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PRAIRIECARE 9400 ZANE AVENUE NORTH BROOKLYN PARK, MN Jan. 24, 2019
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on observation, interview and document review, the hospital failed to report in a timely manner an allegation of sexual assault for 1 of 10 patients (P1) in the sample who alleged sexual assault perpetrated by P10, another adolescent psychiatric patient who was receiving treatment at the facility.

Findings include:

P1's current diagnosis listing included major depressive disorder, recurrent, anxiety and motor or vocal tic disorder.

Review of a Hennepin County Child Protection Intake (CPS) report, dated 1/12/19, indicated P1 had being molested by a peer at the facility a couple of days previously, stating, "It was like when I was raped." The report indicated that P1 stated she had reported the incident to hospital staff. The report was intially received by CPS from family (F)-B. The CPS report was forwarded to the Minnesota Department of Health, an onsite investigation was conducted on 1/23/19-1/24/19.

During observation on 1/23/18, at 9:50 a.m. the adolescent general unit was observed. The unit consisted of a section of double and single occupancy rooms. The single occupancy rooms were utilized for adolescent patients who were assessed not to be safe to room with others. The registered nurse educator (NE) stated that P1 had been staying in a private room at the time of the allegation, P10 had also been in a private room on the same hall. The unit also contained a separate room utilized for small group activities. The door to the activity room remained locked unless a session was in progress, and the individual patient rooms were locked at all times from the outside, however, allowed the patient to leave the room once inside. At the present time, P1 was in the adolescent intensive care unit due to an increase in her behavioral symptoms.

Video surveillance tapes of the activity room for the date of the alleged incident were viewed with the chief nursing officer (CNO) on 1/24/19, at 9:05 a.m. Video surveillance revealed:

-On 1/9/19, at 7:00 p.m. P1 and P10 were observed attending an activity group and entered the room separately. The recreational therapy supervisor (RTS) was observed to be seated near the middle of the table. P1 had set her things down on the left side of the table (camera view), then turned toward P10 and another adolescent boy (unidentified) to speak to him. P1 was observed to be looking up at the camera, and moved her belongings to the right side of the table. P10 came in and seated himself at the table, P1 then came into the room and sat next to P10 and began journaling in a notebook. The RTS was observed to be seated in the middle of the table with P1 to her left and P10 seated directly next to P1 on her left side. At 7:05 p.m., P10's right hand was observed to go underneath the table, P1 appeared to flinch. P1 was observed to continue journaling. P10 played a game and then cards with 1 other male and the activities leader with his left hand, the right hand primarily remained underneath the table. P10's right hand looked to be angled toward P1's lower body and thigh area. Two other male patients wrote in journals. Over approximately a 30 minute time frame, P10's hand went under the table and moved toward P1's lower body multiple times. The angle of the video camera and barrier of the table top did not allow for full visualization of what type of contact was made, however, at 7:12 p.m., P1 moved her chair closer to P10, and leaned toward him, and proceeded to begin picking at her face. At 7:21 p.m., P10's hand was observed to be very far under the table, and based on the angle there was a high index of suspicion that inappropriate touch was occurring at this time. At 7:25 p.m., P1 appeared to be staring forward, not speaking, and glanced toward P10 with a tense look on her face. At 7:32 p.m. P1, capped her pen, got up and left the room. P1 went down the hallway to her room, and was observed to be standing with her back to the hallway camera waiting for an RN to come to her to unlock her room door. P1 was observed to be speaking to the registered nurse (RN)-A in the hallway. Footage stopped.

Review of P10's record at this time revealed no previous history or at the hospital after admission of sexually inappropriate behaviors. P10's medical record indicated he had been put on sexual precautions (3 foot rule) on 1/10/19, and had not had any further incidents with other patients. In addition, the record indicated P10 had become more withdrawn and depressed immediately following the allegation being made.

During interview on 1/23/19, at 12:50 p.m. P1's psychiatrist, who was also the chief medical officer (CMO) stated that he moved P1 to the adolescent ICU on 1/10/19, due to escalating behaviors related to head banging and self-injurious behaviors, as well as P1 exhibiting purging behaviors. The CMO indicated P1 had a pattern of setting people up for conflict with herself and others, however, didn't realize/understand the consequences of her behavior to herself and others. The CMO also stated that because P1's condition had declined and speaking about the allegation triggered more bad memories for her. F-A was contacted by survey staff at this time, and did not wish the surveyors to speak with P1. F-B had no legal custody or decision making authority with respect to P1.

During interview on 1/23/19, at 2:45 p.m. the recreational therapy supervisor (RTS) stated she typically held evening activities on the adolescent general unit on Wednesday evenings. During the session on 1/9/19, about 8 patients were in the room. The group was originally intended to be for teaching journaling skills to help the patients express their emotions, however, at least P10 and one other boy were not interested in this, so the RTS played bananagrams and another card game with them instead. This was the first occasion P1 and P10 had been in a group together with her personally, although, she was familiar with P10 and had never witnessed any inappropriate sexual behavior towards others. P10 had only been in the facility for about two days prior to 1/9/19. The RTS stated P1 had seemed happy to join the group as journaling about her feelings was an activity of interest. The RTS reported the patients and herself were seated around a big square table. P1 was immediately to her left, with P10 sitting next to P1. When the RTS had started the bananagrams game with P10 and another boy, she had offered P1 to switch chair and sit on her right side, so she could better interact with P10 and control the card games. P1 declined. The RTS had not noted anything out of the ordinary until P1 suddenly stood up, left the room and walked out with a serious look on her face. Shortly thereafter, the RN-A on duty for the unit popped her head into the room to tell the RTS that they needed to "connect about something that happened in the group." The RTS proceeded to finish up with the group, then went to the calming room on the unit where P1 was seated with the RN and the RTS was informed that P10 had allegedly touched P1 in the genitals during the group. According to the RTS, an incident report was written up, the RTS apologized to P1. The charge nurse was notified of the incident and the RTS stated P10 appeared "ashamed" when immediately confronted about the allegation, and indicated he had only held hands with P1. The RTS had the impression that P10 was not telling the truth.

During interview on 1/23/19, at 3:30 p.m. RN-A stated that she was the nurse in charge the evening of the 1/9/19, incident. P1 had abruptly left the journaling group which had begun at 7 p.m., and was observed out in the hallway picking at her arms. RN-A approached her and was able to get her to open up enough to report that P10 had touched her in the privates "for a long time" during the group. Initially, RN-A was concerned with getting P1 to stop picking at herself as her arms were bleeding. Once he was able to redirect P1, she got the RTS who had finished up with the group and sat down in the calming room with P1 and the RTS. RN-A reported the incident to the facility charge nurse as she was unsure if the police needed to be involved and felt more managerial direction was needed at the time. RN-A stated that P10 told her P1 had "made weird comments to him all day," of a sexual nature and this made him think it was o.k. to "hold hands" with P1 during the group. P10 seemed very upset and indicated he did not want to be accused of something he did not do. P1's F-A was notified of the allegation as they were the responsible party. RN-A indicated that normally the staff member who received the report from the patient was the staff member responsible for notifying CPS of abuse allegations.

During interview on 1/23/19, at 3:20 p.m. PT-B stated she had been working with P1 and P10 on the evening of 1/9/19. PT-B recalled P1 stating another patient had grabbed her in her privates during group that evening and reporting this to the RN on duty. PT-B stated both patients had been on 15 minute checks, and P1 had required close supervision nearly the entire length of her stay due to self-injurious behaviors including picking at herself. After the incident, P10 had been placed on a 3 foot rule to limit his physical proximity to female clients.

During interview on 1/23/19, at 3:39 p.m. psychiatric tech (PT)-A stated she had worked with P10 on 1/9/19. P10 had not exhibited any sexually inappropriate behavior prior to 1/9/19, and had never witnessed any inappropriate interaction between P10 and P1 prior to that day. According to PT-A, P1 had already been having a "rough day," prior to going into the group due to an unrelated counseling session during which she had reported some traumatic events that had happened to her out in the community, before admit to PrairieCare. PT-A recalled P1 going into the journaling group with "no problem." P1 stepped out of the group, was upset and stepped into the calming room to report the incident to the RN on the unit. The RN then informed staff that P1 and P10 needed to remain separated from each other and were brought to their rooms. P10 had subsequently been placed on a "3 foot rule" after the incident to prevent any inappropriate contact with other females, and did not exhibit any further sexually inappropriate behavior with other patients. PT-A further stated after P1 reported the incident on 1/9/19, P10 had become much more withdrawn and "within himself." P10 presented initially as angry and upset after the incident was first made, and had been put on 15 minute safety checks.

During a group interview with several RN staff on 1/24/19, at 10:20 a.m. the nurse manager for adolescent general (RN)-C stated she had been informed of the incident on 1/10/19, the day after it had occurred. P1's psychiatrist and the entire treatment team were apprised of the incident. RN-C spoke with the CNO, to get permission to view the video tapes, which she was finally able to get access to at 7 p.m. on 1/10/19. After viewing the tapes, her initial impression was "Oh my God, this [inappropriate touching between P1 and P10] happened for 30 minutes." P1 had been transferred off of adolescent general to an intensive care section of the facility due to increasing self injurious behaviors and depressive behavior. P10 remained on adolescent general in a private room, and appeared to be having a "hard time," after that. P1's F-A was her legal guardian and was aware of the incident, however, did not wish to press charges against P10 and was satisfied with the hospital's efforts to keep P1 safe. RN-C stated security had been increased after the allegation was made on adolescent general. RN-D, who was supposed to be the person in charge of the overall facility and who was on call to receive abuse allegations on the evening of 1/9/19, was present during this interview and stated no staff had informed her of the allegation at the time, she did not become aware of it until several days later when she returned to work. In addition, RN-D stated the situation had "turned into quite a critical event." RN-E, who was the nursing supervisor indicated that she had received the initial report from staff about the interaction between P1 and P10 and had left a voice message for RN-C that she would probably need to "look at this [the incident] right away," when RN-C arrived on 1/10/19.

On 1/11/19, two days after the allegation, the chief nursing officer (CNO) reviewed the video, and interviewed P1 and P10. She then contacted P1's mother who did not want to pursue charges.

On 1/11/19, P1 had a phone conversation with her father. P1's father reported the event to Brooklyn Park Police Department.

On 1/11/19, at 7:00 p.m. Brooklyn Park Police responded to the hospital, conferred with the administrator on call and P1's mother. No further action was taken.

During interview on 1/24/19, at 11:47 a.m. the CNO stated she would have expected the charge nurse on the shift to fill out an incident report and pass the information along. The CNO stated, "I would not have expected the charge nurse to call CPS [child protective services] or State agency [SA], I do not feel that falls under child protection." The CNO further stated her thinking was CPS would be called/notified if someone of authority over the affected child, or a parent, sibling, or anyone else in the home/community had perpetrated an assault. "This was two peers, it was reported and we had not done an investigation into it at that point. I think the incident report is enough to start that process into investigation. Incident report was done on the 9th, filed into the system, the nurse manager on the unit, who did follow up on the 10th, I believe I was notified late that evening on the 10th, I came in early on the 11th, we had a meeting scheduled to review this with legal and the CMO. After the tape was reviewed by the unit nurse manager, I had come in and reviewed the video. I went to the floor and tried to talk to each individually. I just wanted more clarity if possible. At 1:30 on the 11th , we had our meeting, I presented what I knew, no one else on the team had seen the video. At that time we discussed if reportable event, looked at policies, had legal counsel review. We determined it was not penetration, was it consensual, P1 said no, so we said no. Next bullet point is was it witnessed, we did not consider it witnessed, we thought it was not reportable. At that point we put it in [F-A's] hands. If [F-A] wants to pursue charges we would report it. To prevent something like this happening again, we looked at immediate things, clear top tables, education to staff to be vigilant. We also started a root cause analysis and we have another meeting scheduled for 1/26/19, to follow up on this event."

PrairieCare policy Critical Incident Reporting and Response dated 5/23/18, 1.4 Sexual contact between patients (i.e., vaginal intercourse, anal sex, or oral sex) and /or any contact between a staff member and a patient that is of sexual nature. The policy language stated 3.0 Certain incidents are reported to the Commissioner of the Minnesota Department of Health in accordance with Minnesota Statute 144.7065 as soon as is reasonably and practically possible, but no later than 15 working days after discovery of the event. The CNO stated the incident did not meet the definition of Critical Incident, because there was no sexual penetration.

PrairieCare policy Child Protection Reports: Alleged Child Abuse, Neglect, Exploitation dated 8/30/18, 3.3 directs staff to: report cases of abuse/neglect by PrairieCare staff to the Minnesota Department of Health, Office of Health Facility Complaints. A staff person having received direct knowledge of suspected abuse or neglect is responsible to make the child protection report.