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CHI HEALTH IMMANUEL 6901 NORTH 72ND ST OMAHA, NE 68122 March 17, 2021

Based on observation of security video, staff interviews, record reviews and policy review the facility failed to supervise/monitor patient interaction to prevent abuse and failed ensure notification of a patient allegation of patient to patient sexual abuse (by Patient 4) was done in accordance with facility policy. This failure had the potential to allow further abuse to occur to any patient on the unit as current staff were unaware of the allegations reported to the previous charge nurse. The abuse occurred on 3/8/21 on the Special Care (Psychiatric) Intensive Care Unit. The unit has a capacity of 13 patients with a census of 9 on 3/8/21. The total sample size was 10 . The facility census was 113. Findings are:

A. Record review of the Electronic Medical Record (EMR) for Patient 4 on 3/15/21 revealed the patient was admitted to the Psychiatric Special Care Intensive Care Unit (SCICU) on 2/26/21. The female patient is [AGE] and admitted by the Mother who is the legal guardian. The History and Physical on admission notes the patient was suicidal, has a history of self harm behaviors such as biting self, head banging and scratching self. The patient also has a history of physical and sexual abuse as a child. Diagnosis included Major Depressive Disorder with severe psychotic features, anxiety disorder, Borderline Personality Disorder, Post Traumatic Stress Disorder (PTSD). The Plan of Care developed 2/27/21 included Self Harm, Auditory, Visual hallucinations, Homicidal Ideation toward a friend, anxiety, risk of suicide. Use of restraints was added due to multiple episodes of self harm (head banging), physical and verbal assault of staff.
Shift Nursing Notes(NN) dated 3/8/21 for 7:00 AM - 7:00 PM shift by Registered Nurse (RN) A on Patient 1's record states that "Yelling and argument heard between peer [Patient 1] and patient [Patient 4] that continued to escalate from peer [Patient 4] after lunch. Peer [Patient 4] heard shouting 'we are going to talk about what happened last night!' Patient 4 told RN A that she was called inappropriate names like "baby." The patient further reported that while the 2 patients were in the activity area at around 3:45 AM - 4:15 AM sitting at the dining table by the phones closest to the nurses station, Patient 1 groped her inappropriately touching her "butt and boobs." Patient 4 said the peer "told her he wanted her to be his girl." Patient 4 reported "feeling violated due to [Patient 4] being a minor and patient [1] being several years older. Security reviewed cameras and "confirmed inappropriate sexual contact multiple times during period of time in question". The patient's mother, local police and Child Protective Services were notified. Patient 1 stayed in his room "most of shift after peer yelled at him in activity area."

B. Record review of the EMR for Patient 1 on 3/11/21 revealed he was admitted from jail to the SCICU. Diagnosis listed as 'Psychosis" with history of Chronic Schizophrenia. The record notes the patient was completely psychotic, delusional, responding to internal stimuli and combative in jail. The patient was in locked seclusion due to significant aggression and psychosis from 3/4 -3/7/21. The patient was receiving anti psychotic medications during this time. He came out of seclusion and into the general area with other patients at 11:42 PM on 3/7/21. NN by RN B on 3/7/21 noted the patient woke up at 11:42 PM and was not aggressive or assaultive, the locked seclusion door was opened. The patient was cooperative and was given snacks and water. At midnight the patient closed the door to his room and went to sleep. NN at 2:45 AM on 3/8/21 note he was awake and responding to internal stimuli pacing in his room. He was given Haldol and Ativan (medications used to calm anxiety and psychosis). He was noted as socializing with peers and at 3:41 AM was sitting at a table "socializing, laughing, interacting peers-talking and giggling." At 4:05 AM he was given a peer [Peer 4's] teddy bear and took it to his room to sleep with.

C. Review of Security video on 3/15/21 with administrative staff of the SCICU Commons area notes at 3:34 AM on 3/8/21 Patient 4 is sitting with Patient 1 at the table. The nurses station is adjacent to this area and is visible through clear windows. The patients looked toward the nurses station (3 staff present) and Patient 1 walked over to Patient 4, who was standing up at the table, and touched her bottom at 3:35 AM. At 3:41 AM Patient 1 again touches Patient 4's butt through her clothes. At 3:46 AM Patient 4 walks up and stands in front of Patient 1. Patient 1 is observed touching Patient 4's bottom and crotch area. They return to their seats. At 3:50 AM Patient 4 lifts up her shirt to flash her bra at Patient 1. Staff were in the nurses station the entire time of the video and seem to be unaware of the sexual abuse occurring in the Commons area.

D. Telephone interview with RN B on 3/15/21 at 3 PM confirmed he was working as Charge Nurse on 3/7 and 3/8/21 on the night shift. RN B recalled another RN and he were sitting at the desk around 4-5 AM on 3/8/21 when Patient 4 came to the Nurses Station and said "[Name of Patient 1] touched her boobs and bottom. She was laughing. " Patient 4 told them not to talk to Patient 4 "you cannot do that he may be mad." RN B stated "I documented the conversation in [name of Patient 4] chart. I did not report to the manager or the next Charge Nurse. I just talked with [name of RN co-worker]. She [Patient] 4 was laughing, smiling. I told her not to be near peer [Patient 1], not to sit with him. I thought it was a behavior/attention seeking, unsure about believing her." RN B stated that when Patient 1 got out of seclusion he was not ordered to be a 1:1 or line of sight but "I kept my eye on him." The patient was on Assault Precautions, 10 minute checks, boundary precautions and fall precautions. RN B recalled he was in the Nurses Station with the door opened and was looking at him constantly. He had his back to us and [name of Patient 4] was across the table facing us. We also had the camera on him." RN B did not observe the patients closely enough to protect Patient 4 from sexual abuse by Patient 1.

The next night RN B worked from 6:30 PM on 3/8/21 to 7 AM on 3/9/21. RN B recalled being told in report that the police had come on the day shift. The Behavioral Supervisor was there and said Patient 4 had to be within the line of sight and put the order in. Patient 1 was also to be line of sight and on Boundary Precautions. The record confirms these interventions. Patient 4 discharged [DATE]. RN B stated he did not see Patient 1 talking with other females on the unit or having sexual behaviors.

RN B could identify the Adult and Child Protective Services numbers to report abuse. RN B keeps them in his phone. RN B stated he "didn't make the call because I thought it was a behavior. [Name of Patient 4] is highly attention seeking." RN B recalled he told her when she reported it to him to "stay away from [Name of Patient 1] but even though I told her that she gave him her teddy bear."

E. Interview with RN C, Interim Behavioral Manager of Adult and Psychiatric Units on 3/15/21 at 4 PM. RN C came in and reviewed the video with the Behavioral Health Supervisor on 3/8/21. RN C was unaware Patient 4 had told RN B of the inappropriate touching in the early AM on 3/8/21. RN C verified RN B "should have reported that allegation to the Charge Nurse. RN C also stated that after watching the video staff should have been out in the Commons Area with the patients [monitoring and observing] instead of the inside nurses station." Education to staff on "Therapeutic Milieu and Precaution levels" was provided to the staff on 3/12/21 after this incident.

F. Record review of facility policy titled "Suspected Abuse/Neglect of a Child or Vulnerable Adult" last revised 1/2020. The policy defines a child as "Any person under the age of 18 years in Iowa and under the age of 19 years in Nebraska. The policy states under the title "Procedure" that "If there is any suspicion either as a result of the admission screening or noted during course of the patient's hospitalization , the staff member who identifies the suspicion will make a report immediately" to the DHHS Division of Child and Family 24/7 Hotline with the number listed as the same one that RN B had in his phone to report abuse. The policy further states that "Action will be taken to ensure the safety of patient." Since RN B did not report it to anyone other than the nurse on shift with him, no one on day shift was aware and could take precautions to protect patients from further potential abuse by Patient 1. It was only when staff overheard Patient 4 yelling at Patient 1 about what he did (after lunch on 3/8/21) that staff followed their policy and took steps to ensure Patient safety.