The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on interview and record review the facility failed to follow their policies and procedures for allegations of patient to patient sexual assault for one (#1) of ten patients, resulting in the potential of reoccurrence and less than optimal outcomes. Findings include:

On 11/4/19 at 1430, review of an incident/accident/investigation report revealed that on 10/31/19 at 1800 patient #1 informed Medical Health Technician (MHA) Staff J that he was forced to perform a sexual act on patient #2 following a safety check between the hours of 1600 and 1630 on 10/31/19.

A phone interview was conducted with Registered Nurse Staff I on 11/4/19 at 1630. When queried regarding the allegations of patient to patient sexual abuse involving the patient of concern (#1) she stated, "I only worked until 5 PM on that day (10/31/19)." Staff I explained that she was informed of the event on the following day. She said I was told that he (#1) never said anything to anyone until around 6 PM. She said the patient of concern (#1) never said anything to her in regarding the incident.

An interview and review of the surveillance footage was conducted with MHA staff J on 11/4/19 at 1640. Staff J explained the patient (#1) reported to him on 10/31/19 at 6 PM that patient #2 had forced him to perform oral sex on him. Staff J said he immediately reported what the patient (#1) said to the Nurse Manager.

On 11/5/19 at 0945, review of the medical record for patient #1 was conducted with the Administrator and revealed the following:
Per medical history and physical:
Patient #1 was a [AGE] year-old male that was admitted to the facility on [DATE] for suicidal thoughts with a plan to cut his wrists. The patient had reported that he does "cut himself" and he presented with multiple cuts over both of his forearms and also on his abdomen that all appeared to be healing.

Per behavioral medicine:
Patient #1 has borderline personality disorder:
Problem regulating emotions and thoughts, impulsive, reckless behavior and unstable relationships with other people. As a result, the patient has also been struggling with depression and anxiety, along with self harm and suicidal behavior.
Plan: Suicide precautions, along with 15 minute safety checks...

Anxiety disorder:
Assessment and plan: Patient (#1) volunteers history of sexual trauma and get nightmares.
Need collateral info to substantiate this info.

At risk for suicide:
Assessment and plan:
Patient (#1) has demonstrated to be at risk for suicide as evidenced by one or more of the following: Previous suicide attempt and/or suicidal ideation, Poor behavioral control/impulse control and High emotional distress.
Given the concerns listed above, the patient is considered to be at moderate risk: Not currently suicidal but recent suicidal behaviors or multiple risk factors. The patient was placed on every 15 minute safety checks and precautions. 1:1 observation was not required because the patient was not displaying self injurious behaviors...The patient will be evaluated every 24 hours to reassess the need for level of observation.

Review of the facility policy/procedure titled "Patient to Patient Sexual Assault" dated effective 2/11/2017, documented "Patients who have been assaulted or been assaulted by other patients will be assessed and changes in treatment or management will be instituted as appropriate to remove immediate risk of further incidents ...
Procedure: In all cases of patient to patient assault, it is the priority of the nurse in charge, in collaboration with the physician, to take immediate action to ensure the safety of all patients ...J. In the case of report of sexual assault, the patient reporting said assault will be transported to 'Haven' for rape kit and assessment. Every effort should be made to protect the integrity of any evidence that might be used in a criminal investigation to protect the integrity of any evidence that might be used in criminal investigation such as requesting the clothing of alleged victim and perpetrator to be bagged and labeled. The alleged victim should monitored until transferred for medical care at anytime. The alleged perpetrator and victim will immediately be separated by transfer of one of the patients to another unit. In all cases of alleged sexual assault, the unit manager or house manager will be notified and initiate a chain of command. The physician will immediately be notified of report and notification documented in the medical record.
K. In the case of physical or sexual assault of minor child, the parent/guardian will be immediately notified of report and said notification documented in the medical record. The House Manager, and (name of facility) security will be immediately notified. The Clinical Director/Medical Director and Recipient Rights officer needs to be notified. The attending physician will be notified as will social work. Child Protective Services (CPS) will be notified by Social Work or Nursing phone number (for CPS).

On 11/5/19 at 1300 further medical record review for patient #1 revealed no evidence in the medical record that documented that patient #1 had alleged that he had been sexually assaulted, nor was there any evidence in the medical record that documented that the patient's (#1's) parent/guardian had been notified of the alleged sexual assault.

During an interview on 11/5/19 at 1500 the Administrator was queried in regards to:
1. If a police report was filed for the allegation of sexual assault for patient (#1).
2. If the patient (#1) was transported to 'Haven' for rape kit and assessment according to their policy and procedure.
3. If CPS had been notified of the allegations of patient to patient sexual abuse.
Additionally, the Administrator was asked to explain why there was no evidence in the medical record that documented that the patient's (#1's) parent/guardian had been notified of the alleged sexual assault.

At that time the Administrator said, "No. It was not done." She said, "We did not follow our policy."