutes in the kitchen of 4 East. This writer utilized open ended questions for the pt to express how she was feeling, and how to initially cope with what had occurred. . . . This writer told the pt that it was her right to report this alleged assault to the authorities, and that it was also her right to be evaluated for a possible sexual assault. She said she would like to. The pt then phoned her mother. Pt's mother then phoned this writer and explained that she would be coming to Prairie St Johns, and that she would be contacting the authorities. Fargo Police met with the pt in the North Group room on the units between 4 west and 4 east. The content of this interview is unknown d/t [due to] pt not wanting staff present. The Chief Operating Officer [name] has been notified of this situation by the House Charge RN [name], and we are in contact with her continually. Furthermore, [name] the Director of Nursing has been notified by the House Charge RN [name]. Additionally, the patient has been changed to q8 [every 8] minutes observation, with added sexual aggression and sexual victimization precautions initiated. On call Prairie St Johns physician [name] has been notified of this situation and has ordered that the pt be sent out for evaluation. . . . The pt has been sent to . . . ER via . . ambulance at 0115 [1:15 a.m.] on 08/20/17 for evaluation by a Registered Nurse for sexual assault. . . ."

A physician's order, dated 08/19/17 at 11:17 p.m., stated, "1. [Change] pt to Q8 minutes observation 2. Initiate Sexual Victimization Precautions 3. Initiate Sexual Aggression Precautions." Prior to the incident on 08/19/17, Patient #1 had been on every 15 minute checks.

Patient #1's "Progress Note" dated 08/20/17 at 7:19 a.m., stated the following:
*4:30 a.m. - "Received first phone call from [Name of Hospital] nurse . . . regarding pt update. RN reports that sexual examination was performed, and all corresponding materials were sent to the crime lab. . . ."
*4:45 a.m. - "This writer spoke with the chief operating officer of Prairie St Johns, . . . regarding this situation. . . ."
*7:11 a.m. - "[Name of hospital] nurse . . . notified this writer . . . is releasing patient with family. . . ."

- Review of Patient #2's medical record occurred on 08/30/17. The record identified an admission date of [DATE] and medical diagnoses including schizophrenia, psychosis - paranoid and delusional. Patient #2's admission High Risk Factors included Assault/Homicide due to "psychosis; agitated upon arrival to ED [emergency department]" and Elopement due to "psychosis."

A "Nursing Note" dated 08/20/17 at 7:42 p.m. and written by a nurse on 4 West, stated, "Incident of 08/19/17 - It was reported to me by the RN on 4 East that a female patient from their pod was reporting that a patient on 4 west raped her in his room on 4 west. At approximately 2245 [10:45 p.m.] I called the male into the consult room to talk to. I asked him if there was a female in his room tonight and he said 'I'm not going to lie yes there was.' I asked him what they were doing and he at first said hanging out. When I questioned him more he said they had sex as in intercourse. I asked him who's idea it was he said hers. The male said that they were talking at the table outside his room and were going to get together in the bathtub room in the hallway. The patient asked the tech if he could take a bath and was told yes. The patient asked to get into his locked room to get his bath supplies. After the patient was in his room collecting his supplies the female involved walked into the males room on her own and that is when the sexual encounter occurred. The tech was in the day room at the time and saw nor heard any commotion in the room. The RN also was in the office and heard nothing. When I asked the patient if the female screamed or anything. [sic] The male involved said, 'You heard nothing because there was no noise coming from the room.'"

Physician's orders for Patient #2, dated 08/20/17 at 12:11 a.m., stated, "Change pt to Q 8 min [minute] checks. Initiate sexual aggression precautions. Add 5 foot rule [with] females." Prior to the incident on 08/19/17, the facility had Patient #2 on 15 minute checks.

Review of Patient #2's "24 Hour Nursing Observation Record - Close Observation" form identified staff initiated eight minute checks on 08/20/17 at 12:15 a.m. The observation record, dated 08/20/17 at 12:15 a.m to 08/21/17 at 7:00 a.m., did not have the "5 Foot Rule" on the observation documentation.

- Observation of the 4 West unit occurred on 08/30/17 at 2:20 p.m. An administrative staff member (#1) stated hospital policy is to have patient rooms locked when the patient is not in the room. Observation showed Room 423 and Room 427 unlocked, with no patients in the room.

Review of the video recorded on the evening of 08/19/17 occurred at 3:00 p.m. with administrative staff members (#1, #2, #3, #4, and #5). Observation showed Patient #1 walked from the common area towards a room (video does not show the rooms) and shortly after, Patient #2 got up from his chair in the commons area and followed her. The video showed another male patient got up from his chair in the common's area one minute later and walked in the same direction. The administrative staff identified this male as Patient #2's roommate. Observation showed Patient #2 came into the commons area approximately 8 minutes later, followed shortly thereafter by Patient #1.

An administrative staff member (#3), during interview on 08/30/17 at 3:15 p.m., stated the House Charge nurse "did not interview the roommate because the patients did not say the roommate was involved." The staff member stated when she investigated the incident on 08/21/17, the roommate (#3) was no longer a patient at the facility.

A review of Patient #3's medical record occurred on 08/30/17 at 3:45 p.m. Review of Patient #3's photograph in the record showed a different person than the one in the video who followed Patient #1 and #2.

A second review of the video occurred at approximately 4:15 p.m. on 08/30/17 with two administrative staff members present (#1 and #3). Both staff members (#1 and #3) agreed the male patient they had earlier identified as Patient #2's roommate (Patient #3) was not the same person as the photograph in the medical record of Patient #3.

During an interview on 08/30/17 at 5:15 p.m., an administrative staff member (#2) stated the Hospital completed an "Intensive Analysis" report on 08/21/17. This investigative report stated the following: " . . . the HC ( House Charge Nurse) was notified by the 4E nursing staff and had met with the patients separately to obtain comments of the event. Per [name of HC] . . . [Patient #1] . . . walk onto to (sic) the 4W unit . . . [Patient #1] then entered [Patient #2's] room and he followed her into his room. It is at this time that both were in agreement that intercourse did not occur. . . They were in the room for approximately 10 minutes as was the roommate to the male patient for a somewhat lesser time. . . . Camera review was completed, and it showed . . . [Patient #1] then walked to 4W and into male patient's room. The roommate followed shortly. . . . Staff Interview: [Name of House Charge Nurse] on-site interviewed patients [Patient #1 and Patient #2] regarding event. . . . DON [Director of Nursing] reviewed incident on Sunday [08/20/17] when on site. Provided individual training to staff while doing AOC [administrator on call] rounding. . . . 4W - door had been left open for patient to access showering belongings, patient left room however and sat at table while staff was cleaning shower. By door not being locked the female patient was allowed to enter the room to without staff knowing. . . ." NOTE: The Hospital provided no documentation of the House Charge Nurse's interviews with Patients' #1 and #2.

Review of the "All Employee Meeting" agenda, dated 08/29/17, identified at the end of the agenda "Reminders . . . Sexual Aggression/Sexual Acting Out." When asked if the meeting was in response to the event that occurred on 08/19/17, and administrative staff member (#3) stated the meeting was a regularly scheduled meeting, but they discussed sexual aggression interventions.

During an interview on 08/30/17 at 6:00 p.m., an administrative staff member (#3) stated the Hospital did not obtain the police report or the ER record of the sexual assault exam.

The Hospital did not ensure a safe environment for patients by failure to ensure staff locked unoccupied patient rooms according to policy, failure to conduct a thorough investigation, failure to follow their policy regarding notification of the police and the State agency about the alleged sexual assault (the patient/family called the police) and failure to obtain copies of external reports (police report and ER record).