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Based on record review and interviews, the hospital failed to ensure a patient complaint of alleged sexual abuse was recognized as a grievance. This deficient practice was evidenced by failing to correctly identify a patient grievance for 1 (#3) of 3 (#1-#3) patients reviewed for complaints/grievances.
Findings:

Review of hospital policy titled "Complaints and Grievances: Patient/Family," approved June 2025, revealed in part: "Policy Statement: The investigation process for patient complaints and grievances must be initiated within 24 hours. The complaint/grievance resolution process shall take precedence over any and all previously scheduled activities, including but not limited to: administrative scheduled time off, provision of clinical care, and off-site meetings. Purpose: To assure that all Community Care Hospital patient complaints and grievances are addressed and resolved in a timely manner, as well as improve the service provided to patients. Definitions: Patient complaint- any concern expressed by the patient or family member concerning care or service that can be addressed promptly, on the spot, by the staff or managers present. Patient grievance- a formal or informal written or verbal complaint that is made to the hospital by a patient or the patient's representative when the patient issue cannot be resolved promptly by staff or manager present. If a complaint cannot be resolved promptly by staff present, and as a result is referred to a manager or to the Patient Representative, it is considered a grievance. Concerns regarding the following issues are automatically considered patient grievances: The exercise of patient rights regarding his/her care, Premature discharge, Privacy and safety of the patient, Confidentiality and access to patient records, Civil rights or issues of disability, Accusations of abuse."

Review of LDH Health Standard Section document titled Self-Reporting Process for Hospitals - Abuse/Neglect revealed in part: "11. Facility Investigation (Administrative Review) and Final Investigative Report: In accordance with regulations, facilities are directed to process an allegation of abuse or neglect as a grievance in accordance with facility Grievance Processes and Abuse/Neglect policies. In accordance with §482.13, an allegation of abuse/neglect is to be treated as a grievance even if the complainant recants or indicates that the issue is resolved. A written response must be issued to the reporting patient or patient's representative. In many cases, the presentation of an abuse investigation handled in this manner will satisfy surveyor reviews related to the manner in which a facility processes grievances."

Patient #3
Review of Patient #3's medical record revealed Patient #3 was admitted on 11/01/2024 with an admit diagnosis of Schizoaffective Disorder, Bipolar type.
Review of nursing note on 11/03/2024 at 6:05 PM revealed in part the following: Patient #3's mother called to inform her that we are investigating the accusation of him being raped in his sleep last night.

In an interview on 06/25/2025 at 12:40 PM, S1ADM stated that the facility has not had any complaints or grievances since October 2024 through April 29, 2025.

In an interview on 06/25/2025 at 3:17 PM, S3DON stated the mother called and said she was upset Patient #3 told her that he was raped. S3DON stated she informed the mother that incident would be investigated. S3DON confirmed that this incident failed to be identified as a grievance.

Based on record review and interview, the hospital failed to ensure the patient's right to receive care in a safe setting. This deficient practice was evidenced by:
1) failure to ensure all exit doors were secured leading to patient elopements; and
2) failure to ensure the elevator was monitored per hospital protocol leading to the elopement of Patient #3.
Findings:

Review of hospital policy titled "Patient Rights," approved June 2025, revealed in part: "Procedure: Community Care Hospital supports and protects the basic human, civil, and constitutional rights of all patients. All patients have the right to: 18. The right to receive care in a safe setting."

Review of hospital policy titled "Abuse and/or Neglect of Patients," approved January 2025, revealed in part: "Purpose: To identify attitudes and behaviors which constitute patient abuse or neglect, and to assure that any incidents of suspected or actual abuse/neglect are reported, investigated, and resolved. To establish a time frame for reported suspected or actual abuse and/or neglect. A. Definitions: Abuse- the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. Neglect- a form of abuse. The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. B. Prevention of Abuse and Neglect: 3. Unit acuity is assessed every shift to determine that the staff to patient ratio is appropriate to meet the specific needs of the patient. C. Identification of Abuse and/or Neglect: 1. Inadequate supervision of patients whose physical or mental condition may result in poor judgment, and who are therefore at risk of injury or illness without supervision. 2. Engaging in sexual conduct of any kind with a patient.
D. Reporting Abuse and/or Neglect of Patients: Staff are required to report any incident which they believe might constitute abuse or neglect of patients. Because safety of patients is our first concern, a reasonable suspicion about the observed behavior is sufficient to warrant reporting the situation so that any necessary corrections can be made to prevent or reduce harm to the patient. 2. Prevention of instances of patient abuse/neglect is a goal of this facility."

Review of hospital policy titled "Escorting Patients Off the Unit," approved January 2025, revealed in part: "Policy Statement: Staff members assigned to escort a patient, or a group of patients shall be responsible for the safety and well-being of the individual and/or group from the time of leaving the unit until return to the unit. Purpose: To establish guidelines for the safe transport of patients off the unit. Procedure, in part: 1. The staff-patient ratio will be no less than two staff members for every group of up to twelve patients when leaving the secured nursing unit. This will apply to meal times and smoke breaks. 2. Prior to leaving the unit, staff members assigned to accompany patients should: a. Evaluate the clinical condition of each patient that the staff member is planning to accompany off the unit. b. Know the number and names of the patients in the group. c. Notify security that the patients are leaving the unit. 3. Security will secure the lobby area and take post in front of the lobby door prior to patients leaving the elevator. 6. Staff members should see that the group stays together."

Review of hospital policy titled "Elopement Assessment and Reporting," approved January 2025, revealed in part: "Procedure: 1. Nursing personnel should assess the risk for elopement during the admission process by utilizing the elopement assessment questions located on the admit nursing assessment. 2. If the patient is shown to be at risk for elopement, the nurse should contact the admitting physician to have elopement precautions ordered. 3. It is the responsibility of all personnel to report any patient discussing an attempt or intent to leave the facility, attempting to leave the premises, or suspected of being missing, to the charge nurse immediately."

Review of document provided by S1ADM titled "Community Care Hospital Day/Night Shift MHT Duties," revealed in part: "Reminders: When getting off the elevator, don't forget to stand in front of it until it closes fully. Some patients might be waiting for the opportunity to jump on when you have stepped away too early. When escorting patients off elevator, staff should exit first as to be between patients and the outside door."

1) Failure to ensure all exit doors were secured leading to patient elopements.
Review of the hospital incident report log revealed the following:
Patient #R2 eloped on 10/15/2024
Patient #3 eloped on 11/04/2024
Patient #R1 eloped on 01/13/2025

Observations of front lobby on 06/25/2025 at 4:30PM revealed S10SEC sitting behind desk facing the front lobby door. During inspection of front lobby door, the door was not secured from inside the facility and could be pushed open allowing exit out of the facility.

In an interview on 06/25/2025 at 4:35 PM, S10SEC confirmed that the front lobby door is not secured from the inside and can be pushed open allowing exit out of the facility. S10SEC further confirmed the front lobby door is secured from the outside and security/staff have to allow entrance into the facility. S10SEC stated prior to patients leaving the unit with staff, they are notified by staff, at which point security will take post in front of lobby door to secure the exit. Security further confirmed that if a patient attempts to elope and security is sitting behind the desk, they are not able to secure the front lobby door in order to prevent patient elopement.


2) Failure to ensure the elevator was monitored per hospital protocol leading to the elopement of Patient #3.
Patient #3
Review of Patient #3's medical record revealed Patient #3 was admitted on 11/01/2024 with an admit diagnosis of Schizoaffective Disorder, Bipolar type. On 11/03/2024 Patient #3 was placed on elopement precautions.
Further review of Patient #3's medical record revealed a nursing note from 11/04/2024 that revealed in part the following: Informed that Patient #3 was able to get in elevator and through front door. MHT grabbed him but Patient #3 was able to get away. Police have been notified.
2:00 PM- Mother notified.
3:00 PM- Mother called and stated her son called her from someone's phone, they tried to talk him to going back but Patient #3 refused.
8:00 PM- Mother called and concerned that Patient #3 has not returned.

Review of incident report involving Patient #3 revealed in part the following:
Date/Time of Incident: 11/04/2024 at 1:45 PM
Type of Incident: Elopement
Describe what happened: Per Security guard, patient got off elevator and ran out front door.

Review of document titled "Investigation Form" for Patient #3 revealed in part the following:
Date/Time: 11/04/2024 at 1:45 PM
Persons involved: S8MHT and S9RN
Witnesses: Watched camera
Description of Incident/Summary of Interview(s): S8MHT called for elevator on 4th floor using her key and pressing button. S8MHT then decided to go down the stairs instead. When elevator arrived, Patient #3 got on and took elevator to first floor, running out front door. S8MHT was standing outside. S8MHT attempted to grab Patient #3 but he pushed her away.
Next Investigative Steps: Police called. Mother called to inform about elopement. Mother called back at 3 PM after she talked to Patient #3. Patient #3 encouraged to return but refused.
Actions to be Taken: S8MHT was terminated for neglect behavior 11/04/2024.
Signed by administrator on 11/05/2024 at 11:22 AM.

In an interview on 06/25/2025 at 3:30 PM, S3DON confirmed that S8MHT did not wait for the elevator to arrive and ensure the doors closed prior to taking the stairs off the unit. S3DON further confirmed S8MHT did not follow hospital protocol for the elevator and that she was terminated.

Based on record review and interview the hospital failed to ensure all patients were free from all forms of abuse or neglect. This deficient practice is evidenced by failure of staff to monitor per hospital policy a 1:1 patient with an intellectual disability possibly leading to a sexual assault.
Findings:

Review of hospital policy titled "Patient Rights," approved June 2025, revealed in part: "Procedure: Community Care Hospital supports and protects the basic human, civil, and constitutional rights of all patients. All patients have the right to: 17. The right to be free from all forms of abuse and harassment."

Review of hospital policy titled "Abuse and/or Neglect of Patients," approved January 2025, revealed in part: "Purpose: To identify attitudes and behaviors which constitute patient abuse or neglect, and to assure that any incidents of suspected or actual abuse/neglect are reported, investigated, and resolved. To establish a time frame for reported suspected or actual abuse and/or neglect. A. Definitions: Abuse- the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. Neglect- a form of abuse. The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. B. Prevention of Abuse and Neglect: 3. Unit acuity is assessed every shift to determine that the staff to patient ratio is appropriate to meet the specific needs of the patient. C. Identification of Abuse and/or Neglect: 1. Inadequate supervision of patients whose physical or mental condition may result in poor judgment, and who are therefore at risk of injury or illness without supervision. 2. Engaging in sexual conduct of any kind with a patient."

Review of hospital policy titled "Patient Observation Record," approved January 2025, revealed in part: "Purpose: To establish guidelines and procedures for completion of the Patient Observation Record Sheet. To ensure that the patient's safety and well-being are maintained and documented. Procedure: The RN is responsible for MHT assignments. 1:1 Observation: Observation Requirement: Continuous observation within arm's length. May not be interrupted for any reason. Privileges: Staff must accompany patient to all areas, including bathroom or group therapy."

Review of hospital policy titled "Staffing Plans and Delivery of Care," approved January 2025, revealed in part: "Purpose: To define guidelines for the utilization of RN's and MHT's, in providing delivery of patient care. Staffing Assessment: Patient care assignments and activities can fluctuate and therefore require ongoing assessment and planning to assure that adequate and qualified staff is available to meet the needs of the patient. The charge nurse, Director of Nursing or designee does this assessment prior to the beginning of each shift and staffing adjustments are made accordingly to accommodate patient needs. Staffing Alternatives: When available personnel are insufficient to meet coverage demand, the charge nurse, Director of Nursing or designee shall evaluate the need for alternative staffing. Available alternatives: Re-assign staff from other units to meet the needs of the patients, if applicable; Contact PRN employees that are interested in working; Contact full time employees that are interested in working overtime hours; Utilize the Director of Nursing or Assistant Director of Nursing, if available, and working does not conflict with maintaining the proper supervision of Community Care Hospital or if administrative duties are not neglected."

Review of Patient #1's medical record revealed Patient #1 was a 23 year old female admitted on 05/29/2025 with a diagnosis of Major Depressive Disorder (MDD). Review of the Coroner Emergency Certificate (CEC) dated 05/30/2025 revealed in part that Patient #1 had a history of schizophrenia and mild intellectual disability. On 05/30/2025, Patient #1 had an order placed for 1:1 observations.
Review of Psychiatric Evaluation dated 05/30/2025 revealed in part: Throughout the interview, Patient #1 was somewhat hypersexual and alluded that she may have asked anybody to help her process her feelings that she can get close to.
On the morning of 05/31/2025, Patient #1 was involved in an alleged patient to patient sexual assault incident with Patient #2. Further review revealed Patient #1 had orders for 1:1 observations prior to the incident. Patient #1 was transferred on 05/31/2025 to the ER for an evaluation and returned later that night.

Review of the Daily Nursing Assignment Sheet dated 05/31/2025 7a-7p revealed a census of 8 patients. Further review revealed that Patient #1 was on a 1:1 level of observation and was assigned to S7MHT and the other patients were assigned to S5MHT. Review of the Daily Nursing Assignment Sheet failed to reveal that S7MHT called out for her shift or that another staff member was reassigned to maintain 1:1 observations of Patient #1.

In an interview on 06/24/2025 at 10:15 AM, S3DON confirmed that Patient #1 had an order for 1:1 observations at the time of the incident. S3DON confirmed that at S7MHT was assigned on the assignment sheet for 05/31/2025 7a-7p. S3DON confirmed that S7MHT called out prior to her shift and stated the call out wasn't communicated. S3DON further confirmed that the night shift MHT's should not have left their shift until they were relieved by another MHT to replace them. S3DON stated that the other units had available staff that could have been reassigned to meet the needs of the unit. S3DON confirmed S4RN did not attempt to call another unit to send an MHT to maintain 1:1 observations of Patient #1 or call the DON and inform her that they didn't have staffing to meet the needs of the unit. S3DON stated that the shift started at 7AM, and the incident occurred an hour after shift change. S3DON confirmed 1:1 observations were not performed per hospital policy. S3DON also confirmed that S4RN neglected to maintain provider orders for 1:1 observation for Patient #1, which potentially led to the sexual assault allegation.

In an interview on 06/24/2025 at 11:26 AM, S5MHT confirmed that she informed S4RN at the beginning of the shift that S7MHT had not arrived to the unit and that the night shift MHT's had gone home. S5MHT stated that S4RN's response was that S7MHT was probably just late. S5MHT also confirmed that at this time she informed S4RN that she was the only MHT and that Patient #1 was a 1:1 observation level. S5MHT further stated that S4RN did not assist in maintaining 1:1 observations of Patient #1. S5MHT also confirmed that at the time of the incident she was the only MHT on the unit.

Based on record review and interview, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by:
1) failure to accurately self-report an incident involving alleged sexual assault of a patient with an intellectual disability; and
2) failure to self-report incidents involving allegations of abuse/neglect within 24 hours to the Department of Health and Hospitals in 5 (#3, #R1-#R4) of 5 (#3, #R1-#R4) incidents reviewed for abuse/neglect.
Findings:

Review of LDH Health Standard Section document titled Self-Reporting Process for Hospitals - Abuse/Neglect revealed in part: "4. Self-Reporting: In the interest of providing information that will indicate the facility's compliance with CMS Regulation 482.13(c) (3) regarding abuse, neglect, and harassment, as well as La R.S. 40:2009.20, the following processes have been developed. It should be noted that a facility's decision to self-report does not eliminate the possibility of an onsite investigation being conducted in response to allegations and/or relevant information received.
Although LA R.S. 40:2009.20 requires a facility to report knowledge of incidents of abuse, within twenty-four hours, to either the local law enforcement agency or LDH (or the Medicaid Fraud Unit as applicable), many facilities find it beneficial to self-report to LDH, even if they have notified law enforcement. It is important to note that contacting law enforcement on behalf or at the request of the patient/complainant (e.g. to press charges, etc.) does not satisfy the statute's intent regarding facility notification.
8: Initial Report (within 24 hours of knowledge): NOTE: Patient-to-patient assaults should be categorized as "Neglect" in relation to "Patient-to-Patient Physical Assault" or "Patient-to-Patient Sexual Assault." From a LDH standpoint, the issue under review is to determine whether the facility failed to take prudent action to prevent, and/or respond to, the (alleged) occurrence. These incidents should be assessed as alleged "Neglect" (i.e. the hospital's failure to act with due diligence). Also indicate what the allegation of neglect involves (i.e. sexual assault, physical assault, elopement, death, or other). The requirement (per statute) is that potential abuse or neglect be reported within 24 hours of knowledge (awareness) of the allegation, suspicion, or occurrence.
12. Special Settings and Considerations: This document describes the type of information needed by the HSS to conduct a thorough review of a hospital's actions in relation to an allegation that abuse and/or neglect has occurred within the facility. In certain settings, including, but not limited to behavioral health facilities, pediatric units, and geriatric units, incidents involving physical or emotional abuse or sexual acting out between patients may be reportable, as the facility has specific responsibilities relative to providing adequate supervision to prevent these occurrences. Minors below the age of consent, psychiatric patients of any age, and cognitively impaired individuals (such as those with dementia or mental retardation) are not considered capable of consenting to sexual activity in a facility. As a result, sexual acts involving patients that fit these categories cannot be categorized as "consensual" even if both parties engage in the act voluntarily, and are reportable, as are occurrences indicating that the facility may have failed to adequately provide safety for the type of patient being treated."

Review of hospital policy titled "Abuse and/or Neglect of Patients," approved January 2025, revealed in part: "Community Care Hospital implements the Louisiana State mandated report law."

1) Failure to accurately self-report an incident involving alleged sexual assault of a patient with an intellectual disability.
Review of Patient #1's medical record revealed Patient #1 was a 23 year old female admitted on 05/29/2025 with a diagnosis of Major Depressive Disorder (MDD). Review of the Coroner Emergency Certificate (CEC) dated 05/30/2025 revealed in part that Patient #1 had a history of schizophrenia and mild intellectual disability. Review of the progress note on 06/02/2025 by S6MD revealed in part: Patient #1 has history of schizophrenia and mild intellectual disability. On 05/30/2025, Patient #1 had an order placed for 1:1 observations.
Review of Psychiatric Evaluation dated 05/30/2025 revealed in part: Throughout the interview, Patient #1 was somewhat hypersexual and alluded that she may have asked anybody to help her process her feelings that she can get close to.
On the morning of 05/31/2025, Patient #1 was involved in an alleged patient to patient sexual assault incident with Patient #2. Further review revealed Patient #1 had orders for 1:1 observations prior to the incident. Patient #1 was transferred on 05/31/2025 to the ER for an evaluation and returned later that night.

Review of Patient #2's medical record revealed Patient #2 was a 44 year old male admitted on 05/27/2025 with a diagnosis of Depression, Suicidal Ideations, and Auditory Hallucinations. On the morning of 05/31/2025, Patient #1 was involved in an alleged patient to patient sexual assault incident with Patient #2. Further review revealed Patient #2 was discharged on 05/31/2025 into police custody.

Review of the Daily Nursing Assignment Sheet dated 05/31/2025 7a-7p revealed a census of 8 patients. Further review revealed that Patient #1 was on a 1:1 level of observation and was assigned to S7MHT.

Review of the Hospital/Licensed Provider Abuse/Neglect Initial Report finalized on 05/05/2025 revealed in part the following documentation:
Incident Type: Alleged Neglect (Patient to Patient Sexual Assault)
Date/Time of Incident: 05/31/2025 at 8:02 AM
Date/Time of Discovery: 05/04/2025 at 8:05 PM
Patient Information documented on report included:
Patient #1 as Victim/Aggressor not documented
Patient #2 as Victim/Aggressor not documented
Incident details revealed in part:
Patient #1 and Patient #2 were discovered in Room a by S5MHT engaged in sexual activity. Penetration was not observed by S5MHT. Five minutes after the incident all patients except Patient #1 went down to breakfast. Patient #1 requested to remain on the floor with S4RN. Patient #1 stated that she went into the bathroom voluntarily, that she pulled her pants down, but she didn't know what was going to happen. Patient #1 stated later that intercourse occurred. Patient #1 wanted to press charges and law enforcement was notified. Patient #2 was taken into police custody. Patient #1 was sent to ER for an evaluation. During readmission nursing assessment she prompted the following notation, Patient #1 "denies ever having been sexually, physically or emotionally abused."
Patient #1 was on 1:1 observation status.
Patient #2 was on Q15 minute observation.
Census on the unit was 9 patients.
Assigned Staff: 1 RN, 2 MHT's.
Staff Present: 1 RN, 1 MHT.
Initial Actions Taken revealed in part the following:
Patient #1 and Patient #2 were separated and Patient #2 went down to breakfast, with Patient #1 remaining on the unit, creating greater separation. Patient #2 was detained by law enforcement. No other patients were involved in the direct incident. When Patient #1 returned to the facility she was admitted to a different floor to avoid uncomfortable interaction or embarrassment. S4RN was suspended until further notice for failing to facilitate and maintain the 1:1 status on Patient #1.
Comments Section revealed in part the following:
Excerpts from nursing note describing the events of 06/02/2025:
Patient #1 told the MHT that she wants to tell the truth and that it was the voices telling her to say that she was raped. Patient #1 admits that she had sex but he did not force her. At 2 PM, Patient #1 met with the detective. Patient #1 admits that she had sex but she had agreed to it and Patient #1 does not want Patient #2 to go to jail for something that he did not do.
Investigation Results revealed in part:
The allegation is unable to substantiate due to lack of evidence.
Update, the allegations of sexual assault have been found to be unsubstantiated (see comment section).

The report failed to reveal that Patient #1 had an Intellectual disability. Further review of the report failed to reveal that S7MHT, who was assigned to Patient #1, had called out for her shift. The report also failed to reveal that 1:1 observations were not being followed for Patient #1 prior to the incident. Additionally, the report failed to substantiated the allegation of neglect.

In an interview on 06/24/2025 at 10:15 AM, S3DON confirmed that Patient #1 was 1:1 at the time of the incident. S3DON confirmed that at S7MHT was assigned on the assignment sheet for 05/31/2025 7a-7p. S3DON confirmed that S7MHT called out prior to her shift and it wasn't communicated. S3DON confirmed that prior to Patient #1 telling S4RN about the alleged rape, S3DON did not know that there was not enough staff to perform 1:1 observation and ensure patient safety. S3DON further confirmed that S4RN assign another staff member to Patient #1 in order to maintain the order for 1:1 observation, which potentially led to the sexual assault allegation.

In an interview on 06/24/2025 at 11:26 AM, S5MHT confirmed that upon arrival to her shift on 05/31/2025 when S7MHT did not arrive for her shift, she informed S4RN that she was the only MHT and that Patient #1 was 1:1 observation. S5MHT stated that she tried to keep Patient #1 with her while she performed unit tasks. S5MHT also confirmed that S4RN made no attempt to assist with performing 1:1 observations of Patient #1 or call another unit to get assistance with coverage. S5MHT stated when she went to put up the vital sign machine, she was unable to locate Patient #1. S5MHT stated she then discovered Patient #1 and Patient #2 in the bathroom together and separated them. S5MHT confirmed that at time of discovery she had not been told by Patient #1 about the alleged rape. S5MHT further confirmed that Patient #1 asked to remain on the unit with the nurse while S5MHT took the other patients to breakfast. S5MHT also stated that prior to exiting the unit with the other patients, she informed S4RN that she discovered Patient #1 and Patient #2 in the bathroom together.

In an interview on 06/24/2025 at 2:16 PM, S1ADM confirmed the above mentioned findings. S1ADM also confirmed the report did not reveal that Patient #1 had an intellectual disability. S1ADM confirmed that the report was unsubstantiated because Patient #1 recanted her original statement of rape and stated to law enforcement she wasn't telling the truth. S1ADM confirmed that staff neglected to provide a safe environment for Patient #1 by not ensuring that she remained on 1:1 observations as ordered by the provider.


2) Failure to self-report incidents involving allegations of abuse/neglect within 24 hours to the Department of Health and Hospitals in 5 (#3, #R1-#R4) of 5 (#3, #R1-#R4) incidents reviewed for abuse/neglect.

Review of the hospital's Incident Log for October 2024 to January 2025 revealed the following incidents involving allegations of abuse/neglect listed:

Patient #3
Review of the hospital's Incident Report involving Patient #3 revealed in part the following:
Date/Time of Incident: 11/03/2024 (no time)
Type of Incident: Sexual Behavior
Describe what happened: Patient stated that he was raped last night in his sleep. He called his mother to also report that he was raped.

In an interview on 06/25/2025 at 2:40 PM, S1ADM stated he did not self-report the sexual assault because Patient #3 was psychotic.

Patient #3 (2nd Incident)
Review of the hospital's Incident Report involving Patient #3 revealed in part the following:
Date/Time of Incident: 11/04/2024 at 1:45 PM
Type of Incident: Elopement
Describe what happened: Per Security guard, patient got off elevator and ran out front door.

Patient #R1
Review of the hospital's Incident Report involving Patient #R1 revealed in part the following:
Date/Time of Incident: 01/13/2025 (no time)
Type of Incident: Elopement
Describe what happened: Security called and stated Patient #R1 ran past him and out the back door as staff were entering in hospital.

Patient #R2
Review of the hospital's Incident Report involving Patient #R2 revealed in part the following:
Date/Time of Incident: 10/15/2024 at 12:00 PM
Type of Incident: Elopement
Describe what happened: Patient #R2 was in the cafeteria, then he went into bathroom within cafeteria. Patient #R2 then ran into the lobby and escaped through the front exit.

Patient #R3
Review of the hospital's Incident Report involving Patient #R3 revealed in part the following:
Date/Time of Incident: 12/12/2024 at 12:45 PM
Type of Incident: Elopement
Describe what happened: Patient #R3 jumped over gate on smoking patio.

Patient #R4
Review of the hospital's Incident Report involving Patient #R4 revealed in part the following:
Date/Time of Incident: 10/14/2024 at 3:15 PM
Type of Incident: Sexual Behavior
Describe what happened: Patient #R4 states she asked male peer to tie her hair back. States he squeezed her left breast.

In an interview on 06/24/2025 at 2:14 PM, S1ADM confirmed the above mentioned incidents were not self-reported. S1ADM further confirmed they were only reported to law enforcement.

Based on record review and interview, the hospital failed to ensure a registered nurse (RN) supervised the care for each patient. This deficient practice is evidenced by failing to immediately address any clinical assessments on 2 (#1, #3) of 3 (#1-#3) patient records reviewed for alleged sexual assault.
Findings:

Review of hospital policy titled, "Admit Nursing Assessment," approved January 2025, revealed in part: "Purpose: To systematically collect relevant data about the patient as the initial step of the nursing process. To continually collect and review patient specific data throughout the patient's hospitalization. To accurately document assessment findings on an approved form in the medical record. 5. Assess each patient at the time of admission and continually throughout the patient's hospitalization at least twice a day or as warranted by changes in the patient's care needs though the systematic collection of data in the following areas: biophysical, psychosocial, risk/environmental and educational."

Patient #1
Review of Patient #1's medical record revealed Patient #1 was admitted on 05/29/2025 with a diagnosis of Major Depressive Disorder (MDD). Review of the Coroner Emergency Certificate (CEC) dated 05/30/2025 revealed in part that Patient #1 had a history of schizophrenia and mild intellectual disability. On the morning of 05/31/2025, Patient #1 was involved in an alleged patient to patient sexual assault incident with Patient #2. Nursing Notes revealed in part, that the incident occurred at 8:03 AM. Patient #1 was interviewed by law enforcement. Patient #1 was transferred on 05/31/2025 at 10:15 AM to the ER for an evaluation.

Review of Patient #1's medical record failed to reveal documented evidence that a clinical assessment was performed by a nurse or provider following the alleged sexual assault prior to being transferred to the ER for an evaluation.

In an interview on 06/25/2025 at 2:00 PM, S3DON confirmed that a clinical assessment was not documented by a nurse or the provider following the alleged sexual assault of Patient #1.


Patient #3
Review of Patient #3's medical record revealed Patient #3 was admitted on 11/01/2024 with an admit diagnosis of Schizoaffective Disorder, Bipolar type.
Review of nursing note on 11/03/2024 at 6:05 PM revealed in part the following: Patient #3's mother called to inform her that we are investigating the accusation of him being raped in his sleep last night. Patient #3's mother talked about how Patient #3 has made accusations of being raped at prior hospitals and when it was investigated it was not substantiated.

Review of Patient #3's medical record failed to reveal documented evidence that a clinical assessment was performed by a nurse or provider following the alleged sexual assault.

In an interview on 06/25/2025 at 2:45 PM, S1ADM and S3DON confirmed that a clinical assessment was not documented by a nurse or the provider following the alleged sexual assault of Patient #3. S1ADM stated that camera footage was reviewed and no one entered his room throughout the night.

Based on record review and interview, the hospital failed to ensure the nursing staff developed an individualized nursing care plan for each patient. This deficient practice was evidenced by:
1) failure to update the treatment plan following an incident for 2 (#1, #3) of 3 (#1-#3) patient records reviewed; and
2) failure of the nursing staff to include medical diagnoses in the treatment plan for 2 (#1, #2) of 3 (#1-#3) patient treatment plans reviewed.
Findings:

Review of hospital policy titled, "Master Treatment Plan/Weekly Update Treatment Plan," approved January 2025, revealed in part: "PURPOSE: To provide comprehensive, individualized plan of treatment for each patient. Procedure: B. Treatment plans will be individualized to address patient specific problems, identified through clinical assessments."

1) Failure to update the treatment plan following an incident for 2 (#1, #3) of 3 (#1-#3) patient records reviewed.
Patient #1
Review of Patient #1's medical record revealed Patient #1 was admitted on 05/29/2025 with an admit diagnosis of Major Depressive Disorder and a wound to her left arm from a suicide attempt prior to admission. Further review of Patient #1's medical record revealed on 05/30/2025 that Patient #1 attempted to tear her stitches from her left arm. Further review failed to reveal that wound care was added to Patient #1's treatment plan.

In an interview on 06/25/2025 at 1:19 PM, S3DON confirmed the above mentioned findings.

Patient #3
Review of Patient #3's medical record revealed Patient #3 was admitted on 11/01/2024 with an admit diagnosis of Schizoaffective Disorder, Bipolar type. Review of Patient #3's physician orders revealed in part that Patient #3 was placed on elopement precautions on 11/03/2024 at 6:40 PM. Further review of Patient #3's treatment plan failed to reveal that Patient #3's treatment plan was updated to include risk for elopement.

In an interview on 06/25/2025 at 3:06 PM, S1ADM confirmed the above mentioned findings.


2) Failure of the nursing staff to include medical diagnoses in the treatment plan for 2 (#1, #2) of 3 (#1-#3) patient treatment plans reviewed.
Patient #1
Review of Patient #1's medical record revealed Patient #1 was admitted on 05/29/2025 with Major Depressive Disorder and a wound to her left arm from a suicide attempt prior to admission. Further review of Patient #1's medical record revealed Patient #1 had a past medical history of HTN and GERD.
Review of Patient #1's treatment plan failed to reveal a treatment plan for the wound, HTN, or GERD.

In an interview on 06/25/2025 at 1:19 PM, S3DON confirmed the above mentioned findings.

Patient #2
Review of Patient #2's medical record revealed Patient #2 was admitted on 05/27/2025 with depression, suicidal ideations, and auditory hallucinations. Further review of Patient #2's medical record revealed Patient #2 had a past medical history of Schizoaffective disorder, Asthma, GERD, HIV, High Cholesterol, and HTN. Review of Patient #2's treatment plan failed to reveal a treatment plan that included Asthma, GERD, High Cholesterol, or HTN.

In an interview on 06/25/2025 at 3:10 PM, S3DON confirmed the above mentioned findings.

Based on record review and interview, the hospital failed to ensure all medical record entries were complete. This deficient practice is evidenced by failing to ensure medical records contained sufficient information to identify the patient for 2 (#1, #3) of 3 (#1-#3) medical records reviewed.
Findings:

Patient #1
A review of Patient #1's medical record revealed the following documents completed by hospital staff:
Columbia-Suicide Severity Rating Scale, dated 05/29/2025
Psychiatric Evaluation Note, dated 05/30/2025
History and Physical Examination (pages 1-4), dated 05/30/2025
Further review of Patient #1's medical record failed to reveal information containing a patient name, date of birth, or medical record number for the above mentioned documents.

In an interview on 06/25/2025 at 2:30 PM, S3DON confirmed the above mentioned medical record documents did not contain information to identify the patient.

Patient #3
A review of Patient #3's medical record revealed the following documents completed by hospital staff:
History and Physical Examination (pages 1-3), dated 11/01/2024
Consent to Release/Obtain information, not dated
Columbia-Suicide Severity Rating Scale, dated 11/01/2024
Further review of Patient #3's medical record failed to reveal information containing a patient name, date of birth, or medical record number for the above mentioned documents.

In an interview on 06/25/2025 at 4:00 PM, S3DON confirmed the above mentioned medical record documents did not contain information to identify the patient.