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.

BRYNN MARR HOSP 192 VILLAGE DRIVE JACKSONVILLE, NC 28540 Dec. 4, 2019
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policy and procedures, review of medical records, investigative reports and staff interviews, the hospital failed to report an allegation of patient to patient sexual abuse to the local police department for 1 of 1 alleged sexual abuse patient records reviewed (Patient #2).

The findings included:

Review of policy and procedure titled Sexual Assault Examination approved 07/25/2019 revealed "Procedure: ...2. Staff will not interview the patient (s) involved. Staff who received the report of sexual assault will document what was reported by the patient. 3. During business hours, the Risk Manager will notify (Named) Police Department (PD) of the allegation of sexual assault. After hours, the Nurse/House Manager/Supervisor will notify (Named) Police Department of the allegation of sexual assault ...6. (Named Facility) will follow the instructions as defined by the (Named) PD on how to proceed..."

Review on 12/03/2019 of the closed medical record for Patient #2 revealed he was a [AGE]-year-old male admitted on [DATE] at 2138 as an involuntary commitment for suicidal ideations. Patient #2 had a history of Attention-deficit/hyperactivity disorder (attention difficulty, hyperactivity and impulsiveness behaviors) and Disruptive Mood dysregulation (a mental disorder in children characterized by a persistently irritable or angry mood and frequent temper outburst). Review of the Nurses note (Registered Nurse- RN #3) dated 08/20/2019 at 2130 revealed " ...'my mood is getting better. I think I'm ready to go home.' Extremely polite with RN staff. During a phone call with mom patient c/o (complained of) roommate touching him inappropriately in his genital area. Physician notified. Pt (patient) placed in room by himself for safety. Notified management. At no point during the shift did pt share this information with staff." Review of the discharge summary dated 08/21/2019 at 1524 (Nurse Practitioner-NP #1) revealed "Pt reported he did not feel safe at the hospital due to his report of sexual allegations from peer toward him. Patient's room was changed at that time to private room ..." Patient #2 was discharged to home with his mother on 08/21/2019 at 1430.

Review of investigative notes dated 08/20/2019 at 1845 revealed House Manager (HM) #1 and HM #2 conducted a patient interview with Patient #2 obtaining facts on the incident. Review revealed Patient #2 stated "(Patient #11) started touched [sic] me in my private part ...over my pants but he tried to put his hand in to [sic] touch my penis ..." Review revealed HM #1 and HM #2 conducted an interview with the Patient #11 on 08/20/2019 at 1850 which revealed he denied the allegations.

Interview on 12/04/2019 at 0956 with HM #1 revealed she was notified by staff that Patient #2 reported to his mother during a phone call that his roommate was sexually inappropriate with him. Interview revealed both the patients involved were interviewed.

Interview on 12/04/2019 at 1613 with Police Department (PD) Detective revealed she was the detective assigned to Patient #2's sexual allegation case. Interview revealed the report was still open. Interview revealed on 09/18/2019 Patient #2 received a forensic interview with the Child Advocacy Center (CAC-professionals trained to conduct forensic interviews with children that have been sexually abused). Interview revealed Patient #2 disclosed during the CAC interview, Patient #11 touched him over his clothes and Patient #2 kept telling him to stop. Interview revealed Patient #11 finally ceased his attempts to touch Patient #2 and they both went to sleep. Interview revealed Patient #2's mother reported the alleged sexual abuse to the PD. Interview revealed PD staff has had conversations in the past with the hospital about not reporting allegations of sexual abuse. Interview revealed the hospital did their own investigations "they are not supposed to do that," and all sexual assault allegations were to be reported to the PD for an investigation by trained professionals. Interview revealed the alleged sexual abuse that Patient #2 reported was considered "sexual battery." Interview with the detective revealed the hospital had a "duty to report" sexual allegations and notify the PD.

Interview on 12/04/2019 at 1641 with the Chief Nursing Officer (CNO) revealed the mother notified the PD after her learning of the alleged sexual abuse by the roommate. Interview revealed the Risk Manager did not notify PD or do a thorough investigation because the PD had been made aware by the mother and would handle the investigation. Interview confirmed the hospital did not follow policy by neglecting to report allegations of sexual assault to the local PD and facility staff conducted patient interviews.

Request revealed the Risk Manager was unavailable for interview.

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