University of Iowa Hospital & Clinics

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48530 Based on medical record review, review of hospital policy, observation and staff interviews, the hospital’s administrative staff failed to ensure that nursing staff appropriately supervised patients receiving services from the inpatient pediatric behavioral health (BH) units (see A0144). The cumulative effect of this deficient practice resulted in the opportunity for inappropriate sexual contact between two inpatient adolescent patients and the hospital’s inability to ensure the nursing staff provided safe and appropriate care in accordance with the hospital’s policies and acceptable standards of practice. The hospital’s administrative staff identified a total capacity potential of 15 patients for the inpatient pediatric behavioral health unit at the time of the investigation.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48530 Based on medical record review, review of hospital policy, observation and staff interviews, the hospital’s administrative staff failed to ensure there nursing staff appropriately supervised patients to meet their safety needs while receiving services from the inpatient pediatric behavioral health (BH) unit (see A0395). The cumulative effect of this deficient practice resulted in the hospital’s inability to ensure an RN supervised and evaluated the nursing care on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy. The hospital’s administrative staff identified a total capacity potential of 15 patients on the inpatient adult behavioral health unit at the time of the investigation.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48530 Based on medical record review, behavioral health (BH) security video review, staff interviews, and observation, the hospital’s administrative staff failed to ensure that nursing staff on the inpatient pediatric BH unit appropriately supervised 2 of 10 patients reviewed (Patient #4, and Patient #7). The effects of the failures and deficient practice resulted in the hospital staff’s inability to ensure that patients received care in a safe setting resulting in allegations of Patient #4 having inappropriate sexual contact with Patient #7 on the evening of 7/26/24 through the early morning on 7/27/24. Findings include: 1. Review of the policy, titled Psychiatric Nursing Precaution/Observation, dated 11/2023, revealed patients were to be observed every 15 minutes, twenty-four hours a day. For sexually acting out behaviors, the policy directed staff to ensure the patients were not left alone with other patients...”May be placed on dayroom restriction or 1:1 at RN discretion for increased monitoring and or safety.” 2. During an interview on 8/21/24 at 3:49 PM, PNA Q recalled Patient #4 would avoid Patient #7. PNA Q stated, (prior to the incident that occurred on the night of 7/26/24 and the early morning of 7/27/24), “(Patient #7) was saying (Patient #4) was obsessed with (Patient #7) and (Patient #4) would say it wasn’t true...we gave them verbal warnings, and if it continued, we would separate them. I did observe (Patient #7) inappropriately touching (Patient #4’s) shoulder or trying to hug (Patient #4) and (Patient #4) would push Patient #7) away and tell staff.” 3. During an interview on 8/21/24 at 1:15 PM, RN N recalled caring for Patient #7 on the evening of 7/26/24. RN N recalled Patient #4 and Patient #7 were sitting together earlier in the evening in the day area and had their hands on each other’s legs. RN N stated, “I told them to move apart or they would be at separate tables. They moved apart and started whispering... I told them to stop or they would go to their rooms.” 4. The hospital nursing staff were aware of the inappropriate physical contact between Patient #7 and Patient #4, but failed to evaluate, assess or counsel the patients about their inappropriate behaviors to keep the behaviors from escalating. The medical records for Patient #7 and Patient #4 lacked any documentation regarding the incidents of inappropriate contact between Patient #4 and Patient #7 prior to the incident that occurred on the night of 7/26/24 and the early morning of 7/27/24. 5. Review of Patient #7’s medical record revealed: a. On 7/6/24 at 6:43 PM, Patient #7 was admitted to the inpatient pediatric BH unit. b. On 7/27/24 at 10:38 PM, RN F documentation revealed “At approximately 1:35 PM (Patient #7) was sitting in the day room with another peer, and reported that (Patient #4) came into (Patient #7’s) room last night, and kissed (Patient #7), grabbed their hand to (touch Patient #4 in a sexual manner). (Patient #7) reported that they told (Patient #4) to stop and (Patient #4) choked (Patient #7). (Patient #7) reported they told the other peer because they feel more comfortable talking the peer. (Patient #7) expressed they were raped before, and this incident triggered them, so they didn’t report it to staff. While talking to the (Patient #7) they saw the staff outside of (Patient #4’s) room, and stated “what is (Patient #4) saying?” “(Patent #4) is going to tell them that I did something to (Patient #4), and I didn’t”... (Patient #7) was able to write a report about what happened last night (between the night of 7/26/24 and the morning of 7/27/24). 6:00 PM, Staff O Rape Victim Advocate did a report (met) with the (Patient #7) in private...The patient (Patient #4) is on 1:1 observation per Staff D, Hospital Operations Manager (HOM). (Patient #7’s) mother called and was notified of the incident ... (Patient #7’s) mother is requesting that 1:1 female staff only, no males due to (Patient #7’s) prior history of sexual assault. No further behavioral concerns reported or noted.” c. On 7/28/24 at 1:44 PM RN V documented Patient #7 discharged from the hospital. 6. Review of BH unit security video footage by the survey team on 8/16/24 at 2:30 PM revealed the following: a. On 7/26/24 at 10:22 PM, Patient #4 entered the open door-way into Patient #7’s room, shut Patient #7’s door, remained in Patient #7’s room for approximately 3 minutes, Patient #4 exited the room at 10:25 PM, left Patient #7’s door partially open and walked 40 steps (equivalent to approximately 40 feet) back to his room. There were 2 staff visible in the nurses station (enclosed area with walls of glass on the top half) at the end of the hallway (approximately 7 feet from Patient #4’s room and approximately 47 feet from Patient #7’s room) during this time (the video angle was too far away to determine the identities of the staff). b. On 7/26/24 at 11:00 PM, Patient #4 talked with nursing staff at the entry way to the nurses station, went to the doorway of his room, looked back periodically at the nurses station as he walked down the hallway and entered Patient #7’s room at 11:01 PM, shut Patient #7’s door, remained in Patient #7’s room for approximately 1 minute, and then Patient #4 exited the room at 11:02 PM, shut Patient #7’s door and returned to his room. There were 2 staff visible in the nurses station during this time. c. On 7/27/24 at 12:06 AM, Patient #4 opened the door of his room, stood at his doorway for 30 seconds facing the nurses station, then walked down the hallway, opened the door to Patient #7’s room and entered, shut the door, remained in Patient #7’s room for approximately 12 minutes, Patient #4 exited the room at 12:18 AM and shut Patient #7’s door, walked down to the hallway and returned to his room. One staff exited the nurses station immediately after Patient #4 returned to his room, but walked in the opposite direction of the camera view (unable to determine the identify of the staff). d. On 7/27/24 at 6:04 AM, Patient #4 opened the door of his room, stood at his doorway for 20 seconds facing the nurses station, walked down the hallway, entered the partially opened door into Patient #7’s room, Patient #4 shut Patient #7’s door, remained in Patient #7’s room for approximately 8 minutes, and then Patient #4 exited the room at 6:12 AM and returned to his room. During this same time frame on 7/27/24 at 6:08 AM, while Patient #4 was in Patient #7’s room, PNA P walked down the hallway directly to Patient #7’s room. PNA P opened Patient #7’s door partially (approximately 18 inches) moved her head forward slightly while looking in the direction of the open doorway and shut the door within 2 seconds of opening the door. PNA P did not enter Patient #7’s room or put her head in the room through the open doorway. PNA P then unlocked and entered the laundry room which was located across the hallway from Patient #7’s room (approximately 6 to 7 feet from Patient #7’s room). The laundry room door had a small quarter glass window, approximately 6 inches in width and 2 feet in length. PNA P remained in the laundry room for approximately 1 minute, exited, looked through the window into the room directly next to the laundry room and then returned to the nurses station. PNA P did not go into or look in the direction of Patient #4’s room. As PNA P got close to the nurses station, Patient #4 could be seen peeking out the partially opened door of Patient #7’s room and looking toward the direction of the nurses station just prior to exiting the room. PNA P failed to notice Patient #4 was in Patient #7’s room and failed to notice that Patient #4 was not in his own room. 7. During an interview on 8/21/24 at 9:05 AM, RN F explained Patient #7 told them Patient #4 had come into Patient #7’s room last night (between the night of 7/26/24 and the early morning of 7/27/24) and used Patient #7’s hand to touch Patient #4 in a sexual manner. RN F reported Patient #4 told them they went to Patient #7’s room because Patient #7 said they had a gift for Patient #4. RN F explained Patient #4 reported no staff was around when they went to Patient #7’s room. 8. During an interview on 8/21/24 at 3:49 PM, PNA Q recalled Patient #7 reported to them (on 7/27/24) Patient #4 had come to their room and kissed them without their consent. PNA Q recalled Patient #4 told them they went to Patient #7’s room because Patient #7 said they had something to give them but when they went to Patient #7’s room they said they didn’t have anything for them and Patient #7 kissed Patient #4. PNA Q reported Patient #4 said they pushed Patient #7 away and ran out and cried. 9. Review of the BH pediatric unit census on the evening of 7/26/24 to the end of the night shift at 7:30 AM on 7/27/24 revealed a census of 4 patients. 10. Review of the BH unit staffing schedule/assignment sheet revealed the following: a. Four staff (RN N, PNA P, PNA AA, PNA BB) on duty during the evening shift (7:00 PM - 11:30 PM) on 7/26/24. b. Four staff (RN J, PNA P, PNA AA, PNA BB ) on duty during the night shift (11:00 PM - 7:30 AM) on 7/26 - 7/27/24. c. RN N worked 3:00 PM to 11:30 PM on 7/26/24 and was responsible for supervision and providing patient care to Patient #4 and Patient #7. d. RN J worked 11:00 PM to 7:30 AM on 7/26/24 and 7/27/24. RN J was responsible for supervision and providing patient care to Patient #4 and Patient #7. e. PNA P worked 7:00 PM to 7:30 AM on 7/26/24 to 7/27/24. PNA P was responsible for laundry and performing 15-minute checks on all patients, including Patient #4 and Patient #7 from 9:30 PM to 1:30 AM (when video footage revealed Patient #4 entered Patient #7’s room 3 times) and 5:30 AM to 7:30 AM (when video footage revealed Patient #4 entered Patient #7’s room 1 time). 11. During an interview on 8/21/24 at 3:17 PM, PNA P could not recall if they worked the evening shift of 7/26/24 through 7/27/24 7:30 AM. PNA P reported they worked the adult BH unit, but had been floated to the pediatric BH unit. PNA P explained when they perform 15-minute checks, the typical routine was to open the door and visualize the patient to make sure they were in the correct room. PNA P did not recall how long the patients would have been unsupervised while PNA P did laundry. 12. Review of documentation of 15-minute checks, “titled Rounding Sheets” by the hospital, revealed: a. RN N performed 15-minute checks on all patients from 7:00 PM to 9:30 PM on 7/26/24. b. RN J performed 15-minute patient checks on all patients from 3:45 AM to 5:00 AM on 7/27/24. c. Various nursing staff, including PNA P, completed 15-minute checks every hour on the hour and every 15 minutes throughout the hour without any variation in the 15-minute check pattern on all patients from 10:15 PM on 7/26/24 to 6:30 AM on 7/27/24. 13. During an interview on 8/21/24 at 1:15 PM, RN N reported staff they walked completely into the patient’s room to ensure the safety of the patient. RN N could not recall if they completed any of the 15-minute patient checks during the evening of 7/26/24. 14. During an interview on 8/21/24 at 10:06 AM, RN J explained when PNAs were busy or needed to take a break, RN J would perform their 15-minute checks for them. RN J recalled Patient #7 was sleeping in their room all night 7/26/24 to 7/27/24 when RN J performed 15-minute checks. RN J explained for 15-minute checks they opened the patient door, saw the patient breathing and then went to the next room. RN J denied they ever saw Patient #4 enter Patient #7’s room. 15. On 8/20/24 at 9:05 AM, during an interview, the Interim Nurse Manager for the pediatric BH unit explained, that prior to the start of the onsite survey, the hospital increased the number of PNAs from 2 to 3 on night shift on 7/29/24. One of the 3 PNAs was assigned hall monitoring duties. The Manager also explained on 7/29/24 they verbally “trained staff to alter night 15-minute check patterns, throw in an extra round during the 15-minute checks, and PNAs go into the room to observe the patient and count respirations”. The Manager explained there was not a new policy on these changes and they were waiting for the new 15-minute check forms to be approved by administration. 16. On 8/19/24 at 9:00 PM, observation conducted on the inpatient pediatric BH unit including reviewing the staffing matrix, revealed, in addition to varied 15-minute checks, one staff member sat and monitored the hallway to ensure patients were not entering another patient’s room. 17. Prior to the end of the survey, hospital administration failed to provide evidence of staff education on the changes to the 15-minute check policy “alter patterns, throw in an extra round during the 15-minute checks, PNAs to go into the patients’ rooms to observe the patient and count respirations, and one staff to monitor the hall at all times on the night shift” prior to the start of the complaint investigation survey on 8/15/24. There was no evidence that hospital staff attempted to take the necessary action to separate or provide ongoing supervision for Patient #4 and Patient #7 after witnessed inappropriate touches prior to the incidents that occurred on 7/26/24 and 7/27/24. Hospital nursing staff failed to appropriately supervise patients on 7/26/24 from 10:22 PM to 7/27/24 at 12:18 AM and on 7/27/24 from 6:04 AM to 6:18 AM. PNA P had laundry responsibilities in addition to the 15-minute patient checks resulting in patients being left unsupervised for an unknown period of time and allegations were made of Patient #4 having sexual acting out behaviors with Patient #7. Nursing staff failed to protect the right of the patients to receive care in a safe setting.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48530 Based on medical record review, behavioral health (BH) security video review, staff interviews, and observation, the hospital’ s administrative staff failed to ensure that RN supervised and evaluated nursing care in accordance with accepted standards of nursing practice and hospital policy. This inaction culminated in an allegation of sexual activity involving Patient #4 and Patient #7 on the evening of 7/26/24 through the early morning on 7/27/24. Findings include: 1. Review of the policy, titled Psychiatric Nursing Precaution/Observation, dated 11/2023, revealed patients were to be observed every 15 minutes, twenty-four hours a day. For sexually acting out behaviors, the policy directed staff to ensure the patients were not left alone with other patients...”May be placed on dayroom restriction or 1:1 at RN discretion for increased monitoring and or safety.” 2. During an interview on 8/21/24 at 3:49 PM, PNA Q recalled Patient #4 would avoid Patient #7. PNA Q stated, (prior to the incident that occurred on the night of 7/26/24 and the early morning of 7/27/24), “(Patient #7) was saying (Patient #4) was obsessed with (Patient #7) and (Patient #4) would say it wasn’t true...we gave them verbal warnings, and if it continued, we would separate them. I did observe (Patient #7) inappropriately touching (Patient #4’s) shoulder or trying to hug (Patient #4) and (Patient #4) would push Patient #7) away and tell staff.” 3. During an interview on 8/21/24 at 1:15 PM, RN N recalled caring for Patient #7 on the evening of 7/26/24. RN N recalled Patient #4 and Patient #7 were sitting together earlier in the evening in the day area and had their hands on each other’s legs. RN N stated, “I told them to move apart or they would be at separate tables. They moved apart and started whispering... I told them to stop or they would go to their rooms.” 4. The hospital nursing staff were aware of the inappropriate physical contact between Patient #7 and Patient #4, but failed to evaluate, assess or counsel the patients about their inappropriate behaviors to keep the behaviors from escalating. The medical records for Patient #7 and Patient #4 lacked any documentation regarding the incidents of inappropriate contact between Patient #4 and Patient #7 prior to the incident that occurred on the night of 7/26/24 and the early morning of 7/27/24. 5. Review of Patient #7’s medical record revealed: a. On 7/6/24 at 6:43 PM, Patient #7 was admitted to the inpatient pediatric BH unit. b. On 7/27/24 at 10:38 PM, RN F documentation revealed “At approximately 1:35 PM (Patient #7) was sitting in the day room with another peer, and reported that (Patient #4) came into (Patient #7’s) room last night, and kissed (Patient #7), grabbed their hand to (touch Patient #4 in a sexual manner). (Patient #7) reported that they told (Patient #4) to stop and (Patient #4) choked (Patient #7). (Patient #7) reported they told the other peer because they feel more comfortable talking the peer. (Patient #7) expressed they were raped before, and this incident triggered them, so they didn’t report it to staff. While talking to the (Patient #7) they saw the staff outside of (Patient #4’s) room, and stated “what is (Patient #4) saying?” “(Patent #4) is going to tell them that I did something to (Patient #4), and I didn’t”... (Patient #7) was able to write a report about what happened last night (between the night of 7/26/24 and the morning of 7/27/24). 6:00 PM, Staff O Rape Victim Advocate did a report (met) with the (Patient #7) in private...The patient (Patient #4) is on 1:1 observation per Staff D, Hospital Operations Manager (HOM). (Patient #7’s) mother called and was notified of the incident ... (Patient #7’s) mother is requesting that 1:1 female staff only, no males due to (Patient #7’s) prior history of sexual assault. No further behavioral concerns reported or noted.” c. On 7/28/24 at 1:44 PM RN V documented Patient #7 discharged from the hospital. 6. Review of BH unit security video footage by the survey team on 8/16/24 at 2:30 PM revealed the following: a. On 7/26/24 at 10:22 PM, Patient #4 entered the open door-way into Patient #7’s room, shut Patient #7’s door, remained in Patient #7’s room for approximately 3 minutes, Patient #4 exited the room at 10:25 PM, left Patient #7’s door partially open and walked 40 steps (equivalent to approximately 40 feet) back to his room. There were 2 staff visible in the nurses station (enclosed area with walls of glass on the top half) at the end of the hallway (approximately 7 feet from Patient #4’s room and approximately 47 feet from Patient #7’s room) during this time (the video angle was too far away to determine the identities of the staff). b. On 7/26/24 at 11:00 PM, Patient #4 talked with nursing staff at the entry way to the nurses station, went to the doorway of his room, looked back periodically at the nurses station as he walked down the hallway and entered Patient #7’s room at 11:01 PM, shut Patient #7’s door, remained in Patient #7’s room for approximately 1 minute, and then Patient #4 exited the room at 11:02 PM, shut Patient #7’s door and returned to his room. There were 2 staff visible in the nurses station during this time. c. On 7/27/24 at 12:06 AM, Patient #4 opened the door of his room, stood at his doorway for 30 seconds facing the nurses station, then walked down the hallway, opened the door to Patient #7’s room and entered, shut the door, remained in Patient #7’s room for approximately 12 minutes, Patient #4 exited the room at 12:18 AM and shut Patient #7’s door, walked down to the hallway and returned to his room. One staff exited the nurses station immediately after Patient #4 returned to his room, but walked in the opposite direction of the camera view (unable to determine the identify of the staff). d. On 7/27/24 at 6:04 AM, Patient #4 opened the door of his room, stood at his doorway for 20 seconds facing the nurses station, walked down the hallway, entered the partially opened door into Patient #7’s room, Patient #4 shut Patient #7’s door, remained in Patient #7’s room for approximately 8 minutes, and then Patient #4 exited the room at 6:12 AM and returned to his room. During this same time frame on 7/27/24 at 6:08 AM, while Patient #4 was in Patient #7’s room, PNA P walked down the hallway directly to Patient #7’s room. PNA P opened Patient #7’s door partially (approximately 18 inches) moved her head forward slightly while looking in the direction of the open doorway and shut the door within 2 seconds of opening the door. PNA P did not enter Patient #7’s room or put her head in the room through the open doorway. PNA P then unlocked and entered the laundry room which was located across the hallway from Patient #7’s room (approximately 6 to 7 feet from Patient #7’s room). The laundry room door had a small quarter glass window, approximately 6 inches in width and 2 feet in length. PNA P remained in the laundry room for approximately 1 minute, exited, looked through the window into the room directly next to the laundry room and then returned to the nurses station. PNA P did not go into or look in the direction of Patient #4’s room. As PNA P got close to the nurses station, Patient #4 could be seen peeking out the partially opened door of Patient #7’s room and looking toward the direction of the nurses station just prior to exiting the room. PNA P failed to notice Patient #4 was in Patient #7’s room and failed to notice that Patient #4 was not in his own room. 7. During an interview on 8/21/24 at 9:05 AM, RN F explained Patient #7 told them Patient #4 had come into Patient #7’s room last night (between the night of 7/26/24 and the early morning of 7/27/24) and used Patient #7’s hand to touch Patient #4 in a sexual manner. RN F reported Patient #4 told them they went to Patient #7’s room because Patient #7 said they had a gift for Patient #4. RN F explained Patient #4 reported no staff was around when they went to Patient #7’s room. 8. During an interview on 8/21/24 at 3:49 PM, PNA Q recalled Patient #7 reported to them (on 7/27/24) Patient #4 had come to their room and kissed them without their consent. PNA Q recalled Patient #4 told them they went to Patient #7’s room because Patient #7 said they had something to give them but when they went to Patient #7’s room they said they didn’t have anything for them and Patient #7 kissed Patient #4. PNA Q reported Patient #4 said they pushed Patient #7 away and ran out and cried. 9. Review of the BH pediatric unit census on the evening of 7/26/24 to the end of the night shift at 7:30 AM on 7/27/24 revealed a census of 4 patients. 10. Review of the BH unit staffing schedule/assignment sheet revealed the following: a. Four staff (RN N, PNA P, PNA AA, PNA BB) on duty during the evening shift (7:00 PM - 11:30 PM) on 7/26/24. b. Four staff (RN J, PNA P, PNA AA, PNA BB ) on duty during the night shift (11:00 PM - 7:30 AM) on 7/26 - 7/27/24. c. RN N worked 3:00 PM to 11:30 PM on 7/26/24 and was responsible for supervision and providing patient care to Patient #4 and Patient #7. d. RN J worked 11:00 PM to 7:30 AM on 7/26/24 and 7/27/24. RN J was responsible for supervision and providing patient care to Patient #4 and Patient #7. e. PNA P worked 7:00 PM to 7:30 AM on 7/26/24 to 7/27/24. PNA P was responsible for laundry and performing 15-minute checks on all patients, including Patient #4 and Patient #7 from 9:30 PM to 1:30 AM (when video footage revealed Patient #4 entered Patient #7’s room 3 times) and 5:30 AM to 7:30 AM (when video footage revealed Patient #4 entered Patient #7’s room 1 time). 11. During an interview on 8/21/24 at 3:17 PM, PNA P could not recall if they worked the evening shift of 7/26/24 through 7/27/24 7:30 AM. PNA P reported they worked the adult BH unit, but had been floated to the pediatric BH unit. PNA P explained when they perform 15-minute checks, the typical routine was to open the door and visualize the patient to make sure they were in the correct room. PNA P did not recall how long the patients would have been unsupervised while PNA P did laundry. 12. Review of documentation of 15-minute checks, “titled Rounding Sheets” by the hospital, revealed: a. RN N performed 15-minute checks on all patients from 7:00 PM to 9:30 PM on 7/26/24. b. RN J performed 15-minute patient checks on all patients from 3:45 AM to 5:00 AM on 7/27/24. c. Various nursing staff, including PNA P, completed 15-minute checks every hour on the hour and every 15 minutes throughout the hour without any variation in the 15-minute check pattern on all patients from 10:15 PM on 7/26/24 to 6:30 AM on 7/27/24. 13. During an interview on 8/21/24 at 1:15 PM, RN N reported staff they walked completely into the patient’s room to ensure the safety of the patient. RN N could not recall if they completed any of the 15-minute patient checks during the evening of 7/26/24. 14. During an interview on 8/21/24 at 10:06 AM, RN J explained when PNAs were busy or needed to take a break, RN J would perform their 15-minute checks for them. RN J recalled Patient #7 was sleeping in their room all night 7/26/24 to 7/27/24 when RN J performed 15-minute checks. RN J explained for 15-minute checks they opened the patient door, saw the patient breathing and then went to the next room. RN J denied they ever saw Patient #4 enter Patient #7’s room. 15. On 8/20/24 at 9:05 AM, during an interview, the Interim Nurse Manager for the pediatric BH unit explained, that prior to the start of the onsite survey, the hospital increased the number of PNAs from 2 to 3 on night shift on 7/29/24. One of the 3 PNAs was assigned hall monitoring duties. The Manager also explained on 7/29/24 they verbally “trained staff to alter night 15-minute check patterns, throw in an extra round during the 15-minute checks, and PNAs go into the room to observe the patient and count respirations”. The Manager explained there was not a new policy on these changes and they were waiting for the new 15-minute check forms to be approved by administration. 16. On 8/19/24 at 9:00 PM, observation conducted on the inpatient pediatric BH unit including reviewing the staffing matrix, revealed, in addition to varied 15-minute checks, one staff member sat and monitored the hallway to ensure patients were not entering another patient’s room. 17. Prior to the end of the survey, hospital administration failed to provide evidence of staff education on the changes to the 15-minute check policy “alter patterns, throw in an extra round during the 15-minute checks, PNAs to go into the patients’ rooms to observe the patient and count respirations, and one staff to monitor the hall at all times on the night shift” prior to the start of the complaint investigation survey on 8/15/24. There was no evidence that hospital staff attempted to take the necessary action to separate or provide ongoing supervision for Patient #4 and Patient #7 after witnessed inappropriate touches prior to the incidents that occurred on 7/26/24 and 7/27/24. Hospital nursing staff failed to appropriately supervise patients on 7/26/24 from 10:22 PM to 7/27/24 at 12:18 AM and on 7/27/24 from 6:04 AM to 6:18 AM. PNA P had laundry responsibilities in addition to the 15-minute patient checks resulting in patients being left unsupervised for an unknown period of time and allegations were made of Patient #4 having sexual acting out behaviors with Patient #7.”

“42 CFR 482.41(b) University of Iowa Hospital & Clinics was found to be not in compliance with the conditions for participation in Medicare/Medicaid at 42 CFR 482.41(b), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition. The State Agency investigated complaint number 122449-C on 08/02/2024. University of Iowa Hospital & Clinics is a two story building with a basement that was built in 1991. The building is composed of Type I (442) construction. The facility is fully sprinklered and there is supervised smoke detection located in the corridors, resident rooms and the spaces open to the corridors. The Adult Inpatient West Psychiatric Unit has 15 certified beds. At the time of the survey the census was 13 patients. The requirement at 42 CFR 482.41(b) is NOT MET as evidenced by:”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 45036 Based on observation and interview, this facility did not assure all staff in the facility have a way to unlock the required exit doors within the means of egress, to allow access to a public way (a street or similar area open to the outside air and dedicated to public use) in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.2.2.2.5.1 and 19.2.2.2.6. This deficient practice affects all occupants including residents, staff, and visitors within 1 of 3 locked psychiatric units (the Adult Psychiatric West Patient Unit). The unit had a capacity of 15 patients and a census of 13 patients at the time of the self report. The facility staff’s inability to access the locked psychiatric unit, during a fire emergency, along with the staff’s inability to remove the patients during a fire, resulted in an Immediate Jeopardy situation (a crisis situation where the staff’s non-compliance placed the patients at a serious liklihood for death or serious injury from a fire. The state agency surveyors notified the hospital’s administrative staff of the Immediate Jeopardy situation on 8/2/2024. The hospital’s administrative staff removed the immedicay by placing a staff member with the appropriate keys outside the locked doors to allow staff entry/egress through the locked doors. The survey team verified the implementation of the plan to remove the immedicay prior to leaving. Upon survey staff leaving on 08/02/24 the deficiency remained, leaving the deficient practice at no actual harm level with the potential for more than minimal harm that is not Immediate Jeopardy that would affect all occupants. Findings include: 1. Observation and interview on 7/11/2024, at 1:57 p.m., the Joint Emergency Communications Center received a 911 call from the University Hospital ( UIHC) stating there was a cell phone fire inside patient room 2781, in the locked Psychiatric Unit within the Pappajohn Pavilion. UI Police and the Iowa City, North Liberty, and Coralville Fire Departments were dispatched to the building. Staff Member A was directed by Staff Member B to the Adult Psychiatric West Patient Unit. Staff Member B attempted to badge into the unit via the main front doors but was denied access. Staff Member B attempted to by-pass the prox. reader by a key switch, which also did not allow access. Staff then, using a key, got Staff Member A through the unit’s interior corridor, where nursing staff had relocated the patients to. The staff were instructed to move the patients further away from the incident scene. Upon arriving to Room 2781, the main corridor was filled with light smoke and residue of dry chemical fire extinguisher use. A well burnt cell phone was on the floor in the room, surrounded by a large puddle of water and dry chemical residue. The Iowa City Fire Department arrived on scene and between them, UIHC security and maintenance staff, they began mechanical smoke removal from the scene. The unit was “evacuated” for a period of 2 hours until the environment was fully clear and approved for re-occupancy by UIHC Engineering and Environmental Services. The doors to this locked Psychiatric Unit did not release upon activation of the fire alarm system. Security and Engineering attempted to determine why the secured perimeter of the Adult Psychiatric Unit didn’t release when it was acted on with keys. There may have been another door open in the perimeter which failed to release the door when it was acted on. DIAL Staff were notified of this event on 7/11/2024. Upon testing of these doors on 8/2/24, it was determined the egress doors for this unit worked for emergency egress and ingress by both door key and emergency override key systems through the replication of smoke induced alarm activation which was the condition set that occurred on 7/11/2024 during the initial fire event. However, given the doors were unable to be opened on 7/11/2024 by the Staff present during the fire event, it was determined that the Staff had used the incorrect key attempting to egress out the doors which resulted in them unable to open the doors. Record review from 7/11/2024, revealed the facility did not meet the requirements for egress doors in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.2.2.2.5.1 and 19.2.2.2.6 which states “Provisions shall be made for the rapid removal of occupants by means of one of the following: (a) Remote control of locks (b) Keying of all locks to keys carried by staff at all times (c) Other such reliable means available to the staff at all times” It was determined on 8/2/24, that although the Staff have access to both keys and badges which satisfy sections (b) and (c) above respectively, they incorrectly used a key that did not operate these egress doors, resulting in them failing to meet the above sections on the day of the event. The University of Iowa Hospital & Clinics Staff and Directors verified these finding at the time of the complaint survey.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48530 Based on medical record review, review of hospital policy, and staff interview, the Acute Care Hospital’s administrative staff failed to follow their policies to ensure hospital staff provide patient care in a safe setting. Failure to follow their policies resulted in the following: 1) Hospital staff not properly securing the patient during transport resulted in the occurrence of an otherwise preventable fall incident on hospital property, which had the potential to result in physical harm or death. (see A0144) The cumulative effect of these systemic failures and deficient practices resulted in the Acute Care Hospital’s inability to ensure patients receive care in a safe setting.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48530 Based on observations, document review, and staff interviews, the Acute Care Hospital (ACH) failed to ensure: 1) Hospital staff nursing supervision, assessment, and evaluation of unidentified new or existing health care conditions that could lead to prolonged illness or death for the patient. (see A0395) The cumulative effect of these systemic failures and deficient practices resulted in the Acute Care Hospital’s administrative staff’s inability to ensure patients receive care in a safe setting.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48530 Based on observations, document review, and staff interviews, the Acute Care Hospital (ACH) failed to provide care in a safe setting to 1 of 20 patients (Patient #5). Failure to properly secure the patient during transport may result in the occurrence of an otherwise preventable fall incident on hospital property, which could result in physical harm or death. The Hospital’s administrative staff identified a daily census of 796 inpatients on 6/17/24. Findings include: 1. Review of policy, “Transport of Patients”, last revised 6/2021, revealed in part: “...The Registered Nurse is responsible for determining the mode of transportation, equipment required, and the level and skill of staff required to provide nursing care ...” 2. During an interview on 6/26/24 at 11:00 AM, Registered Nurse (RN), Staff M explained, when they transferred Patient #5 to the Patient’s customized wheelchair, a blanket was covering the seat and they did not see a seatbelt. Staff M (RN) explained they had taken care of Patient #5 in bed and did not know the patient’s disability required a seatbelt in the wheelchair. Staff M (RN) reported they had not received any instruction on the proper way to secure Patient #5 in their wheelchair. 3. During an interview on 6/24/24 at 12:54 PM, Physical Therapist (PT) Staff D indicated the Physical Therapy department received a consult request from Physician U to evaluate and treat Patient #5. Staff D (PT) reported they did not recall a seatbelt in Patient #5’s customized wheelchair and confirmed the initial physical therapy assessment revealed no documentation of Patient #5’s seatbelt requirement. 4. During an interview on 6/25/24 at 11:15 AM, Physician E explained they performed brain surgery on January 5th, 2024 to repair Patient #5’s malfunctioned shunt (a hollow tube surgically placed in the brain to help drain cerebrospinal fluid and redirect it to another location in the body where it can be reabsorbed). Physician E reported providers rely on the physical therapy staff to assess patients’ mobility. Physician E denied ever ordering specific instructions for the use of personal equipment or placing orders for a seatbelt to be used for a custom wheelchair. 5. During an interview on 6/24/24 at 2:20 PM, Staff N (Transporter) explained nursing staff had placed Patient #5 in their personal customized wheelchair prior to Staff N (Transporter) arrival to the unit. Staff N (Transporter) reported Patient #5 was covered with blankets and no seatbelt was visualized. Staff N (Transporter) recalled when turning the wheelchair toward the transportation van, parked and waiting to transport Patient # 5 to home, a wheel of the customized wheelchair got caught in a small crack in the sidewalk and Patient #5 fell forward striking the head. Staff N (Transporter) called for help. Staff N, with the help of a bystander, placed Patient #5 back into the customized wheelchair and took the Patient back inside the hospital to the emergency department (ED) where Patient #5 was evaluated and re-admitted to the Hospital. 6. Review of Patient #5’s medical record revealed: a. On 1/6/24 at 1:13 PM, Staff D (PT) documentation revealed, “Patient #5 is non-ambulatory; the patient is able to stand and pivot to their customized wheelchair.” b. On 1/7/24 at 1:35 PM, Staff D (PT) documentation revealed, Patient #5 was able to move from “lying to sitting on the edge of the bed, stood, and transferred into the custom wheelchair.” Patient #5 used “feet to propel the custom wheelchair.” 7. .During an interview on 6/25/24 at 3:22 PM, the survey team interviewed Patient #5’s mother/co-guardian via phone. The mother reported the Patient #5’s customized wheelchair did not have foot pegs in order for the patient to maintain mobility using their feet. The mother reported prior to the hospital admission, it was easy for the Patient #5 to hold their feet up to be pushed, if needed. The mother further explained due to Patient #5’s special needs, the “custom wheelchair had an obvious built-in strap that was always buckled across the patient’s lap for safety and positioning.” The nursing staff failed to determine the appropriate mode of transportation to properly secure the patient during transport on 1/8/24, and Patient #5 sustained a fall with subsequent injuries.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48530 Based on observations, document review, and staff interviews, the Acute Care Hospital (ACH) failed to ensure the nursing staff provided adequate supervision, assessment, and evaluation of care for 1 of 20 patients (Patient #5). Failure to adequately provide nursing supervision, assessment, and evaluation of care could result in unidentified new or existing health care conditions that could lead to prolonged illness or death for the patient. The Hospital’s administrative staff identified a daily census of 796 inpatients on 6/17/24. Findings include: 1. During an interview on 6/26/24 at 11:00 AM, Registered Nurse (RN) Staff M explained, when they transferred Patient #5 to the customized personal wheelchair, a blanket was covering the seat and they did not see a seatbelt. Staff M (RN) explained they had taken care of Patient #5 in bed and did not know the patient required a seatbelt when seated in the wheelchair. Staff M (RN) reported they had not received any instruction on the proper way to secure Patient #5 in their wheelchair. 2. During an interview on 6/24/24 at 2:20 PM, Staff N (Transporter) explained nursing staff had placed Patient #5 in their personal customized wheelchair prior to Staff N (Transporter) arrival to the unit. Staff N (Transporter) reported Patient #5 was covered with blankets and no seatbelt was visualized. Staff N (Transporter) recalled when turning the wheelchair toward the transportation van waiting to transport the patient home, a wheel of the customized wheelchair got caught in a small crack in the sidewalk and Patient #5 fell forward onto the sidewalk and struck his head. The Transporter Staff (Staff N) called for help. Staff N, with the help of a bystander, placed Patient #5 back into the customized personal wheelchair and took the Patient back inside the hospital to the Emergency Department where Patient #5 was examined and subsequently re-admitted to the hospital. 3. During an interview on 6/24/24 at 12:54 PM, Physical Therapist (PT) Staff D indicated the Physical Therapy department received a consult request from Physician U to evaluate and treat Patient #5. Staff D (PT) reported they did not recall a seatbelt in Patient #5’s personal wheelchair and confirmed the initial physical therapy assessment revealed no documentation of Patient #5’s seatbelt requirement. 4. Review of Patient #5’s medical record revealed: a. On 1/6/24 at 1:13 PM, Staff D (PT) documentation revealed, Patient #5 was “non ambulatory, but able to stand and pivot to the custom wheelchair.” b. On 1/7/24 at 1:35 PM, Staff D (PT) documentation revealed, Patient #5 was able to move from “lying to sitting on the edge of the bed, stood, and transferred into the custom wheelchair.” Patient #5 used their feet to propel the custom wheelchair. 5. During an interview on 6/25/24 at 3:22 PM, the survey team interviewed the Patient #5’s mother/co-guardian via phone. The mother reported the Patient #5’s custom “hemi wheelchair did not have foot pegs” in order for the patient to move the wheelchair using their feet. The mother reported prior to the hospital admission, it was easy for the Patient #5 to hold their feet up to be pushed, if needed. The mother further explained due to Patient #5’s special needs, the “custom wheelchair had an obvious built-in strap that was always buckled across the patient’s lap for safety and positioning.” The nursing staff failed to properly secure Patient #5 in the customized personal wheelchair for the Patient’s transport on 1/8/24. Patient #5 sustained a fall during the transport that resulted in injuries. The fall from the customized personal wheelchair and associated injuries required evaluation in the emergency department and Patient #5 was subsequently re-admitted to the hospital.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47335 Based on medical record review, review of hospital policy, observation and staff interviews, the hospital’s administrative staff failed to ensure there was appropriate nursing staff available to meet the safety needs of patients receiving services from the inpatient pediatric behavioral health (BH) units (see A0144). The cumulative effect of these deficient practices resulted in the hospital’s inability to ensure the nursing staff provided safe and appropriate care in accordance with the hospital’s policies and acceptable standards of practice for patients receiving services from the inpatient pediatric behavioral health unit. The hospital’s administrative staff identified a total capacity potential of 15 patients for the inpatient pediatric behavioral health unit at the time of the investigation.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 47335 Based on medical record review, review of hospital policy, observation and staff interviews, the hospital’s administrative staff failed to ensure there was appropriate nursing staff available to meet the safety needs of patients receiving services from the inpatient adult behavioral health (BH) units (see A0395). The cumulative effect of these deficient practices resulted in the hospital’s inability to ensure an RN supervised and evaluated the nursing care-including patient care needs, patient health status/conditioning, and response to interventions-for each patient upon admission and when appropriate on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy. The hospital’s administrative staff identified a total capacity potential of 15 patients on the inpatient adult behavioral health unit at the time of the investigation.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47335 Based on document review, staff interviews, and observations the hospital’s administrative staff failed to ensure there were appropriate nursing staff available to the inpatient pediatric behavioral health (BH) unit, and that nursing staff appropriately supervised 4 of 8 patients reviewed (Patient #11, #16, #17, and #18). The effects of the failures and deficient practices resulted in the hospital staff’s inability to ensure that patients received care in a safe setting resulting in allegations of Patient #16 having sexual acting out behaviors with Patient #11, #17, and #18 while hospitalized in the inpatient pediatric BH unit. Findings include: 1. Review of Patient #11’s medical record revealed: a. On 10/25/23 at 12:10 AM, Patient #11 was admitted to the inpatient pediatric BH unit. b. On 11/2/23 at 10:00 PM, Patient #11 reported a peer was making them uncomfortable by their comments earlier in the day. Patient #11 reported the peer told Patient #11 they were going to “come into [Patient #11’s] room at night to rape [Patient #11].” The nurse talked with the peer regarding the alleged statement, the peer denied the statement, and reported Patient #11 was trying to get them into trouble. Nursing failed to provide any additional safety interventions or precautions after Patient #11 reported a peer threatened to rape them. c. On 11/3/23 at 7:55 AM, Patient #11 reported to the psychiatric provider they were feeling unsafe due to a comment reportedly made by a peer. The provider increased Patient #11’s Sertraline (medication used to treat depression) to 125 mg starting on 11/4/23. The provider failed to address Patient #11’s concern of feeling unsafe and to provide any additional safety interventions or precautions. d. On 11/15/23 at 8:00 PM, Patient #11 was observed to be visibly agitated by a male peer that Patient #11 accused of making inappropriate statements, and exhibiting inappropriate actions. Patient #11 and other patients were relocated as a de-escalation strategy. Nursing staff educated and relocated the patient and peers, but again failed to put additional safety precautions in place to maintain patient safety on the inpatient pediatric BH unit. e. On 11/16/23 at 10:53 AM, Physician N noted Patient #11 reported sexual relations with another patient on the unit, when the other patient came to her room Monday night. Physician N noted that Patient #11 reported the sexual relations with the patient on multiple occaisions. Physician N noted they would consider repeat pregnancy testing and sexually transmitted infection (STI) prevention, and would notify Patient #11’s parents. The provider noted they would follow up with Patient #11 on how they wished to disclose the information, and offer a SANE (sexual assault exam) exam. Patient #11 reported the encounter with the peer was non-consensual, nursing spent time processing with Patient #11, and collecting additional information. When the team went back to offer a SANE examination, and STI testing, Patient #11’s parent was present, but hospital staff had not yet discussed with Patient #11 their preferences to disclose the incident to their parent, and the psychiatric provider did not want to broach the subject without Patient #11’s input. The psychiatric provider noted they would discuss further tomorrow. A safety report was filed and leadership was notified. Patient #11 was placed on sexual acting out precautions. f. On 11/16/23 at 1:15 PM, nursing staff documented during physician rounding Patient #11 shared with their team that on Monday, a peer was in their room, and there was sexual contact. g. On 11/16/23 at approximately 1:52 PM, RN E (Registered Nurse) documented they interviewed Patient #11 regarding their allegation about Patient #16. RN E asked Patient #11 multiple questions. During the interview Patient #11 confirmed that Patient #16 was in Patient #11’s room, and Patient #16 and Patient #11 had sex. Patient #11 reported Patient #16 learned the routines, and figured out that sometimes there was a gap between 11:15 PM and 11:45 PM, during shift change lots of nursing assistants left, and Patient #16 would sneak into a room and close the door. Patient #11 then reported that Patient #16 did this before, and identified Patient #17 and Patient #18. h. On 11/16/23 at 6:49 PM, Patient #11 was moved to another room. i. On 11/16/23 at 8:53 PM, Patient #11’s parent/legal guardian requested discharge of Patient #11 upon disclosure of potential abuse. After nursing elicited further details from Patient #11 in the late afternoon, a report to the Police Department (PD) was completed, and Patient #11’s parent was notified. j. On 11/16/23 at 10:30 PM, Patient #11 was 1:1 (one staff to one patient at all times) supervision. k. On 11/16/23 at 11:30 PM, Patient #11 was discharged from the hospital. l. On 11/16/23 at 11:50 PM, Patient #11 arrived to Hospital B’s ED for a SANE examination. Patient #11 was transported by law enforcement, and accompanied by Detective FF. Patient #11’s parent was present at Hospital B, but Patient #11 refused to allow their mother to accompany them for the examination. m. On 11/17/23 at 12:58 AM, MD EE completed the sexual assault examination on Patient #11. MD EE noted it would be possible that an examination could be normal even if there was a sexual assault. Patient #11 reported being raped by another patient on Monday night around midnight. Patient #11 reported the incident in detail including the identity of the other patient (Patient #16). Patient #11’s examination did not reveal any injuries or bruising related to a sexual assault. A sexual assault kit was collected. n. On 11/22/23 at 9:30 AM, MSW with Child Protection Center completed a forensic interview with Patient #11. During the interview, Patient #11 reported that Patient #16 had sex with them without consent. Patient #11 reported that Patient #16 would ask weird questions, and would inappropriately touch over their clothes while they watched movies at the hosptial BH unit. Patient #11 reported they would sit with Patient #16 at the back of a table where it was darker, and no one saw them, but there were other people in the room and at the table. Patient #11 reported that Patient #16 kept looking in her room, and when no one was around, he came into their room. Patient #11 reported they were on their bed when Patient #16 came in, and closed the door. Patient #11 reported that staff were in the hallway, but taking breaks. Patient #11 reported Patient #16 told her to perform sexual acts, and Patient #11 did not want to, but Patient #16 forced her to. Patient #11 continued to report the details of the sexual encounter. Patient #11 reported Patient #16 stopped and left her room. When Patient #11 was asked for more details, Patient #11 reported that staff walked in, and told Patient #16 to leave the room. Patient #11 reported that when staff walked into Patient #11’s room, Patient #11 was unclothed. Patient #11 reported that staff were aware she was taking a shower. 2. During an interview on 12/6/23 at 3:00 PM, RN G recalled Patient #11 reported Patient #16 told Patient #11 during lunch time that day (on 11/2/23), they were going to come into Patient #11’s room and rape Patient #11. RN G recalled having the nursing assistant sit outside Patient #11’s room between 15-minute checks, to monitor Patient #11 and Patient #16’s rooms to make sure neither patient came out of their room. RN G recalled asking Patient #16 about Patient #11’s report, and Patient #16 denied it, and reported Patient #11 was trying to get Patient #16 into trouble. RN G recalled reporting the threat to the day shift staff, and Patient #11’s room was moved away from Patient #16’s room, but may not have been for a couple days, due to the unit being full. RN G then recalled Patient #11 and Patient #16 were placed in separate groups the next day. 3. During an interview on 12/7/23 at 11:00 AM, Physician N recalled during morning rounding (on 11/16/23) with a resident and a medical student, Patient #11 out of nowhere said they needed a pregnancy test. Physician N recalled Patient #11 reported Patient #16 snuck into their room, and they had sex, but then Patient #11 refused to talk anymore about it. Physician N recalled they reported the allegation to RN E, who follow up with Patient #11 to obtain more information. Physician N recalled the nurse manager for the unit was present during rounding that morning, and was aware of the incident. Physician N recalled filing a report. Physician N recalled they sent an email regarding the allegation to the chair of the pediatric BH unit and the medical director of the unit, and the head of the pediatric BH unit became involved in the incident. Physician N denied any other female patients asking them specifically for a pregnancy test or birth control. Physician N reported since Patient #11 made their report about having sex, Physician N feels it could have been possible for patients on the inpatient pediatric BH unit to have sex. 4. During an interview on 1/4/23 at 9:15 AM, Unit Manager JJ recalled the provider mentioned Patient #11 made an allegation, and Unit Manager JJ asked the provider to ask Patient 11 for additional information, but the provider was not comfortable with that, because they had a resident and a student working with them, and felt it would be three staff to the one patient. The provider went to the nurse on duty, and asked them to talk with Patient #11 about the allegation made. Unit Manager JJ reported after the nurse talked with Patient #11, they found there may have been validity to the report, Unit Manager JJ reported the allegation to the director of the inpatient pediatric BH unit. Unit Manager JJ reported they did not receive any staff report that Patient #16 was found in Patient #11’s room, and there were not any witnesses to the allegation. 5. During an interview on 12/6/23 at 12:00 PM, RN E recalled doing an interview with Patient #11 after they reported being sexually assaulted by Patient #16. RN E recalled Patient #11 reported it to Physician N during rounds, and Physician N did not take it further, because there were 3 adults present at the time, and Physician N did not feel it was appropriate to question Patient #11 further about the report. RN E recalled interviewing Patient #11 in two sessions, asked Patient #11 specific questions related to their interaction with Patient #16. RN E recalled Patient #11 reported two other patients being sexually assaulted by Patient #16, and identified Patient #17 and Patient #18. 6. During an interview on 1/3/24 at 9:35 AM, Patient #11’s parent/legal guardian recalled Patient #11 made a comment during their visit on 11/16/23 about hoping they were not pregnant, but then told their parent to leave. After Patient #11’s parent got home from visiting Patient #11, the parent received a call from a nurse reporting that something happened, and a detective was coming to talk with Patient #11. Patient #11’s parent returned to the hosptial. Patient #11’s parent made the decision to have Patient #11 discharged, and taken to Hospital B for a SANE exam. Patient #11’s parent reported Patient #11 did not have a history of making up stories, and that Patient #11’s parent and the hospital staff were agreeable that something happened between Patient #11 and Patient #16. Patient #11’s parent reported she talked with Patient #11 about the allegation, and Patient #11 remains consistent with her initial report of what happened. 7. During an interview on 12/6/23 at 9:30 AM, Detective FF recalled the police department was contacted at 7:22 PM on 11/16/23, two uniformed officers responded. Detective FF arrived around 8:30 PM. Detective FF recalled talking with RN E, Patient #11’s parent, the two uniformed officers, and the security supervisor, and explained to Patient #11’s parent there was a potential that Patient #11 was sexually assaulted, then RN E explained what happened, and read the questions Patient #11 was asked by RN E. Detective FF recalled Patient #11 reported the incident happened on Monday, 11/13/23. Detective FF recalled specifically asking RN E and Patient #11’s parent, if Patient #11 would have made up the allegation to be discharged from the hosptial, and both said no. Detective FF recalled they started the process of emergency contact, and calling Hospital B, and CPC (Child Protective Services) to arrange a child sexual assault examination. Detective FF reported when Patient #11’s made the initial report, they did not report any staff coming into their room during or after the alleged sexual assault, but during Patient #11’s interview with CPC, they learned of a staff person coming into Patient #11’s room while Patient #16 was still in there. Patient #11 identified the staff person from a lineup of staff photos. 8. During a follow up interview on 12/28/23 at 1:00 PM, Detective FF reported having an interview with Staff LL. Staff LL reported remembering two specific incidents on 11/13/23. The first incident Patient #16 was found standing outside of Patient #11’s room. Patient #16 was told by Staff LL to go back to their room, and Staff LL then walked with them back to their room. Staff LL reported both patients were fully clothed. The second incident Staff LL reported they found Patient #16 inside Patient #11’s room, just inside the threshold of the bedroom door, and Patient #11 was across the room standing against the wall. Staff LL reported telling Patient #16 to get out of Patient #11’s room, then again walked Patient #16 back to their room. Staff LL reported both patients were wearing clothing. Detective FF reported Staff LL did not go back to Patient #11’s room after walking Patient #16 back to their room. Detective FF reported Staff LL denied telling Patient #11 to take a shower, get cleaned up in any way, or wash their clothing. Detective FF then reported that Staff LL reported they did not report to anyone else they found Patient #16 in Patient #11’s room. Detective FF reported Patient #16 also made omissions to Detective FF that Patient #16 had kissed and made out with Patient #11, and had been in Patient #11’s room several times, but never overnight and was only caught one time when Staff LL caught them in Patient #11’s room. Detective FF reported that both Patient #11 and Patient #16 disclosed that 15-minute checks are not always done appropriately, all the patients know the routines and schedules of the unit and staff, and they all know when they can get away with things, such as passing notes. 9. During an interview on 1/3/24 at 7:15 PM, Staff LL reported they found Patient #16 in Patient #11’s room, Patient #16 was told to go back to their room, and when Staff LL went back to check on Patient #16 they were sleeping. Staff LL recalled Patient #16 was standing just inside the door of Patient #11’s room, and Patient #11 was across the room against the wall. Staff LL reported both Patient #11 and Patient #16 were wearing clothing. Staff LL denied checking on Patient #11 after Patient #16 was sent back to their room. Staff LL reported telling other staff they were working with to watch Patient #16, because he was not acting normal. Staff LL then reported telling her boss that comes in at 11:00 PM they found Patient #16 in Patient #11’s room and to watch Patient #16. 10. During a follow up interview on 1/8/24 at 8:30 AM, RN D acknowledged that Staff LL just reported a few days ago they had found Patient #16 just inside Patient #11’s bedroom, in front of the bathroom, talking to Patient #11, but RN D was not notified at the time the incident occurred. RN D reported Staff LL did not report whether it happened during the evening shift or night shift, or how long ago it occurred. 11. During an interview on 12/6/23 at 8:00 AM, RN CC recalled Patient #11 reported being sexually assaulted by a peer, sometime around 11 PM on 11/13/23. Patient #11 reported staff did 15-minute checks, but at shift change the routine might have been off. Patient #11 reported the peer knew staff routine, during shift change the checks may have longer periods of time between them, and that was when the peer entered Patient #11’s room to sexually assault them. RN CC recalled Patient #11 reported the peer came into their room right after 15-minute checks were done, assaulted them, and left Patient #11’s room before staff did their next rounds. Patient #11 also reported there may have been other girls that were sexually assaulted by the peer. 12. During an interview on 12/5/23 at 9:00 AM, MD EE recalled Patient #11 reported being sexually assaulted by Patient #16 on Monday. MD EE explained their exam of Patient #11 was negative, but that did not mean an assault had not happened. MD EE recalled Detective FF had reported another patient on the inpatient pediatric BH unit at the hosptial had asked for birth control, but did not receive it because the patient was in the hospital, and the staff did not think anything happened. 13. During an interview on 12/6/23 at 12:45 PM, Educator B recalled finding a sheet of paper in Patient #11’s school tub, that was written by Patient #11, and had a few sentences that talked about Patient #11 and Patient #16 having sex. Educator B reported she reported the note to RN E, then handed the note off to RN E. Educator B recalled finding the note on the day Patient #11 reported the allegation of sexual assault by Patient #16 (11/16/23). 14. During an interview on 12/7/23 at 9:00 AM, RN F recalled Patient #11 was flirty with Patient #16. RN F recalled Patient #11 and Patient #16 sitting in the day room and RN F told them they needed more space between them. RN F denied witnessing any further interactions. 15. Review of Patient #16’s medical record revealed: a. On 10/27/23 at 10:36 PM, Patient #16 was re-admitted to the inpatient pediatric BH unit. b. On 11/3/23 at 8:00 AM, a psychiatric provider noted staff were monitoring Patient #16’s comments to peers. Patient #16 was guarded about conversations about his behaviors on the unit. Patient #16 did not voice insight into making any verbal threats toward others. Expectations of the unit were reviewed with Patient #16. The psychiatric provider and nursing staff failed to increase Patient #16’s safety precautions or add interventions to assure the safety of Patient #16 and others. c. On 11/3/23 at 3:27 PM, Patient #16 continued with inappropriate behavior and statements, and resulted in time away from peers. d. On 11/5/23 at 9:37 AM, Patient #16 continued to require frequent redirection due to inappropriate comments. e. On 11/5/23 at 9:53 PM, Patient #16 required several reminders of appropriate space between peers, and reminded not to pass notes. Patient #16 became upset when the nurse told the unit they would not have movies in a dim room for the remainder of the day due to multiple observations of patients getting cozy with each other. f. On 11/14/23 at 10:43 AM, a psychiatric provider noted Patient #16 made several inappropriate comments to peers in group activities, and was placed on room restriction. Further action for a behavioral plan to be discussed at rounds. The psychiatric provider noted the plan for the day was discussed at Interdisciplinary Team (IDT) rounds, focused on behavioral goals, reinforcements, and actions. Patient #16 will remain on room restriction at this time, with cognitive worksheet completion required to earn out-of-room time. Patient #16 may be moved to a different room, and standards for peer interaction continue to be discussed. g On 11/14/23 at 4:08 PM, Patient #16’s room was moved to another room. h. On 11/15/23 at 8:57 AM, a psychiatric provider noted Patient #16 was upset about the room change. IDT met to discuss a new behavioral plan for Patient #16, a new behavioral plan was developed, and put into place, but failed to increase Patient #16’s safety precautions. i. On 11/15/23 at 8:00 PM, Patient #16 was observed to be interacting inappropriately with peers. j. On 11/16/23 at 12:42 PM, -Patient #16 made a derogatory comment toward a peer and was told they needed to complete 30 minutes in their room for the behaviors. Patient #16 was made a 1:1 for safety concerns. Patient #16 had allegedly sexually assaulted a peer. Patient #16 was told they had 1:1 supervision due to accusations by several others that Patient #16 was sneaking into their peers’ rooms at night. Patient #16 reported the female peer was lying. Later requested a PRN and told their 1:1 staff “I want a PRN before I go beat her up.” k. On 11/16/23 at 5:20 PM, Patient #16 was redirected from telling a peer they were assigned a 1:1, for making acusations in a derogatory manner regarding another patient. l. On 11/16/23 at 6:23 PM, Patient #16 heard the female peer down the hallway, and told the 1:1 staff, “If I hear [Patient #11’s] voice one more time, I am going to walk out of my room, and beat her up.” m. On 11/16/23 at 10:20 PM, Patient #16 verbalized that a female peer was lying. Patient #16 stated “I know who it was. It was [Patient #11]” Patient #16 stated the peer warned them on 11/16/23 that they would tell lies about them, because Patient #16 had been bullying Patient #11’s friend. Patient #16 also reported Patient #11 had previously warned Patient #16, they would tell lies about them to nurses, to make another peer mad, because Patient #11 thought it “was funny” when the other peer got mad. n. On 11/16/23 at 10:39 PM, Patient #16 had sexual acting out precautions added. o. On 11/17/23 at 12:24 PM, Patient #16 was 2:1 (two staff to one patient) supervision following peer accusation of sexual acting out (SAO) behavior. 16. During an interview on 12/6/23 at 12:00 PM, RN E reported Patient #16 would develop relationships with other peers, and was “always looking for the next relationship.” RN E recalled Patient #16 would pick a female peer, develop a relationship with them, flirt with them, and as soon as they discharged, Patient #16 would move on to another female peer. RN E recalled staff were always redirecting Patient #16 for whispering with female peers, for sitting too close, touching under the table, or sliding really low in their chair to touch their leg against a female peer’s leg. RN E reported they had to split up male and female patients for entire shifts, because of flirtation, and Patient #16 was always involved. RN E reported Patient #16 would make a lot of sexually inappropriate comments. RN E recalled witnessing Patient #16 calling Patient #11 by a derogatory name with sexual connotations. 17. During an interview on 12/6/23 at 1:30 PM, RN H recalled Patient #16 would make sexually inappropriate comments to Patient #11. RN H reported Patient #11 would get upset, but Patient #16 was flirting with Patient #11. RN H reported Patient #16 would require redirection for being intrusive and verbally inappropriate with their peers, making sexual comments toward peers and staff. RN H reported that female patients have reported being scared of Patient #16, and that staff were trying to keep Patient #16 away from peers they wanted to flirt with. 18. During an interview on 1/2/24 at 10:05 AM, Staff HH reported that Patient #16 made a lot of sexually inappropriate comments, and would act out to get the attention of female peers. Staff HH reported Patient #11 and Patient #16 did not get along at all, and Patient #16 would make comments to Patient #11 with derogatory sexual connotations. 19. During an interview on 1/2/24 at 3:45 PM, Staff GG reported Patient #16 would make sexual comments to female peers, would touch their leg against a peer’s leg under the table, or would sit too close to female peers. Staff GG reported they had to remind Patient #16 about personal space, but they would just say “I don’t care.” Staff GG recalled Patient #16 and Patient #11’s rooms were close to each other at one time, like 3 doors away from each other, but Patient #11 was moved due to their negative interaction, and negative comments toward each other. Staff GG recalled Patient #16 would call Patient #11 derogatory names. 20. During an interview on 1/3/24 at 3:25 PM, Staff KK recalled receiving emails regarding sexually inappropriate behaviors demonstrated by Patient #16, but Staff KK did not directly see or hear anything. Staff KK reported the emails said to be careful of Patient #16, and another patient, because sexually inappropriate remarks were made, but the email did not have anything specific. Staff KK could not recall the other patient identified in the email. 21. During an interview on 1/4/23 at 3:45 PM, Patient #16’s family member reported that Patient #16 told him about the allegations of sexual assault, but has denied it, and would not discuss anything about it. Patient #16’s family member recalled finding Patient #16 one other time, about four or five years ago, where Patient #16 was demonstrating sexually inappropriate behavior toward another person. Patient #16’s family member reported the hospital staff was not aware of the incident. Patient #16’s family member reported Patient #16 was given repeated warnings for getting too close to female peers, and felt hospital staff would do more to intervene. 22. During an interview on 12/6/23 at 12:45 PM, Educator B recalled a lot of female peers were uncomfortable around Patient #16. 23. During an interview on 12/6/23 at 1:00 PM, RN L recalled Patient #11 and Patient #16’s interactions with each other became challenging to redirect and hospital staff would do their best to limit their interactions with each other by separating them in groups when programming for the day. 24. During an interview on 12/6/23 at 4:00 PM, Staff M recalled Patient #11 and Patient #16 would demonstrate flirty behavior when together in group, and they would be split up. Staff M also recalled Patient #11 and Patient #16 would exchange dergogatory coments to each other. Staff M reported they do not feel the inpatient pediatric BH unit is observed as closely at night as it could be. 25. During an interview on 12/7/23 at 8:15 AM, RN D recalled that Patient #11 did not get along with Patient #16. RN D recalled Patient #16 would not take no for an answer, and if Patient #16 was told no, their behaviors would escalate, and it would take a lot to calm them down. RN D reported seeing a “very bad” interaction with Patient #11 and Patient #16. Patient #16 would call Patient #11 inappropriate names and deragatory statements and Patient #11 would get upset. RN D recalled Patient #11 and Patient #16 had to be separated. RN D reported that Patient #16’s interaction with other female peers on the unit was a big concern when working on the weekend. RN D recalled witnessing Patient #18 and Patient #16 sitting close to each other, and Patient #16 touched their knee to Patient #18’s leg. RN D reported they felt uncomfortable with Patient #16 touching a female peer like that, and acknowledged that Patient #16 could probably touch anyone like that. RN D reported that when staff saw Patient #16 touch female peers or making inappropriate verbal comments, they would take immediate action, redirect Patient #16, and separate them, but Patient #16 was never made a 1:1 prior to the allegation of sexual assault. 26. During an interview on 12/7/23 at 11:00 AM, Physician N recalled Patient #16 demonstrated flirtatious behaviors toward female peers, and staff felt like they were often redirecting Patient #16 for this behavior. Physician N reported that Patient #16 was not place on 1:1 supervision prior to the allegation, because the unit had at least a dozen teenage patients, flirtation were typical behaviors demonstrated, and Patient #16’s flirtation was not above the level of flirtation for their age group for appropriate flirtation. Physician N then verbalized that most teenagers would end up on 1:1 supervision if they did that for every teenager who was flirtatious. 27. Review of Patient #17’s medical record revealed: a. On 10/12/23 at 3:00 PM, Patient #17 was admitted to the inpatient pediatric BH unit. b. On 10/25/23 at 2:34 PM, Patient #17 received a warning for whispering to another peer and was caught getting too close with physical touch. Patient #17 was reprimanded multiple times about behavior and continued to disobey. c. On 10/26/23 at 1:46 PM, Patient #17 required redirection about personal space and flirty comments. d. On 10/26/23 at 2:57 PM, Patient #17 was passing notes with a peer that had sexual content and was inappropriate. Patient #17 was to fill out another CRP and would remain in their room the remainder of the shift other than for activity, meals, and group. Staff failed to increase safety precautions. e. On 10/27/23 at 1:59 PM, Patient #17 was discharged from the hospital. 28. During an interview on 12/6/23 at 12:00 PM, RN E recalled a full sheet of paper being found in Patient #16’s room that had notes written on it between Patient #16 and Patient #17 that were sexual in nature. 29. Review of Patient #18’s medical record revealed: a. On 11/2/23 at 10:31 PM, Patient #18 was admitted to the inpatient pediatric BH unit. b. On 11/3/23 at 8:23 AM, Patient #18 was being monitored for boundaries with a male peer. c. On 11/4/23 at 7:32 AM, Patient #18 was continuing to be monitored for boundaries with a male peer. d. On 11/4/23 at 1:41 PM, Patient #18 appeared distracted and flirty with a peer. e. On 11/5/23 at 8:53 AM, Patient #18 reported a male peer continued to do things Patient #18 asked him to stop. It was noted that this same male peer was who Patient#18 had been struggling to maintain boundaries with. Patient #18 continued to require observation for boundaries with the male peer. Education was provided to Patient #18, and were asked if they were being made to feel uncomfortable by the male peer, but then reported they were not. Staff failed to increase safety precautions. f. On 11/9/23 at 2:00 PM, Patient #18 was discharged from the hospital. 30. During an interview on 12/6/23 at 9:30 AM, Detective FF reported Patient #17 and Patient #18 were identified as having sexual interaction with Patient #16. Detective FF reported having two hospital providers, and the Director of the BH units present when Detective FF notified the parents of the two additional patients identified, and informed them of the allegations made. Detective FF reported they have not talked to Patient #17 or Patient #18 regarding the allegations. Detective FF also recalled RN E reported a 17-year-old patient asked for a pregnancy test and emergency birth control when they were discharged from the hospital. 31. During an interview on 1/10/24 at 5:00 PM, Patient #18’s family member reported they talked with Patient #18 regarding the allegation made about Patient #18 and Patient #16 having sexual contact. Patient #18 reported Patient #16 would try to be sexual with female peers, would grab Patient #18 and made sexual advances toward Patient #18, but Patient #18 and Patient #16 did not do anything more than that. Patient #18 reported Patient #16 never went into their room. Patient #18 reported other female peers would say Patient #16 was “creepy”, but did not report Patient #16 going into the rooms of their peers. 32. During an interview on 12/6/23 at 12:00 PM, RN E reported the day shift was fully staffed, but as the day went on, staffing became shorter on the night shift. RN E reported the inpatient pediatric BH unit was staffed with two nurses after 11:00 PM. RN E reported a few nursing assitants did not know how to redirect problematic pediatric patients. RN E reported that staff floated from other units of the hospital and lacked experience working with pediatric patients. 33. During an interview on 12/6/23 at 1:30 PM, RN H reported that during the day staffing was adequate, but after 7:00 PM, they usually had the wrong kind of staff that were not appropriately trained. RN H reported shifts changed every 4 hours, and a different staff would come and go, which made it difficult to keep a routine on track. RN H recalled when they started working for the hosptial on the inpatient pediatric BH unit, staff received a “stern” discussion, and were told that staff have to physically lay eyes on each patient when doing 15-minute checks, because in the past, staff would call to the location of the patient, asking if the patient was there. 34. During an interview on 12/6/23 at 2:15 PM, Educator A reported the inpatient pediatric BH unit did not have enough adequately trained staff taking care of the patients on the unit, and the quantity and quality of staff were both lacking. Educator A reported they believed that patients on the unit could have sexual interaction. 35. During an interview on 12/7/23 at 9:00 AM, RN F reported a lot of staff from other units of the hospital floated to the inpatient pediatric BH unit to help out, and they were not familiar with the unit rules, such as when to shut down conversations that were inappropriate, or how to work with kids. RN F reported staff that floated to the unit did not know the processes of how the unit works. RN F reported sexual activity was possible during the day, but more likely to happen at night due to the decreased number of staff scheduled to work the night shift. 36. During an interview on 12/7/23 at 10:00 AM, RN C reported that 15-minute checks were being done appropriately, but acknowledged there could always be room for improvement, such as when a patient’s behavior was escalating, checks could become more complicated. RN C recalled there was a period where Patient #11 and Patient #16 did not like each other, and other times where they were part of a little group that always wanted to hang out. RN C recalled the period in time Patient #11 and Patient #16 did not get along, they had to be separated for being verbal with each other. RN C reported there were too many people on the unit and too many activities going on during the day for patients to have an opportunity to have sex, but on the night shift there were less staff present. 37. During an interview on 12/7/23 at 10:30 AM, MD (Medical Doctor) O did not recall witnessing any concerning interactions with Patient #11 and Patient #16. MD O did not recall any female patients asking them directly for a pregnancy test or birth control. MD O reported that 15-minute checks were being done, patients were constantly being monitored, and the hospital had things in place to prevent patients from having sex on the unit. MD O acknowledged that nothing was impossible. MD O recalled discussion in rounding about peer interactions, and making sure peers were interacting appropriately. 38. During an interview on 12/7/23 at 11:30 AM, RN J reported concern about the staff that floated from other units of the hospital performing 15-minute checks, and the staff’s ability to identify who each patient was when they checked on the patients. RN J reported that patients wore identification bands on the wrist, but some patients would remove them. RN J also reported that shift change could have been more dangerous for doing 15-minute checks, but if assignments were done prior to shift change, then there was not of much a lapse in checks. RN J explained when staff floated from other units of the hospital, those staff may not have been there right on time, at shift change. 39. During an interview on 1/3/24 at 7:15 PM, Staff LL reported they would leave a 1:1 patient unattended to do laundry during the night. Staff LL reported that patients did sometimes go into the rooms of their peers, but staff were watching for this. 40. During an interview on 1/2/24 at 3:45 PM, Staff GG reported that staff from other units of the hospital floated to the inpatient pediatric BH unit to assist, but were not always trained on how to handle patient behaviors, or how to combat behaviors. Staff GG reported when they were short staffed on night shift, staff that were assigned to do 2:1 or 1:1 supervision with a patient, would also do laundry while the patient was in bed sleeping. Staff GG reported leaving 1:1 patients unattended while they were sleeping for a minute and a half to two minutes to do laundry, and then they would return to sit outside the patient’s room. 41. During an interview on 1/4/23 at 9:15 AM, Unit Manager JJ reported all staff hired by the hospital received general orientation with a brief overview of the BH units, and when staff floated to the inpatient pediatric BH unit, they were given a set of keys, a tour of the unit and an overview of the tasks for the unit. Unit Manager JJ reported staff were not required to have any special training to float to the unit. 42. During an interview on 1/3/24 at 3:25 PM, Staff KK reported having a lot of medical staff that floated to the inpatient pediatric BH unit to assist with staffing needs and they were not trained to do certain things on the unit. 43. Review of staffing schedules for the months of October and November 2023 for the hospital’s inpatient pediatric BH unit on the 11:00 PM to 7:00 AM shift revealed staffing assignments were not completed for 26 out of 36 schedules reviewed, and 6 out of 10 schedules where staff were given assignments, there was one staff member assigned to do 1:1 supervision and laundry. 11 out of 36 schedules reviewed revealed there was not enough nursing assistance working for the required assignments. The hospital failed to assure there was enough staff working the inpatient pediatric BH unit, and staff were given assignments to assure the safety of all inpatient pediatric BH patients. 44. Review of the policy “Psychiatric Nursing Precautions/Observation,” Last Revised 10/20, revealed in part: a. “Purpose: To provide the level and type of precautions/observation necessary to meet the safety needs of a patient.” b. “ ...A patient will be placed on the precaution/observation procedure based on a RN and/or Licensed Independent Practitioner (LIP) Admission Assessment or risk related to ... sexual acting out ... RN initiated precaution/observations based upon patient needs with the exception of 1:1 for history of sexually acting out behavior in a hospital ...” c. “ ...1:1 is a continuous one to one staff supervision of the patient ...” 45. Review of the policy “Unit Rounds,” Last Revised 1/22, revealed in part: a. “ ...Staff member assigned to unit rounds reports any unusual patient event or environment safety issue to an RN ...” 46. Review of the policy “Sexual Activity Between Patients - Staff Response to,” Last Revised 9/17, revealed in part: a. “To ensure appropriate care of patients in the event they are involved, reported to be involved or appear to have been involved in sexual activity on the inpatient units...” b. “ ...Notify the immediate nursing supervisor. The nursing supervisor will determine if immediate notification of the Associate Director Clinical Services and the Director of Nursing Research, Quality and Outcomes Management or designee is warranted. If yes, the nursing supervisor will then determine if notification of other departments, hospital attorney or hospital administration is warranted ...” c. “A determination by the treating physician should be made regarding the capacity of each individual to consent to the sexual activity. Question if the patient is ... a child in our care and custody ...””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50212 Based on a review of patient medical records, review of hospital policies and procedures, interviews with hospital staff (including 9 Registered Nurses (RNs) and 4 Psychiatric Nurse Assistants (PNAs), and observations of nursing services, the hospital failed to ensure an RN supervised and evaluated the nursing care-including patient care needs, patient health status/conditioning, and response to interventions-for each patient upon admission and when appropriate on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy. Despite hospital staff observing inappropriate behaviors between Patient 2 and Patient 5 on 9/13/23, UIHC staff failed to implement necessary precautions in a timely manner to prevent further inappropriate behaviors and to maintain the safety and wellbeing of the Adult Psychiatric Unit patient population. This inaction culminated in a credible allegation of sexual activity involving Patient 2 and Patient 1 on the evening of 9/13/23. The cumulative effect of this deficient practice resulted in the hospital’s inability to ensure the nursing staff provided safe and appropriate care in accordance with the hospital’s policies and acceptable standards of practice for patients receiving services from the inpatient Adult Psychiatric Unit. The hospital’s administrative staff identified a total capacity potential of 15 patients for the inpatient Adult Psychiatric Unit. Findings include the following: 1. Review of the hospital’s incident report regarding the alleged sexual encounter between Patient 1 and Patient 2 on 9/13/23 revealed the following: a. On 9/14/23 at 6:50 PM, Patient 3 reported having witnessed a sexual encounter between Patient 1 and Patient 2 in Patient 2’s room on 9/13/23. Patient 3 reported the incident to Staff K (PNA) who subsequently reported the incident to Staff J (RN). the hospital placed Patient 2 on 1:1 monitoring at this time until 8:20 PM. b. On 9/14/23 at an unspecified time, per instruction by Staff J (RN), Staff G (RN) and Staff H (RN) spoke to Patient 1 and Patient 2 separately about the alleged sexual encounter on 9/13/23. Staff G and Staff H reported that both Patients (1 and 2) indicated that they had previously engaged in sexual acts. c. On 9/14/23 at 8:20 PM, the hospital staff transferred Patient 2 to another patient unit. d. On 9/15/23 at an unspecified time in the morning, the hospital nursing staff discussed the alleged sexual encounter during the morning nursing report. The hospital nursing staff received encouragement to remain hypervigilant of Patient 1’s behaviors and interactions. e. On 9/15/23 at 10:00 AM, Staff H (RN) attempted to contact Patient 1’s legal guardian to provide notification of the alleged sexual encounter. At 11:00 AM, Staff H received a return phone call and notified the legal guardian, who then expressed skepticism that the incident actually occurred. f. On 9/15/23 at 1:00 PM, the hospital staff relocated Patient 1 to a room closer to the nurse’s station to facilitate closer monitoring of the patient and preclude further inappropriate interactions from occurring with other patients on the unit. 2. Review of the hospital’s internal investigation report regarding the alleged sexual encounter between Patient 1 and Patient 2 on 9/13/23 revealed the following: a. On 9/13/23 at 3:00 PM, per Staff I, the hospital evening staff observed Patient 1 and Patient 2 touching each other inappropriately. b. On 9/15/23 at 10:30 AM, Staff L (Public Safety Officer (PSO) and Staff N (PSO) spoke to Patient 2 to inquire about the incident. Patient 2 stated that she hugged Patient 1 but denied any sexual activity occurring between them. Patient 2 admitted that she slept in Patient 1’s room while he worked on a computer in the dayroom. Staff L and Staff N then spoke to Staff I who reported being previously notified by evening staff that they had observed Patient 1 and Patient 2 touching each other inappropriately on 9/13/23 at 3:00 PM. Additionally, Staff I reported observing Patient 1 and Patient 5 laying together in an inappropriate manner on multiple occasions within the previous few days. Staff I redirected the Patients (1 and 5) and reminded them that this behavior did not comport with the patient behavior guidelines in the unit. c. On 9/15/23 at an unspecified time, Staff L (PSO) and Staff N (PSO) spoke to Staff H (RN) and Staff J (RN) regarding the incident. Both Staff (H and J) reported receiving notification of the incident from Staff K (PNA) who received notification of the incident from Patient 3. d. On 9/15/23 at an unspecified time, Staff L (PSO) and Staff N (PSO) spoke to Patient 1 to inquire about the incident. Patient 1 reported that he had previously engaged in a consensual kiss with Patient 2 but did not admit to engaging in other sexual activities. e. On 9/15/23 at an unspecified time, Staff L (PSO) and Staff N (PSO) spoke to Patient 3 to inquire about the incident. Patient 3 reported that she observed Patient 1 and Patient 2 engaging in sexual activity on 9/13/23. Patient 3 stated that Patient 2 spent much of the day in Patient 1’s bed but stated that she did not believe any additional sexual activity occurred between the Patients (1 and 2). Patient 3 stated that she hesitated to report the incident due to fearfulness of Patient 1. 3. Review of Patient 1’s medical records revealed the following: a. On 9/14/23 at 7:18 PM, Staff H documented overhearing Patient 3 discussing with another patient that she witnessed Patient 2 engage in sexual activity with Patient 1. b. On 9/15/23 at 10:16 AM, restricted activity order was entered until 9/18/23 at 10:54 AM. c. On 9/15/23 at 10:19 AM, sexual acting out (SAO) precautions were entered until 9/18/23 at 9:59 AM. d. On 9/15/23 at 2:18 PM, Patient 1 relocated from room 2779 on 2JPW Unit to 2784 on 2JPW Unit. e. On 9/18/23, SAO precautions were removed. f. On 9/18/23 at 10:54 AM, restricted activity order was removed. 4. Review of Patient 2’s medical records revealed the following: a. On 9/13/23 at 9:54 AM, Staff I documented in a nursing note that she observed Patient 2 laying closely with Patient 5 in the day room with the lights off while fully clothed. Staff I turned on the lights, instructed the Patients (2 and 5) to leave the room, and locked the door to the day room. Staff I reminded Patients (2 and 5) not to touch each other and to keep a modest distance. Review of Patient #5’s medical record lacked documentation of any inappropriate encounter with Patient #2 on 9/13/23. b. On 9/14/23 at 7:45 PM, Staff S placed an order for transfer of Patient 2 to another unit within the hospital. c. On 9/14/23 at 7:52 PM, the hospital staff entered the incident report for the alleged sexual activity between Patient 1 and Patient 2 on 9/13/23. d. On 9/14/23 at 8:18 PM, Staff G documented in a nursing note that the patient’s roommate (Patient 3) observed Patient 2 leaving a male patient’s (Patient 1) room the previous night. e. On 9/14/23 at 8:34 PM, Patient 2 relocated to another unit within the hospital. f. On 9/15/23 at 8:15 AM, SAO (sexually acting out) precautions were entered until 9/18/23 at 2:30 PM. g. On 9/18/23 at 2:30 PM, SAO precautions were removed. 5. Interview with Staff H (RN) revealed the following: a. On 11/29/23 at 12:35 PM, Staff H stated that she did not witness Patient 2 engage in any sexual activity with other patients, but the Patient (2) did attempt to hold hands with other patients, which would warrant redirection by staff. Staff H recalled that Staff K previously stated that Patient 3 informed her (Staff K) that she (Patient 3) observed Patient 2 engaging in sexual activity. Staff H stated that Patient 1 does not always reliably tell the truth about events. 6. Interview with Staff T (RN) revealed the following: a. On 11/29/23 at 2:45 PM, Staff T stated that he never saw Patient 1 or Patient 2 in each other’s rooms and he (Staff T) never witnessed any inappropriate behaviors between them; however, Staff T indicated that Patient 1 and Patient 2 appeared to be flirting with each other in the day room on the day prior to the allegation. Staff T stated that Patient 1 fabricates and hyperbolizes stories and indicated that he (Staff T) was skeptical that Patient 1 and Patient 2 engaged in sexual activity. Additionally, Staff T stated that Patient 2 was believed to manufacture information on occasion. 7. Interview with Staff K (PNA) revealed the following: a. On 11/29/23 at 1:06 PM, Staff K reported that she observed Patient 2 and Patient 5 sitting in the day room together with the lights off, which did not comport with the expectation of patients in the unit. Staff K recalled that a table separated the Patients (2 and 5) so she did not witness any touching, and she (Staff K) did not see any clothing removed from either patient. 8. Interview with Staff V (RN) revealed the following: a. On 11/29/23 at 3:25 PM, Staff V reported that she did not witness any inappropriate behaviors between Patient 1 and Patient 2, and she (Staff V) stated that Patient 2 appeared to gravitate toward men to converse; however, she (Patient 2) did not appear to be motivated by sexual interests. Staff V stated that Patient 3 (Patient 2’s roommate) did not think highly of Patient 2 and indicated that Patient 3 often told stories that were not based in fact. Staff K also indicated that Patient 1 could not be relied upon for accurate portrayals of situations due to an inclination to lie. Staff V indicated that she did not believe that Patient 1 possessed sufficient intelligence to calculate when to engage in sexual activity between 15-minute checks, but could not rule out Patient 2 having this capability due to limited interactions with the Patient (2). Staff K did not observe Patient 1 or Patient 2 in each other’s rooms at any time. 9. Interview with Staff W (PNA) revealed the following: a. On 11/30/23 at 8:12 AM, Staff W stated that she was not made aware of any sexual activity between Patient 1 and Patient 2, she did not witness any sexually inappropriate behaviors exhibited by either patient, and she did not observe either patient in the other’s room. 10. Interview with Staff X (RN) revealed the following: a. On 11/29/23 at 2:00 PM, Staff X stated that Patient 3 periodically changed details, including the date of occurrence, of the alleged sexual activity between Patient 1 and Patient 2-even outright denying that she (Patient 3) reported the incident at one point. Staff X stated that Patient 3 could not be relied on to be truthful and had a patent motivation to lie about the incident because she did not want to remain roommates with Patient 2. Staff X indicated that Patient 3 knew that manufacturing the alleged incident would likely result in Patient 2’s relocation. Staff X also indicated that Patient 1 frequently manufactured stories to represent himself in a good light and that Patient 2 could be characterized as a poor historian and ‘storyteller’. 11. Interview with Staff G (RN) revealed the following: a. On 11/30/23 at 12:00 PM, Staff G reported that, to his knowledge, no UIHC staff witnessed any sexual activity between Patient 1 and Patient 2, and he (Staff G) expressed skepticism that the incident actually occurred. Staff G indicated that Patient 1 often lied or made delusional statements and was motivated to maintain an appearance of toughness. Staff G stated that he had limited interactions with Patient 2, but he recalled that Patient 3 treated other patients and staff poorly and frequently complained about trivialities. 12. Interview with Staff Z (PNA) revealed the following: a. On 11/29/23 at 1:30 PM, Staff Z did not recall any inappropriate interactions between Patient 1 and Patient 2, but reported that Patient 1 very commonly lied in an attempt to appear wealthy or famous. Per Staff Z, Patient 1 did not appear to be motivated, however, by a desire to project sexual prowess to other patients. 13. Interview with Staff J (RN) revealed the following: a. On 11/30/23 at 10:30 AM, Staff J stated that Staff K informed her of the alleged sexual activity between Patient 1 and Patient 2 on 9/13/23. She then proceeded to speak with Patient 3 to confirm details of the allegation. Per Staff J, Patient 3 informed her (Staff J) that she (Patient 3) witnessed Patient 1 and Patient 2 kissing in Patient 1’s room but that did not mention witnessing any sexual acts. The following day, Staff K accompanied Staff L (PSO) and Staff M (PSO) to speak to Patient 1 about the incident. Patient 1 stated that Patient 2 pushed him against the wall and kissed him, but Patient 1 did not mention sexual acts occurring during the interaction either. 14. Interview with Staff AA (RN) revealed the following: a. On 12/7/23 at 11:50 AM, Staff AA reported that he only recalled one observation of Patient 1 and Patient 2 together, which he characterized as strictly verbal and social, but not inappropriate. Staff AA indicated that Patient 1 exhibited behavioral issues, including impulsivity, but was not known to be sexually inappropriate with other patients or staff. 15. Review of the policy “Psychiatric Nursing Precautions/Observation,” Last Revised 10/20, revealed in part: a. “Purpose: To provide the level and type of precautions/observation necessary to meet the safety needs of a patient.” b. “ ...A patient will be placed on the precaution/observation procedure based on a RN and/or Licensed Independent Practitioner (LIP) Admission Assessment or risk related to ... sexual acting out ... RN initiated precaution/observations based upon patient needs with the exception of 1:1 for history of sexually acting out behavior in a hospital ...””