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Based on observation, interview, and record review, the facility failed to follow their policies to ensure prevention and protection from sexually acting out patients for 1 (P-1) of 10 patients reviewed, resulting in sexual assault and the potential for unsatisfactory patient outcomes for all patients served by the facility. Findings include:

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0145 - Failure to protect patients from abuse

Based on observation, interview, and record review, the facility failed to follow their policies to ensure prevention and protection from sexually acting out patients for 1 (P-1) of 10 patients reviewed, resulting in sexual assault and the potential for unsatisfactory patient outcomes for all patients served by the facility. Findings include:

On 4/1/2025 at 1555 record review for P-1 was conducted and a History and Physical dated 3/14/2023 revealed she was a 22-year-old who was admitted to the facility on 3/13/2023 from an Adult Foster Care Home for chronic and severe mental health issues including religious preoccupations, aggressive behaviors including hitting, kicking and spitting at staff and her mother. P-1's Past Medical History (PMH) includes Schizoaffective Disorder, Bipolar Type, Schizophrenia, depression, premenstrual dysphoric disorder and anorexia. P-1 is under a court order for treatment, and she continues to experience auditory and visual hallucinations, paranoia and aggressive behaviors, and continues to exhibit abusive behaviors to herself and others. Review of the Medical History and Physical exam dated 3/14/2025 reveals P-1 has intermittent episodes of very good behaviors which last approximately 3 weeks and then she cycles back to physical aggression and assaulting staff which require manual holds, restraints and 1:1 observation for an increased level of safety.

On 4/1/2025 at 1400 record review for P-2 was conducted and revealed she is a 44-year-old who is hospitalized after she was found Not Guilty by Reason of Insanity (NGRI) related to charges of Homicide-Open Murder, two counts of Animal-Killing/Torturing-Third Degree and three counts of Weapons-Felony Firearm for stabbing her boyfriend and their 2 dogs on 3/17/2021. P-2 has been diagnosed with Schizoaffective Disorder, Bipolar, and attention deficit hyperactivity disorder (ADHD). P-2 was transferred to the facility on 1/12/2023 for treatment. Review of a memorandum dated 10/22/2024 regarding "NGRI Request for Commencement of Planning for Discharge" reveals the treatment team has discussed that she be recommended for "discharge into the community" and that she has reached her maximum benefit at the facility.

During a tour of the facility on 4/1/2025 it was observed this was a 100-bed facility with 70 male beds and 30 female beds and a current census of 98 patients. The facility is separated into 4 separate units named Winter, Spring, Summer and Fall. A tour of the Winter Unit that was conducted on 4/1/2025 at 1103 and observation reveals the locked unit is divided into 3 patient care hallways. Hallway C has 5 private rooms designated for female patients and hallways A & B have 8 rooms, two of which are shared which are designated for male patients. Resident Care Aids (RCA) are observed to be seated at a desk off to the side near the entry of hallway. The nursing staff workspace is located behind a door (without a window) on the unit and does not allow for the ability to observe patients/staff on the unit. All patient care hallways are unable to be observed by nurses in the workspace or by RCA's.

Review of the Incident Report #16781, dated 3/29/2025 at 2156 reveals the following:

Date Incident Occurred: 3/29/2025
Time Incident Occurred: 08:45PM
Date Incident Reported: 3/29/2025
Time Incident Reported: 08:46PM

Type of Incident: PATIENT TO PATIENT ASSAULT, SEXUAL PROBLEM BEHAVIOR

Incident Location/Details: Winter-Peer/Bedroom

Explain what happened: Staff opened peer's bedroom door to find this patient fully undressed in her peer's bed, humpin [sic] her peer. Staff verbally redirected this patient to get out of her peer's bed and to get dressed immediately. Pt complied and began getting dressed and exited the room. Pt made no verbal comments during this incident. Victim denies injury. Nurse notified.

Action taken by staff: De-escalation Techniques Used, Re-direct/Defuse, Separated Patients

Additional action taken by staff: Staff ensure that both patients were not harmed. Staff will continue to monitor for safety.

On 4/1/2025 at 1448 review of video from 3/29/2025 at 2052 from the Winter Unit, Hallway C (the female unit) was conducted. The video reveals P-1 (identified by facility staff) walking out into the hallway from her room, dressed and attempting to go into 2 other patient rooms, which she did not enter. She then went to a third patient's door, looking in and then walking back out. At 2120 P-1 is observed walking into P-2's room and after 2 minutes and 26 seconds 4 staff members walk into the hallway and into P-2's room, the light in the room is turned on and 1 minute later P-2 walks out into the hallway. P-1 is observed to be fully dressed and exiting P-2's room after 7 minutes with facility staff.

An interview with the RN3 Manager, Associate Nurse Executive (Staff J) was conducted on 4/2/2025 at 0945 and reveals he reviewed the remainder of the video and confirmed 1:1 supervision for P-1 did not begin until the following morning on 3/30/2025 at 0850, which was approximately 12 hours following the alleged sexual assault of P-2. Staff J also confirmed an order for 1:1 supervision was not entered until 3/30/2025 at 0850 and Sexual Precautions orders were never ordered prior to or after the incident.

On 4/2/2025 at 0932 review of the Overview Report of Seclusion & Restraint Events from 10/1/2024 to 4/1/2025 with the Assistant Nurse Executive (Staff B) reveals P-1 required restraint or seclusion 36 times for behavioral issues, 13 of the incidents included inappropriate sexual behavior and 2 incidents involved patient to patient assault. When queried whether Sexual Precaution orders were entered, Staff B explained the facility would increase the level of monitoring as required when an incident occurred, but Sexual Precaution orders have not been entered.

During record review of Orders for P-1 on 4/1/2025 at 1400 documentation reveals P-1 was not ordered to have 1:1 Supervision on 3/29/2025 following the alleged sexual assault of P-2. An order for 1:1 Supervision, Ongoing at all times due to violence and unpredictable behaviors, Staff can sit outside room when patient sleeping was discontinued on 3/24/2025 (5 days prior to the incident). A new order for 1:1 Supervision was not placed until 3/30/2025 at 0850 (approximately 12 hours following the alleged sexual assault).

On 4/1/2025 at 1145 an interview with P-2 was conducted with Staff B present. P-2 revealed P-1 walked into her room on 3/29/2025 and began taking her clothes off, crawled into bed with her and whispered in her ear that she wanted to have sex. P-2 explained she began screaming for help and told P-1 to get off of her, but she kept touching her through the blanket. P-2 revealed that staff arrived in less than a minute and told P-1 to get dressed and they asked her to leave her room. When queried if she was injured during the assault, P-2 replied, "no". P-2 revealed her room was moved to another unit 2 days later and she observed that P-1 now has 1:1 supervision. P-2 revealed she contacted the police to file a report. During the interview P-2 shared she had observed P-1 grab another male patient in his genitalia area and it took a day for her to be put on 1:1 supervision following this incident.

An interview with the House Supervisor RN2 (Staff K) was conducted on 4/2/2025 at 1030. Staff K revealed she was alerted about the situation involving P-1 and P-2 by the nurse (Staff P) working on the unit. Staff K explained that Staff P reported to her that P-1 was found on top of P-2 naked in her bedroom humping her. Staff P revealed she asked Staff P what he did and he reported to her that P-1 was told to get dressed and go back to her room. Staff K added that she mentioned the need for 1:1 supervision for P-1 to the nurse but Staff P told her he was going to medicate her once she was back in her room, and they had no further issues with P-1's behavior that evening. When queried whether she was asked for 1:1 supervision for P-1, Staff P revealed "if the doctor told the nurse to implement a 1:1, I would have figured something out."

On 4/2/2025 at 1000 an interview with the Licensed Psychiatrist (Staff D) that was caring for P-1 and P-2 was conducted. Staff D explained that he sees all of his patients at the facility via telemedicine and was made aware of the incident when he took report from the on-call psychiatrist (Staff E) the following Monday. Staff D revealed that P-1's behaviors have improved lately, and they were able to take her off of 1:1 supervision recently. When queried if P-1 should have been put back on 1:1 observation by the on-call Psychiatrist following the incident involving P-2 Staff D revealed, "that is not acceptable at all, she should have been put on a different level" and an order should have been placed immediately for 1:1 observation. When queried why P-1 did not have a Sexual Precaution Order in place throughout her admission, with a history of 13 episodes of sexually inappropriate behaviors since 1/1/2025, Staff D explained the most appropriate way to manage P-1's behavior is with 1:1 supervision, medications or restraints. Staff D added that it has been difficult to manage P-1's behaviors with medication as she has been treatment resistant, and a Sexual Precaution order would have been appropriate for her.

On 4/1/2025 at 1537 an interview with the Recipient Rights Advisor (Staff I) was conducted and revealed she was notified about the incident involving P-1 and P-2 and met with P-2 the following Monday (2 days after the incident). When queried how she was made aware of the incident, Staff I revealed the nurse (Staff P) that was working at the time of the incident sent her an email. Staff I explained it was reported to her that P-2 was awakened by P-1 humping her and then staff came in after she called for help. Staff I revealed she spoke with P-2 who shared with her that the incident brought back some childhood trauma. Staff I explained she attempted to interview P-1 but all she would say was she was "heartbroken". Staff I added that she has been told that P-1 has been acting out sexually and staff have been trying to redirect her. When queried whether it was her opinion that P-2's rights were violated, Staff I stated, "absolutely".

Review of facility policy titled "Special Precautions and Management Instructions/LOS", procedure #3.67, last revised 3/2024 revealed in the section, "Sexual Precautions: Upon the clinical assessment and per the order of a physician, sexual precautions are initiated for those patients who are at risk for sexually acting out." Review of the section titled "Standards", #7. An RN may, to prevent injury to the patient or others, initiate limiting Management Instructions including Special Precautions level of monitoring until the physician is notified."