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Based on interview and record review, the facility neglected to ensure the necessary therapeutic services were provided when staff did not maintain professional boundaries with a patient by engaging in inappropriate physical touching, removing an item of clothing, and preventing a patient from exiting a room for 1 of 10 patients (P1) reviewed for patient rights. P1 had a history of mental illness and trauma. In addition, the allegation was not immediately reported to the state agency, the incident was first reported to facility management on 10/24/25 and reported to the state agency on 10/29/25.

The deficient practice resulted in an immediate jeopardy. The hospital was found out of compliance with the Condition of Participation Patient Rights at 42 CFR 482.13.

See A-0145 for additional information.

Based on interview and record review, the facility neglected to ensure the necessary therapeutic services were provided when staff did not maintain professional boundaries of a patient by engaging in inappropriate physical touching, removing an item of clothing, and preventing a patient from exiting a room resulting in a risk of serious injury, serious harm, serious impairment or death for 1 of 10 patients (P1) reviewed for patient rights. P1 had a history of mental illness and trauma. In addition, the allegation was not immediately reported to the state agency, the incident was first reported to facility management on 10/24/25 and reported to the state agency on 10/29/25.

The investigation resulted in an Immediate Jeopardy (IJ) at the Condition of Participation: Patient Rights at 42 CFR 482.13. The IJ began on 10/20/25, when the facility neglected to ensure the necessary therapeutic services were provided when staff engaged in inappropriate physical touching, removed items of clothing, and prevented a patient from exiting a room. In addition, the incident was first reported to facility management on 10/24/25 and not reviewed until 10/27/25 that allowed staff access to patients. The compliance and licensing manager were notified of the IJ on 11/20/25 at 1:05 p.m. The immediate jeopardy was removed on 11/24/25 at 4:30 p.m., after it could be verified the agency had implemented an acceptable removal plan, but noncompliance remained at a condition level.

Findings Include:

P1 was admitted to the psychiatric hospital on 10/11/25 and discharged on 10/31/25. Diagnoses included recent suicide attempt, depression, and anxiety. P1 had previous recent hospital admission on 8/2025.

P1's initial psychiatric evaluation dated 10/11/25, indicated P1 reported experiencing traumatic event, emotional trauma, avoiding traumatic stimuli, blocking out past memories/details, feelings of guilt/low self-esteem, increased arousal, impaired function, and history of trauma.

A facility incident report last updated on 11/3/25 indicated an event occurred on 10/24/25 at 8:00 p.m. The situation indicated during live video surveillance multiple staff, psychiatric technician (PT)-B, PT-C, and PT-D observed a fellow staff PT-A in the sensory room with P1 touching and rubbing P1's arm for several minutes. Physical contact with patients is discouraged due to being inappropriate and unsafe. Therefore, staff notification to supervisor and incident report completed and sent to management. The incident was reviewed and indicated PT-A was fired. The reviewer notes for the results of the investigation were left blank.
-What happened that should not have happened?
-What was done to prevent this from occurring again?
-Were staff educated on what went wrong and what to do next time?
-Ultimate outcome to the patient?
-Describe injury and treatment, if applicable?

A report to the state agency regarding the incident was filed by the hospital on 10/29/25. The incidents outlined in the report identified incidents on 10/20/25 and 10/21/25 indicating internal review of the video footage was ongoing and PT-A was removed from the schedule.

Video footage from 10/20/25 to 10/26/25 was reviewed with hospital staff. Six separate occasions were identified that included PT-A touching/playing with P1's feet, forceful removal of her socks, inappropriate contact/intervention to prevent her from leaving the room, and inappropriate, both forceful and playful, grabbing P1's hands, arms, and clothing.

During review of video footage on 11/19/25, at 9:18 a.m. the video showed the following:
-On 10/20/25, at 9:21 p.m. PT-A and P1 enter the sensory room. PT-A sits in the chair provided for staff to sit on while in the sensory room. P1 is seen lying on a large, inflated blue mat. At 9:25 p.m. P1 stands up and attempts to leave the sensory room. PT-A stands from their chair and moves to block P1 from reaching the door. PT-A places his left hand on P1's forearm to physically stop her from leaving the room and prevents P1 from leaving the room. PT-A proceeds to pat/rub the top of P1's head. At 9:26 p.m., PT-A places both of his hands on P1's upper back to guide her back to the mat. At 9:28 p.m. PT-A gets up from a chair and lays on the floor near P1. At 9:31 p.m. PT-A moves closer to P1 and reaches out his hand and begins touching P1's feet. At 9:39 p.m. PT-A attempts to remove P1's left sock. Once P1 is aware of this she attempts to resist, but PT-A is able to remove the sock after seven seconds. After removing the sock, PT-A places the sock directly behind him. After slightly over a minute, PT-A returns the sock to P1, which P1 puts the sock back on her foot. At 9:41 p.m. PT-A begins poking at P1's feet again, P1 gets up and leaves the sensory room without PT-A attempting to stop her.
-On 10/21/25, at 10:01 p.m. PT-A and P1 enter the sensory room. PT-A sits in the provided chair and P1 sits on the large inflated blue mat. At 10:24 p.m. PT-A gets up and walks over to P1 on the mat. PT-A places their left hand on P1's forehead and pushes firmly, enough for P1 to lean back despite resistance. PT-A then proceeds to lay parallel to P1 on the mat, about the width of a hand away. PT-A and P1 high fived. At 10:27 p.m. PT-A begins patting the top of P1's feet for approximately 1 minute. At 10:40 p.m. PT-A rotates perpendicular to P1, with their heads remaining roughly the width of a hand away. At 10:41 p.m. PT-A reaches up and firmly tugs at the sleeve of P1's shirt. PT-A places four fingers inside the shirt sleeve and the thumb on the outside and is firm enough to stretch P1's shirt. P1 leans away to resist, and PT-A releases the shirt. This same action occurs repeatedly at 10:44 p.m., 10:47 p.m., and 10:49 p.m. each time P1 resists by attempting to pull away. At 10:49 p.m. PT-A again pulls at P1's shirt and P1 gets up and leaves the sensory room.
-On 10/24/25, at 7:38 p.m. PT-A and P1 enter the sensory room. Both PT-A and P1 proceed to lay on the inflated blue mat, with PT-A face down and within approximately one foot between himself and P1. P1 has her back against the wall in an upright fetal position. At 7:39 p.m. PT-A begins tugging at P1's socks. PT-A pulls softly at first, then begins pulling at a strength that would remove them from P1. Once firm tugging begins, P1 grabs hold of her sock to prevent it from being pulled off. After approximately 34 seconds of tugging, P1 concedes and allows PT-A to remove her socks. Immediately after, P1 rotates 90 degrees to move her legs away from PT-A. The socks are placed an arm's length away behind PT-A, and fully out of reach of P1's reach. At 7:40 p.m. PT-A after P1 turns away, begins pulling at P1's left arm and leg with moderate force enough for the patient to lean. This action continued repeatedly for approximately 30 minutes. Contact includes repeated full hand poking at P1's arm, leg, and side. PT-A pulling P1's arm for prolonged lengths of time with one or both of PT-A's hands, placing P1's hands into his face or chest while P1 attempts to pull her hands away from PT-A, with enough strength to move P1's full body.
-At 7:48 p.m. PT-A begins tossing/pulling the left side of P1's hair for approximately 47 seconds, PT-A then returns to interacting with the P1's arm. At 8:20 p.m. an unidentified staff member enters the sensory room, and physical interactions stop during this period, but PT-A continues to lay on the mat approximately one foot away from P1. Almost immediately after the unidentified staff member leaves the room, PT-A begins pulling at P1's arms again. After this occurrence, PT-A rolls away from P1 and off the mat. PT-A lays on the floor next to the mat. They are now a full body length apart. At 8:22 p.m. P1 moves to where her socks were placed and begins to put them back on. PT-A touches and begins pulling at P1's hand again. At 8:24 p.m. P1 stands up and leaves the sensory room.
-On 10/24/25, at 10:14 p.m. PT-A is seen entering P1's room. P1 appears to be asleep when PT-A enters. P1's roommate is not in the room. P1 removes her headphones and sets them on the pillow beside her. P1 hides under the blanket while PT-A grabs the headphones. After pretending to leave with them, PT-A places the headphones back on P1's head. PT-A and P1 appear to be talking for approximately two minutes with PT-A standing directly next to P1's bed for most of the time. PT-A pushes P1's forehead down onto the pillow. PT-A then exits P1's room. At 10:21 p.m. PT-A re-enters P1's room. P1 appears to be sleeping in her bed. P1 then sits up in bed when PT-A is standing next to her bed. Once PT-A is at the bed, he begins to poke at P1's backside that is covered by a blanket. For approximately two minutes PT-A's hand is at P1's side/back and does not leave for the duration of the event. PT-A does a mix of poking at the patient's side, tugging at the blanket, or leaving their hand still with a firm grasp of the blanket. At 10:23 p.m. PT-A exits P1's room.
-On 10/26/25, at 10:19 p.m. PT-A enters P1's room. P1 appears to be sleeping when PT-A enters her room. Upon PT-A entering P1's room, P1 sits up in her bed. PT-A walks over to her bed, and grabs P1's pillow. PT-A then hits P1 with the pillow four times, before putting the pillow back down on the bed. PT-A then spreads his arms open briefly to prompt a hug. P1 turns towards PT-A, and the two hug with arms fully wrapped around each other for approximately two and a half seconds. At 10:20 p.m. PT-A leaves P1's room.

PT-A's personnel file was reviewed and indicated PT-A was observed to have inappropriate physical contact with P1 on 10/20/25, 10/21/25, 10/24/25 in the unit sensory room. P1 had a history of suspected trauma in 2024 relevant to P1's understanding of healthy relationship boundaries, including the relationship between healthcare staff and P1, and the incidents taking place in an intimate space where P1 and PT-A were alone with considerations to trauma. PT-A received previous coaching in July 2023 regarding a breach of therapeutic boundaries with another female patient involving physical contact intended to be "playful". Observations of PT-A's interactions with P1 were considered inappropriate as a caregiver, unwanted sexual contact with flirtatious gestures, and excessive and egregious physical contact, which violated the hospitals code of conduct. PT-A was terminated from employment on 10/29/25.

PT-C did not respond to a request for an interview.

PT- D did not respond to a request for an interview.

During an interview on 11/19/25, at 9:16 a.m. Registered (RN)-A stated he was the nurse manager who was notified on 10/27/25 to review the incident that was reported to management on 10/24/25 regarding concerns of inappropriate contact and boundary violations between PT-A and P1. RN-A stated staff did not notify the RN working at the time nor was the RN on call manager notified of the incident. It was not until 10/27/25, that the incident report was reviewed by nursing leadership. On 10/27/25, upon reviewing the incident report, video footage was reviewed. Video footage revealed repeated occurrences of what is deemed inappropriate contact between PT-A and P1 that occurred on 10/20/25, 10/21/25, 10/23/25, 10/24/25, 10/25/25, and 10/26/25. PT-A was immediately placed on leave and terminated on 10/29/25. PT-A did continue to work and have direct contact with patients including P1 on 10/25/25, and 10/26/25, due to the fact staff did not follow process and procedure which included immediately notifying nursing leadership of the concern. Other than posting laminated signage on one of the units, no additional training was provided to direct care staff related to inappropriate contact with patients, boundary violations and reporting of an allegation of abuse or neglect.

During an interview 11/19/25, at 2:31 p.m. PT-A stated he was recently terminated for having inappropriate boundaries with a female patient. All patients admitted to the hospital are considered vulnerable and have the right to receive care in a safe setting. Patients have the right to leave the sensory room at any time and it was not appropriate to stop P1 from leaving the sensory room. He had removed P1's socks but felt that was just being playful. Touching a P1's hair, pulling her close to his body and hugging P1 was not part of the training and is not considered appropriate. He had previously received corrective action for not following therapeutic boundaries. Training on therapeutic boundaries is part of the annual training, and his actions were not part of the training he has received.

During an interview 11/19/25, at 3:26 p.m. PT-B stated she was working on 10/24/25, with PT-A. When she looked at the cameras which was showing video of the sensory room she saw PT-A lying on the mattress next to P1. PT-B stated this was a boundary being crossed and filled out an incident report. PT-B stated she was afraid to say anything to PT-A. The RN in charge was not told about the incident, only an online incident report was completed. Since the incident, I realize I should have immediately gone to the RN in charge and told her, to prevent PT-A from having further contact with P1 and all other patients in the hospital. PT-A was known to pay extra attention to certain female patients, P1 was one of them. P1 has been a patient numerous times. Boundaries are important to maintain for all the patients to protect them.

Hospitals Professional Boundaries & Expectations policy review date 11/21/25, indicated staff members will treat all patients and their families respectfully and impartially, avoid favoritism, special treatment, or forming exclusive relationships. All interactions should directly support the patient's treatment plan. Personal, intimate, or emotionally dependent relationships are prohibited. Boundary Violations include any form of romantic, sexual, or intimate contact including tickling, hugging, or touching not required for professional duties. Physical behavior that could be misinterpreted as affectionate or suggestive, singular or unusually personal friendship, becoming affectionately and emotionally involved with a current or former patient or encouraging this involvement with another staff member of other patients, and any staff who become aware of a suspected boundary violation, repeated boundary crossings or any behavior that could be misinterpreted or raise concern must report this immediately.

Hospital's Vulnerable Adult (VA) Maltreatment policy review date 4/23/2025, indicated the purpose of the policy included to provide for the care and welfare of vulnerable adult patients and ensure patient safety in allegations of maltreatment including abuse and/or neglect. The policy directed all staff employed by PrairieCare are mandated to report suspected maltreatment (including abuse, neglect, and/or financial exploitation) of vulnerable adults. Any staff person having received direct knowledge of suspected abuse or neglect is responsible to make the adult protection report. Staff that has questions about whether a situation is subject to mandated reporting should consult with their immediate supervisor, the patient's treatment team, or the Director of Social Work.

Hospital's Staff Boundary Violation Prevention Guidelines review date 8/30/2022, indicated the policy purpose included to enforce a policy of appropriate boundaries and non-fraternization with current and former patients. Staff that interacts with patients receive ongoing education, at least annually, regarding therapeutic boundaries. Any person who becomes aware of a boundary violation must report this immediately to any of the following individuals:
Supervisor
Chief Nursing Officer
Chief Medical Officer
Chief Executive Officer
Chief Psychotherapy Officer
Compliance Office

The immediate jeopardy that began 10/24/25, was removed on 11/24/25, at 4:30 p.m. when it was verified by interview, and document review the hospital completed review the Staff Boundary Violation Prevention Guidelines, Inappropriate Staff Conduct and Progressive Disciplinary Process, Incident/Critical Incident Reporting, Allegations Involving Abuse or Neglect by Employee, Child Protection Reports, and Vulnerable Adult Maltreatment Reporting were reviewed, identified policy revisions completed, education was initiated on 11/21/25, by leadership for all locations with employees to validate understanding of mandated reporting requirements, reviewed annual computer-based education and deployed reports to leaders to ensure all staff complete required training. Education also included immediately following a patient report of an allegation of abuse, staff to intervene to remove the alleged perpetrator from providing patient care, communicate to care team/leadership to ensure an internal safety report has been filed and an investigation initiated, and a Mandated report filed to the State of Minnesota. To ensure the effectiveness of corrective actions, the facility increased the frequency of employee education to semiannually.