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.

NORTHWEST MISSOURI PSYCHIATRIC REHAB CTR 3505 FREDERICK AVENUE SAINT JOSEPH, MO May 9, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview, record review, policy review, and video review, the facility failed to:
- Provide timely assessment and evaluation for two current patients (#1 and #2) of two current patients reviewed for timely assessment and evaluation;
- Report allegations of sexual abuse between two current patients (#1 and #2), of two current patients reviewed for allegations of sexual abuse;
- Immediately investigate reported allegations of sexual abuse made by one current patient (#1) of one current patient's reported allegations of sexual abuse reviewed;
- Assess the mental and physical well-being of one current patient (#1) of one current patient reviewed following allegations of sexual abuse; and
- Remove one current patient (#3) from the psychiatric unit pending the completion of an internal investigation after she manipulated and coerced two current inpatients (#1 and #2) to engage in sexual activity.
These failed practices had the potential to place all patients in an unsafe environment and at risk for abuse and neglect. The facility census was 108 and the psychiatric unit census was 20.

The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13, Condition of Participation (CoP): Patient's Rights, resulting in an Immediate Jeopardy (IJ).

As of 05/09/18, at the time of the survey exit, the facility provided an immediate action plan sufficient to remove the IJ when the facility implemented the following actions:
- Train every nursing staff member including Psychiatric Technicians (PTs), Licensed Practical Nurses (LPNs), and Registered Nurses (RNs) on every shift, every day, for the next two weeks, followed by alternating shifts daily, until revisit.
- Beginning 05/10/18, staff were not allowed to work until trained.
- As needed (PRN) staff and staff on leave (annual leave, sick leave, Family Medical Leave Act, etc.) would be trained on the day they arrive for work. There is a Nurse Manager on duty 24-hours per day.
- Agency nurses on premises would be trained daily per the same protocol.
- Staff would be trained to watch for consorting, close proximity of patients, patients in rooms or hallways that were not their own (guardians or court appointment healthcare decision makers when a patient cannot make appropriate healthcare decisions themselves, includes minors), touching or horseplay or suspicious behavior (i.e., watching staff, whispering, and passing notes).
- All other staff would be trained one time.
- Currently, nursing provides 30-minute environmental safety surveys. The leadership team would revise this policy and procedure requiring nursing to provide 15-minute environmental safety checks for all patients on the wings (units).
- In addition, nursing staff (including PTs, LPNs, and RNs) would be engaged with patients.
- The Medical Director would personally speak one-on-one with each physician who would be on-call before their next shift on what is expected of the psychiatrists with a call of patient sexual activity or other unsafe situations, areas covered would be: 1) The officials that are available after hours for consultation with the psychiatrist; 2) Measures for safety to suggest, i.e., hallway monitoring, line-of-sight, or one-on-one observation for one or all patients involved; transfer one or all patients involved to a different unit; and ensure new unit is educated if a patient is moved; 3) Scenarios would be covered; 4) The Chief Operating Officer (COO) would personally speak one-on-one with each staff member who is in the administrator on-duty (AOD) rotation before their next AOD round on what is expected of the AOD with a call of patient sexual activity or other unsafe situation. The areas covered would be: 1) The officials that are available after hours for consultation with the administrators; 2) Scenarios would be covered.
- Patient #1 has been placed on line-of-sight when out of room. When she is in her room, she may close her door. The staff member who is assigned to monitor on line-of-sight would sit outside of the patient's door to monitor. The staff member may also stand outside of the bathroom of unit that she is using, if it is a one-stall bathroom. Individual therapy was added to Patient #1's individualized treatment and rehabilitation plan (ITRP) to help her learn basic sexual education, appropriate boundaries in relationships and coping. This intervention is currently underway. Additionally, developmentally appropriate interventions for treating sexual behaviors have been added to her ITRP, including redirection and in-the-moment teaching in the general milieu, when needed.
- Patient #2 was placed on line-of-sight when out of room until treatment team is able to meet to assess treatment needs related to incident such as counseling/processing and education related to appropriate sexual behaviors/boundaries. Patient's#2 ITRP would be updated as appropriate.
- Patient #3 has been placed on line-of-sight when out of room until treatment team is able to meet to assess treatment needs specifically related to negatively influencing other patients, treatment, and education regarding appropriate sexual behaviors. ITRP would be updated as appropriate.
- Treatment teams would review the ITRP of every patient and, if indicated, update with appropriate interventions to ensure safety related to their recent behaviors.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, policy review, and video review, the facility failed to:
- Provide timely assessment and evaluation;
- Report allegations of sexual abuse between two current patients (#1 and #2) of two current patients on a psychiatric wing (unit) reviewed;
- Immediately investigate reported allegations of sexual abuse reported by one current patient (#1) of one current patient's reported allegations of sexual abuse reviewed;
- Assess the mental and physical well-being of one current patient (#1) of one current patient following the abuse allegation; and
- Remove two current patients (#2 and #3) of two current patients on a psychiatric wing pending the completion of an internal investigation after Patient #3 manipulated and coerced two patients (#1 and #2) to engage in sexual activity.
These failed practices have the potential to place all patients in an unsafe environment and at risk for abuse and neglect. The facility census was 108 and the wing census was 20.

Findings included:

1. Review of the facility's policy titled, "Sexual Activity/Assault," revised 07/10/17, showed:
- Sexual behavior involving a patient and any other individual is not permitted at this hospital.
- The facility is committed to doing everything possible, including education and intervention, to prevent sexual behavior involving a patient.
- All allegations of assault, rape, or other sexual assault made by a patient will be immediately addressed and reported. Appropriate steps will be taken to assure the victim is protected, evidence is preserved, and required documentation and reporting are done expediently.
- Sexual Behavior: Any physically intimate behavior between two individuals that potentially could result in exposure to bodily fluids and exposure to sexually transmitted disease. This would include, but is not limited to, any contact between the mouth, penis, vagina, or anus of one individual and the mouth, penis vagina, or anus of another individual.
- Sexual Assault: Causing or attempting to cause another to engage involuntarily in any sexual act by force, threat of force, or duress.

Review of the facility's policy titled, "Environmental Safety Survey," revised 02/25/16, showed that all patients shall be counted by face check every 30 minutes by assigned staff. Assigned staff will carry the board with the Environmental Safety Survey form attached and immediately document after completing each face check.

Review of the facility's policy titled, "Individual Treatment Planning, Review, and Documentation," revised 04/25/18, showed that information generated through the analysis of assessment data is used to identify and prioritize the patient's need for treatment and rehabilitation.

Review of the facility's policy titled, "Pass Privilege - Wing Daily Living Guidelines and Rules," revised 03/2018 showed the following directives for staff:
- The following are expectations which will allow the facility to provide a healthy and safe environment for all patients residing in a Wing. While patients are in the hospital, the following guidelines must be followed. Individual needs may be addressed with the assigned treatment team,
- The following guidelines will identify acceptable and unacceptable behaviors.
- In order to provide a therapeutic and safe environment, patients are expected to consider the rights of others and refrain from behaviors which are illegal and may result in dangerousness to patients and staff.
- Illegal activity, dangerous behaviors, or other behaviors that interfere with the psychiatric rehabilitation/treatment process are not permitted.
- Acts of this nature are a serious matter and will be addressed with the individual patient by the patient's treatment team. These behaviors include, but are not limited to: assaults, inappropriate sexual behavior and dictating another patient's treatment. Appropriate action will be taken up to and including prosecution.

2. Review of Patient #1's electronic health medical record (EHMR) showed she was voluntarily admitted to the facility on [DATE] with complaints of incompetent to proceed with trial.

Review of the patient's EHMR showed:
Medical and Psychiatric Assessment:
- The patient's Annual assessment dated [DATE] showed that the patient was a [AGE]-year-old woman with a history of Fetal Alcohol Syndrome (FAS - a condition in a child that results from alcohol exposure during pregnancy. FAS causes brain damage and growth problems and are not reversible) that resulted in cognitive deficits, who was admitted to the facility on [DATE], after being adjudicated (formal judgement) permanently incompetent to stand trial related to a charge of trafficking in children.
- A pretrial evaluation was completed and it was opined (opinion) that the patient had a mental disease or defect, lacks capacity to understand proceedings against her or to assist in her own defense, that her illness was chronic and continuous and that there was no substantial probability that she would be mentally fit to proceed in the reasonably foreseeable future. Her intellectual level was below normal.
- She functioned apparently at the level of a five to six-year-old. Her judgment was below normal and insight is very limited.
- Over the course of this past year a guardianship packet was submitted and the patient awaited a court date for appointment of a guardian.
Single Event Reports:
- On 02/27/17 at 10:32 AM staff documented that it was reported that the patient had engaged in sexual activity with a (male) patient on the wing 02/22/17. Video review confirmed that the patient and (male) patient (this patient was a registered sex offender) had sexual relations under a blanket at a table in the day hall.
- On 09/26/17 at 9:12 AM staff documented that the patient was observed standing in line at the cafeteria in front of a (male) patient. The writer observed the patient pull her shorts down a bit and showed her underwear to the (male) patient.
- On 11/14/17 at 9:22 AM staff documented that the patient reported two (male) patients came into her room and touched her breast.
- On 02/13/18 at 11:39 AM staff documented that Patient #3 reported that Patient #1 had kissed a male patient and touched his penis. Staff asked the male patient about the reported allegations and he stated yes, she did "kiss" him and touched his "penis".
- On 04/30/18 at 4:04 PM staff documented that Patient #3 reported that she observed Patient #1 and Patient #2 (male patient) "fucking" in Patient #2's doorway between 7:00 PM and 8:00 PM. Patient #3 reported that Patient #1 told her I hope I'm not "pregnant".
Patient Care Flow Sheet showed:
- On 04/29/18 staff did not document categories of Sexual Behavior or Followed Wing Rules (a set of guidelines to identify acceptable and unacceptable behavior for patients to follow) for the evening shift.
Treatment Plan Dated 06/26/17 showed: staff failed to initiate and address her sexual acting out/behavior in the Individualized Treatment Plan that included goals, interventions and timeframes for the sexual events reported on 02/27/17, 09/26/17, 11/14/17, 02/13/18 and 04/30/18.

Staff failed to identify and address the patient's numerous sexual acting out/behaviors with an Individualized Treatment Plan that included goals, interventions and timeframes to assist her in dealing with inappropriate sexual activity with male patients on the wing. Staff had prior knowledge that the patient had "hypersexual" behavior as reflected by the four documented incidents that had occurred before the sexual activity with Patient #2 on 04/29/18, however; staff failed to implement a plan that addressed her inappropriate sexual acting out/behavior. Staff failed to identify and document the patient's inappropriate sexual activity on the Patient Care Flow Sheet for the incident on 04/29/18 during the evening shift. Staff failed to protect the patient from Patient #3 when they had prior knowledge that Patient #3 manipulated Patient #1 as well as other patients on the wing. Staff failed to assess, treat, evaluate and provide physical and emotional support for Patient #1 after staff received a report that she had engaged in sexual activity with Patient #2 during the evening shift on 04/29/18.

3. Review of Patient #2's EHMR showed:
Medical and Psychiatric Assessment:
- The patient's initial assessment dated [DATE], showed that he was involuntarily committed to the Department of Mental Health on Incompetent to Proceed with Trial status on 08/14/17, and he was admitted to the facility on [DATE].
- The patient was a [AGE]-year-old male with a history of Phencyclidine (PCP) Induced Psychosis (drug use that is known to cause or produce psychotic symptoms in individuals who have schizophrenia or other psychotic illnesses), Major Depressive Disorder, Recurrent (a mental health disorder characterized by persistently depressed mood causing significant impairment in daily life), Schizoaffective Disorder (a mental health condition including schizophrenia and mood disorder symptoms), and Paranoid Schizophrenia (a severe mental disorder that can result in hallucinations, delusions, and extremely disordered thinking and behavior).
- A pretrial evaluation was completed and it was opined that the patient had a mental disease or defect, lacked the capacity to understand the proceedings against him or to assist in his own defense, and that he lacked the mental fitness at that time to proceed with the charges against him, based on the diagnoses Intellectual Disability, Moderate (disability characterized by significant limitations both in intellectual functioning [reasoning, learning, problem solving] and in adaptive behavior, which covers a range of everyday social and practical skills), and Schizoaffective Disorder.
- Psychological assessment indicated the patient produced a full scale intelligence quotient (IQ - test to reveal a person's intellectual functioning) of 61, which indicated overall cognitive abilities fall in the extremely low range.
- Performance on the reading and comprehension subtest indicated functioning comparative to a student in the first grade.
Treatment Plan Dated 05/09/18 showed:
- Staff failed to initiate an individualized treatment plan to address his sexual acting out/behavior that included goals, interventions, and timeframes for the sexual event reported on 04/29/18.
Physician's Orders showed:
- On 04/30/18 at 8:07 PM, an order was received to have urine and blood samples collected for testing for sexually transmitted diseases on 05/01/18, two days after the incident.
- On 05/01/18 at 1:30 PM, an order was received to have the patient transferred to another wing, two days after the incident (to separate him from Patient #1 and #3).
Patient Care Flow Sheet Dated 04/29/18 through 05/05/18 showed:
- Staff failed to document categories of Sexual Behavior and Follow Wing Rules (guidelines to routine acceptable and unacceptable behavior) on all three shifts, nights/days/evenings.
Progress Notes:
- On 04/29/18 at 11:04 PM, showed Staff F, Psychiatric Technician (PT) I, documented it was reported by Patient #3 to Staff F that Patient #1 and #2 had sex in Patient #2's room. Staff F further documented that she reported to Staff H, Registered Nurse(RN), and Staff J, RN, Associate Nurse Manager, at the time the incident was reported to Staff F, at 10:32 PM. Staff F, also noted that Patient #2 had been seen with Patient #1 outside Patient #2's door at approximately 8:30 PM.
- On 04/29/18 at 11:24 PM, showed Staff K, PT, documented that Patient #2 was inside his room while Patient #3 and #1 were standing outside the doorway talking with Patient #2. Staff K overheard Patient #1 speaking with Patient #3 while outside Patient #2's room. Patient #1 said to Patient #3, "I hope I don't get pregnant, I'm not taking my birth control." Staff K further documented she told Patient #1 and #3 not to stand outside Patient #2's door. Patient #1 and #3 refused to leave the doorway and continued the conversation. Patient #3 later informed staff that Patient #2 and #1 were having sexual intercourse as well as the conversation between Patient #3 and #1. Staff K completed an incident report and documented she would continue to monitor and report as necessary.
- On 04/30/18 at 4:00 PM, showed Staff M, Doctor of Medicine (MD), documented it was reported yesterday (04/29/18) that Patient #2 was involved in sexual activity with a female patient. A female patient entered Patient #2's room and they had sex. When Patient #2 was interviewed, he strongly denied it, but it was obvious that he was scared that there could be some consequences. During the meeting with the team, Patient #2 denied the incident in spite of being told that he would have immunity, that is, no one would be told his name and no measures would be applied.
- On 04/30/18 at 7:13 PM, showed Staff L, PT, documented that Staff L overheard a conversation between Patient #2 and #3. Patient #3 said to Patient #2, "She's out at the hospital. Don't say nothing. You're not going to say anything, right?" And Patient #2 shook his head no. Staff L documented that she would continue to monitor.
Event Report:
- On 04/29/18 at 10:32 PM, Staff F reported Patient #3 asked to speak with Staff F privately and reported that Patient #1 and #2 were having sex from 8:00 PM to 9:00 PM in Patient #2's doorway. Staff F, documented that she reported this information to Staff H, RN, and Staff J, RN, Associate Nurse Manager (ANM), on 04/29/18 at 10:33 PM.
- Staff N, RN, reported Patient #3 reported to Staff N, that Patient #1 and #2 had sex between 7:00 PM and 8:00 PM that evening. Patient #3 claimed to have witnessed them in Patient #2's room. Patient #3 also stated that Patient #1 stated to Patient #3, "I hope I'm not pregnant."
- On 04/29/18 at 11:45 PM, Staff J documented that he notified Staff O, Psychiatrist on-call, of the sexual encounter between Patient #1 and #2, with no new orders received.
- On 04/30/18 at 6:40 AM, Staff J documented that he notified Staff P, Administrator on-call, of the sexual encounter between Patient #1 and #2.

Review of Patient #3's EHMR showed she was admitted to the facility on [DATE] from a detention center. The patient is her own guardian and opined incompetent to proceed with trial related to a charge of stealing pens.

Review of the patient's EHMR showed the following information:
Medical and Psychiatric Assessment:
- The patient's Initial assessment dated [DATE] showed that the patient was a [AGE]-year-old married female. She was considered to be a poor historian due to her decreased level of intellectual functioning. The patient underwent IQ testing and scored 52, which placed her in the intellectually disabled range.
- The patient also performed equally poor with vocabulary, verbal reasoning and perceptional reasoning tasks.
- During the assessment the patient presented very childlike in her speech and demeanor.
- The patient was diagnosed with intellectual disability, mood and anxiety disorder.
Progress Note:
- On 04/29/18 at 11:00 PM staff documented that Patient #3 reported that Patient #1 and #2 had sexual relations in Patient #2's room doorway. Patient #3 was crying and upset and stated "I've been raped in jail, what if this happens to someone else." "What's going to happen now?"
Patient Care Flow Sheet showed:
-On 04/29/18 on the evening shift and on 04/30/18 on the night shift staff did not document categories of Sexual Behavior or Followed Wing Rules.
Treatment Plan Dated 12/14/17 showed:
- Objective: Patient #3 will refrain from sexually inappropriate behavior toward staff and patients, including comments, gestures and touching.
- Interventions: Nursing staff will monitor and redirect Patient #3 for sexually inappropriate behavior. Nursing staff will encourage Patient #3 to demonstrate appropriate interactions with staff and patients.
- Starting Date: 12/22/18; Status: Active; and Revised Date: 03/22/18.

Staff identified that Patient #3 acted out and/or behaved inappropriately with patients and staff sexually but did not prevent Patient #3 from coercing/encouraging Patient #1 and #2 from sexual activity. Staff had prior knowledge that Patient #3 had the ability to manipulate both Patient #1 and #2 as well as other patients on the wing and other patients throughout the facility but did not address her manipulative behavior in her Individualized Treatment Plan that included goals, interventions and timeframes. Staff failed to protect Patient #1 and #2 from Patient #3's inappropriate manipulative behavior when she coerced and/or manipulated Patient #1 and #2 to have sexual activity on the wing. Staff failed to address and evaluate her inappropriate behavior on 04/29/18.

4. During concurrent interviews on 05/07/18 at 2:07 PM, Staff A, Clinical Services Director (CSD), stated there had recently been sexual contact between two patients within the facility and the male patient (#2) was moved to another wing where other female patients also resided. Staff I, Chief Medical Officer (CMO), stated the female patient (#1) was examined in the emergency department (ED) and lab tests were conducted on the male patient (#2).

Observation on 05/07/18 at 3:00 PM, showed the wing where the three patients resided on 04/29/18. Patient #2's room was the last room on the left by the exit door, Patient #1's room was next to Patient #2's room, and Patient #3's room was two doors up from Patient #1's room.

During interview on 05/07/18 at 2:46 PM, Patient #1 stated that:
- Patient #3 encouraged her to engage in sexual activity with Patient #2.
- Patient #3 told her to do it to see what it felt like.
- Patient #3 told Patient #1 that she would be the lookout for Patient #1 and #2 so they could have sex but then Patient #3 snitched.
- She told Patient #3 that she did not want to have sex with Patient #2 but Patient #3 shoved her into Patient #2's room.
- Patient #2 had her lean forward on the bed, and then Patient #2 pulled down her pants and entered her from behind.
- Patient #3 coerced her into having sex with Patient #2.
- Patient #2 forcefully thrusted (Patient #1 demonstrated by moving her hips in a rocking motion back and forth) and scratched her upper thigh.
- She cried out for help but staff did not respond.
- She wrote a statement for facility security as she wanted to pursue charges against Patient #2 and #3.
- She showered before going to the ED for evaluation.
- Patient #2 was moved to another wing the following day.
- She was not afraid of Patient #2 and still had contact with him at meals and recreation, although "staff watch us".

During an interview on 05/07/18 at 2:24 PM, Staff A, CSD, stated that there were cameras on the wings within the facility with the ability to capture video.

5. Review of the facility's video dated 04/29/18 from 8:27 PM to 9:27 PM showed that:
- Staff made 30 minute face rounds on the hall that the three patients' resided at 8:00 PM, 8:29 PM and 9:16 PM.
- At the beginning of the video Patient #1 had on black pants, a dark blue shirt and a head scarf on her head.
- At the beginning of the video Patient #2 had on blue jeans, a white t shirt and a light blue du rag (cloth used to cover the head) on his head.
- Patient #3 exited her room, walked down the hall by Patient #2's room and paced up and down the hall from Patient #2's room to Patient #1's room. Patient #3 appeared to be looking up and down the hallway toward the nurse's station. After pacing back and forth, Patient #3 returned to her room. Patient #3 then exited her room and walked down the hall past the nurse's station and in the direction of the day room.
- Patient #2 exited his room and walked to Patient #1's doorway and stood in her doorway.
- Patient #3 walked past the nurse's station and walked down the hall to Patient #2's room.
- Patient #2 returned to his room as Patient #3 walked down the hall to his room.
- Patient #1 exited her room and walked down the hall to Patient #2's room and stood in the doorway with Patient #3. After several minutes had passed with Patient #1 and #3 standing in the doorway of Patient #2's room, Patient #3 appeared to shove Patient #1 into Patient #2's room.
- Patient #3 stood outside of Patient #2's room for approximately three minutes when Patient #2 appeared in the doorway. Patient #2 and #3 appeared to be talking. After several minutes passed Patient #2 went back into his room and Patient #3 remained outside Patient #2's room for approximately two more minutes and paced back and forth from Patient #2's room to the room across the hall.
- When Patient #3 saw staff walking down the hall, Patient #3 walked back to Patient #2's doorway and stood.
- After approximately six minutes from when Patient #3 appeared to shove Patient #1 into Patient #2's room, Patient #1 exited the room and had on black shorts, a pink top and head scarf. Patient #1 had a white sheet in her hands and walked down the hall and placed the white sheet in the laundry hamper at the front of the hallway. Patient #3 remained at Patient #2's doorway when Patient #1 exited the room with the white sheet.
- After Patient #1 placed the white sheet in the hamper, she walked up and down the hall past the nurse's station, entered her room, then exited and walked down to Patient #2's room and stood in the doorway with Patient #3.
- Patient #3 and Patient #1 walked down the hall past the nurse's station and in the direction of the day room.
- Patient #2 exited his room and had on light tan pants, a light red/coral colored shirt and a light blue du-rag on his head and walked down the hall past the nurse's station in the direction that Patient #3 and #1 had gone.

Staff failed to intervene when Patient #3 and #1 were congregated at Patient #2's doorway for a considerable amount of time. Staff failed to recognize the suspicious behavior that Patient #3 displayed as she stood next to Patient #2's doorway and paced back and forth from Patient #2's room to the room across the hall from Patient #2.

During interview on 05/07/18 at 2:30 PM, Staff A, CSD, stated the sexual contact between the two patients (#1 and #2) was initially reported by both patients (# 1 and #2) as consensual, and it wasn't until Patient #1 reported burning that she was sent out to the ED for evaluation.

During an interview on 05/08/18 at 8:26 AM, Staff B, RN, Chief Nursing Executive (CNE), stated that:
- Patient #1 and #2's rooms were located next to each other on the same side of the hall.
- Patient #2 was moved off the wing the next day following the sexual encounter with Patient #1.
- The sexual encounter was reported to staff by Patient #3.
- Patient #3 reported that she had encouraged Patient #1 and #2 to engage in sexual activity and then reported to staff after the incident had occurred.
- The facility did not have documentation of the training/education provided to staff working on the wing that the incident occurred and there was no sign in sheet of staff that attended the training/education.
- She did not know if any "formal" education had been provided to staff for the wing that Patient #2 had been transferred to related to his involvement with sexual activity with a female patient.
- The sexual activity between patients on the wing was not reported to any agency, neither the Department of Mental Health nor the Department of Health and Senior Services and she did not know what the timeframe for reporting was.
- If sexual activity between patients was considered consensual then patients were not sent to the emergency room (ED) for an exam.
- It was not reported to her by staff that Patient #1 told Patient #2 "no" and that she did not consent or want sex with the Patient #2.
- When Patient #1 went to the ED, she told ED staff that she had been "raped" and that was the first time Patient #1 had mentioned she had not consented to sex with Patient #2.
- She did not know if staff asked Patient #1 if she had consented to the sex with Patient #2 or not.

During an interview on 05/08/18 at 10:31 AM, Staff C, Masters of Forensic Psychiatry - Wing Manager (of the wing the three patients resided), stated that Patient #1 never reported to staff that she told Patient #2 "no", she did not want to have sex with him. Staff C stated that she had not provided any direct education or training for staff and had not been involved in any "formal" educational process related to the sexual encounter between patients on 04/29/18.

During an interview on 05/08/18 11:15 AM, Patient #3 stated that:
- She did not get along with Patient #1 on the wing.
- Staff did not make rounds when they should have.
- Denied encouraging Patient #1 to have sex with Patient #2.
- She saw Patient #1 pull her pants down, bent over and had sex with Patient #2.
- At no time did Patient #1 say "no" to Patient #2 or asked him to stop.
- Patient #1 began to moan sexually.
- She reported the sexual encounter between the two patients approximately 15 minutes after the sexual activity because she was afraid to report it when she first saw them having sex.

During an interview on 05/08/18 at 3:15 PM, Patient #2 stated that:
- The team requested for him to move from the wing because they did not want him to have "relations" with female patients on the wing.
- He is not a "snitch" because snitching on someone will get you killed.
- He moved from his previous wing (wing that Patient #1 and #3 resided) due to "having problems with a couple of girls over there."

During an interview on 05/08/18 at 4:00 PM, Staff E, PT I, stated that:
- It should be a "red" flag for staff when they see patients congregating together.
- Patient #3 was a bad influence on Patient #1.
- She and a security officer transported Patient #1 to the ED on 04/30/18.
- Patient #1 told ED staff that she said "no" but Patient #2 did not stop and that Patient #3 kept telling Patient #2 to touch her "boobs"
- Both Patient #1 and #3 are to stay away from young male patient on the wing because of their sexual behavior.
- Patient #1 had tried to have sex with another male patient on the wing and did get caught having sex with a male patient on the wing in the day room that was a registered sex offender.
- After the male patient that was a registered sex offender was discharged from the facility, Patient #1 was allowed to receive telephone calls from him but after the sexual encounter with Patient #2 she was restricted from talking to him by the facility.
- Denied receiving any education and/or training by administrative staff or nursing managers since the sexual encounter by patients on 04/29/18.

During an interview on 05/08/18 at 4:27 PM, Staff F, Psych Tech I, stated that:
- She was working the evening of the sexual encounter between Patient #1 and #2.
- After Patient #1 and #2 had went to bed, Patient #3 came to her and reported that the two patients had engaged in sexual activity.
- There was no change in monitoring for Patient #1 after her sexual encounter with Patient #2.
- Patient #1 had sexual relations with a male patient that had been discharged from the facility and had attached herself to another male patient on another wing.
- Another male patient was moved off the wing because Patient #1 was accused of inappropriate touching him and the male patient admitted that she had touched his "penis".
- Patient #1 was hypersexual toward male patients on the wing and it was a well-known fact by staff that she was hypersexual.
- She felt like Patient #1 and #2 were talked into having sex by Patient #3 because Patient #1 had never showed any interest in Patient #2 before.
- Patient #3 had been "stuck (liked)" on Patient #2 and Patient #2 could easily be manipulated by Patient #3.
- Patient #3 manipulated Patient #2 in passing notes from her to another male patient on another wing.
- Denied nurse managers providing any education or training related to patients having sex on 04/29/18.

During an interview on 05/08/18 at 4:52 PM, Staff G, Security Officer I, stated that:
- He received a call on 04/30/18 to assist with transporting a patient (Patient #1) to the hospital for blood work and Staff E, Psych Tech I accompanied them.
- Patient #1 stated that she had sex that she did not want to have with a male patient (Patient #2).
- Patient #1 stated that a female patient (Patient #3) pushed her into the male patient's (Patient #2) room and the male patient grabbed her "boobs", bent her over, pulled down her pants and forced himself on her and entered her from behind.
- Patient #1 stated that she yelled out to get staffs' attention because she did not want to have sex with the male patient.
- When Patient #1 was taken into an ED exam room, she reported that she had been raped.
- After the ED visit and on the way back to the facility, Patient #1 voiced concerns about if the male patient would be moved to another wing or not.

During an interview on 05/09/18 at 8:14 AM, Staff J, RN, ANM, stated while working the evening of 04/29/18, at approximately 10:30 PM, Patient #3 reported Patient #1 and #2 had sex on the wing. Staff J, stated that he called Staff O, Psychiatrist on-call, and reported the sexual encounter between Patient #1 and #2, with no new orders received. Staff J, stated that he also called Staff P, Administrator on-call, with no instructions given. Staff J, further stated that he had not received any education or re-training from administrative staff to this date related to the incident on 04/29/18. Staff J, stated that he had heard of Patient #1 acting out sexually on one previous occasion. Staff J, stated that the facility's process, if sexual behavior had been verified, is to move the patient closer to the nurse's station.

Staff had prior knowledge of Patient #1's hypersexual acting out/behavior but failed to address her hypersexual activity with several male patients on the wing and in the cafeteria. Staff failed to put into place interventions to assist and prevent Patient #1 from having sexual activity with male patients on the wing that included a registered sex offender. Staff failed to protect Patient #1 from the registered sex offender when he was on the wing and after he was discharged from the facility by allowing Patient #1 to have continued telephone contact with him. Staff failed to protect Patient #1 and #2 from Patient #3 when they had prior knowledge that she had manipulated both patients in the past and admitted to encouraging Patient #1 and #2 into having sexual activity in Patient #2's room. Staff had prior knowledge and had identified that Patient #3 had a history of inappropriate sexual acting out/behavior and did not protect either Patient #1 or Patient #2 from her manipulative and inappropriate behavior. Staff failed to provide timely assessment, evaluation, physical and emotion support to Patient #1 and #2 after their sexual activity on the evening of 04/29/18. These failures by the facility to identify, recognize and put into action an Individualized Treatment Plan with goals, interventions and timeframes to address Patient #1, #2 and #3's sexual acting out/behaviors and manipulative behavior by Patient #3 had the potential to place all patients on the wing where Patient #1, #2 and #3 resided at risk.