HospitalInspections.org

Based on document review and interview, the Hospital failed to comply with the Condition of Participation of Patient Rights, 42 CFR 482.13.

Findings include:

1. The Hospital failed to have a sexual abuse policy/protocol that would detail procedures to follow in the event of a sexual abuse allegation or inappropriate sexual behavior. See deficiency at A-145.

Based on document review and interview, for 3 of 3 clinical records (Pt. #1, Pt #2, Pt #8) reviewed for sexually acting out behavior, the Hospital failed to have a sexual abuse policy/protocol that would detail procedures to follow in the event of a sexual abuse allegation or inappropriate sexual behavior.

Findings include:

1. On 8/11/2025, a sexual abuse policy/protocol was requested. The facility could not provide a sexual abuse policy/protocol that would include procedures to follow in the event of a sexual abuse allegation (protection of patient, offering of a sexual assault kit, examination, notification to the required parties, etc.)

2. An incident report (dated 6/26/2025), documented by the 3 East Behavioral Health RN (E #5) was reviewed on 8/11/2025. The report included, " ...Behavioral incident: Patient found in a compromising position with a ...peer. Location: 3 East. At about 1050 [AM] while staff [E #4] were doing rounds found patient [Pt #1] in Rm 359 standing by the bed in a compromising position with [Pt #1's] gown up to [Pt #1's] waist with a ...peer [Pt #2] still with clothes on ran towards the bathroom. When approached [Pt #1] stated, 'My doctor said I am the only one who could have sex with anyone, and yes, I did have sex with [Pt #2] and it feels so good, I was stressed out and it calmed me down. I did it with [Pt #2's] roommate last night too!' referring to patient [Pt #8]. I [E #5] talked to patient [Pt #2] and [Pt #2] stated, 'We were about to finish when [staff member] knocked and opened the door!' both patients admitted that it was consensual. Talked to [Pt #8] [Pt #8] did state that, '[Pt #1] came to my room last night pulled my shirt up and we did it!'. I [E # 5] asked patient [Pt #8] if it was consensual, [Pt #8] replied 'yes!'.

3. The 3 East & 3 West "Community Rules" (Behavioral Health units), included, "No touching, hugging, kissing or sexual contact..."

4. On 8/11/2025, Pt. #1's clinical record included the following:
- Pt #1 presented to the ED on 6/22/2025, voluntarily, for a psychiatric evaluation.

- The ED physician note (dated 6/22/2025), included, "Reason for visit: Suicidal ideation ...history of major depression complains of suicidal ideation with no specific plan ...Review of past medical records reveal several different diagnoses bipolar disorder, schizophrenia as well as schizoaffective disorder [serious mental illnesses] ...Psychiatric: Denies any visual auditory hallucinations or +suicidal ideation+ depression ...Discharge/Disposition: Inpatient Admission ..."

- ED nursing note (dated 6/22/2025 at 5:22 AM), indicated that Pt #1 was transported/admitted to 3 East (co-ed behavioral health unit).
- The Psychiatric Evaluation (dated 6/22/2025), documented by the Advanced Practice Nurse (APN #2), included, " ...admitted voluntarily ...brought in for suicidal ideation without a plan, depression and medical non-compliance ...behavior: cooperative, anxious, guarded, impulsive, isolated. Insight poor, Judgement poor ...Plan: Patient will be admitted to locked unit ..."
- Nursing notes from 6/22/2025-7/1/2025, were reviewed and included the following notes:
- 6/22/2025 at 6:40 AM: (Admission note): " ...admitted to the behavioral health unit with a diagnosis of schizophrenia ...patient is alert, coherent and oriented X3 [person, place, time] ...patient will be placed on SP [suicidal] and AP [assault] precautions ..."
- 6/26/2025 at 5:06 PM, documented by a RN (E #5), "At about 10:50 [AM] patient was found in RM 359 standing by the bed in a compromising position with [Pt #1's] gown up to [Pt #1's] waist with a ...peer. When approached patient [Pt #1] stated, 'My doctor said I am the only one who could have sex with anyone and yes I did have sex with [Pt #2] and it feels so good. I was stressed out and it calmed me down, I did it with [Pt #2's] roommate last night too!' Attending physicians made aware orders received, noted and carried out. Patient was placed on SAO [sexually acting out precautions], placed on 1:1 [sitter within arm's length] for safety."
- 6/27/2025 at 7:00 AM: APN #1's orders for STI testing (HIV, RPR, Hepatitis) offered. Refused by patient (Pt #1).
Pt #1's record did not include an examination or offer of sexual assault kit.

5. Pt #2's clinical record included that Pt #2 was admitted to 3 East on 6/25/2025, for self-reporting of suicidal ideation. Pt #2's physician orders indicated that Pt #2 was on assault and suicide precautions on admission. SAO precautions were initiated and marked on the rounding sheets, after the 6/26/2025 incident. Pt #2 was moved to a different unit (3 West/Behavioral Health unit-male unit) due to the 6/26/2025 incident with Pt #1. STI testing was ordered and completed on 6/27/2025. Pt #2's record did not include an examination or offer of sexual assault kit.

6. Pt #8's clinical record included that Pt #8 was admitted to 3 East on 6/24/2025 for psychiatric evaluation, due to aggressive and combative behavior. Pt #8's physician orders indicated that Pt #8 was on assault precautions on admission. SAO precautions were initiated and marked on the rounding sheets, after the 6/26/2025 incident. Pt #8 was moved to a different unit (3 West/Behavioral Health unit-male unit) due to the 6/26/2025 incident with Pt #1. STI testing ordered and completed on 6/26/2025. Pt #8's record did not include an examination or offer of sexual assault kit.

7. On 8/12/2025 at 10:00 AM, an interview was conducted with the Chief Nursing Officer (E #11). E #11 stated that E #11 was made aware by the Behavioral Health Director, of an incident involving Pt #1 and 2 other patients (Pt #2, Pt #8). E #11 stated that a Mental Health Specialist (E #4) found Pt #1 and Pt #2 in a compromising position. E #11 stated that E #11 immediately began investigating to determine if there was actual witnessed sexual intercourse. E #11 stated that E #4 did not witness the patients in the physical sexual act, just the implied positioning of the 2 patients. E #11 stated that both Pt #2 and Pt #8 were interviewed regarding the allegation of engaging in sexual activity with Pt #1. E #11 stated that although it was documented that Pt #8 engaged in sexual activity with Pt #1 (on 6/25/2025), E #11 stated that when Pt #8 was interviewed again, Pt #8 denied it. E #11 stated that this incident was taken seriously, as even consensual sex is not allowed on the unit.

8. On 8/11/2025 at 1:40 PM, a phone interview was conducted with the Lead Mental Health Specialist (E #4). E #4 stated that while doing every 15 minutes rounds, E #4 entered Pt #2's and Pt #8's room. E #4 stated that Pt #1 was found bent over in a "compromising position" with Pt #2 behind Pt #1. E #4 stated Pt #2 yelled out "hey!" and then ran into the bathroom. E #4 stated that Pt #2's roommate (Pt #8) was also in the room when E #4 entered, but there was no interaction between Pt #1 and Pt #8 at that time. E #4 stated that E #4 then left out of the room to inform the assigned nurse (E #5) about the incident. E #4 stated E #5 then came in and questioned both Pt #2 and Pt #8 about the occurrence. All three patients stated that sexual activity was consensual. E #4 stated that originally Pt #1 was on assault and suicide precautions, but later SAO precautions were added due to the incident. E #4 stated that Pt #1 was moved to a private room closer to the nurse's station. E #4 stated Pt #1 was also put on 1:1 (sitter).

9. On 8/12/2025 at 2:30 PM, an interview was conducted with the Attending Psychiatrist (MD #1). MD #1 stated that no one complained that Pt. #1 was violated. MD #1 stated that, therefore, there was no indication that a rape kit should have been offered for Pt. #1. MD #1 stated that the protocol for sexual abuse allegation is that a rape kit would be offered. MD #1 stated that 1:1 monitoring was done for Pt. #1 following the incident.

10. On 8/12/2025 at 2:45 PM, an interview was conducted with the Director of Quality (E #1). E #1 confirmed and acknowledged that the Hospital does not have a sexual abuse protocol or policy. E #1 stated that the Hospital has a policy on reporting sexual abuse allegations to the State, but does not have a policy or protocol on the steps/process required for a sexual abuse allegation.