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.

METROWEST MEDICAL CENTER 115 LINCOLN STREET FRAMINGHAM, MA 01701 Nov. 21, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
The Hospital was out of compliance for the Condition of Participation for Patient Rights.

Findings included:

The Hospital failed to ensure for one (Patient #1) of 11 sampled patients that the Hospital provided care in a safe setting.

Refer to TAG: A-0144.

The Hospital failed for two (Patient #1 & Patient #11) of 11 sampled patients to investigate allegations of sexual assault occurring on 1/17/18 and 11/2/18.

Refer to TAG: A-0145.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on interviews and record reviews, the Hospital failed to ensure for one (Pediatric Patient #1) of 11 patients sampled, to provide care in a safe setting to prevent an alleged sexual assault on the Children's Development Unit. Findings include:

Patient #1 was a pediatric patient who was admitted to the Hospital in 10/2018 with a diagnosis of post traumatic stress disorder related to previous sexual assault.

A late entry Mental Health Worker note dated 11/3/18 at 10:04 P.M., indicated that Patient #1 told Mental Health Councilor (MHC) #1 that after his/her 8:00 P.M. shower on 11/2/18, Patient #2 forced Patient #1 into the bathroom and that Patient #2 was behind Patient #1 and Patient #2 pulled Patient #1's pants down and had sex with him/her. The note indicated that when questioned, Patient #1 told MHC #1 that Patient #2 had told Patient #1 that he/she wanted to put his/her fingers inside of him/her. Patient #1 then repeated the story of being forced into the bathroom, having his/her pants pulled down and Patient #2 having sex with Patient #1.

The Surveyor interviewed MHC #1 on 11/20/18 at 1:41 P.M. MHC #1 said that, on 11/2/18, Patient #1 told her that Patient #2 came into Patient #1's bedroom and had sex with Patient #1. She said that she then told Nurse #1.

A Nurse's Note written on 11/3/18 at 1:46 A.M. indicated that, on 11/2/18, Patient #1 told MHC
#1 that Patient #2 (pediatric patient under the age of 15) sexually assaulted Patient #1 in his/her bedroom. Nurse #1 indicated that she met with Patient #1 and Patient #1 told her he/she was unsure if Patient #2 used his/her fingers or penis to assault him/her. Nurse #1 indicated that Patient #1 was tearful when discussing the sexual assault allegation.

The Surveyor interviewed Nurse #1 on 11/20/18 at 1:00 P.M. Nurse #1 said that on 11/2/18, MHC #1 told her that Patient #1 informed her that he/she and Patient #2 had sex. Nurse #1 said that she then met with Patient #1 and discussed what happened. Patient #1 said that it was unclear if Patient #2 used fingers or a penis. Nurse #1 said she then notified the Children's Development Unit Manager via telephone of the incident. Nurse #1 said she was directed to contact the Registered Nurse Medical Supervisor. The Registered Nurse Medical Supervisor working the 11-7 shift came to the unit and met with Nurse #1 and Patient #1. At this time, Patient #1 recounted the events and started to tear up.

A late entry Mental Health Worker note, dated 11/3/18 at 7:40 A.M. indicated that Patient #1 told MHC #3 that an inappropriate sexual conversation between Patient #1 and Patient #2 took place on 10/31/18, (2 days prior to the alleged rape) but failed to communicate this with the staff that were taking over on the next shift during shift report. MHC #3 wrote a late entry note, dated 11/3/18 at 7:30 A.M., which indicated that on 11/2/18, after morning meeting but prior to the rape of Patient #1, Patient #1 told MHC #3 that, on 10/31/18, Patient #2 told Patient #1 that "I would like to finger you" and this conversation triggered Patient #1 due to his/her past history of trauma. MHC #3 said she told Patient #1 that she would address this and was sorry that it happened.

The late entry Mental Health Worker note, dated 11/3/18 at 7:40 A.M., further indicated that Patient #2 told MHC #3 that Patient #1 was the one who initiated the conversation and Patient #1 asked Patient #2 to "finger him/her." MHC #3 said she spoke with Patient #2 about the severity of this type of discussion and how triggering it can impact on all patients on the unit. MHC #3 said that Patient #2 was apologetic.

The Surveyor interviewed MHC #3 on 11/19/18 at 2:20 P.M. MHC #3 said that prior to the alleged rape on 11/2/18, Patient #1 told her that, on 10/31/18, Patient #2 asked Patient #1 if he/she liked "porn" and said that he/she wanted to "finger" Patient #1. MHC #3 said that she immediately went to the nurse on that morning and told him. MHC #3 said that she also told the Unit Manager and another nurse. MHC#3 said that they kept a close eye on the two patients for the remainder of the day. MHC #3 said that she didn't write a note and thought that "the nurse would take care of it". She said that she did not inform the second shift MHC about the incident at change of shift. MHC #3 said that she did write a late entry note regarding the conversation on 11/3/18 after she learned of the sexual assault allegation.

The Hospital failed to identify the potential for sexual assault on Patient #1 by not communicating effectively and addressing the allegations that took place prior to the sexual assault allegation appropriately.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review and staff interview, the Hospital failed to ensure, for two (Patient #1 & Patient #11) of 11 sampled patients, that patients were protected from sexual abuse/assault. In addition, the Hospital failed to investigate allegations of sexual abuse/assault for two (Patient #1 and Patient #11) of 11 sampled patients.

Review of the Hospital's policy titled "Reporting of Allegations of Patient Neglect or Physical or Sexual Abuse or Assault", dated 1/10/17, indicated that all individuals, including patients, have the right to be free of abuse, neglect and assault. The Administrator on Call is responsible for immediate reporting of allegations of abuse neglect or assault occurring in the Facility to the local police and/or other appropriate authorities. All Facilities are responsible for immediately implementing measures to protect any individual impacted by such conduct for taking immediate and effective corrective action in response to such allegations. The Complaints Officer, Risk Manager and Human Resources Director are each responsible for maintaining complete documentation of all allegations of abuse, neglect or assault: the specifics of the allegations made; the specific steps taken by law enforcement and or other appropriate authorities and the Facility to review the allegations and the results of the review including the results of any review by law enforcement or other external agency. Documentation must be made in the appropriate electronic documentation system and maintained according to Administrative policy.

All employees whose responsibilities are affected by this policy are expected to be familiar with the basic procedures and responsibilities created by this policy.

The policy didn't include information related to how the physician is informed or what exam or support services are offered to sexual assault patients.

1. Patient #1 was a pediatric patient who was admitted to the hospital in 10/2018 with diagnoses which include post traumatic stress disorder related to a previous sexual assault.

A late entry Mental Health Worker note dated 11/3/18 at 10:04 P.M., indicated that Patient #1 told Mental Health Councilor (MHC) #1 that after his/her 8:00 P.M. shower on 11/2/18, Patient #2 forced him/her into the bathroom and that Patient #2 was behind Patient #1 and Patient #2 pulled Patient #1's pants down and had sex. During the interview, Patient #1 told MHC #1 that Patient #2 had told Patient #1 that he/she wanted to put his/her fingers inside of him/her. Patient #1 then repeated the story of being forced into the bathroom, having his/her pants pulled down and Patient #2 having sex with Patient #1.

The Surveyor interviewed MHC #1 on 11/20/18 at 1:41 P.M. MHC #1 said that, on 11/2/18, Patient #1 told her that Patient #2 came into Patient #1's bedroom and had sex with Patient #1. MHC #1 said that she then told Nurse #1.

A Nurse's Note written on 11/3/18 at 1:46 A.M., indicated that on 11/2/18, Patient #1 alleged to MHC#1 that Patient #2 sexually assaulted Patient #1 in his/her bedroom. The Nurses Note indicated that Nurse #1 met with Patient #1 to discuss the allegation and Patient #1 was unsure if Patient #2 used his/her fingers or penis to assault him/her. Nurse #1 indicated that Patient #1 was tearful when discussing the sexual assault allegation.

The Surveyor interviewed Nurse #1 on 11/20/18 at 1:00 P.M. Nurse #1 said that, on 11/2/18, she was told by MHC #1 that Patient #1 told MHC #1 that he/she and Patient #2 had sex. Nurse #1 said that she then met with Patient #1 and discussed what happened. At that point, Patient #1 said that it was unclear if Patient #2 used fingers or a penis. Nurse #1 notified the Children's Development Unit Manager via telephone of the incident and was directed to contact the Registered Nurse Medical Supervisor. The Registered Nurse Medical Supervisor working the 11-7 shift came to the unit and met with Nurse #1 and Patient #1. At this time, Patient #1 recounted the events and started to tear up.

The Surveyor interviewed the Registered Nurse Medical Supervisor on 11/20/18 at 2:26 P.M. via telephone. The Registered Nurse Medical Supervisor said he arrived to work for the 11:00 P.M.-7:00 A.M. shift and was notified that something happened on the Children's Development Unit at approximately 11:15 P.M. and he went to the unit to look into it. The Registered Nurse Medical Supervisor said that staff from the Children's Development Unit told him that there was an allegation of sexual nature. The Registered Nurse Medial Supervisor said that he then walked to the Emergency Department and, due to his inexperience with sexual assault, spoke with an Emergency Department nurse about the incident. The Registered Nurse Medical Supervisor said that the Emergency Department Registered Nurse directed him to call the Administrator on Call as the policy indicated. The Registered Nurse Medical Supervisor said that he spoke with Patient #1 and was informed that Patient #2 "fingered" Patient #1 and there was nothing else mentioned and, at that point, he contacted the Administrator on Call and the Administrator on Call said she would contact Risk Management. The Registered Nurse Medical Supervisor said he told the staff to keep a close eye on Patient #1 and Patient #2 throughout the night.

The Surveyor interviewed the Children's Development Unit Manager on 11/19/18 at 12:00 P.M. The Children's Development Unit Manager said that, at 10:15 P.M., she was notified by Nurse #1 of the allegation. The Children's Development Unit Manager said that she directed Nurse #1 to follow the Hospital's policy "Reporting of Allegations of Patient Neglect or Physical or Sexual Abuse or Assault" and to call the Registered Nurse Medical Supervisor. The Children's Development Unit Manager said she told Nurse #1 to call the police and the Administrator on Call. The Children's Development Unit Manager said that she then attempted to contact the Inpatient Director of Psychology and the Executive Director of Behavioral Health to inform them of the sexual assault allegation and that she didn't hear from anyone again that evening. The Children's Development Unit Manager said she came to work the following day at 12:00 P.M. at the request of the Inpatient Director of Psychiatry.

There was no indication that the police were notified of the rape allegation immediately or that the parents of the minor children involved in the rape allegation were notified immediately, no indication that a physical exam was performed on the alleged rape victim or that efforts were made to protect/screen the alleged rape victim regarding post sexual exposure risks.

The Surveyor interviewed the Administrator on Call (Senior Director for Professional Development) on 11/20/18 at 11:35 A.M. The Administrator on Call said that the Registered Nurse Medical Supervisor called her at 12:11 A.M. on 11/3/18 and informed her of an incident between Patient #1 and Patient #2 on the Children's Development Unit. She said that she was informed that Patient #1 alleged sexual assault against Patient #2. She said that the pediatric Patient #1 was not pressing charges and the police weren't called. Parents of the pediatric patients were not immediately notified as Patient #1 is a minor to determine whether the parents wanted to press charges. She was told that both patients were now asleep and that they were on 5 minute checks. Patient #2 was not placed on 1:1 monitoring until the next day. She then told the Registered Nurse Medical Supervisor she would follow up with Risk Management in the morning.

The Surveyor interviewed the Inpatient Director of Psychology on 11/19/18 at 12:20 P.M. The Inpatient Director of Psychology said that he returned a missed call to the Unit at 1:30 A.M. and was informed of the allegation of sexual assault. The Inpatient Director of Psychology said he asked the staff if the police and parents had been called and they had not. The Inpatient Director of Psychology said that he arrived on the unit the following morning and called the police and the parents of both Patient #1 and Patient #2 to inform them of the allegation of rape around 7:30 A.M. on 11/3/18. The Inpatient Director of Psychology said that he didn't interview Patient #2 because he has learned not to interview before the Police do. The Inpatient Director of Psychology said that the "Reporting of Allegations of Patient Neglect or Physical or Sexual Abuse or Assault Policy" is followed in an instance such as this.

A late entry Mental Health Worker note indicated that Patient #1 told MHC #3 that an inappropriate sexual conversation between Patient #1 and Patient #2 took place on 10/31/18, (2 days Prior to the alleged rape) but failed to communicate this with the staff that were taking over on the next shift during shift report. MHC #3 wrote a late entry note dated 11/3/18 at 7:30 A.M., which indicated that on 11/2/18 after morning meeting but prior to the alleged rape of Patient #1, Patient #1 told MHC #3 that, on 10/31/18 Patient #2 told Patient #1 that "I would like to finger you" and this conversation triggered Patient #1 due to his/her past history of trauma. MHC #3 said she told Patient #1 that she would address this and was sorry that it happened.

The late entry Mental Health Worker note dated 11/3/18 at 7:40 A.M., further indicated that Patient #2 told MHC #3 that Patient #1 was the one who initiated the conversation and Patient #1 asked Patient #2 to "finger him/her". MHC #3 said she spoke with Patient #2 about the severity of this type of discussion and how triggering it can impact on all patients on the unit. MHC #3 said that Patient #2 was apologetic.

The Surveyor interviewed MHC #3 on 11/19/18 at 2:20 P.M. MHC #3 said that prior to the alleged rape on 11/2/18, Patient #1 told her that, on 10/31/18, Patient #2 asked Patient #1 if he/she liked "porn" and said the he/she wanted to "finger" Patient #1. MHC #3 said that she immediately went to the nurse on that morning and told him. MHC #3 said that she also told the Unit Manager and another nurse. MHC #3 said that they kept a close eye on the two patients for the remainder of the day. MHC #3 said that she didn't write a note and thought that "the nurse would take care of it". She said that she did not inform the second shift MHC about the incident at change of shift. She said that she did write a late entry note regarding the conversation on 11/3/18 after she learned of the sexual assault allegation.

The Surveyor interviewed the Risk Management Coordinator and the Patient Safety Officer on 11/19/18 at 10:20 A.M. The Risk Management Coordinator said that other than ascertaining Patient #1's mental health, the Hospital did not do any further medical evaluation on Patient #1. The Risk Management Coordinator said that the allegation didn't rise to the level of concern for a physical or Sexual Assault Nurse Examiner (SANE) evaluation because the allegation involved only "fingers". The Patient Safety Officer said she believed that the Police were treating it as a sexual assault with hands and they didn't believe it was rape. The Hospital did not obtain a copy of the police report to verify this statement. The Risk Management Coordinator and the Patient Safety Officer both said that when the Hospital calls the police in for an allegation like this they defer the investigation to the Police.

The Risk Management Coordinator said "they don't want to interfere with the Police investigation" or words to that effect. The Risk Management Coordinator interviewed a nurse and a mental health clinician who worked 11/2/18 from 7:00 A.M.-3:00 P.M. The Risk Management Coordinator said she spoke with the nurse and a mental health councilor about the inappropriate sexual conversation between Patient #1 and Patient #2, but not regarding the actual sexual allegation. The Patient Safety Officer said that she did not interview anyone as she didn't want to interfere with the police investigation.

There was no documentation that Patient #1 had or was offered a physical exam to evaluate the need for post exposure prophylaxis and for sexually transmitted disease in response to the allegation.

The Surveyor interviewed MHC #2 on 11/20/18 at 2:05 P.M. MHC #2 said that, on 11/2/18 after the allegation of rape, the Psychiatrist came to meet with Patient #1 but a medical doctor did not. The Patient Safety Officer who was sitting in on the meeting said that, because it is a psychiatric unit, medical physicians do not go to the unit.

Review of the Risk Event Report dated 11/4/18 indicated that the summary content was alleged sexual abuse. The follow up comments on 11/5/18 indicated that Risk was notified and the Hospital was awaiting further review instructions. The Event Report indicated that an investigation was to be initiated.

On 11/19/18, the Quality of Care Event Reporting Tool was provided to the Surveyors by the Patient Safety Officer. The document indicated that the Root Cause Analysis took place on 11/12/18. It was discussed that adolescents often make sexually suggestive comments and they felt they had handled it well by talking to both patients. Review of the undated Quality and Safety Investigation describes the event and time line of the event but does not indicate that any investigation had begun.

The Surveyor interviewed the Chief Executive Officer/Chief Nursing Officer on 11/21/18 at 2:16 P.M. The Chief Executive Officer/Chief Nursing Officer said that it has been the approach of the Hospital Attorneys to let the police do their investigation and then the Hospital would follow up.

2. Patient #11 was admitted to the Hospital in 1/2018 with diagnoses of bipolar disorder, attention deficit disorder, post traumatic stress disorder and presented with increased thoughts of cutting.

On 11/21/18, record review indicated that, an Event Report dated 1/19/18, indicated that Patient #6 was seen touching genitals with his/her hands to another patient sexually (later identified as Patient #11). Patient #6 didn't deny doing this.

The Surveyor requested a copy of the investigation for this event. The Safety Rights Officer provided a copy of a Risk Event Report dated 1/19/18 which indicated the exact same wording as the Event Report above. The follow-up comments to the Event Report dated 2/13/18 indicated that "per the director, consenting adults". Patient #11 was discharged due to activities not appropriate for the Behavioral Health Unit.

The Surveyor interviewed the Patient Safety Officer on 11/21/18 at 1:00 P.M. The Patient Safety Officer said that she didn't know who the other patient involved was. The Patient Safety Officer said she was not working at her position in 1/2018. She then returned to the conference room at 1:30 P.M. and indicated that the patient in question was Patient #11.

Review of a Nurse's Note dated 1/19/18 indicated that Patient #11 was reported by peers to be sitting close to a male peer who appeared to be putting his/her hands under the blanket that Patient #11 had wrapped around his/her body. The staff member verified this via camera and Patient #11 denied any sexualized behavior. A Nurses Note dated 1/20/18, indicated that Patient #11 was informed that Patient #6 was discharged and it was the staff member's job to keep Patient #11 and all other patients on the unit safe.

No further information was provided to the Surveyor regarding the investigation and determining consent vs. assault.

As of 11/21/18 the investigation involving the alleged sexual abuse/assault cases regarding Patient #1 was not fully investigated by the Hospital and Patient #11 alleged sexual abuse/assault case was not investigated by the Hospital.
VIOLATION: QAPI Tag No: A0263
The Hospital was out of compliance for the Quality Assessment & Performance Improvement (QAPI) Condition of Participation.

Findings include:


1.) The Hospital failed for two (Patient #1 & Patient #11) of eleven sampled patients to ensure investigation and implementation of preventative actions after Patient #1 and Patient #11's sexual assault.
Refer to TAG: A-0286.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on interviews and records reviewed the Hospital failed, for two (Patient #1 & Patient #11) of 11 patient sampled, to ensure investigation and implementation of preventative actions after Patient #1 and Patient #11's alleged sexual assault.

1. Patient #1 was a pediatric patient who was admitted to the hospital in 10/2018 with diagnoses which included post traumatic stress disorder related to a previous sexual assault.

Review of a late entry Mental Health Worker note, dated 11/3/18 at 10:04 P.M., indicated that Patient #1 told Mental Health Councilor (MHC) #1 that after his/her 8:00 P.M. shower on 11/2/18, Patient #2 forced him/her into the bathroom and that Patient #2 was behind Patient #1 and Patient #2 pulled Patient #1's pants down and had sex. During the interview, Patient #1 told MHC #1 that Patient #2 had told Patient #1 that he/she wanted to put his/her fingers inside of him/her. Patient #1 then repeated the story of being forced into the bathroom, having his/her pants pulled down and Patient #2 had sex with Patient #1.

Review of the Hospital's policy titled "Reporting of Allegations of Patient Neglect or Physical or Sexual Abuse or Assault", dated 1/10/17, indicated that all individuals, including patients, have the right to be free of abuse, neglect and assault. The Administrator on Call is responsible for immediate reporting of allegations of abuse neglect or assault occurring in the Facility to the local police and/or other appropriate authorities. All Facilities are responsible for immediately implementing measures to protect any individual impacted by such conduct for taking immediate and effective corrective action in response to such allegations. The Complaints Officer, Risk Manager and Human Resources Director are each responsible for maintaining complete documentation of all allegations of abuse, neglect or assault: the specifics of the allegations made; the specific steps taken by law enforcement and or other appropriate authorities and the Facility to review the allegations; and the results of the review including the results of any review by law enforcement or other external agency. Documentation must be made in the appropriate electronic documentation system and maintained according to Administrative policy.

A review of the incident failed to identify the following:

1. The police were not notified immediately after the incident.
2. Patient #1 and Patient #2's (both minors) parents were not notified immediately.
3. Patient #1 was not physically examined after the incident for the possible need for post-exposure prophylaxis or need for treatment of possible sexually transmitted disease.
4. The Hospital failed to collect interview statements after the incident.
5. Patient #2 was not immediately placed on 1:1 supervision after the sexual allegation.
6. Failed to identify that staff did not document or investigate Patient #2's comments to Patient #1.
7. The Hospital failed to identify that the penetration of any bodily orifice by any part of the body, performed against the victim's will without consent and with the threat of or actual use of force inserting fingers/penetrating an individual sexually, is rape.

All employees whose responsibilities are affected by this policy are expected to be familiar with the basic procedures and responsibilities created by this policy.

The Surveyor interviewed the Risk Management Coordinator and the Patient Safety Officer on 11/19/18 at 10:20 A.M. During this interview, the Patient Safety Officer provided the Surveyor with the investigation file. The Risk Management Coordinator said that on 11/2/18, Patient #1 told Mental Health Councilor #3 that, on 10/31/18, Patient #2 told Patient #1 that he/she wanted to "finger" him/her. At this point, both Patient #1 and Patient #2 were spoken to by Nurse #2 and MHC #3. Nurse #2 and MHC #3 informed the Unit Manager of the Children's Development Unit and "kept and eye on" on Patient #1 and Patient #2 for the remainder of the first shift on 11/2/18. During change of shift, the information was not shared with the oncoming 3:00 P.M.-11:00 P.M. staff members.

The Risk Management Coordinator said that, at roughly 10:00 P.M. on 11/2/18, Patient #1 told MHC #1 that Patient #2 "fingered" him/her. At this time MHC#1 notified Nurse #1 who contacted the Registered Nurse Medical Supervisor. The Risk Management Coordinator said that the police were not called that evening, Patient #1 did not have a physical examination because the allegation didn't rise to the level of concern for physical or Sexual Assault Nurse Examination (SANE) because they thought the allegation was only fingers.

The investigation file included:

1. Event Report, dated 11/4/18. The Event Report alleged that there was an alleged sexual abuse case on the Children's Development Unit and emotional harm was involved. The comments dated 11/4/18 at 8:32 P.M. indicated that the Medical Supervisor contacted the Administrator on Call and was told to wait until the morning when Risk Management is notified before proceeding further. The comments dated 11/5/18 at 11:33 A.M., indicated that Risk was notified and they were awaiting further review instructions.

2. A Quality of Care Event Reporting Tool (undated) which identified the situation and background, including a statement that adolescents often make sexually suggestive comments, indicated that they felt they handled it well. It indicated that Root Cause Analysis meeting took place 11/12/18. Causal factor being that the MHC is always too busy to attend shift change report and didn't share the information with the rest of the team. The Registered Nurse who knew about the incident also didn't attend shift change report. They identified that both patient rooms were near each other. Corrective actions were Notify the Charge RN, Notify the MD using SBAR (situation background assessment notification) format, consider moving the patient room, don't assume that comments are benign, make sure information gets documented and shared, stop and make a plan once we have new information and separate male and female patients if possible. The Quality of Care Event Reporting Tool indicated that the completed root cause analysis was due 11/16/18, 14 days after the event occurred. This was not complete as of 11/21/18.

3. Interview with MHC #3 on 11/8/18 and Interview with Nurse #2 on 11/8/18.

4. Quality and Safety Investigation indicated an event description including three different stories of sexual assault, a timeline of the event on 11/2/18 and the timeline of investigation is blank.

Review of the investigation file prompted questions as to who attended the Root Cause Analysis meeting. The Patient Safety Officer said there were staff involved that were unable to attend the meeting and she anticipates interviews with them will take place and they will be part of the Root Cause Analysis #2 when it takes place. Date to be determined.

No further staff interviews, patient interviews or internal investigation into the allegation were provided in the investigation file.

The Surveyor interviewed the Children's Development Unit Manger on 11/19/18 at 12:00 P.M. The Children's Development Unit Manger said that she received a call at 10:15 P.M., informing her of the allegation of sexual assault. She said that she informed Nurse #1 to follow the policy, "Reporting of Allegations of Patient Neglect or Physical or Sexual Abuse" and to contact the Registered Nurse Medical Supervisor. She said to call the Police and the Administrator on Call as well. She said that she came in the following afternoon around 12:00 P.M. She interviewed MHC #3 and learned of the conversation that took place on 10/31/18 between Patient #1 and Patient #2. She said that the day shift staff did not inform the evening shift staff that they had been keeping a close eye on Patient #1 and Patient #2 due to the sexual conversation. The Children's Development Unit Manager did not interview anyone else involved in the sexual assault allegation.

The Surveyor interviewed the Inpatient Director of Psychiatry on 11/19/18 at 12:20 P.M. The Inpatient Director of Psychiatry said that he had a missed call and called the facility back at 1:30 A.M. and learned of the sexual assault allegation. He said the Registered Nurse Medical Supervisor and the Administrator on Call were involved. He asked if they notified the Police and the parents and they said no. He said that he notified the Police and parents the next morning at 7:30 A.M. of the allegation of sexual assault. He did not interview Patient #1, Patient #2 or staff involved. He said that he learned not to interview before the Police. He said that the policy, Reporting of Allegations of Patient Neglect or Physical or Sexual Abuse should be followed.

The Surveyor interviewed the Administrator on Call (Senior Director for Professional Development) on 11/20/18 at 11:35 A.M. The Administrator on Call said that the Registered Nurse Medical Supervisor called her at 12:11 A.M. on 11/3/18 and informed her of an incident between Patient #1 and Patient #2 on the Children's Development Unit. The Administrator on Call said that she was informed that Patient #1 alleged sexual assault against Patient #2. The Administrator on Call said that pediatric Patient #1 was not pressing charges and the Police weren't called and the parents of the pediatric patients were not notified either. The Administrator on Call said she was told that both patients were now asleep and that they were on 5 minute checks. She then told the Registered Nurse Medical Supervisor she would follow up with Risk Management in the morning.

The Surveyor interviewed the Registered Nurse Medical Supervisor on 11/20/18 at 2:26 P.M. via telephone. The Registered Nurse Medical Supervisor said when he arrived to work for the 11:00 P.M.-7:00 A.M. shift he was notified that something happened on the Children's Development Unit and around 11:15 P.M. he went to the unit to look into it. The Registered Nurse Medical Supervisor said that staff from the Children's Development Unit told him that there was an allegation of a sexual nature. The Registered Nurse Medial Supervisor said that he then walked to the Emergency Department and, due to his inexperience with sexual assault, he spoke with a nurse who was working. The Registered Nurse Medical Supervisor said the Emergency Department Registered Nurse directed him to call the Administrator on Call as the policy indicated. The Registered Nurse Medial Supervisor said that he spoke with Patient #1 and was informed that Patient #2 "fingered" Patient #1 and there was nothing else mentioned and, at that point, he contacted the Administrator on Call and she told him she'd contact Risk Management. The Registered Nurse Medical Supervisor said he told the staff to keep a close eye on Patient #1 and Patient #2 throughout the night.

The Surveyor interviewed the Chief Executive Officer/Chief Nursing Officer on 11/21/18 at 2:16 P.M. The Chief Executive Officer/Chief Nursing Officer said that it has been the approach of the Hospital Attorneys to let the Police do their investigation and then the Hospital would follow up with their own investigation. He said that Risk Management is expected to do their investigation by reaching out to the Unit, talking to the patients and staff involved, documenting and following the guidelines to communicate findings.

The Hospital did not notify the patient's parents, the police, have a medical/SANE exam conducted or initiate and investigate the allegation of sexual assault after it was made by Patient #1.

2. Patient #11 was admitted to the Hospital in 1/2018.

On 11/21/18, record review indicated that,an Event Report dated 1/19/18 indicated that Patient #6 was seen touching another patient's genitals sexually. Patient #6 didn't deny doing this.

The Surveyor requested a copy of the investigation for this event. The Safety Rights Officer provided a copy of a Risk Event Report dated 1/19/18 which indicated the exact same wording as the Event Report above. The follow-up comments to the Event Report dated 2/13/18 indicated that "per the director, consenting adults". Patient #6 was discharged due to activities not appropriate for the behavioral health unit.

The Surveyor interviewed the Patient Safety Officer on 11/21/18 at 1:00 P.M. The Patient Safety Officer said that she didn't know who the other patient involved was. The Patient Safety Officer said she was not working in her role in 1/2018. She then returned to the conference room at 1:30 and indicated that the patient in question was Patient #11.

Review of a Nurses Note dated 1/19/18, indicated that Patient #11 was reported by peers to be sitting close to a peer who appeared to be putting his/her hands under the blanket that Patient #11 had wrapped around his/her body. The staff member verified this via camera and Patient #11 denied any sexualized behavior. A Nurses Note dated 1/20/18, indicated that Patient #11 was informed that Patient #6 was discharged and it was the staff members job to keep Patient #11 and all other patients on the unit safe.

No further information was provided to the Surveyor regarding the investigation and determining consent vs. assault.

As of 11/21/18 the investigation involving the two alleged sexual abuse/assault cases regarding Patient #1 and patient #11 were not investigated by the Hospital.