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Based on interview, record review, review of the facility's risk management investigation, and review of the facility's policies, the facility failed to ensure patients were free from abuse for 1 of 29 sampled patients, Patient (P) 27.
In addition, the facility failed to ensure complete abuse investigations were completed for 2 of 29 sampled patients, P1 and P2.

The findings include:

Review of the facility's policy titled, "Abuse and Neglect Reporting," revised 03/2024, revealed patients had the right to be free from physical, mental, verbal, and sexual abuse, neglect, and exploitation. Per the policy, all allegations, observations, or suspected cases of abuse, neglect, or exploitation that occurred in the hospital would be investigated by the hospital. Further review revealed cases of suspected sexual assault, physical abuse, or neglect would be given priority and would be investigated thoroughly. Continued review revealed in instances of investigations concerning a staff member's behavior, the involved staff member would be immediately suspended. Additionally, any allegation of suspected or alleged abuse or neglect against a staff member would require the staff member be immediately suspended while the allegation was investigated, and the employee would not be permitted to work until the investigation was completed.

Review of the facility's policy titled, "Patient Rights and Responsibilities," PolicyStat ID 14085180, revised 01/2018, revealed the patient had the right to be free of abuse, neglect, or exploitation; and to be treated in a safe treatment environment, with respect for personal dignity, autonomy, and privacy, in accordance with existing federal, state, and local laws and regulations. Additional review revealed the patient had the right to reasonable protection from physical, sexual, or emotional abuse or harassment.

1. Review of P26's "Face Sheet" revealed he/she was admitted on 06/03/2023 with a primary diagnosis of unspecified mood (affect) disorder.

Review of P27's "Face Sheet" revealed he/she was admitted on 06/06/2023 with a primary diagnosis of major depressive disorder, recurrent severe without psychotic features.

Review of the facility's risk management "Investigation," undated, revealed on 06/07/2023, at approximately 7:57 PM, P26 physically attacked P27, picking him/her up without provocation in the common area of the Boy's Compass Unit (BCU). Per the investigation, P26 slammed P27 to the floor, and when P27 got up, P26 then punched him/her in the jaw. Continued review of the investigation revealed P26 was moved to a secure locked area, and P27 was assessed for injuries. Further review revealed during P27's ongoing assessment, it was reported P27 suffered seizure-like activity and was transported to a local hospital. Additional facility investigation review revealed notifications were made and orders were obtained for both patients.

Continued review of the facility's risk management "Investigation," undated, revealed a video was available from the incident involving P26 and P27. The facility provided the State Survey Agency (SSA) Surveyor with a copy of the video.

Review of the facility's provided video of the incident between P26 and P27 on 06/07/2023, revealed at 7:54:00 PM, P26 was observed to be standing in the center of the BCU common area. At 7:56:05 PM, P26 entered the frame from the left side medication (med) room area. Observations of this area revealed it was a very small area with a chair and was out of the frame for the video. Between 7:56:12 PM to 7:56:36 PM, P26 walked to the front of the nurse's station without acknowledging P27. P26 then walked back out of the frame to the med room area. From 7:56:51 PM to 7:56:58 PM, P26 returned to the video frame and walked toward the center of the BCU common area. P27 was still standing in the center of the area. Three unidentifiable staff members were within approximately five feet of both patients.

Continued review of the facility's provided video of the incident between P26 and P27 on 06/07/2023, revealed at 7:57:03 PM, P26 walked to approximately three feet behind P27. At 7:57:06 PM, P26 walked up and back a couple of steps from behind P27. At 7:57:10 PM to 7:57:12 PM, P26 took P27 down to the floor by grabbing his/her legs. At 7:57:13 PM to 7:57:15 PM, P26 ran away from the area to the TV area of the BCU with staff following. P27 picked himself/herself up from the floor. Between 7:57:15 PM and 7:57:22 PM, P26 ripped off his/her shirt, advanced to P27, and delivered a right upper cut punch to P27's left jaw. Staff was immediately at P27's side.

Continued review of the facility's provided video of the incident between P26 and P27 on 06/07/2023, revealed at 7:57:26 PM to 7:57:59 PM, P26 walked away from P27 out of the frame and returned to the frame with staff at hand. P26 then walked to the nurse's station window with two staff at P26's side. At 7:58:07 PM, P26 remained at the window and staff walked away. Between 7:59:12 PM and 7:59:47 PM, Registered Nurse (RN) 3 motioned for P27 to follow him, and they left the frame and then returned to the frame. At 7:59:57 PM, P27 walked out of the frame to the med room window.

Continued review of the facility's provided video of the incident between P26 and P27 on 06/07/2023, revealed at 8:08:25 PM, P27 came back into the frame and went to the nurse's station window with RN3 at his/her side; P27 was led to a chair with nursing staff at hand. At 8:09:41 PM to 8:15:40 PM, staff fixed an ice pack for P27's jaw. At 8:16:40 PM, staff took P27's blood pressure (b/p), which was 166/99, and heart rate, which was 125 beats per minute (bpm). At 8:20:08 PM, P27 leaned to the left side and fell from the chair, striking his/her head. Staff was approximately three to four feet from P27 and advanced to assist P27. At 8:20:10 PM, numerous staff attended to P27; turned him/her to the left side; and brought the emergency cart containing items such as oxygen and a mask, defibrillator, glucose monitor, and vital sign machine. At 8:20:15 PM staff surrounded P27, preventing P27's reported seizure activity from being seen. Between 8:22:15 PM to 8:38:30 PM, emergency medical services (EMS) and a police escort arrived and assessed, evaluated, and departed with P27.

Review of RN3's "Progress Note," dated 06/07/2023 at 11:30 PM, revealed P26 assaulted P27, and they were separated with P26 placed in a secure, locked area. Per the note, P27 walked around the BCU common area and told RN3 how mad and agitated he/she was about the incident. The note revealed P27 was given medication for agitation and shoulder and jaw pain, which was described as 9/10 on the pain scale. The note stated while RN3 was on the phone with the Physician (PHYS) 2, P27 fell out of the chair and had seizure activity that lasted approximately a minute. Further review of RN3's progress note revealed that at 8:26 PM (after seizure activity), P27 had a b/p of 145/87, oxygen saturation of 99 percent, heart rate of 77 bpm, and respirations of 18 per minute. The note stated P27 was alert and oriented to self but not time or place, and both pupils were sluggish and dilated to 4+ (normal).

While interviewing RN3 on 05/15/2024 at 9:23 AM, he stated that after the incident, P26 was taken to a secure, locked area with a staff member present at all times, and P27 was assessed and treated at the time for reported shoulder and jaw pain. He stated, as P27 was moving around the environment, prior to the reported seizure activity, he was constantly being assessed for level of consciousness, mental status, and motor/verbal responses. He also stated that P26 had not displayed aggressive behaviors since admission (06/03/2023).

During an interview with the House Supervisor on 05/13/2024 at 3:19 PM, she stated she was the House Supervisor the evening of 06/07/2023 and had been notified about the incident between P26 and P27, but it was over by the time she arrived to the BCU. She further stated she remained on the BCU to assist as needed. The House Supervisor stated the environment was under control, and P27 had been assessed and treated for pain prior to the reported seizure activity. She stated re-assessment of P27 occurred after the reported seizure activity and prior to P27 being sent out for further evaluation and treatment.

During an interview with PHYS2, a medical physician, on 05/14/2024 at 8:52 AM, he stated he had been notified of P27's initial injuries and was still on the phone with RN3 when she reported P27 was exhibiting seizure like activity. He stated he gave the order for P27 to be sent out for further evaluation and treatment.

While interviewing PHYS1, a psychiatric physician, on 05/14/2024 at 3:20 PM, he stated P26 had not exhibited aggressive behaviors since admission. However, he stated P26's anger and aggressiveness was due to choices, and there was no medication that would help.

While interviewing the Chief Nursing Officer (CNO) on 05/14/2024 at 10:07 AM, she stated she had reviewed the incident and felt P27 was assessed and treated appropriately. The CNO also stated she felt patient safety had been provided with P26 placed in a secure, locked area with a staff member present at all times.


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During an interview with the Director of Quality, Performance Improvement, and Risk Management (RM) 1 on 05/03/2024 at 9:30 AM, she stated videos for the alleged incidents with P1 and P2 had been requested by the Department of Community Based Services Social Worker (SSA) 1, and the facility did not realize they needed to keep them after that, and they were erased. She stated the facility usually kept the videos for about 30 days unless they were made aware of an incident, and they specifically saved the videos. She stated, since neither P1's or P2's allegations were made during their hospitalizations, and a specific date was not specified in the allegations, the facility did not save the videos. She stated cameras were in the hallways and common areas but not the patient rooms or bathrooms.

2. Review of P1's "Face Sheet" revealed the facility admitted the patient on 02/03/2024 with diagnoses of major depressive disorder (MDD), recurrent, severe, without psychotic features. Further review revealed P1 was discharged from the facility on 02/13/2024.

Review of P1's "Physician's Orders," dated 02/04/2024, revealed an order for one-on-one observation, from 02/04/2024 to 02/09/2024, and an order for Close Visual Observation (CVO), dated 02/09/2024, now until discharge on 02/13/2024.

Review of the facility's risk management "Investigation," dated 02/20/2024, revealed P1 alleged Mental Health Technician (MHT) 1 raped him/her during the patient's one-on-one assignment sometime during P1's hospitalization between 02/03/2024 and 02/13/2024. Further review revealed the complaint was received by SSA1 on 02/20/2024. Continued review revealed SSA1 investigated the allegation with the facility's staff present. Additionally, the facility investigation revealed SSA1 unsubstantiated the allegation. However, there was no documentation of the facility's findings. The investigation did state the facility was unaware of the patient's allegation while the patient was hospitalized at the facility.

Review of the facility's February 2024 staffing schedules revealed MHT1 was scheduled to work on P1's unit on 02/03/2024 and 02/04/2024.

Review of P1's "Supervision" sheets revealed MHT1 signed as supervising the patient on 02/04/2024 in the patient's room from 11:00 AM until 12:45 PM. Further review revealed MHT1 signed as supervising P1 in the patient's room on 02/07/2024 from 2:00 PM to 3:30 PM.

During an interview with RM1 on 05/01/2024 at 12:45 PM, she stated she was unaware of P1's allegation of rape until notified by SSA1 on 02/20/2024. She further stated SSA1 investigated the allegation and completed a documentation review and interviews and concluded MHT1 did not work with P1 directly, and SSA1 unsubstantiated the allegation. She stated the facility did not complete a separate investigation and did their investigation along with SSA1. Additionally, she stated the staffing sheets reviewed by SSA1 showed MHT1 did not work on P1's unit. She stated MHT1 had stated he never worked on P1's unit; therefore, MHT1 was not suspended.

During an additional interview with RM1 on 05/01/2024 at 1:50 PM, she stated upon review of the February 2024 staffing sheets this afternoon, she discovered MHT1 did work directly with P1 on a one-on-one basis, and MHT1 was immediately suspended for "lying regarding his observation with P1." She further stated SSA1 had only asked for night shift schedules during her investigation, and no one had looked at day shift scheduling for February 2024.

During an interview with SSA1 on 05/01/2024 at 3:48 PM, she stated she did initiate an investigation for MHT1 regarding P1's allegations on 02/18/2024 and completed the investigation on 03/27/2024.

3. Review of P2's "Face Sheet" revealed the facility admitted the patient on 02/06/2024 with diagnoses of major depressive disorder (MDD), recurrent, severe, without psychotic features and post-traumatic stress disorder. Further review revealed Patient 2 was discharged from the facility on 02/14/2024.

Review of P2's "Physician's Orders" revealed P2 had no orders for one-on-one observation or CVO during his/her hospitalization.

Review of the facility's risk management "Investigation," dated 04/24/2024, revealed P2 alleged MHT1 raped him/her during the patient's one-on-one assignment sometime during P2's hospitalization between 02/06/2024 and 02/14/2024. Further review revealed the complaint was received by SSA1. Continued review revealed SSA1 investigated the incident with facility staff present. Additionally, there was no documentation of the facility's findings. The investigation included an interview in which MHT1 told SSA1 he never worked on P2's unit.

Review of P2's "Supervision" sheets revealed MHT1 signed as supervising P2 on 02/07/2024 in the day room from 4:30 PM until 4:45 PM and at 6:15 PM. Further review revealed MHT1 supervised P2 on 02/07/2024 in a group session from 7:00 PM to 7:15 PM.

During an interview with RM1 on 05/01/2024 at 12:45 PM, she stated she was unaware of P2's allegation of rape until notified by SSA1 on 04/24/2024. She further stated SSA1 conducted an investigation and completed documentation review and interviews and concluded MHT1 did not work with P2 directly, and SSA1 unsubstantiated the allegation. She stated the facility did not complete a separate investigation and did their investigation along with SSA1. Additionally, she stated the staffing sheets reviewed by SSA1 showed MHT1 did not work on P2's unit. She stated MHT1 had stated he never worked on P2's unit; therefore, MHT1 was not suspended.

During an interview with RM1 on 05/01/2024 at 1:50 PM, she stated upon review of the February 2024 staffing sheets this afternoon, she discovered MHT1 did work directly with P2, and MHT1 was immediately suspended for "lying regarding his observation with P2." She further stated SSA1 had only asked for night shift schedules during her investigation, and no one had looked at day shift scheduling for February 2024.

During a continued interview with SSA1 on 05/01/2024 at 3:48 PM, she stated she did initiate an investigation for MHT1 regarding P2's allegations on 04/24/2024 and had not completed her investigation.

During an additional interview with RM1 on 05/03/2024 at 9:30 AM, she stated MHT1 had been interviewed and suspended, and staff had been provided abuse education.

During an interview with MHT1 on 05/10/2024 at 9:37 AM, he stated his job duties included providing direct care to patients on his unit. He further stated he primarily worked the adolescent boys units but occasionally was pulled to other units if extra staff was needed or to give other staff breaks. He stated he remembered P1 and might have provided increased supervision for him/her during visitation hours when extra staff was required or to provide breaks for other staff. Additionally, he stated he did not remember P2.

During an interview with RN1 on 05/07/2024 at 1:54 PM, she stated she had annual abuse training. She further stated if an abuse allegation was made against a staff member, the staff member would be suspended pending the investigation.

During an interview with MHT2 on 05/08/2024 at 10:43 AM, she stated she had annual abuse training. She further stated if she was made aware of an abuse allegation against a staff member, she would report it to the Charge Nurse (CN) and send an email to the Unit Manager, as well as make a note of the allegation in the patient's chart.

During an interview with RN2 on 05/08/2024 at 11:24 AM, she stated she remembered P1 had Covid while in the facility and was isolated to his/her room. She further stated the facility tried to schedule same sex staff to stay with patients on increased supervision levels, but it was not always possible. She stated she did not remember any allegations made by P1 or P2 while they were hospitalized in the facility. She stated she had abuse training annually, and if an abuse allegation was made, she would notify the Unit Manager and House Supervisor, separate the staff member from the patient, then complete an incident report and call the patient's guardian.

During an interview with PHYS1 on 05/09/2024, he stated he took care of P1 and P2 while they were hospitalized, but he did not remember them making any accusations while they were in the facility.

During an interview with Licensed Professional Clinical Counselor (LPCC) 2 on 05/09/2024 at 12:32 PM, she stated she currently worked with P1 on an outpatient basis at the facility since 04/16/2024. She further stated P1 "brought up" the allegation against MHT1 during his/her outpatient stay and expressed concern over the possibility of seeing MHT1 while in the facility. She stated P1 had told her MHT1 had sexually assaulted him/her while being an inpatient, but he/she did not offer specifics. Additionally, she stated it was her opinion P1 had been questioned by multiple people regarding the allegation and would respond negatively in treatment if he/she was questioned by this State Survey Agency Surveyor.

During an interview with the Chief Operating Officer (CEO) on 05/15/2024 at 10:26 AM, he stated his expectation was for staff to follow the facility's policies.