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.

AURORA BEHAVIORAL HEALTHCARE-SANTA ROSA, LLC 1287 FULTON ROAD SANTA ROSA, CA 95401 Feb. 27, 2020
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interview, and record review, the facility failed to ensure that the Condition of Participation for 482.13 - Patient Rights, was met when:

1) Two patients (Patients 4 and 7) were inappropriately touched by Licensed Staff K. (Cross Reference Q - 0144, 0145, 0286)

2) Two adolescent patients (Patients 5 and 6) engaged in inappropriate behavior with each other. (Cross Reference Q - 0144, 0145, 0286)

3) One adult patient (Patient 2), was slapped by another adult patient (Patient 1). (Cross Reference Q - 0144, 0145, 0286)

4) Two adolescent patients (Patients 3 and 8) engaged in inappropriate behavior with each other. (Cross Reference Q - 0144, 0145, 0286)

The cumulative effects of the failures resulted in the facility's inability to comply with the statutorily-mandated Condition for Coverage to protect and promote patients' right to be free from abuse.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure patients were provided care in a safe setting for 7 patients (Patients 1, 2, 3, 4, 5, 6, 7) when:

1. Two patients (Patients 4 and 7) were inappropriately touched by Licensed Staff K;
2. Two adolescent patients (Patients 5 and 6) engaged in inappropriate behavior with each other;
3. One adult patient (Patient 2), was slapped by another adult patient (Patient 1); and,
4. Two adolescent patients (Patients 3 and 8) engaged in inappropriate behavior with each other.

These failures violated the patients' right to receive care in a safe setting.

Findings:

1. During an interview with Director C, on 2/18/20, at 3 p.m., she stated everyone who worked at the facility was a Mandated Reporter (a person who is legally required to report any suspicion of child abuse or neglect to the relevant authorities. These laws are in place to prevent children from being abused and to end any possible abuse or neglect at the earliest possible stage). She stated her expectations for staff was to follow facility Policy and Procedure for abuse and mandated reporting, notify the Chief Nursing Officer (CNO), Nurse Manager, Administrator On Call (AOC), and initiate an incident report, if advised, before the end of the shift. Director C stated there was an incident where mandated reporting did not occur, according to facility Policy and Procedure (P&P) for reporting abuse. She stated the facility became aware an incident of abuse had occurred, and was not reported, when an adolescent patient (Patient 4), was readmitted on [DATE], and requested to not receive care from Licensed Staff K.

During an interview with Director F, on 2/18/20, at 4:20 p.m., she stated she was informed by the facility charge nurse that, during Patient 4's readmission, on 2/5/20, Patient 4 had reported Licensed Staff K touched her inappropriately during a previous hospitalization on [DATE]. Director F stated the facility was unaware if an incident report was completed during Patient 4's initial hospitalization on [DATE]. She stated staff did not followed facility P&P for mandated reported when the facility AOC was not immediately notified, and an incident report was not completed. Director F stated the previous Chief Nursing Office Officer (CNO), was informed of Patient 4's complaint during Patient 4's initial hospitalization on [DATE], but had not informed the AOC, and did not investigate Patient 4's initial abuse claim. Director F stated, on 1/27/20, the facility first became aware of a complaint about Licensed Staff K, when Patient 7's parents reported their daughter informed them Licensed Staff K inappropriately touched Patient 7 and acted inappropriately with her. Director F stated Licensed Staff K was placed on leave during an investigation of the alleged behavior with Patient 7. Director F stated, as part of the facility investigation, video tapes of the hallway of Patient 7's room were reviewed, and stated Licensed Staff K was observed going into Patient 7's room frequently and spending a suspicious amount of time with her. Director F stated, when Patient 4 was readmitted on [DATE], and asked not to be taken care of by Licensed Nurse K, she realized Licensed Staff K had done something inappropriate with both Patient 4 and Patient 7.

Director F stated the previous CNO had, "dropped the ball," and admitted she did not report the initial allegation of abuse by Patient 4 on 11/16/19. Director F stated the CNO was not the AOC on 11/16/19, and she should have contacted the AOC to report the allegation when she was first informed. Director F stated the CNO never informed the facility.

During an interview with Licensed Staff J, on 2/19/20, at 9:50 a.m., he stated he was aware of an abuse accusation by Patient 4 on 2/5/20. He stated when Licensed Staff L informed him that Patient 4, during her readmission process, stated she (Patient 4), did not want to be taken care of by Licensed Staff K. Licensed Staff J stated Licensed Staff L informed him Patient 4 s, the said the lastt time she (Patient 4), was hospitalized at the facility, Licensed Staff K placed Patient 4's hand on his genitals. Licensed Staff J stated, when Licensed Staff L notified him, he called the CNO who he thought was the AOC, and was advised by her to get statements from Patient 4, Licensed Staff K and J and complete an incident report. He stated he did not interview Patient 4, did not interview the alleged perpetrator, Licensed Staff K, or any of the witnesses. He stated, when he interviewed Licensed Staff K, he denied the allegation, and stated there was a witness. Licensed Staff J stated adolescent patients made accusations of sexual abuse all the time.

Licensed Staff J stated he was not advised by the CNO to place Licensed Staff K on Administrative Leave. He stated everyone was finished with the night shift and in the process of going home, so he asked Licensed Staff K to complete the witness statements, and he left. He stated he turned the paperwork to Director O's mailbox and went home. He stated he did not remember if Licensed Staff K was placed on Administrative Leave or not, but stated if Licensed Staff K was back at work, he thought Licensed Staff K must have been investigated, and it was appropriate for him to return. Licensed Staff J stated Licensed Staff K was odd and was not aware why he was removed from the adolescent unit schedule and assigned to work the night shift in the adult unit.

During an interview on 2/19/20, at 3:45 p.m., Director F stated the facility investigated the abuse of two patients (Patient 4 and Patient 7) by Licensed Staff K. She stated in November 2019, Patient 4 made an abuse allegation against Licensed Staff K, and the Chief Nursing Officer (CNO), not the AOC, was informed, and did not do anything about the allegation; as a result, the facility was unaware of the allegation. Director F confirmed Licensed Staff K was not placed on Administrative Leave after the allegation and returned to work assigned night shifts from 11/16/19, until 2/5/20. She stated on 1/26/20, Patient 7 parents informed the facility that during a home visit, Patient 7 told them a facility staff member placed her hands on his genitals. Director F stated staff followed facility P&P for Abuse Prevention; the AOC was informed, Licensed Staff K was placed on Administrative Leave during the investigation, and an investigation was initiated. She stated CPS (Child Protective Services), police, physician and California Department of Public Health (CDPH) were notified.

Director F stated Patient 4 was readmitted to the facility 2/5/20, and made the claim Licensed Staff K placed her hand on his genitals the last time she was in the hospital and did not want him to be assigned to her care. Director F stated staff followed facility P&P for Abuse Prevention, the AOC was informed, and an investigation was initiated. She stated Licensed Staff K was on Administrative Leave from the previous event and was not interviewed. The facility terminated Licensed Staff K. CPS, police, physician and California Department of Public Health (CDPH) were notified. Director F stated the previous CNO dropped the ball, and she admitted it. The previous CNO admitted in an interview she believed Licensed Staff K's statement of having a witness, exonerated him. Director F stated Licensed Staff J told her he assumed the investigation was all taken care of. Director F stated, as part of the facility investigation, she reviewed video surveillance of Patient 7's hallway, outside her door, and observed Licensed Staff K entering Patient 7's room alone, without another staff member, much more often than was required by his night shift duties and spent long periods of time which could not be accounted for. She stated the result of the dual investigation into Patient 4's and Patient 7's allegations of abuse was substantiated by the facility. She stated the alleged molestation of Patients 4 and 7 appeared to have happened. Director F stated, when Incident Reports were completed on the night shift and on weekends, they were not immediately reviewed by a manager and were reviewed on Monday mornings. She stated the paper-based Incident Reporting System was a challenge. For example, in the case of the last incident, the CNO just did not turn it in.

During an interview with Director O on 2/20/20, at 4 p.m., she stated she interviewed Licensed Staff K regarding the 11/16/20, allegation of abuse by Patient 4, and he stated Patient 4 did not want to go home and was trying to sabotage her discharge from the facility. Director O stated patients make up stuff all the time so they can stay in the facility longer. She stated Licensed Nurse K claimed there was a witness, but she did not interview any witnesses. She stated she interviewed Patient 4's mother, who stated Patient 4 was manipulative and lied all the time. She stated most of the adolescent patients made untrue accusations all the time. Director O stated, when the second accusation against Licensed Staff K occurred, she believed it was true based on the two allegations and review of the video surveillance. Director O stated she was not the AOC on 11/16/20, but staff called her 24/7, and she responded by conducting the investigation when she returned to work on 11/17/20. She stated she should have contacted the AOC at the time. Director O stated she completed the incident report and investigation and turned it into Director F's mailbox.

During an interview with Licensed Staff S, on 2/25/20, he stated in the past, if they became aware of any kind of abuse which occurred, or was alleged, if it involved an adolescent, they independently notified Children Protective Services (CPS), police and the facility administration. He stated the process had recently changed, when nothing was investigated after an allegation of staff-to-patient abuse. Licensed Staff S stated, prior to the recent incident, staff had the ability to contact the authorities and begin the Abuse Prevention P&P process independently, but when the last accusation was not investigated, the process changed to include first contact the AOC and then follow the Abuse Prevention P&P.

During an interview and record review, on 2/25/20, at 3:05 p.m., a document titled "[Facility Name's] Facesheet," indicated Patient 4 was a [AGE]-year-old female admitted [DATE], for diagnoses including, "Major depressive disorder, Suicidal ideations and Post-traumatic stress disorder." A document titled, "INCIDENT REPORT ...Date of Incident: 11/16/19 Time of Incident 0700 am Location unit 400 (Locked Adolescent Unit), ...Other: (describe) Patient made allegation against me. Description of Incident (Summarize what happened): Patient's vital signs were been taken by this writer. The machine was not functioning properly, so this writer had to retake the vitals. Patient's door was wide open. MHW (Mental Health Worker) were in the hallway right next to pt's room and looking into pt's room throughout the time. This writer was talking with patient all throughout, MHW heard us talking. ...Completed By ... (Licensed Staff K). Date: 11/16/19 Time: 0807."
Director F stated the alleged perpetrator completed the Incident Report on the date of the allegation on 11/16/19. She stated it was not a good idea to have the perpetrator complete an Incident Report against himself. She stated a stamp indicated, "Received [DATE]," indicated the Incident Report was received by the Quality Department. She stated the stamp indicated the prior CNO completed the paperwork and turned it into the facility. She stated the reason it was never investigated by the facility, was the Incident Report paperwork was filed by someone in her office before she had a chance to review it. She stated, as a result, Licensed Staff K continued to work assigned night shifts for eleven weeks and four days, until Patient 4 was readmitted on [DATE], and the second allegation of
staff-to-patient abuse was made. Licensed Staff K was placed on Administrative Leave during the investigation.

During an interview on 2/26/20 at 10:30 a.m., Patient 4's Aunt confirmed Patient 4 reported the events of abuse on 11/16/19, prior to her discharge from the facility. Patient 4's Aunt stated, during the drive home on 11/16/19, Patient 4 started telling her the details of the event when Licensed Staff K took her vital signs in the morning prior to her discharge. Patient 4's Aunt stated Patient 4 told her Licensed Staff K put her hand on his genitals. Patient 4 felt uncomfortable and pulled her hand away. Licensed Staff K grabbed Patient 4's hand and put it back on his genitals stating it was ok and proceeded to take her vital signs.

A review of a document titled, "[Facility Name's] Facesheet," indicated Patient 4 was a [AGE]-year-old female readmitted [DATE], for diagnoses including, "Major depressive disorder, Personal History of self-harm and Personal history of physical and sexual abuse in childhood." A document titled, "PROGRESS NOTES," dated 2/5/20 at 8:35 a.m., indicated, "Report Note-Upon intake assessment by this nurse on unit 400 exam room, pt. said, 'Does (Licensed Staff K) still work here?' This nurse said, 'No.' Pt. appeared very emotional when asked what happened. ...Pt. said, 'Last time I was here, Licensed Staff K came into my room and forced my hand onto his genitals.' ...Patient 4's mother said 'Yeah, she told me about it when I packed her up last time. I told her she did the right thing by telling the nurse. Pt. reported that she told the day time nurse lady. Incident occurred at approximately 6 a.m. on 11/16/19.'"

2. Review of Patient 5's medical record document titled, "[Facility Name's] Face sheet," indicated he was a [AGE]-year-old male, admitted [DATE], for diagnoses including, "Major depressive disorder, Attention-deficit hyperactivity disorder. A medical record document titled, "PROGRESS NOTES," dated 5/21/19, at 11:30 a.m., indicated, "Patient discharged ...Time of discharge 11:17 a.m."

Review of Patient 5's medical record document titled, "PROGRESS NOTES," dated 5/21/19, at 4:20 p.m., indicated, "Nursing note - It has come to this nurses attention that at some point, early in the pt. stay, the pt. roommate (Patient 6) might have preformed oral sex on the pt. (Patient 5). The roommate was overheard bragging about it to other patients. ...CNO and psychiatrist were notified. CNO called AOC and CEO. Parents of both children were notified. Pt. father was spoken to. A CPS report was filed."

During a record review and interview on 2/19/20, at 10:55 a.m., Patient 5's medical record, containing a document titled, "Suspected Children's Abuse Report," dated 5/21/19, indicated, "Date/Time of Incident 5/18/2019, Place of Incident Room at hospital, Narrative Description Pt (Patient 5) was rooming with a 12 y/o male. On 4/21/19, the staff became aware of a rummer(rumor) involving the two boys. The 12 y/o had performed oral sex on the 14 year old." Nursing Consultant F stated, after Patient 5 was discharged on [DATE], the facility became aware Patient 5 was alleged to be the victim of sexual molestation by Patient 6.

Nursing Consultant F and Director C stated, after Patient 5 was discharged , a Licensed Nurse overheard Patient 6 bragging about having performed oral sex on Patient 5. They stated Licensed Staff followed the P&P for Mandatory Reporting, informed the AOC, completed an Incident Report and notified the parents and the Physician. Director C stated the facility had a system to prevent abuse by having a Hall Monitor position and every 15-minute monitoring of patients.

During an interview on 2/21/20 at 9:55 a.m., Administrator B stated Patient 6 was assigned to a room on his admission on 5/17/19 at 12:15 p.m. Administrator B stated Patient 5 was assigned to a room, with Patient 6 as a roommate, on 5/17/19 at 7:50 p.m., upon admission, until his discharge on 5/21/19. He stated Patient 6 was reassigned to a no-roommate room, on 5/19/19.

During an interview with Administrator A, Administrator B and Nursing Consultant F, and record review on 2/21/20 at 8 a.m., the facility document titled, "Root Cause Template," dated 1/26/20, indicated for the 5/18/19, incident investigation, Patient 6 was interviewed about the incident. The documentation indicated Patient 6 denied the incident occurred. Patient 5's father was notified about the alleged incident, via a telephone interview with a social worker, after Patient 5's discharge. Patient 5's father asked Patient 5 if he had engaged in a sex act with Patient 6, and confirmed it happened. A review of the Root Cause Analysis documentation, indicated; every 15 minute monitoring was predictable and allowed the boys to plan the incident, the mother of Patient 6 did not disclose he had a history of sexually abusing his younger brother, and the information from the referral center about aggressive and sexual behavior was not communicated, and factors contributing to the incident included: "Staff did not use critical thinking in the process of supervising safety of adolescents. ...Staff did not anticipate adolescent boys ages 12 and [AGE] years old would engage in sexual acting out behavior. ...Staff performance did not meet expectations. ...Leadership unaware that patients were able to predict patient safety rounding every 15 minutes and plan unsupervised activity."

During an interview on 2/25/20 at 7:15 a.m., Licensed Staff S stated nursing assessment for new admits included review of information from the referral/transfer facility as part of the patient assessment. Licensed Staff S stated they did not admit patients with a recent history of assaultive behavior. Licensed Staff S stated, with a push to fill empty beds and increase facility census, recent history of assaultive behavior meant the patient was not assaulting someone upon intake to this facility. Licensed Staff S stated, when staffing was low, patients were sometimes directly admitted to the units without having a thorough review of intake paperwork, and things got missed.

During an interview on 2/25/20 at 10:45 a.m., Licensed Staff Z stated the Admission and Referral (A&R) department was responsible for filling the beds in the facility. Licensed Staff Z stated the facility never turned down an admit. Licensed Staff Z stated patient referrals came in from the phone transfer center, and then they faxed us a referral packet with patient information which included history or psychiatric issues. Staff were expected to review the information. Licensed Staff Z stated patients who were inappropriate to admit, were dementia, autism, and aggression. Licensed Staff Z stated aggressive behavior was defined as being in physical restraints. Licensed Staff Z stated the admit process included checking the acuity on the units, making appropriate room assignments, and making recommendation for a 1:1 monitoring.

During an interview with Director C, on 2/26/20 at 2:45 p.m., she stated, a patient with a high assaultive risk could go into a room with patients who had a low vulnerability risk score.

During a phone interview with Physician Y, on 2/27/20 at 2 p.m., he stated patient safety began in the A&R Department when they reviewed patient information from the transfer center / referral facility. He stated they assessed the information to determine if the patients met the criteria for admission, which included: Risk of aggressive behavior, risk of assault, risk of sexual acting out. He stated Patient 6, who had a Risk Score of 35+ (15+ high risk), was a risk of assault or improper sexual acting out behavior. He stated it was not appropriate for a patient, admitted with a high risk score and history of assaultive behaviors, to be roomed with a vulnerable patient.

Review of Patient 6's medical record document titled, "[Facility Name's] Facesheet," indicated he was a [AGE]-year-old male, admitted [DATE], with diagnoses including, "Bipolar disorder, Attention deficit hyperactivity disorder."

Review of Patient 6's transfer medical record document titled "[County Name's] Department of Behavioral Health CRISIS ASSESSMENT," dated 5/16/19, which indicated, "Referring Persons' Statement of Client's Presenting Problem(s) Mother reports that since incident that occurred in October 2018 involving assault of her (?) siblings by the client, his behaviors have increase in intensity. Mother further reports fear she has in regards to impulse control of the client and it possibly leading to attempts on the lives of the siblings or parents. ...Current Risk of Self Harm or Risk of Harm to Others Ideation of Harm to Others, Suspected, Mother reports fear for her and her family's life due to increase in severity in impulse control. ...Recent Assaultive Behaviors, Yes, Assaultive behaviors towards a classmate today led to being expelled today."

Review of Patient 6's medical record document titled, "Intake Assessment," dated 5/17/19, indicated, "SEXUAL ACTING OUT RISK SCREEN," with the following categories checked and scored: 15 points-History of sexual assault, 5 points-Increase in sexual thoughts, 5 points-History of sexual abuse victim, 5 points-indiscriminate sexual activity. "Sexual Risk Score 35 - 15+=High Risk."

Review of a document titled, "PSYCHIATRIC EVALUATION," dated 5/18/19, indicated, "The patient's mother, who provided collateral information reported history of aggressive behavior for a long time, including trying to stab his father with a pencil and punching siblings....TREATMENT PLAN: 1. The patient will be placed on general suicide and assault precautions with every 15-minute checks."

Review of Patient 6's medical record document titled, "PHYSICIAN'S ORDERS:"
-Admission Orders, Dated 5/17/19 at 7:18 p.m., indicated, "Level of Observation - Every 15 minutes observation, Precautions: Suicide.
-Dated 5/19/2019 at 6:12 p.m., indicated, "ADD Sexual Precautions."
-Dated 5/19/2019 at 9:45 p.m., indicated, "BLOCK ROOM - NO ROOMMATE. Due to history of sexual inappropriateness."

Review of Patient 6's medical record document titled, "PROGRESS NOTES:"
-Dated 5/19/2019, dictated by Physician Y, on 5/20/19 at 1:52 a.m., indicated, "PLAN ...Continue precautions and close monitoring."
-Dated 5/20/19, dictated 5/21/19 at 2:48 a.m., indicated, "The patient's social worker in the unit reported to this examiner that according to the patient's mother, there has been an extensive history of physical and sexual assaults on the part of the patient towards siblings and also towards classmates in the school. ...When patient was confronted about this history, the patient stated, 'I was physically abusing my younger brother but I have not been doing that for the past 1 year."
-Dated 5/21/19, dictated 5/21/19 at 11:19 p.m., indicated, " ...I was informed by the nursing staff in the unit that there has been a report from other patients that the patient has engaged in sexual activity with another male patient, who was discharged in the morning. ...TREATMENT PLAN: ...started the patient on suicide precautions."

Review of Patient 6's medical record document titled, "Inpatient Interdisciplinary Notes," dated 5/19/19 at 5 p.m., indicated, "Sexual precautions added to precaution list due to report from therapist that mom reported alleged inappropriate sexual behaviors with siblings."

Review of Patient 6's medical record document titled, "Inpatient Interdisciplinary Notes," dated 5/19/19 at 7:08 p.m., written by the Social Worker, indicated, "Pt. had faced 2 suspensions for sexually harassing one fell ow student online on two separate occasions. ...October 2018 when the pt. was [AGE] years old, it was reported to the parents that the pt. had been sexually abusing his two younger brothers. ...This staff made nursing staff aware to add sexual precautions due to ongoing predatory behaviors and impulsivity as reported by parent."

Review of Patient 6's document title, "Patient Observation Record," dated, "Admit @ 1215," indicated, "Precautions - Suicide, Observation Level: 15 minute checks," on 5/18/19, 5/19/19, 5/20/19. On 5/20/19 at 12 p.m., Sexual Precautions were added to the every 15-minute observation record.

3. During an observation of Unit 100 Group Music Therapy, on 2/13/20, at 2:45 p.m., Patient 2 was listening to the music, and chose as part of the therapy, the emoji of, "Horrified." He stated it was related to experiences and feelings regarding sex abuse.

During an interview on 2/18/20, at 1:55 p.m., Social Services Staff D stated he observed Patient 2 express feelings during music therapy yesterday, related to sexual abuse. He stated he should have informed the nurse about Patient 2's statement and documented it in the medical record. Social Services Staff D stated he was a Mandated Reporter, by law and should have reported it. He stated patients do not talk about sexual abuse often, and the comment stood out.

During an interview and record review on 2/18/20, at 2:40 p.m., Manager G stated she recently had training for Mandated Reporter education. She was asked if there were any incidents of abuse she was aware of, and stated there was a recent incident which occurred when a patient accused a staff member of touching her inappropriately. During a review of Patient 2's medical record, she (Manager G) stated, if there were any comments regarding sexual abuse, they should be in the medical record. She stated there was nothing in Patient 2's medical record regarding any kind of abuse and would expect there to be something documented.

During an interview with Director C on 2/18/20, at 3 p.m., she stated everyone was a Mandated Reporter, and licensed and unlicensed staff were supposed to report it to their managers, who inform her. She stated she followed up and made sure the incident was reported to Quality to investigate: To be sure it was reported. She stated her expectation of staff was for staff to report abuse immediately and complete the paperwork documentation before the end of the shift. She stated the only incident she was aware of recently was abuse related to a licensed staff to two patients. Director C stated, if a patient slapped another patient it may, or may not, be abuse.

During a record review and interview on 2/19/20, at 12:45 p.m., Manager G stated she was informed yesterday of a witnessed incident between Patient 1 and Patient 2. She stated, around 10 a.m., Patient 1 slapped Patient 2 across the face. She stated an incident report was initiated, Director C was notified, the physician was notified, and the treated plan was updated for Patient 1 to reflect assault precautions. She provided a document titled, "Progress Notes," dated 2/18/20, at 5:52 p.m., which indicated, "Social Worker met 1:1 with Patient 2 to discuss his comment about molestation in group. ... Social Worker informed Patient 2 she wanted to check on him after the comment about sexual abuse was brought up in group." She stated there was no documentation regarding Patient 1 slapping Patient 2. She stated the documentation was in Patient 1's medical record.

Director F stated an adult patient slapping another patient did not qualify as abuse and was not reported. Nursing Consultant F stated, when one adult patient slapped another adult patient, the facility was only obligated to report the adult patient to adult patient physical abuse if one patient was either defined as incapacitated or vulnerable, or if a patient needed emergency medical care. Director F stated, for adults, the facility does not have to report the slap unless the patient wanted to press charges. She stated Patient 2 was not vulnerable or incapacitated, and the situation was not reported to police, Adult Protective Services or the California Department Public Health.

During an interview on 2/19/20 at 2:50 p.m., Mental Health Worker (MHW) H stated she was not aware of any incident of abuse, except one patient hitting another patient. She stated she came back from her morning break, and observed Patient 1 walk up to Patient 2, in the activity room and punch him in the face. She stated Patient 1 was moved to another unit. She stated she observed Patient 2 isolating himself afterwards, in his room, sue to his being hit by Patient 1.

During an interview on 2/19/20 at 3:05 p.m., Licensed Staff I stated the only abuse she was aware of occurred the previous week, when she witnessed Patient 1 slap Patient 2. She stated Patient 2 was scared by just looking at the expression on his face. She stated Patient 1 was moved to another unit, the physician was notified, the incident report was completed, and Manager G was notified.

During an interview and record review on 2/26/20, at 2 p.m., Director C reviewed a Progress Note, dated 2/13/20 at 5 p.m., which indicated Patient 2 was slapped by Patient 1, and the physician and nurse manager were notified. She stated there was no report to CDPH, because severe harm and assaultive behavior was not unusual with their patients, so they did not call. Director F stated there was no serious harm or death, so the incident was not reportable according to their definition.

During an interview and record review of Patient 1's medical record on 2/26/20 at 3 p.m., Director C, Administrator A and Nursing Consultant F stated the MHW's are expected to document on the Patient Observation Sheet, every 15 minutes. They stated the sheet included what risks the staff should be aware of, including assaultive behaviors. Review of Patient 1's documentation indicated a Risks Stratification Score for Assault Risk Score 20 (15+=High Risk), and HIGH RISK ALERT for DANGER TO OTHERS upon admission. Nursing Consultant F stated the Patient Observation Sheet for Patient 1 did not indicate Assault risk, and should have indicated Assault Risk. She stated the risk to patients was, if staff were not aware of the risk assaultive behavior, staff might not implement prevention strategies, resulting in the staff not being able to stop an assault.

Review of a document for Patient 2, titled, "Facesheet," dated 2/11/20, indicated Patient 2 was a [AGE]-year-old male, admitted with diagnoses of Schizoaffective disorder, bipolar type, post-traumatic stress disorder, Attention-deficit hyperactivity stress disorder, Personal history of physical and sexual abuse in childhood, Personal history of psychological abuse in childhood.

Review of a document titled, "RISK STRATIFICATION," dated 2/11/20, indicated, "VULNERABILITY RISK SCORE 10 (15+=High Risk)."

Review of a document for Patient 1, titled, "Facesheet," dated 2/8/20, indicated Patient 1 was a [AGE]-year-old male, admitted for diagnoses of Schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions).

A document titled, "RISK STRATIFICATION," 2/8/20, at 2 a.m., indicated, "DANGER TO OTHERS RISK SCREEN ...ASSAULT RISK SCORE 20 (15+ = High Risk) ... HIGH RISK ALERT (To be completed ... when patient arrives) DANGER TO OTHERS."

During a review of Patient 1's medical record, a document titled, Physicians, "PROGRESS NOTES," dated 2/13/20, indicated, "As per nursing staff, the patient continues to be very paranoid, he ended up assaulting another patient on the unit, the patient was moved to unit [#] after being aggressive towards another patient on the unit....He was asked for his reason behind his aggressive behavior, the patient replied...I smacked him."

A document titled, "PROGRESS NOTES," dated 2/19/20, at 8:39 a.m., indicated, "Treatment team reviewed pt's treat plan to address physical aggression exhibited by pt. 1 on unit [#]....Pt. 1 had slapped pt. 2."

A document titled, "Patient Observation Sheet," dated: 2/8/20, at 12:15 a.m., indicated Patient 1 was being observed for, "Routine - 15 - minute observations ...Vulnerability." 2/13/20 7:30 a.m. - 2/14/20 7:30 a.m., indicated Patient 1 was being observed for precautions of, "Sexual / Sexual acting out, Vulnerability."

A review of a facility Policy and Procedure titled, "Precautions, Inpatient units Policy Number PC 360.24," revised 8/1/19, indicated, "Assault/Violence Precautions INTERVENTIONS for a patient with potential for harming others include ...f. Ensure safety of vulnerable patients."

4. Review of a document titled, "[Facility Name's] Facesheet," indicated Patient 3 was a [AGE]-year-old female admitted [DATE], for diagnoses of Major depressive disorder, recurrent, severe
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure patients were provided care in a safe setting, for 7 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8) when:

1. Two patients (Patients 4 and 7) were inappropriately touched by Licensed Staff K;
2. Two adolescent patients (Patients 5 and 6) engaged in inappropriate behavior with each other;
3. One adult patient (Patient 2) was slapped by another adult patient (Patient 1); and,
4. Two adolescent patients (Patients 3 and 8) engaged in inappropriate behavior with each other.

These failures violated the patients' right to freedom from abuse.

Findings:

1. During an interview with Director C, on 2/18/20, at 3 p.m., she stated everyone who worked at this facility was a Mandated Reporter (a person who is legally required to report any suspicion of child abuse or neglect to the relevant authorities. These laws are in place to prevent children from being abused and to end any possible abuse or neglect at the earliest possible stage). She stated her expectations for staff was to follow facility Policy and Procedure for abuse and mandated reporting, notify the Chief Nursing Officer (CNO), Nurse Manager, Administrator On-Call (AOC), and initiate an incident report, if advised, before the end of the shift. Director C stated there was an incident where mandated reporting did not occur, according to P&P. She stated the facility became aware an incident of abuse occurred when an adolescent patient (Patient 4) was readmitted to the facility on [DATE], and requested to not receive care from Licensed Staff K.

During an interview with Director F on 2/18/20 at 4:20 p.m., she stated she was informed, during Patient 4's readmission on 2/5/20, Patient 4 reported to staff, during a previous hospitalization in November 2019, Licensed Staff K touched her inappropriately. Director F stated she was unaware if, at that time, an incident report was completed. She stated staff did not follow facility P&P for mandated reporting, when the facility AOC was not immediately notified. Director F stated the previous Chief Nursing Officer was informed of Patient 4's complaint, did not inform the AOC, and did not investigate the abuse claim.

During an interview with Licensed Staff J, on 2/19/20 at 9:50 a.m., he stated he was aware of an abuse accusation by a patient. He stated, during readmission, Patient 4 told Licensed Staff L she (Patient 4), did not want to be taken care of by Licensed Staff K. Licensed Staff L stated Patient 4 told her (Licensed Staff L), the last time Patient 4 was hospitalized at the facility, Licensed Staff K placed Patient 4's hand on his genitals. Licensed Staff J stated, when Licensed Staff L notified him, he (Licensed Staff J), called the AOC and was advised to get statements from Patient 4, Licensed Staff K and J and complete an incident report. He called the physician and parents to notify them. He stated he did not interview Patient 4, did not interview the alleged perpetrator, Licensed Staff K or any of the witnesses. Licensed Staff J stated adolescent patients made accusations of sexual abuse all the time.

Licensed Staff J stated he was not advised by the AOC to place Licensed Nurse K on Administrative Leave. He stated everyone was finishing the night shift, completed the witness statements and left. He stated he turned the paperwork to Director O's mailbox and went home. He stated he did not remember if Licensed Staff K was placed on Administrative Leave or not, but if Licensed Staff K was back at work, it must have been investigated, and it was appropriate for him to return. Licensed Staff J stated Licensed Staff K was odd and was not aware why he was removed from the adolescent unit schedule and assigned to work the night shift in the adult unit.

During an interview on 2/19/20, at 3:45 p.m., Director F stated the facility had investigated the abuse of two patients (Patient 4 and Patient 7) by Licensed Staff K. She stated in November 2019, Patient 4 made an abuse allegation against Licensed Staff K, and the Chief Nursing Officer (CNO), not the AOC, was informed, but did not do anything about the allegation, and as a result, the facility was unaware of the allegation. Licensed Staff K was not placed on Administrative Leave and returned to work assigned night shifts until 2/5/20.

On 1/26/20, Director F stated Patient 7's parents, informed the facility, that during a home visit, Patient 7 told them a facility staff member placed her hands on his genitals. Director F stated staff followed the facility P&P for Abuse Prevention; the AOC was informed, Licensed Staff K was placed on Administrative Leave during the investigation, and an investigation was initiated. She stated CPS, police, physician and California Department of Public Health (CDPH) were notified.

Director F stated Patient 4 was readmitted to the facility 2/5/20, and made the claim Licensed Staff K placed her hand on his genitals the last time she was in the facility and did not want him to be assigned to her care. Director F stated staff followed the facility P&P for Abuse Prevention, the AOC was informed, and an investigation was initiated. She stated Licensed Staff K was on Administrative Leave from the previous event and was not interviewed. The facility terminated Licensed Staff K. CPS, police, physician and California Department of Public Health (CDPH) were notified. Director F stated the previous CNO admitted she dropped the ball for reporting the event to administration. The previous CNO admitted , in an interview, she believed Licensed Staff K's statement of having a witness, exonerated him. Director F stated Licensed Staff J told her he assumed the investigation was all taken care of.

During an interview with Director O on 2/20/20, at 4 p.m., she stated she interviewed Licensed Staff K regarding the 11/16/19, allegation of abuse by Patient 4, and he stated Patient 4 did not want to go home and was trying to sabotage her discharge from the facility. Director O stated patients make up stuff so they can stay in the facility longer. She stated Licensed Staff K stated there was a witness, but she did not interview any witnesses. She stated she interviewed Patient 4's mother, who stated Patient 4 was manipulative and lied all the time. She stated most of the adolescent patients made untrue accusations all the time. Director O stated, when the second accusation against Licensed Staff K occurred, she believed it was true based on the two allegations and review of the video surveillance.

During an interview with Licensed Staff S, on 2/25/20, he stated, in the past, if they became aware of any kind of abuse which occurred, or was alleged, if it involved an adolescent, they notified Children Protective Services (CPS), police and the facility administration. He stated the process had recently changed, when nothing was investigated after an allegation of staff-to-patient abuse. Licensed Staff S stated, prior to the recent incident, staff had the ability to contact the authorities and begin the Abuse Prevention P&P process independently, but when the last accusation was not investigated, the process changed to include first contact the AOC and then follow Abuse Prevention P&P.

During an interview and record review, on 2/25/20, at 3:05 p.m., a document titled, "[Facility Name's Facesheet]," indicated Patient 4 was a [AGE]-year-old female admitted [DATE], for diagnoses including, "Major depressive disorder, Suicidal ideations and Post-traumatic stress disorder." A document titled, "INCIDENT REPORT ...Date of Incident: 11/16/19 Time of Incident 0700 am Location unit [#] (Locked Adolescent Unit), ...Other: (describe) Patient made allegation against me. Description of Incident (Summarize what happened): Patient's vital signs were taken by this writer. The machine was not functioning properly, so this writer had to retake the vitals. Patient's door was wide open. MHW (Mental Health Worker) were in the hallway right next to pt's room and looking into pt's room throughout the time. This writer was talking with patient all throughout, MHW heard us talking. ...Completed By ... (Licensed Staff K). Date: 11/16/19 Time: 0807."

Director F stated the alleged perpetrator completed the Incident Report on the date of the allegation, on 11/16/19. She stated it was not a good idea to have the perpetrator complete the Incident Report against himself. She stated a stamp indicated, "Received [DATE]," indicating the Incident Report was received by the Quality Department. She stated the stamp indicated the prior CNO completed the paperwork and turned it into the facility. She stated, the reason it was never investigated by the facility, was the paperwork was filed by someone in her office before she had a chance to review it. She stated, as a result, Licensed Staff K continued to work assigned night shifts for eleven weeks and four days, until Patient 4 was readmitted on [DATE], and the second allegation of staff-to-patient abuse was made. Licensed Staff K was placed on Administrative Leave during the investigation. Director F stated, as part of the facility investigation, she reviewed video surveillance of Patient 7's hallway, outside her door, and observed Licensed Staff K entering Patient 7's room alone, without another staff member, much more often than was required by his night shift duties and spent long periods of time which could not be accounted for. She stated, the result of the dual investigations into Patient 4's and Patient 7's allegations of abuse was substantiated by the facility. She stated the alleged molestation of Patients 4 and 7 appeared to have happened.

During an interview on 2/25/20, at 8 a.m., Director F stated, when Incident Reports were completed on the night shift and on weekends, they were not immediately reviewed by a manager. She stated the paper-based Incident Reporting System was a challenge. For example, in the case of the last incident, the CNO just did not turn it in.

During an interview on 2/26/20 at 10:30 a.m., Patient 4's Aunt confirmed Patient 4 reported the events of abuse, on 11/16/19, prior to her discharge from the facility. Patient 4's Aunt stated, during the drive home on 11/16/19, Patient 4 started telling her the details of the event when Licensed Staff K took her vital signs in the morning prior to her discharge. Patient 4's Aunt stated Patient 4 told her Licensed Staff K put her hand on his genitals. Patient 4 felt uncomfortable and pulled her hand away. Licensed Staff K grabbed Patient 4's hand and put it back on his genitals stating it was ok and proceeded to take her vital signs.

A review of a document titled, "[Facility Name's] Facesheet," indicated Patient 4 was a [AGE]-year-old female readmitted [DATE], for diagnoses including, "Major depressive disorder, Personal History of self-harm and Personal history of physical and sexual abuse in childhood." A document titled, "PROGRESS NOTES," dated 2/5/20 at 8:35 a.m., indicated, "Report Note-Upon intake assessment by this nurse on unit [#] exam room, pt. said, 'Does (Licensed Staff K) still work here?' This nurse said, 'No.' Pt. appeared very emotional when asked what happened.....Pt. said, 'Last time I was here, Licensed Staff K came into my room and forced my hand onto his genitals.' ...Patient 4's mother said, 'Yeah, she told me about it when I packed her up last time. I told her she did the right thing by telling the nurse.' Pt. reported she told the daytime nurse lady. Incident occurred at approximately 6 a.m. on 11/16/19."

A review of Licensed Staff K's employee filed indicated a document titled, "Sexual Harassment Quiz," dated 8/26/19, was completed by Licensed Nurse K, but not scored. A document titled, "Abuse Reporting and Tarasoff Quiz," dated 8/27/19, was completed by Licensed Nurse K, but not scored. A document titled, "Therapeutic Boundaries Test," dated 11/13/19, indicated Licensed Nurse K wrote an example of a boundary violation: "Kissing a patient." The test was not scored by the facility.

2. Review of Patient 5's medical record document titled, "[Facility Name's] Face sheet," indicated he was a [AGE]-year-old male, admitted [DATE], for diagnoses including, "Major depressive disorder, Attention-deficit hyperactivity disorder. A medical record document titled, "PROGRESS NOTES," dated 5/21/19, at 11:30 a.m., indicated, "Patient discharged ...Time of discharge 11:17 a.m."

Review of Patient 5's medical record document titled, "PROGRESS NOTES," dated 5/21/19, at 4:20 p.m., indicated, "Nursing note - It has come to this nurses attention that at some point, early in the pt. stay, the pt. roommate (Patient 6) might have performed oral sex on the pt. (Patient 5). The roommate was overheard bragging about it to other patients. ...CNO and psychiatrist were notified. CNO called AOC and CEO. Parents of both children were notified. Pt. father was spoken to. A CPS report was filed."

During a record review and interview on 2/19/20, at 10:55 a.m., of Patient 5's medical record, a document titled, "Suspected Children's Abuse Report," dated 5/21/19, indicated, "Date/Time of Incident 5/18/19, Place of Incident Room at hospital, Narrative Description Pt (Patient 5) was rooming with a 12 y/o male. On 4/21/19 the staff became aware of a rummer(rumor) involving the two boys. The 12 y/o had performed oral sex on the 14-year-old." Nursing Consultant F stated after Patient 5 was discharged on [DATE], the facility became aware Patient 5 was alleged to be the victim of sexual molestation by Patient 6.

Nursing Consultant F and Director C stated, after Patient 5 was discharged , a Licensed Nurse overheard Patient 6 bragging about having performed oral sex on Patient 5. They stated Licensed Staff followed the P&P for Mandatory Reporting, informed the AOC, completed an Incident Report, and notified the parents and the Physician. Director C stated the facility had a system to prevent abuse by having a Hall Monitor position and every 15-minute monitoring of patients.

During an interview on 2/21/20 at 9:55 a.m., Administrator B stated Patient 6 was assigned to Room [#] on his admission on 5/17/19 at 12:15 p.m. Administrator B stated Patient 5 was assigned to Room [#], with Patient 6 as a roommate, on 5/17/19 at 7:50 p.m., upon admission, until his discharge on 5/21/19. He stated Patient 6 was reassigned to a no roommate Room [#], on 5/19/19.

During an interview with Administrator A, Administrator B and Nursing Consultant F, and record review on 2/21/20 at 8 a.m., the facility document titled, "Root Cause Template," dated 1/26/20, indicated for the 5/18/19, incident investigation, Patient 6 was interviewed about the incident. The documentation indicated Patient 6 denied the incident occurred. Patient 5's father was notified about the alleged incident, via a telephone interview with a social worker, after Patient 5's discharge. Patient 5's father asked Patient 5 if he engaged in a sex act with Patient 6 and confirmed it happened.

During a review of a document title, "Root Cause Analysis," indicated observation documentation every 15-minute monitoring was predictable and allowed the boys to plan the incident.

The Root Cause Analysis indicated Patient 6's mother did not disclose he had a history of sexually abusing his younger brother, and the information from the referral center about aggressive and sexual behavior was not communicated.

The Root Cause Analysis indicated factors contributing to the incident included: "Staff did not use critical thinking in the process of supervising safety of adolescents. ...Staff did not anticipate adolescent boys ages 12 and [AGE] years old would engage in sexual acting out behavior. ...Staff performance did not meet expectations. ...Leadership unaware that patients were able to predict patient safety rounding every 15 minutes and plan unsupervised activity."

During an interview on 2/25/20 at 7:15 a.m., Licensed Staff S stated nursing assessment for new admits included review of information from the referral/transfer facility as part of the patient assessment. Licensed Staff S stated they did not admit patients with a recent history of assaultive behavior. Licensed Staff S stated, with a push to fill empty beds and increase the census, recent history of assaultive behavior meant the patient was not assaulting someone upon intake to the facility. Licensed Staff S stated, when staffing was low, patients were sometimes directly admitted to the units without having a thorough review of intake paperwork. Things get missed.

During an interview on 2/25/20 at 10:45 a.m., Licensed Staff Z stated the Admission and Referral (A&R) Department was responsible for filling the beds in the facility. Licensed Staff Z stated the facility never turned down an admit. Licensed Staff Z stated patient referrals came in from the phone transfer center, and then they faxed us a referral packet with patient information which included history or psychiatric issues. Staff were expected to review the information. Licensed Staff Z stated patients who were inappropriate to admit, were dementia, autism, and aggression. Licensed Staff Z stated aggressive behavior was defined as being in physical restraints. Licensed Staff Z stated the admit process included checking the acuity on the units and making appropriate room assignments and making recommendation for a 1:1 monitoring.

During an interview with Director C, on 2/26/20 at 2:45 p.m., she stated a patient with a high assaultive risk could go into a room with patients who had a low vulnerability risk score.

During a phone interview with Physician Y on 2/27/20 at 2 p.m., he stated patient safety began in the A&R Department when they reviewed patient information from the transfer center / referral facility. He stated they assessed the information to determine if the patients met the criteria for admission, which included : Risk of aggressive behavior, risk of assault, risk of sexual acting out. He stated Patient 6, who had a Risk Score of 35+ (15+ high risk), had a risk of assault or improper sexual acting out behavior. He stated it was not appropriate for a patient admitted with a high-risk score and history of assaultive behaviors to be roomed with a patient with a vulnerable patient.

Review of Patient 6's medical record document titled, "[Facility Name's] Facesheet," indicated he was a [AGE]-year-old male, admitted [DATE] with diagnoses including, "Bipolar disorder, Attention deficit hyperactivity disorder."

Review of Patient 6's transfer medical record document titled, "[County Name's] Department of Behavioral Health CRISIS ASSESSMENT," dated 5/16/19, indicated, "Referring Persons' Statement of Client's Presenting Problem(s) Mother reports that since incident that occurred in October 2018 involving assault of her (?) siblings by the client, his behaviors have increase in intensity. Mother further reports fear she has regarding impulse control of the client and it possibly leading to attempts on the lives of the siblings or parents. ...Current Risk of Self Harm or Risk of Harm to Others Ideation of Harm to Others, Suspected, Mother reports fear for her and her family's life due to increase in severity in impulse control. ...Recent Assaultive Behaviors, Yes, Assaultive behaviors towards a classmate today led to being expelled today.

Review of Patient 6's medical record document titled, "Intake Assessment," dated 5/17/19, indicated, "SEXUAL ACTING OUT RISK SCREEN," with the following categories checked and scored: 15 points-History of sexual assault, 5 points-Increase in sexual thoughts, 5 points-History of sexual abuse victim, 5 points-indiscriminate sexual activity. "Sexual Risk Score 35 - 15+=High Risk."

Review of a document titled, "PSYCHIATRIC EVALUATION," dated 5/18/19, indicated, "The patient's mother, who provided collateral information reported history of aggressive behavior for a long time, including trying to stab his father with a pencil and punching siblings. ...TREATMENT PLAN: 1. The patient will be placed on general suicide and assault precautions with every 15-minute checks."

Review of Patient 6's medical record document titled, "PHYSICIAN'S ORDERS:"
-Admission Orders, dated 5/17/19 at 7:18 p.m., indicated, "Level of Observation - Every 15 minutes observation, Precautions: Suicide.
-Dated 5/19/19 at 6:12 p.m., indicated, "ADD Sexual Precautions.
-Dated 5/19/19 at 9:45 p.m., indicated, "BLOCK ROOM - NO ROOMMATE. Due to history of sexual inappropriateness."

Review of Patient 6's medical record document titled, "PROGRESS NOTES:"
-Dated 5/19/19, dictated by Physician Y, on 5/20/19 at 1:52 a.m., indicated, "PLAN ...Continue precautions and close monitoring."
-Dated 5/20/19, dictated 5/21/19 at 2:48 a.m., indicated, "The patient's social worker in the unit reported to this examiner that according to the patient's mother, there has been an extensive history of physical and sexual assaults on the part of the patient towards siblings and also towards classmates in the school......When patient was confronted about this history, the patient stated, 'I was physically abusing my younger brother, but I have not been doing that for the past 1 year.'"
-Dated 5/21/19, dictated 5/21/19 at 11:19 p.m., indicated, " ...I was informed by the nursing staff in the unit that there has been a report from other patients that the patient has engaged in sexual activity with another male patient, who was discharged in the morning. ...TREATMENT PLAN: ...started the patient on suicide precautions."

Review of Patient 6's medical record document titled, "Inpatient Interdisciplinary Notes," dated 5/19/19 at 5 p.m., indicated, "Sexual precautions added to precaution list due to report from therapist that mom reported alleged inappropriate sexual behaviors with siblings."

Review of Patient 6's medical record document titled, "Inpatient Interdisciplinary Notes," dated 5/19/19 at 7:08 p.m., written by the Social Worker, indicated, "Pt. had faced 2 suspensions for sexually harassing one fell ow student online on two separate occasions. ...October 2018 when the pt. was [AGE] years old, it was reported to the parents that the pt. had been sexually abusing his two younger brothers. ...This staff made nursing staff aware to add sexual precautions due to ongoing predatory behaviors and impulsivity as reported by parent."

Review of Patient 6's document title, "Patient Observation Record," dated, "Admit @ 1215," indicated, "Precautions - Suicide, Observation Level: 15-minute checks," on 5/18/19, 5/19/19, 5/20/19. On 5/20/19 at 12 p.m., Sexual Precautions were added to the every 15-minute observation record.

3. During an observation of Unit [#] Group Music Therapy, on 2/13/20, at 2:45 p.m., Patient 2 was listening to the music and chose as part of the therapy, the emoji of, "Horrified." He stated it was related to experiences and feelings regarding sex abuse.

During an interview on 2/18/20, at 1:55 p.m., Social Services Staff D stated he observed Patient 2 express feelings during music therapy yesterday related to sexual abuse. He stated he should have informed the nurse about Patient 2's statement and documented it in the medical record. Social Services Staff D stated he was a Mandated Reporter by law and should have reported it. He stated patients do not talk about sexual abuse often, and the comment stood out.

During an interview and record review on 2/18/20, at 2:40 p.m., Manager G stated she recently had training for Mandated Reporter education. She was asked if there were any incidents of abuse she was aware of, and stated there was a recent incident which occurred when a patient accused a staff member of touching her inappropriately. During a review of Patient 2's medical record, she stated, if there were any comments regarding sexual abuse, they should be in the medical record. She stated there was nothing in Patient 2's medical record regarding any kind of abuse and would expect there to be something documented.

During an interview with Director C on 2/18/20, at 3 p.m., she stated every was a Mandated Reporter, and licensed and unlicensed staff were supposed to report it to their managers, who informed her. She stated she followed up and made sure the incident was reported to Quality to investigate: To be sure it was reported. She stated her expectation of staff was for staff to report abuse immediately and complete the paperwork documentation before the end of the shift. She stated the only incident she was aware of recently was abuse related to a licensed staff to two patients. Director C stated, if a patient slapped another patient it may, or may not, be abuse.

During an interview with Director F on 2/18/20, at 4:20 p.m., she stated she was not informed of an incident report for abuse for any patient in the last two weeks.

During a record review and interview on 2/19/20, at 12:45 p.m., Manager G stated she was informed the previous day of a witnessed incident between Patient 1 and Patient 2. She stated around 10 a.m., Patient 1 slapped Patient 2 across the face. She stated an incident report was initiated, Director C was notified, the physician was notified, and the treatment plan was updated for Patient 1 to reflect assault precautions. She provided a document titled, "Progress Notes," dated 2/18/20, at 5:52 p.m., which indicated, "Social Worker met 1:1 with Patient 2 to discuss his comment about molestation in group. ... Social Worker informed [Patient 2] she wanted to check on him after the comment about sexual abuse was brought up in group." She stated there was no documentation regarding Patient 1 slapping Patient 2. She stated the documentation was in Patient 1's medical record.

Director F stated an adult patient slapping another patient did not qualify as abuse and was not reported. Nursing Consultant F stated, when one adult patient slapped another adult patient, the facility was only obligated to report adult patient to adult patient physical abuse, if one patient was either defined as incapacitated or vulnerable, or if a patient needed emergency medical care. Director F stated, for adults, the facility did not have to report the slap unless the patient wanted to press charges. She stated Patient 2 was not vulnerable or incapacitated, and the situation was not reported to police, Adult Protective Services or the California Department Public Health.

During an interview on 2/19/20 at 2:50 p.m., Mental Health Worker (MHW) H stated she was not aware of any incident of abuse except one patient hitting another patient in unit [#]. She stated she came back from her morning break and observed Patient 1 walk up to Patient 2 in the activity room and punch him in the face. She stated Patient 1 was moved to another unit. She stated she observed Patient 2 isolating himself afterwards, in his room, due to his being hit by Patient 1.

During an interview on 2/19/20 at 3:05 p.m., Licensed Staff I stated the only abuse she was aware of occurred the previous week, when she witnessed Patient 1 slap Patient 2. She stated Patient 2 was scared by just looking at the expression on his face. She stated Patient 1 was moved to another unit, the physician was notified, the Incident Report was completed, and Manager G was notified.

During an interview and record review on 2/26/20, at 2 p.m., Director C reviewed a Progress Note dated 2/13/20 at 5 p.m., which indicated Patient 2 was slapped by Patient 1, and the physician and nurse manager were notified. She stated there was no report to CDPH, because severe harm and assaultive behavior was not unusual with their patients, so they did not call. Director F stated there was no serious harm or death, so the incident was not reportable, according to their definition.

During an interview and record review of Patient 1's medical record on 2/26/20 at 3 p.m., Director C, Administrator A and Nursing Consultant F stated the MHW's were expected to document on the Patient Observation Sheet every 15 minutes. They stated the sheet included what risks the staff should be aware of, including assaultive behaviors. Review of Patient 1's documentation indicated a Risks Stratification Score for Assault Risk Score 20 (15+=High Risk) and HIGH-RISK ALERT for DANGER TO OTHERS, upon admission. Nursing Consultant F stated the Patient Observation Sheet for Patient 1 did not indicate Assault Risk and should have indicated Assault Risk. She stated the risk to patients was, if staff were not aware of the risk assaultive behavior, staff might not implement prevention strategies, resulting in staff not being able to stop an assault.

Review of a document for Patient 2, titled, "Facesheet," dated 2/11/20, indicated Patient 2 was a [AGE]-year-old male, admitted with diagnoses of Schizoaffective disorder, bipolar type, post-traumatic stress disorder, Attention-deficit hyperactivity stress disorder, Personal history of physical and sexual abuse in childhood, Personal history of psychological abuse in childhood.

Review of a document titled, "RISK STRATIFICATION," dated 2/11/20, indicated, "VULNERABILITY RISK SCORE 10 (15+=High Risk)

Review of a document for Patient 1, titled, "Facesheet," dated 2/8/20, indicated Patient 1 was a [AGE]-year-old male, admitted for diagnoses of Schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions).

A document titled, "RISK STRATIFICATION," 2/8/20, at 2 a.m., indicated, "DANGER TO OTHERS RISK SCREEN ...ASSAULT RISK SCORE 20 (15+ = High Risk) ... HIGH RISK ALERT (To be completed ... when patient arrives) DANGER TO OTHERS."

During a review of Patient 1's medical record, a document titled, Physicians, "PROGRESS NOTES," dated 2/13/20, indicated, "As per nursing staff, the patient continues to be very paranoid, he ended up assaulting another patient on the unit, the patient was moved to unit [#] after being aggressive towards another patient on the unit....He was asked for his reason behind his aggressive behavior, the patient replied ...'I smacked him.'"

A document titled, "PROGRESS NOTES," dated 2/19/20, at 8:39 a.m., indicated, "Treatment team reviewed pt's treat plan to address physical aggression exhibited by pt. 1 on unit [#]......Pt. ...had slapped pt. 2.

A document titled, "Patient Observation Sheet," dated: 2/8/20, at 12:15 a.m., indicated Patient 1 was being observed for, "Routine - 15 - minute observations ...Vulnerability. 2/13/20 7:30 a.m. - 2/14/20 7:30 a.m. Sexual / Sexual acting out, Vulnerability."

A review of a facility Policy and Procedure titled, " Precautions, Inpatient units Policy Number PC 360.24," revised 8/1/19, indicated, "Assault/Violence Precautions INTERVENTIONS for a patient with potential for harming others include ...f. Ensure safety of vulnerable patients."

4. Review of a document titled, "[Facility Name's] Facesheet," indicated Patient 3 was a [AGE]-year-old female admitted [DATE], for diagnoses of Major depressive disorder, recurrent, severe with psychotic symptoms, Suicidal Ideations, Urinary Tract Infections, Personal history of physical and sexual abuse in childhood, Personal history of psychological abuse in childhood, Personal history of self-harm, Post-traumatic stress disorder."

Review Patient 3's medical record document titled, "PROGRESS NOTES," indicated on 5/24/29, at 11 p.m., "Nursing - Pt told this nurse that she wanted to change rooms. After being asked why she wanted to change rooms, the pt. stated that she had been 'pressured' into having sexual interactions with her roommate. ...Pt stated that her roommate performed oral sex on her; ...Pt. stated that the above events happened in the daytime and nighttime, three days ago. ...House charge notified. The Dr. was notified. Sexual precautions with no roommate were ordered for the pt. and her roommate. The p.m. roommate was transferred to a new unit. 5/25/19 2:20 p.m., ...Pt. feels that she is a victim of sexual assault and staff are trying to say that it was her fault."

Review of a document titled, "[Facility Name's] Facesheet," indicated Patient 8 was a [AGE]-year-old female admitted [DATE], with a diagnosis of Major depressive disorder, recurrent severe without psychotic features. Personal history of physical, psychological, and sexual abuse in childhood.

Review of Patient 8's medical record document titled, " Progress Notes," indicated on 5/24/19, at 12:40 a.m., "Nursing - P
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility did not ensure patients were provided care in a safe setting for seven patients (Patients 1, 2, 3, 4, 5, 6, 7 and 8) when:

1. Two patients (Patient 4 and Patient 7) were inappropriately touched by one nurse;
2. Two adolescent patients (Patient 5 and Patient 6) engaged in oral sex;
3. One adult patient (Patient 2) was slapped by another adult patient (Patient 1); and,
4. Two adolescent patients (Patient 3 and Patient 8 ) sexually acted out with each other.

These failures violated patients' right to freedom from abuse in the care environment.

Findings:

1. During an interview with Director C, on 2/18/20, at 3 p.m., she stated everyone who worked at this facility was a Mandated Reporter (a person who is legally required to report any suspicion of child abuse or neglect to the relevant authorities. These laws are in place to prevent children from being abused and to end any possible abuse or neglect at the earliest possible stage). She stated her expectations for staff was to follow facility Policy and Procedure for abuse and mandated reporting, notify the Chief Nursing Officer (CNO), Nurse Manager, Administrator On-Call (AOC), and initiate an incident report, if advised, before the end of the shift. Director C stated there was an incident where Mandated Reporting did not occur according to P&P. She stated the facility became aware an incident of abuse occurred when an adolescent patient (4), was readmitted on [DATE], and requested to not receive care from Licensed Staff K.

During an interview with Director F, on 2/18/20, at 4:20 p.m., she stated she was informed that, during Patient 4's readmission on 2/5/20, Patient 4 reported to staff that during a previous hospitalization in November 2019, Licensed Staff K touched her inappropriately. Director F stated she was unaware at that time if an incident report was completed. She stated staff did not follow facility P&P for mandated reporting, when the facility AOC was not immediately notified. Director F stated the previous Chief Nursing Officer was informed of Patient 3's complaint, did not inform the AOC, and did not do investigate the abuse claim.

During an interview with Licensed Staff I, she stated she received training on being a Mandated Reporter which included patients have the right to be free from harm and abuse.

During an interview with Licensed Staff J, on 2/19/20 at 9:50 a.m., he stated he was aware of an abuse accusation by a patient. He stated during readmission, Licensed Staff L was told by Patient 4 she did not want to be taken care of by Licensed Staff K. Licensed Staff L stated Patient 4 told her (Licensed Staff L) the last time Patient 4 was hospitalized at the facility, Licensed Staff K placed Patient 4's hand on his genitals. Licensed Staff J stated, when Licensed Staff L notified him, he called the AOC and was advised to get statements from Patient 4, Licensed Staff K and J and complete an incident report. He called the physician and parents to notify them. He stated he did not interview Patient 4, did not interview the alleged perpetrator, (Licensed Staff K), or any of the witnesses. Licensed Staff J stated adolescent patients made accusations of sexual abuse all the time.

Licensed Staff J stated he was not advised by the AOC to place Licensed Staff K on Administrative Leave. He stated everyone was finishing the night shift, he completed the witness statements and left. He stated he turned the paperwork to Director O's mailbox and went home. He stated he did not remember if Licensed Staff K was placed on Administrative Leave or not, but if Licensed Staff K was back at work it must have been investigated, and it was appropriate for him to return. Licensed Staff J stated Licensed Staff K was odd and was not aware why he was removed from the adolescent unit schedule and assigned to work the night shift in the adult unit.

During an interview on 2/19/20, at 3:45 p.m., Director F stated the facility investigated the abuse of two patients (Patient 4 and Patient 7) by Licensed Staff K. She stated, in November 2019, Patient 4 made an abuse allegation against Licensed Staff K, and the Chief Nursing Officer (CNO), not the AOC, was informed, but did not do anything about the allegation, and as a result, the facility was unaware of the allegation. Licensed Staff K was not placed on Administrative Leave and returned to work assigned night shifts, until 2/5/20.

On 1/26/20, Director F stated Patient 7's parents informed the facility, during a home visit, Patient 7 told them a facility staff member placed her hands on his genitals. Director F stated staff followed the facility P&P for Abuse Prevention; the AOC was informed, Licensed Staff K was placed on Administrative Leave during the investigation, and an investigation was initiated. She stated CPS, police, the physician and California Department of Public Health (CDPH) were notified.

During an interview on 2/26/20, at 3:15 p.m., Licensed Staff CC stated Patient 7 went home for weekend. When she returned, Patient 7's father called the facility and reported the incident to Licensed Staff CC. The father stated Patient 7 told the parents Licensed Staff K put her hand on his genitals when taking vital signs. When interviewing Licensed Staff CC, she stated Licensed Staff K worked nights and would report off to her in the morning. Licensed staff CC stated she never witnessed anything, but noticed Licensed Staff K was very close and friendly with the kids. Licensed Staff CC felt there was not enough staff coverage on shifts to cover Mental Health Workers (MHW) for breaks. She reported the incident to Administration right away.

Director F stated Patient 4 was readmitted to the facility 2/5/20, and made the claim Licensed Staff K placed her hand on his genitals the last time she was in the hospital and did not want him to be assigned to her care. Director F stated staff followed the facility P&P for Abuse Prevention, the AOC was informed, and an investigation was initiated. She stated Licensed Staff K was on Administrative Leave from the previous event and was not interviewed. The facility terminated Licensed Staff K. CPS, police, the
physician and California Department of Public Health (CDPH) were notified. Director F stated the previous CNO admitted she dropped the ball reporting the event to Administration. The previous CNO admitted , in an interview, she believed Licensed Staff K's statement having a witness exonerated him. Director F stated Licensed Staff J told her he assumed the investigation was all taken care of.

During an interview with Director O on 2/20/20, at 4 p.m., she stated she interviewed Licensed Staff K regarding the 11/16/19, allegation of abuse by Patient 4, and he stated Patient 4 did not want to go home and was trying to sabotage her discharge from the facility. Director O stated patients made up stuff so they could stay in the facility longer. She stated Licensed Nurse K stated there was a witness, but she did not interview any witnesses. She stated she interviewed Patient 4's mother, who stated Patient 4 was manipulative and lied all the time. She stated most of the adolescent patients made untrue accusations all the time. Director O stated, when the second accusation against Licensed Staff K occurred, she believed it was true based on the two allegations and review of the video surveillance.

During an interview with Licensed Staff S, on 2/25/20, he stated, in the past, if they became aware of any kind of abuse which occurred, or was alleged, if it involved an adolescent, they notified Children Protective Services (CPS), police and the facility Administration. He stated the process recently changed, when nothing was investigated after an allegation of staff-to-patient abuse. Licensed Staff S stated, prior to the recent incident, staff had the ability to contact the authorities and begin the Abuse Prevention P&P process independently, but when the last accusation was not investigated, the process changed to include first contact the AOC and then follow the Abuse Prevention P&P.

During an interview and record review, on 2/25/20, at 3:05 p.m., a document titled, "[Facility Name's] Face sheet," indicated Patient 4 was a [AGE]-year-old female admitted [DATE], for diagnoses including, "Major depressive disorder, Suicidal ideation's and Post-traumatic stress disorder." A document titled, "INCIDENT REPORT ...Date of Incident: 11/16/19 Time of Incident 0700 am Location unit 400 (Locked Adolescent Unit), ...Other: (describe) Patient made allegation against me. Description of Incident (Summarize what happened): Patient's vital signs were taken by this writer. The machine was not functioning properly, so this writer had to retake the vitals. Patient's door was wide open. MHW (Mental Health Worker) were in the hallway right next to pt's room and looking into pt's room throughout the time. This writer was talking with patient all throughout, MHW heard us talking. ...Completed By ... (Licensed Staff K). Date: 11/16/19 Time: 0807."

Director F stated the alleged perpetrator completed the Incident Report on the date of the allegation on 11/16/19. She stated it was not a good idea to have the perpetrator complete the Incident Report against himself. She stated a stamp indicated, "Received [DATE]," indicated the Incident Report was received by the Quality Department. She stated the stamp indicated the prior CNO completed the paperwork and turned it into the facility. She stated the reason it was never investigated by the facility was the paperwork was filed by someone in her office before she had a chance to review it. She stated, as a result, Licensed Staff K continued to work assigned night shifts for eleven weeks and four days, until Patient 4 was readmitted on [DATE], and the second allegation of staff-to-patient abuse was made. Licensed Staff K was placed on Administrative Leave during the investigation. Director F stated, as part of the facility investigation, she reviewed video surveillance of Patient 7's hallway, outside her door, and observed Licensed Staff K enter Patient 7's room alone, without another staff member, much more often than was required by his night shift duties and spent long periods of time which could not be accounted for. She stated the result of the dual investigation into Patient 4's and Patient 7's allegations of abuse was substantiated by the facility. She stated the alleged molestation of Patients 4 and 7 appeared to have happened.

During an interview on 2/25/20, at 8 a.m., Director F stated, when Incident Reports were completed on the night shift and on weekends, they were not immediately reviewed by a manager. She stated the paper-based Incident Reporting System was a challenge. For example, in the case of the last incident, the CNO just did not turn it in.

A review of a document titled, "[Facility Name's] Facesheet," indicated Patient 4 was a [AGE]-year-old female readmitted [DATE], for diagnoses including, "Major depressive disorder, Personal History of self-harm and Personal history of physical and sexual abuse in childhood." A document titled, "PROGRESS NOTES," dated 2/5/20 at 8:35 a.m., indicated, "Report Note-Upon intake assessment by this nurse on unit [#] exam room, pt. said, 'Does (Licensed Staff K) still work here?' This nurse said, 'No.' Pt. appeared very emotional when asked what happened....Pt. said, 'Last time I was here, [Licensed Staff K] came into my room and forced my hand onto his genitals.' ...Patient 4's mother said, 'Yeah, she told me about it when I packed her up last time. I told her she did the right thing by telling the nurse.' Pt. reported that she told the daytime nurse lady. Incident occurred at approximately 6 a.m. on 11/16/19."

A review of Licensed Staff K's employee filed indicated a document titled, "Sexual Harassment Quiz," dated 8/26/19, was completed by Licensed Staff K, but was not scored. A document titled, "Abuse Reporting and Tarasoff Quiz," dated 8/27/19, was completed by Licensed Staff K, but was not scored. A document titled, "Therapeutic Boundaries Test," dated 11/13/19, indicated Licensed Staff K wrote an example of a boundary violation: "Kissing a patient." The test was not scored by the facility.

2. Review of Patient 5's medical record document titled, "[Facility's Name] Facesheet," indicated he was a [AGE]-year-old male, admitted [DATE], for diagnoses including, "Major depressive disorder, Attention-deficit hyperactivity disorder." A medical record document titled, "PROGRESS NOTES," dated 5/21/19, at 11:30 a.m., indicated, "Patient discharged ...Time of discharge 11:17 a.m."

Review of Patient 5's medical record document titled, "PROGRESS NOTES," dated 5/21/19, at 4:20 p.m., indicated, "Nursing note - It has come to this nurses attention that at some point, early in the pt. stay, the pt. roommate (Patient 6) might have performed oral sex on the pt. (Patient 5). The roommate was overheard bragging about it to other patients. ...CNO and psychiatrist were notified. CNO called AOC and CEO. Parents of both children were notified. Pt. father was spoken to. A CPS report was filed."

During a record review and interview on 2/19/20, at 10:55 a.m., Patient 5's medical record, a document titled, "Suspected Children's Abuse Report," dated 5/21/19, indicated, "Date/Time of Incident 5/18/19, Place of Incident Room at hospital, Narrative Description Pt (Patient 5) was rooming with a 12 y/o male. On 4/21/19, the staff became aware of a rummer(rumor) involving the two boys. The 12 y/o had performed oral sex on the 14-year old." Nursing Consultant F stated, after Patient 5 was discharged on [DATE], the facility became aware Patient 5 was alleged to be the victim of sexual molestation by Patient 6.

Nursing Consultant F and Director C stated, after Patient 5 was discharged , a Licensed Nurse overheard Patient 6 bragging about having performed oral sex on Patient 5. They stated Licensed Staff followed the P&P for Mandatory Reporting, informed the AOC, completed an Incident Report and notified the parents and the Physician. Director C stated the facility had a system to prevent abuse, by having a Hall Monitor position and every 15-minute monitoring of patients.

During an interview on 2/21/20 at 9:55 a.m., Administrator B stated Patient 6 was assigned to Room [#] on his admission on 5/17/19 at 12:15 p.m. Administrator B stated Patient 5 was assigned to Room [#], with Patient 6 as a roommate, on 5/17/19 at 7:50 p.m., upon admission, until his discharge on 5/21/19. He stated Patient 6 was reassigned to a no-roommate Room [#], on 5/19/19.

During an interview with Administrator A, Administrator B and Nursing Consultant F, and record review on 2/21/20 at 8 a.m., the facility document titled, "Root Cause Template," dated 1/26/20, indicated for the 5/18/19, incident investigation, Patient 6 was interviewed about the incident. The documentation indicated Patient 6 denied the incident occurred. Patient 5's father was notified about the alleged incident, via a telephone interview with a Social Worker, after Patient 5's discharge. Patient 5's father asked Patient 5 if he had engaged in a sex act with Patient 6 and confirmed it happened.

The Root Cause Analysis documentation indicated every 15-minute monitoring was predictable and allowed the boys to plan the incident.

The Root Cause Analysis indicated Patient 6's mother did not disclose he [Patient 6] had a history of sexually abusing his younger brother, and the information from the referral center about aggressive and sexual behavior was not communicated.

The Root Cause Analysis indicated factors contributing to the incident included: "Staff did not use critical thinking in the process of supervising safety of adolescents. ...Staff did not anticipate adolescent boys ages 12 and [AGE] years old would engage in sexual acting out behavior. ...Staff performance did not meet expectations. ...Leadership unaware that patients were able to predict patient safety rounding every 15 minutes and plan unsupervised activity."

During an interview on 2/25/20 at 7:15 a.m., Licensed Staff S stated nursing assessment for new admits included review of information from the referral/transfer facility as part of the patient assessment. Licensed Staff S stated they did not admit patients with a recent history of assaultive behavior. Licensed Staff S stated, with a push to fill empty beds and increase facility census, recent history of assaultive behavior meant the patient was not assaulting someone upon intake to this facility. Licensed Staff S stated, when staffing was low, patients were sometimes directly admitted to the units without having a thorough review of intake paperwork. Things got missed.

During an interview on 2/25/20 at 10:45 a.m., Licensed Staff Z stated the Admission and Referral (A&R) Department was responsible for filling the beds in the facility. Licensed Staff Z stated the facility never turned down an admit. Licensed Staff Z stated patient referrals came in from the phone transfer center, and then they faxed a referral packet with patient information which included history or psychiatric issues. Staff were expected to review the information. Licensed Staff Z stated patients who were inappropriate to admit were dementia, autism, and aggression. Licensed Staff Z stated aggressive behavior was defined as being in physical restraints. Licensed Staff Z stated the admit process included checking the acuity on the units and making appropriate room assignments and making recommendation for a 1:1 monitoring.

During an interview with Director C, on 2/26/20 at 2:45 p.m., she stated a patient with a high assaultive risk could go into a room with patients who had a low vulnerability risk score.

During a phone interview with Physician Y on 2/27/20 at 2 p.m., he stated patient safety began in the A&R Department when they reviewed patient information from the transfer center / referral facility. He stated they assessed the information to determine if the patients met the criteria for admission, which included: Risk of aggressive behavior, risk of assault, risk of sexual acting out. He stated Patient 6, who had a Risk Score of 35+ (15+ high risk), had a risk of assault or improper sexual acting out behavior. He stated it was not appropriate for a patient admitted with a high-risk score and history of assaultive behaviors to be roomed with a vulnerable patient.

Review of Patient 6's medical record document titled, "[Facility's Name] Facesheet," indicated he was a [AGE]-year-old male, admitted [DATE] with diagnoses including, "Bipolar disorder, Attention deficit hyperactivity disorder."

Review of Patient 6's transfer medical record document titled, "[County Name] County Department of Behavioral Health CRISIS ASSESSMENT," dated 5/16/19, indicated, "Referring Persons' Statement of Client's Presenting Problem(s) Mother reports that since incident that occurred in October 2018 involving assault of her (?) siblings by the client, his behaviors have increase in intensity. Mother further reports fear she has regarding impulse control of the client and it possibly leading to attempts on the lives of the siblings or parents. ...Current Risk of Self Harm or Risk of Harm to Others Ideation of Harm to Others, Suspected, Mother reports fear for her and her family's life due to increase in severity in impulse control. ...Recent Assaultive Behaviors, Yes, Assaultive behaviors towards a classmate today led to being expelled today."

Review of Patient 6's medical record document titled, "Intake Assessment," dated 5/17/19, indicated, "SEXUAL ACTING OUT RISK SCREEN," with the following categories checked and scored: 15 points-History of sexual assault, 5 points-Increase in sexual thoughts, 5 points-History of sexual abuse victim, 5 points-indiscriminate sexual activity. "Sexual Risk Score 35 - 15+=High Risk."

Review of a document titled, "PSYCHIATRIC EVALUATION," dated 5/18/19, indicated, "The patient's mother, who provided collateral information reported history of aggressive behavior for a long time, including trying to stab his father with a pencil and punching siblings. ...TREATMENT PLAN: 1. The patient will be placed on general suicide and assault precautions with every 15-minute checks."

Review of Patient 6's medical record document titled, "PHYSICIAN'S ORDERS:"
-Admission Orders, dated 5/17/19 at 7:18 p.m., indicated, "Level of Observation - Every 15 minutes observation, Precautions: Suicide.
-Dated 5/19/19 at 6:12 p.m., indicated, "ADD Sexual Precautions."
-Dated 5/19/19 at 9:45 p.m. indicated, "BLOCK ROOM - NO ROOMMATE. Due to history of sexual inappropriateness."

Review of Patient 6's medical record document titled, "PROGRESS NOTES:"
-Dated 5/19/19, dictated by Physician Y, on 5/20/19 at 1:52 a.m. indicated, "PLAN ...Continue precautions and close monitoring."
-Dated 5/20/19, dictated 5/21/19 at 2:48 a.m., indicated, "The patient's social worker in the unit reported to this examiner that according to the patient's mother, there has been an extensive history of physical and sexual assaults on the part of the patient towards siblings and also towards classmates in the school. ...When patient was confronted about this history, the patient stated, 'I was physically abusing my younger brother, but I have not been doing that for the past 1 year."
-Dated 5/21/19, dictated 5/21/19 at 11:19 p.m., indicated, " ...I was informed by the nursing staff in the unit that there has been a report from other patients that the patient has engaged in sexual activity with another male patient, who was discharged in the morning. ...TREATMENT PLAN: ...started the patient on suicide precautions."

Review of Patient 6's medical record document titled, "Inpatient Interdisciplinary Notes," dated 5/19/19 at 5 p.m., indicated, "Sexual precautions added to precaution list due to report from therapist that mom reported alleged inappropriate sexual behaviors with siblings."

Review of Patient 6's medical record document titled, "Inpatient Interdisciplinary Notes," dated 5/19/19 at 7:08 p.m., written by the Social Worker, indicated, "Pt. had faced 2 suspensions for sexually harassing one fell ow student online on two separate occasions. ...October 2018 when the pt. was [AGE] years old, it was reported to the parents that the pt. had been sexually abusing his two younger brothers. ...This staff made nursing staff aware to add sexual precautions due to ongoing predatory behaviors and impulsivity as reported by parent."

Review of Patient 6's document title, "Patient Observation Record," dated, "Admit @ 1215," indicated, "Precautions - Suicide, Observation Level: 15-minute checks," on 5/18/19, 5/19/19, 5/20/19. On 5/20/19 at 12 p.m., Sexual Precautions were added to the every 15-minute observation record.

3. During an observation of Unit [#] Group Music Therapy, on 2/13/20, at 2:45 p.m., Patient 2 was listening to the music and chose as part of the therapy, the emoji of, "Horrified." He stated it was related to experiences and feelings regarding sex abuse.

During an interview on 2/18/20, at 1:55 p.m., Social Services Staff D stated he observed Patient 2 express feelings during music therapy yesterday related to sexual abuse. He stated he should have informed the nurse about Patient 2's statement and documented it in the medical record. Social Services Staff D stated he was a Mandated Reporter by law and should have reported it. He stated patients do not talk about sexual abuse often, and the comment stood out.

During an interview and record review on 2/18/20, at 2:40 p.m., Manager G stated she recently had training for Mandated Reporter education. She was asked if there were any incidents of abuse she was aware of, and stated there was a recent incident which occurred when a patient accused a staff member touching her inappropriately. During a review of Patient 2's medical record she stated, if there were any comments regarding sexual abuse, they should be in the medical record. She stated there was nothing in Patient 2's medical record regarding any kind of abuse and would expect there to be something documented.

During an interview with Director C on 2/18/20, at 3 p.m., she stated everyone was a Mandated Reporter, and licensed and unlicensed staff were supposed to report it to their managers, who informed her. She stated she followed-up and made sure the incident was reported to Quality to investigate; to be sure it was reported. She stated her expectation of staff was for staff to report abuse immediately and complete the paperwork documentation before the end of the shift. She stated the only incident she was aware of recently was abuse related to a licensed staff to two patients. Director C stated, if a patient slapped another patient it may, or may not be, abuse.

During an interview with Director F on 2/18/20, at 4:20 p.m., she stated she was not informed of an incident report for abuse for any patient in the last two weeks.

During a record review and interview on 2/19/20, at 12:45 p.m., Manager G stated she was informed yesterday of a witnessed incident between Patient 1 and Patient 2. She stated, around 10 a.m., Patient 1 slapped Patient 2 across the face. She stated an Incident Report was initiated, Director C was notified, the physician was notified, and the treated plan was updated for Patient 1, to reflect assault precautions. She provided a document titled, "Progress Notes," dated 2/18/20, at 5:52 p.m., which indicated, "Social Worker met 1:1 with Patient 2 to discuss his comment about molestation in group. ... Social Worker informed [Patient 2] that she wanted to check on him after the comment about sexual abuse was brought up in group." She stated there was no documentation regarding Patient 1 slapping Patient 2. She stated the documentation was in Patient 1's medical record.

Director F stated, an adult patient slapping another patient did not qualify as abuse and was not reported. Nursing Consultant F stated, when one adult patient slapped another adult patient, the facility was only obligated to report adult-patient to
adult-patient physical abuse if one patient was either defined as incapacitated or vulnerable, or if a patient needed emergency medical care. Director F stated, for adults, the facility did not have to report the slap unless the patient wanted to press charges. She stated Patient 2 was not vulnerable or incapacitated, and the situation was not reported to police, Adult Protective Services or the California Department Public Health.

During an interview on 2/19/20 at 2:50 p.m., Mental Health Worker (MHW) H stated she was not aware of any incident of abuse except one patient hitting another patient in Unit [#]. She stated she came back from her morning break and observed Patient 1 walk up to Patient 2 in the activity room and punch him in the face. She stated Patient 1 was moved to another unit. She stated she observed Patient 2 isolating himself afterwards, in his room, due to being hit by Patient 1.

During an interview on 2/19/20 at 3:05 p.m., Licensed Staff I stated, the only abuse she was aware of occurred last week when she witnessed Patient 1 slap Patient 2. She stated Patient 2 was scared by just looking at the expression on his face. She stated Patient 1 was moved to another unit, the physician was notified, the Incident
Report was completed, and Manager G was notified.

During an interview and record review on 2/26/20, at 2 p.m., Director C reviewed a Progress Note dated 2/13/20 at 5 p.m., which indicated Patient 2 was slapped by Patient 1, and the physician and nurse manager were notified. She stated there was no report to CDPH, because severe harm and assaultive behavior was not unusual with their patients, so they did not call. Director F stated there was no serious harm or death, so the incident was not reportable according to their definition.

During an interview and record review of Patient 1's medical record on 2/26/20 at 3 p.m., Director C, Administrator A and Nursing Consultant F stated the MHW's were expected to document on the Patient Observation Sheet every 15 minutes. They stated the sheet included what risks the staff should be aware of including assaultive behaviors. Review of Patient 1's documentation indicated a Risks Stratification Score for Assault Risk Score 20 (15+=High Risk), and HIGH-RISK ALERT for DANGER TO OTHERS upon admission. Nursing Consultant F stated the Patient Observation Sheet for Patient 1 did not indicate Assault Risk and should have indicated Assault Risk. She stated the risk to patients was if staff were not aware of the risk assaultive behavior, staff might not implement prevention strategies, which might result in the staff not being able to stop an assault.

Review of a document for Patient 2, titled, "Facesheet," dated 2/11/20, indicated Patient 2 was a [AGE]-year-old male, admitted with diagnoses of Schizoaffective disorder, bipolar type, post-traumatic stress disorder, Attention-deficit hyperactivity stress disorder, Personal history of physical and sexual abuse in childhood, Personal history of psychological abuse in childhood."

Review of a document titled, "RISK STRATIFICATION," dated 2/11/20, indicated "VULNERABILITY RISK SCORE 10 (15+=High Risk)."

Review of a document for Patient 1, titled, "Facesheet," dated 2/8/20, indicated Patient 1 was a [AGE]-year-old male, admitted for diagnoses of Schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions).

A document titled, "RISK STRATIFICATION," 2/8/20, at 2 a.m., indicated, "DANGER TO OTHERS RISK SCREEN ...ASSAULT RISK SCORE 20 (15+ = High Risk) ... HIGH RISK ALERT (To be completed ... when patient arrives) DANGER TO OTHERS."

During a review of Patient 1's medical record, a document titled Physician's, "PROGRESS NOTES," dated 2/13/20, indicated, "As per nursing staff, the patient continues to be very paranoid, he ended up assaulting another patient on the unit, the patient was moved to unit [#] after being aggressive towards another patient on the unit...He was asked for his reason behind his aggressive behavior, the patient replied ...I smacked him."

A document titled, "PROGRESS NOTES," dated 2/19/20, at 8:39 a.m., indicated, "Treatment team reviewed pt's treat plan to address physical aggression exhibited by pt. 1 on unit [#]. ...Pt. ...had slapped pt. 2."

A document titled, "Patient Observation Sheet," dated: 2/8/20, at 12:15 a.m., indicated Patient 1 was being observed for, "Routine - 15 - minute observations ...Vulnerability. 2/13/20 7:30 a.m.. - 2/14/20 7:30 a.m. Sexual / Sexual acting out, Vulnerability."

A review of a facility Policy and Procedure titled, "Precautions, Inpatient units Policy Number PC 360.24," revised 8/1/19, indicated, "Assault/Violence Precautions INTERVENTIONS for a patient with potential for harming others include ...f. Ensure safety of vulnerable patients."

4. Review of a document titled, "[Facility's Name] Facesheet," indicated Patient 3 was a [AGE]-year-old female admitted [DATE], for diagnoses of Major depressive disorder, recurrent, severe with psychotic symptoms, Suicidal Ideations, Urinary Tract Infections, Personal history of physical and sexual abuse in childhood, Personal history of psychological abuse in childhood, Personal history of self-harm, Post-traumatic stress disorder."

Review Patient 3's medical record document titled, "PROGRESS NOTES," indicated on 5/24/29, at 11 p.m., "Nursing - Pt told this nurse that she wanted to change rooms. After being asked why she wanted to change rooms, the pt. stated that she had been 'pressured' into having sexual interactions with her roommate. ...Pt stated that her roommate performed oral sex on her; ...Pt. stated that the above events happened in the daytime and nighttime, three days ago. ...House charge notified. The Dr. was notified. Sexual precautions with no roommate were ordered for the pt. and her roommate. The pt's roommate was transferred to a new unit. 5/25/19 2:20 p.m., ...Pt. feels that she is a victim of sexual assault and staff are trying to say that it was her fault."

Review of a document titled, "[Facility's Name] Facesheet," indicated Patient 8 was a [AGE]-year-old female admitted [DATE], with a diagnosis of Major depressive disorder, recurrent severe without psychotic features. Pers
VIOLATION: RN/LPN STAFFING Tag No: A0393
Based on observation and interview, the facility did not ensure enough staffing for safe patient care, based on the acuity of patients. This failure resulted in patient abuse for seven patients (Patient 1, 2, 3, 4, 5, 6 and 7).

Findings:

During an interview on 2/13/20, at 11:50 a.m., Director C stated the Staffing Sheet was checked two hours before every shift, and any changes to the census or acuity of patients was considered before making staffing assignments. She stated each unit had two resource nurses and, if needed, Nurse Managers filled in for needed staffing.

During an interview on 2/18/20, Mental Health Worker (MHW) G stated staffing was short on nights and weekends, and when staff worked short there was a patient safety risk for suicide or assault.

During an interview on 2/18/20 at 2:15 p.m., Manager G stated, when the unit was short staffed, they would come in and pass medications or work as a Hall Monitor. Manager G stated, when staffing was short due to sick calls or scheduling conflicts, patient safety was compromised and there was a risk to patient safety.

During an interview on 2/19/20 at 11:25 a.m., Licensed Staff I stated, about once a month the medication nurse must work as the Hall Monitor, and the Administrator On-Call came in to pass medications.

During an interview on 2/20/20, Director O stated most 12-hour Licensed Staff worked 16 hour shifts to cover for short staffing. Director O stated the risk to patient safety was that incidents occurred because Licensed Staff were short, they were busy trying to finish documentation and would not be on the floor working with patients.

During an interview on 2/20/20, Licensed Staff J stated staffing was a patient safety issue and weekends were very hard. Licensed Staff J stated, on weekends if there were not enough staff, the house Charge Nurse worked as a Medication Nurse, and the Administrator On-Call came in and worked as the Hall Monitor position. There was huge risk to patient care when they worked short. Licensed Staff J worked short on three out of ten scheduled work weeks.

During an interview on 2/24/20 at 8 a.m., Licensed Staff U stated he tried to inform the facility and the compliance department about staffing concerns. They stated the emphasis in the facility was complete documentation and pass medications. Licensed Staff U stated there were not enough staff to implement therapeutic interventions. He stated the facility could not hire enough staff, and yet the Administration pushed to keep the census at 90. Licensed Staff U stated the facility did not have staff to meet the needs of 90 patients, and if staff did not keep up with the work, they were deemed incompetent and moved out. Licensed Staff U stated there was a long history of retribution for anyone speaking up about staffing shortages.

During an interview on 2/24/20 at 5:30 p.m., Licensed Staff DD stated the facility was understaffed frequently; there was not enough staff to adequately complete the intakes. There were times they did not have a resource nurse to give nurses and staff breaks.

During an interview on 2/25/20 at 7 a.m., Mental Health Worker T stated he worked short four days out of seven. MHW T stated he frequently got pulled to work in other units to cover for sick calls or short staffing. Mental Health Worker T stated staffing was at bare minimum if nothing went wrong or there were no admits or discharges. He stated things went wrong all the time, and it resulted in a lot of overtime and staff not taking breaks. He stated staff were afraid to report missed breaks or late lunches. Mental Health Worker T stated when staff did not get breaks, they got tired and mistakes happened.

During an interview on 2/25/20, Licensed Staff P stated staffing was not great. Many staff worked 10-12 hour or longer shifts, and when they went home before the end of a shift, there was no safe staffing. Licensed Staff P stated she worked double shifts all the time to cover lack of staffing. She stated working without staff was a patient safety risk, because if she was busy doing documentation or taking vital signs, she could not observe patients or implement therapies.

During an interview on 2/25/20 at 6 a.m., Licensed Staff Q stated, during the night shift there was one Mental Health Worker going home at 5 a.m., because they worked a double shift. Licensed Staff Q stated three Mental Health Workers worked double shifts that day.

During an interview on 2/25/20 at 6:15 a.m., Licensed Staff AA stated they had 15-17 patients to care for, and staff must rotate breaks throughout the night shift with the hall monitor. When there was an admission, it took about 3-4 hours to complete the charts. Licensed Staff AA stated staff felt squeezed for time and were rushing to ensure the charting was complete before the end of the shift. Staff did not always get to take 30-minute breaks if there were no charge nurse. Licensed Staff AA stated she did not always feel safe because they received very acute patients at times with only one MHW. She stated she called a code about one month ago and staff was slow to respond, due to being short staffed. NOC and weekends were always short staffed, and they could not keep staff there for very long.

During an interview on 2/25/20, Licensed Staff R stated he worked short every single night. He stated staffing was so bad, it contributed to two patients punching each other in the face and having to go out to the hospital. More staff could have helped to keep patients away from one another. He stated Friday, Saturdays and Sundays were the worst for staffing, and staff were afraid to say anything about it because they needed their jobs. He worked a double the previous night and had 30 minutes overtime to finish documenting.

During an interview on 2/25/20 at 6:30 a.m., Licensed Staff S stated, when patients became agitated, help was not available. Staff must call around for help, especially if the charge nurse was doing patient care. Licensed Staff S stated the risk to patient safety was patient-to-patient abuse, and recently, staff-to-patient abuse. Licensed Staff S stated staff miss their lunch breaks at least once a week and must find their own relief to take a break.

During an interview on 2/25/20 at 8 a.m., Director C and Director F stated the facility currently had a total of nine open Licensed Nursing positions and 19 open Mental Health Worker positions. They stated there were a total of 28 open positions. They stated the facility used three traveling nurses to address the staffing shortage.

During an interview on 2/25/20 at 8:30 a.m., Unlicensed Staff U stated he was unable to fill staffing needs at least once a week and mostly on night shift.

During an interview on 2/25/20 at 7:15 a.m., Licensed Staff Z stated the facility had never turned down an admission. He stated there was a push to fill the beds and increase the facility census. Management stated the faster staff worked, the less likely a potential admission was re-directed to another facility. Licensed Staff Z stated staff burn-out was a patient safety risk. He also stated staff could not get vacation requests granted, and they became exhausted and called in sick or quit.

During an interview on 2/25/20 at 6:15 a.m., Licensed Staff BB stated there was not enough staff to cover shifts for breaks. The RN had to break the MHW and relieve the hall monitor. The lack of staff made her feel uncomfortable and unsafe. "We do not have enough older staff that can support newer staff. I do not get all my breaks all the time, on weekends we do not receive our full 30-minute lunch break because we have to wear many hats to get our work done." Licensed Staff BB stated they had about 15 patients and no resource nurse. "I complete assessments as much as I can, it takes about three hours to complete some assessments." She confirmed staff overturn was high.

During an interview on 2/26/20, at 2:15 p.m., Administrator A stated the facility did not document when emergency response codes were called, and there was no way to check how staff responded to codes. She stated the facility did not de-brief and only tracked codes which resulted in manual holds or seclusion.

During an interview on 2/26/20 at 3:15 p.m., Licensed Staff CC stated the facility did not have enough staff coverage on shifts to cover MHW for breaks. "You don't always get your break at a convenient time, sometimes there is a break nurse often times there is not." Licensed Staff CC stated they recently had a patient with an order for a 1:1 sitter. Staff was so short on a Saturday and Sunday the patient's medication was prolonged until a 1:1 could be staffed. Staffing was the shortest on the weekends, Friday to Monday. Licensed Staff CC stated the staff must take on patients with more medical issues and are not equipped to take care of them. The facility could not keep staff because the workload was too heavy. There was no unit secretary on weekends, and staff must do everything. Licensed Staff CC felt it was unsafe at times to work here.
VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to supervise one contracted Licensed Staff (Licensed Staff K) to ensure provision of safe patient care. This failure resulted in the sexual molestation of two adolescent patients (Patients 4 and 7).

Findings:

During an interview with Manager G on 2/18/20, at 2:15 p.m., she stated her responsibilities as a Nurse Manager included staffing, rounding, hiring new staff, discipline and establishing priorities.

During an interview with Director C, on 2/18/20, at 3 p.m., she stated the facility became aware an incident of abuse occurred when an adolescent patient (Patient 4) was re-admitted on [DATE], and requested to not receive care from Licensed Staff K.

During an interview with Director F, on 2/18/20, at 4:20 p.m., she stated she was informed, during Patient 4's re-admission on 2/5/20, Patient 4 reported to staff, during a previous hospitalization in November 2019, Licensed Staff K touched her inappropriately. Director F stated she was unaware, at that time, if an Incident Report was completed. She stated staff did not follow facility Policy and Procedure (P&P) for Mandated Reporting, when the facility Administrator On-Call (AOC) was not immediately notified. Director F stated the previous Chief Nursing Officer was informed of Patient 4's complaint, but did not inform the AOC, and did not investigate the abuse claim.

Licensed Staff J stated, during an interview, on 2/19/20 at 9:50 a.m., staffing was a large patient safety issue, especially on weekends. Licensed Staff J stated, when there was not enough staff and no Charge Nurse, he worked as a medication nurse for the shift. Licensed Staff J stated they worked short staffed, three out of ten weekends.

Licensed Staff J stated, during a re-admission on 11/16/19, Patient 4 told Licensed Staff L she did not want to be taken care of by Licensed Staff K, because the last time Patient 4 was hospitalized at the facility, Licensed Staff K placed Patient 4's hand on his genitals. Licensed Staff J stated he was advised to get statements from Patient 4 and Licensed Staff K and complete an Incident Report. Licensed Staff J stated it was a night shift, the facility was short staffed, and he was trying to finish his direct patient care documentation and go home. He stated Licensed Staff K told him he had a witness, and it did not happen. Licensed Staff J stated he had Licensed Staff K fill out the Incident Report and get the witness statement. Licensed Staff J stated he did not interview Patient 4, did not interview Licensed Staff K, or any of the witnesses, and did not place Licensed Staff K on Administrative Leave during the investigation.

Licensed Staff J stated he turned the paperwork to Director O's mailbox and went home. He stated he did not remember if Licensed Staff K was placed on Administrative Leave or not, but if Licensed Staff K was back at work, it must have been investigated, and it was appropriate for him to return. Licensed Staff J stated Licensed Staff K was odd and was not aware why he was removed from the adolescent unit schedule and assigned to work the night shift in the adult unit. Licensed Staff J stated adolescent patients made accusations of sexual abuse all the time and made things up.

During an interview on 2/19/20, at 3:45 p.m., Director F stated the facility investigated the abuse of two patients (Patient 4 and Patient 7) by Licensed Staff K. She stated in November 2019, Patient 4 made an abuse allegation against Licensed Staff K, and the Chief Nursing Officer (CNO), not the AOC, was informed, but did not do anything about the allegation, and as a result, the facility was unaware of the allegation. Licensed Staff K was not placed on Administrative Leave on 11/16/19, and returned to work assigned night shifts until 2/5/20. Director F stated Patient 7's parents informed the facility on 1/26/20, that during a home visit, Patient 7 told them a facility staff member placed her hands on his genitals. Director F stated Licensed Staff K was placed on Administrative Leave during the investigation, and an investigation was initiated.

Director F stated Patient 4 was readmitted to the facility 2/5/20, and made the claim Licensed Staff K placed her hand on his genitals the last time she was in the hospital and did not want him to be assigned to her care. Director F stated an investigation was initiated. She stated Licensed Staff K was on Administrative Leave from the previous event and was not interviewed. Director F stated the previous CNO admitted she dropped the, "ball" on reporting of the allegation. Director F stated Licensed Staff J told her he assumed the investigation was all taken care of when Licensed Staff K returned to work his normal night shifts.

During an interview on 2/19/20, at 3:45 p.m., Nursing Consultant F stated the facility had a staff competency validation program which included tests, discussion and validation. She stated the test results were scored by someone and documented. She stated all staff needed to be competent to provide safe patient care. Nursing Consultant F stated, if competency determination was inconsistent, there was a risk to patient safety.

During an interview and review, on 2/20/20 at 8:15 a.m., Licensed Staff K's employee file document titled, "Sexual Harassment Quiz," dated 8/26/19, was completed by Licensed Staff K, but not scored. A document titled, "Abuse Reporting and Tarasoff Quiz," dated 8/27/19, was completed by Licensed Staff K but not scored. A document titled, "Therapeutic Boundaries Test," dated 11/13/19, indicated Licensed Staff K wrote an example of a boundary violation: "Kissing a patient." The test was not scored by the facility. Nursing Consultant F stated the new employee orientation tests for abuse were not scored, and the risk of not scoring a test was they could not validate if the employee had the information they needed to provide safe care.

During an interview with Director O on 2/20/20, at 4 p.m., she stated she interviewed Licensed Staff K regarding the 11/16/19, allegation of abuse by Patient 4, and he stated Patient 4 did not want to go home and was trying to sabotage her discharge from the facility. Director O stated patients made up stuff so they could stay in the facility longer. She stated Licensed Nurse K stated there was a witness, but she did not interview any witnesses. She stated most of the adolescent patients made untrue accusations all the time. Director O stated when the second accusation against Licensed Staff K occurred, she believed it was true based on the two allegations and review of the video surveillance. Director O stated she was a new Nurse Manager and did not feel she received a good orientation which addressed staffing. She stated she increased the staffing on units to include a Resource Nurse and was disciplined for not adhering to the posted staffing plan.

Licensed Staff S stated, during an interview on 2/25/20, the unit was short staffed all week.

During an interview on 2/25/20, at 6 a.m., Licensed Staff R stated he was the Charge Nurse and his responsibilities included staffing, acting as a resource, and giving staff breaks.

During an interview and record review, on 2/25/20, at 3:05 p.m., a document titled, "[Facility's Name] Face sheet," indicated Patient 4 was a [AGE]-year-old female admitted [DATE], for diagnoses including, "Major depressive disorder, Suicidal ideations and Post-traumatic stress disorder." A document titled, "INCIDENT REPORT ...Date of Incident: 11/16/19 Time of Incident 0700 am Location unit [#] (Locked Adolescent Unit), ...Other: (describe) Patient made allegation against me. Description of Incident (Summarize what happened): Patient's vital signs were taken by this writer. The machine was not functioning properly, so this writer had to retake the vitals. Patient's door was wide open. MHW (Mental Health Worker) were in the hallway right next to pt's room and looking into pt's room throughout the time. This writer was talking with patient all throughout, MHW heard us talking. ...Completed by ... (Licensed Staff K). Date: 11/16/19 Time: 0807."

A review of a document titled, "[Facility's Name] Face sheet," indicated Patient 4 was a [AGE]-year-old female readmitted [DATE], for diagnoses including, "Major depressive disorder, Personal History of self-harm and Personal history of physical and sexual abuse in childhood." A document titled, "PROGRESS NOTES," dated 2/5/20 at 8:35 a.m., indicated, "Report Note-Upon intake assessment by this nurse on unit [#] exam room, pt. said, 'Does (Licensed Staff K) still work here?' This nurse said, 'No.' Pt. appeared very emotional when asked what happened. ...Pt. said, 'Last time I was here, Licensed Staff K came into my room and forced my hand onto his genitals.' ...Patient 4's mother said, 'Yeah, she told me about it when I packed her up last time. I told her she did the right thing by telling the nurse.' Pt. reported that she told the daytime nurse lady. Incident occurred at approximately 6 a.m. on 11/16/19."

Director F stated the alleged perpetrator completed the Incident Report on the date of the allegation on 11/16/19. She stated it was not a good idea to have the perpetrator complete the Incident Report against himself. She stated a stamp indicated, "Received [DATE]," indicated the Incident Report was received by the Quality Department. She stated the stamp indicated the prior CNO completed the paperwork and turned it into the facility. She stated the reason it was never investigated by the facility, was the paperwork was filed by someone in her office before she had a chance to review it. She stated, as a result, Licensed Staff K continued to work assigned night shifts for eleven weeks and four days, until Patient 4 was re-admitted on [DATE], and the second allegation of staff-to-patient abuse was made, and Licensed Staff K was placed on Administrative Leave during the investigation.

On 1/26/20, Director F stated Patient 7's parents informed the facility that during a home visit, Patient 7 told them a facility staff member had placed her hands on his genitals. Director F stated staff followed facility the P&P for Abuse Prevention; the AOC was informed, Licensed Staff K was placed on Administrative Leave during the investigation, and an investigation was initiated. She stated CPS, police, the physician and California Department of Public Health (CDPH) were notified.

During an interview on 2/26/20, at 3:15 p.m., Licensed Staff CC stated Patient 7 went home for a weekend, and when she returned, Patient 7's father called the facility and reported the incident to Licensed Staff CC. The father stated Patient 7 told the parents Licensed Staff K put her hand on his groin when taking vital signs. When interviewing Licensed Staff CC, she stated Licensed Staff K worked nights and would report off to her in the morning. Licensed staff CC stated she never witnessed anything, but noticed Licensed Staff K was very close and friendly with the kids. Licensed Staff CC felt there was not enough staff coverage on shifts to cover Mental Health Workers (MHW) for breaks. She reported the incident to Administration right away, and an investigation was started.

Director F stated, as part of the facility investigation, she reviewed video surveillance of Patient 7's hallway, outside her door, and observed Licensed Staff K entering Patient 7's room alone, without another staff member, much more often than was required by his night shift duties and spent long periods of time which could not be accounted for. She stated the result of the dual investigation into Patient 4 and Patient 7's allegation of abuse was substantiated by the facility. She stated the alleged molestation of Patients 4 and 7 appeared to have happened.

During an interview and record review on 2/26/20, at 3:40 p.m., Administrator A, Director C, and Director F stated, on the night shift there was only one licensed nurse and two Mental Health Workers for each unit . They stated Licensed Staff K would have worked independently as the night nurse, and the Charge Nurse would provide oversight during rounding and breaks.

Review of facility Policy and Procedure titled, "ORIENTATION AND COMPETENCY TRAINING Policy Number: HR 200.08," revised 6/25/19, indicated, "PURPOSE: ...Competency training and assessments are completed to confirm staff understanding of policies, procedures, and work processes established to support quality care and customer service. ...Competency Assessment ...Training is conducted, and verification of competency is verified by an individual with expertise in content of topic..."

Review of a facility document titled, "JOB DESCRIPTION," not dated, indicated, "Registered Nurse, House Charge ...KEY RESPONSIBILITIES ...Directly supervise nursing staff on assigned shift ..."
VIOLATION: Admission Reason Tag No: A1624
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure the admission and transfer information was accurate and complete, when one patient (Patient 6) was admitted to the facility with a history of increased aggressive behavior and sexual acting out, and facility staff proceeded to assign him to a double-occupancy room, without assault precautions. This failure to completely review the admission and transfer documentation contributed to a patient-to-patient abuse event.

Findings:

On 5/21/20 at 9:55 a.m., during a record review, a document titled, "Face sheet," indicated Patient 5 was a [AGE]-year-old male, admitted [DATE] at 11:49 a.m., with a diagnosis of, "Major Depressive Disorder."

A document titled, "SUSPECTED CHILD ABUSE REPORT," dated 5/21/19, indicated, "E. Incident Information Date / Time of Incident 5/18/19 night, Place of Incident room @ hospital Narrative Description, Pt. was rooming with a [AGE] year-old male. On 4/21/19, the staff became aware of a rumor involving the two boys. The 12 y/o had performed oral sex on the 14-year-old. ...When parents asked the [AGE]-year-old about it, he confirmed the event had happened."

A document titled, "INPATIENT INTERDISCIPLINARY NOTES PROGRESS NOTES," dated 5/21/19, at 4:20 p.m., indicated, "Nursing note, it has come to this nurses attention that at some point early in the pt. (Patient 5) stay, ...Patient 6 might have performed oral sex on the pt."

A document titled, "DISCHARGE SUMMARY," for 5/21/19, not timed, was dictated on 5/25/19 at 3:06 p.m., indicating for Patient 5, "HOSPITAL COURSE: Following admission to inpatient unit, the patient was placed on general suicide and assault precautions with every-15-minute check."

During a record review, a document titled, "Face sheet," indicated Patient 6 was a [AGE]-year-old male, admitted [DATE] at 12:36 p.m., for, "OD (overdose) attempt yesterday on Tylenol."

A document titled, "[County Name] County Department of Behavioral Health (BCDBH) CRISIS ASSESSMENT," dated 5/16/19, indicated Patient 6, "Disclosed having difficult in controlling impulses ... Referring Person's Statement of Client's Presenting Problem(s) Mother reports that since incident that occurred in October 2018 involving assault on ...siblings by the client, his behaviors have increased in intensity. Mother further reports fear she has in regard to impulse control of the client and it possibly leading to attempts on the lives of the siblings or parents. ...Current Risk of Self Harm or Risk of Harm to others ... Recent Assaultive Behaviors-Yes -Assaultive behaviors towards a classmate today led to being expelled today. ...Other Risk Factors ...Conflict with Peers - Yes- Physical conflicts at school with students."

A document titled, "INTAKE ASSESSMENT," dated 5/17/19 at 12:38 p.m., indicated, "DANGER TO OTHERS RISK SCREEN," was blank and not scored. "SEXUAL ACTING OUT RISK SCREEN - Historical Information, 15 points History of sexual assault, 5 points increase in sexual thoughts, 5 points History of sexual abuse victim. Behavior Observations, 5 points Manic state, 5 points Indiscriminate sexual activity. ...SEXUAL RISK SCORE: 35. ...15+ High Risk: RN to consult MD for Sexual Acting Out (SAO) precautions and MD will order at least one of the following: Blocker room/"no roommate" status, "12-foot rule" from peers, observation level changes."

A document titled, "Adolescent Admission Orders," dated 5/17/19 at 8:04 a.m., indicated for Patient 6, " ... Precautions: Suicide." The space indicated for Aggression/Assault was not checked.

A document titled, "PHYSICIAN'S ORDERS," dated 5/19/19 at 6:12 p.m., indicated, "ADD sexual Precautions." On 5/19/19 at 9:45 p.m., it indicated, "Block Room - No Roommate Due to hx (history) of sexual inappropriateness."

A document titled, "Patient Observation Record (revised 9/16/16)," indicated, "Precautions: Suicide." The boxes for Sexual and Assault precautions were unchecked from admission on 5/17/19 - 5/20/19.

A document titled, "Inpatient Interdisciplinary Notes," dated 5/19/19 at 7:30 p.m., indicated, "Pt. has faced 2 suspensions for sexually harassing one fell ow student online on two separate occasions. ...It was reported to the parents that the pt. had been sexually abusing his two younger brothers. ...Mom now has cameras installed in the apartment. This staff made nursing staff aware to add sexual precautions due to ongoing predatory behaviors and impulsivity as reported by parent. ...Mom reports that pt. lack impulse control and shows no empathy. ...When his room was searched by mom after pt. was hospitalized , she found kitchen knives hidden in his room. Mom reports pt. is quick to anger and becomes aggressive and volatile. He has physically attacked both parents. ...As per parent report there are valid concerns that would indicate that having a, "no roommate order" and sexual precautions necessary to maintain the safety of the unit ..."

During an interview with Mental Health Worker G, on 2/18/20, she stated staffing was short on nights and weekends, and when staff worked short there was a patient safety risk for suicide or assault.

During an interview on 2/18/20 at 2:25 p.m., Manager G stated when the facility was short staffed, she would come in and pass medications or work as a Hall Monitor. Manager G stated, when staffing was short patient safety was compromised, and there was a risk to patient safety.

During a record review and interview on 2/19/20, at 10:55 a.m., Nursing Consultant F stated, after Patient 5 was discharged on [DATE], the facility became aware Patient 5 was alleged to be the victim of sexual molestation by Patient 6.

During a record review and interview on 2/19/20, at 10:55 a.m., Nursing Consultant F and Director C stated, after Patient 5 was discharged , a Licensed Nurse overheard Patient 6 bragging about having performed oral sex on Patient 5. They stated Licensed Staff followed the P&P for Mandatory Reporting, informed the Administrator On Call (AOC), completed an Incident Report and notified the parents and the Physician. Director C stated the facility had a system to prevent abuse, by having a Hall Monitor position and every 15-minute monitoring of patients. She stated it did not prevent this event.

During an interview on 2/20/20, Director O stated most 12-hour Licensed Staff work 16 hour shifts to cover for short staffing. She stated the risk to patient safety was that incidents occurred because Licensed Staff were busy trying to finish documentation and were not on the floor working with patients.

During an interview on 2/21/20, at 9:55 a.m., Administrator B stated both Patient 5 and Patient 6 were assigned to the same room on 5/17/19, and remained in the same room until 5/19/19.

During an interview on 2/21/20, at 11:30 a.m., Administrator A stated the facility assessed its ability to provide care to patients, by reviewing the pre-admit packet and a telephone report from the transferring facility. She stated the transferring facility never communicated the high-risk behaviors of Patient 6.

During a phone interview on 2/21/20, at 2 p.m., Medical Director W stated the facility reviewed transfer information on patients to determine if they met admission criteria. He stated a patient who scored 35+ on the SEXUAL ACTING OUT RISK SCREEN tool should be on Assault Precautions and would be at risk of assault or inappropriate sexual conduct. He stated it was inappropriate for a patient with a score of 35+ to be assigned a room with a patient who had an assessment of vulnerable.

During an interview on 2/27/20, at 2:40 p.m., Director F stated Patient 5 and Patient 6 were roomed together because the transferring facility did not communicate Patient 6's history of assaultive / sexual acting out behavior.

A review of a facility Policy and Procedure (P&P) titled, "PRECAUTIONS, Inpatient units Policy Number: PC 360.24," reviewed 10/15/19, indicated, "All patients admitted to [Facility's Name] Hospital will be assessed for precautions risks. Prior to admission, the Assessment and Referral RN will review the patient's case with the admitting psychiatrist and consider the type of precautions necessary to maintain the safety of the patient...patient observation record will list all precautions required to maintain patient safety."

A review of a facility P&P titled, "SAO - Sexual Acting Out Policy Number: PC 360.24.01," reviewed 7/24/19, indicated, "No patient shall participate in any sexual acts while undergoing treatment at the facility ... The facility will protect all patients from sexual advances intimidation, and abuse from other patients. ...All patients are assessed and scored for current and history of risk for sexual intimidating and;/or abusive behavior and sexual vulnerability."

A review of a facility booklet titled, "HANDBOOK Rights for Individuals in Mental Health Facilities," revised July 2018, indicated, "You have the right to be free from abuse ... or harm ... You also have the right to be free from potentially harmful situations or conditions."