Henry Ford Health Behavioral Health Hospital

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to obtain consent for psychotropic medications according to facility policy for 2 (P-1, P-7) of 11 patients and failed to follow policy obtaining consent for treatment for 2 (P-7, P-8) of 11 patients reviewed, resulting in the potential loss of making informed decisions regarding care. Findings include: On 07/14/2026 at 12:35 PM, P-1’s medical record was reviewed with Director of Utilization Management Staff I. According to P-1’s medication administration record, P-1 received Risperidone (an antipsychotic medication) 2 mg by mouth on the following dates and times: - 03/18/2026 at 9:00 PM - 03/21/2026 at 9:25 PM - 03/22/2026 at 9:00 AM - 03/22/2026 at 9:56 PM - 03/23/2026 at 9:00 AM - 03/23/2026 at 8:27 PM - 03/24/2026 at 9:00 AM P-1 received Paliperidone Palmitate (an antipsychotic medication) 235 mg intramuscularly once on 03/24/2026 at 9:00 AM. A review of P-1’s consents revealed that P-1 did not have a medication consent completed for antipsychotic medications. Staff I confirmed the finding of the missing medication consent at the time of discovery. According to the facility’s policy “Informed Consent,” dated 12/2025, “If treatment being provided includes medication, an additional informed consent form for psychotropic medication is required to be completed.” 48772 P-7: This 28-year-old with a history of cognitive impairment, behavioral dysregulation, and autism spectrum disorder was admitted to the facility on 7/8/26 for suicidal ideation and aggressive behavior. During record review on 7/14/26 at 1:50 PM, it was noted that the medical record contained “letters of guardianship of individuals with developmental disability,” dated 7/19/16, naming P-2’s father as plenary guardian (a plenary guardian is a court-appointed legal guardian with full authority over an incapacitated adult or minor child). It was also noted that the formal voluntary admission application was signed by the patient on 7/8/26 at 2:30 PM and did not contain guardian signature. A review of medication orders revealed P-7 was ordered Vraylar 4.5mg for mood changes, Remeron 15mg for major depressive disorder, and trazadone 50mg as needed for insomnia. The medical record failed to include psychotropic medication consents. P-8: This 23-year-old with a history of developmental disability, mood disorder, and depression was admitted to the facility on 7/10/26 for suicidal ideation. During record review on 7/14/26 at 2:20 PM, it was noted that the medical record contained an “order appointing guardian for individual with a developmental disability” dated 9/23/21, which named a partial guardian for a term of 5 years to have the power to “consent to medical, dental and optical treatment.” It was also noted that the formal voluntary admission application was signed by the patient on 7/10/26 at 4:00 PM and did not contain guardian signature. The Chief Nursing Officer (Staff C) reviewed and acknowledged these findings at the time of discovery stating the patient’s guardians should have been given the opportunity to sign the documents. Policy-20025844 Informed Consent (last approved 12/2025). States, “At the time of admission and prior to commencing services, recipients shall be assessed to determine whether any legal (i.e., guardianship status) or clinical issue may compromise the individual’s ability to give informed consent. If it is determined that delivery of services can proceed, the adult recipient or their legally empowered guardian will be asked to read, discuss, and sign the Consent for Treatment, MDHHS Formal Voluntary Admission form, Recipient Rights Acknowledgment form and any other required documents. Recipients and legally empowered guardians shall be given adequate opportunity to read the documents and ask questions before signing them. Consent shall generally be signified by the signature of the recipient or legally empowered guardian and is not executed unless witnessed.””

“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: 50585 Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment for 35 of 35 patients who were on patient care units 1 B and 2 B and for 1 (P-1) of 4 patients reviewed in seclusion resulting in an increased likelihood of undesirable outcomes for the patients. Findings include: On 07/14/2026 at 9:48 AM, during a tour of the 1 B patient care unit, the seclusion area was observed. The patient toilet had urine present, a bandage was sticking to the floor of the seclusion room, a crumpled piece of paper was on the chair located outside the seclusion room, and plaster on the seclusion room wall had indents and gouges. Chief Nursing Officer (CNO) Staff B confirmed the findings at the time of discovery. On 07/14/2026 at 10:22 AM, during a tour of the 2 B patient care unit, the seclusion area was observed. The patient toilet had urine present and there was residue on the lower portion of the wall padding in the seclusion room. Director of Clinical Services Staff D and CNO Staff B confirmed the findings at the time of discovery. On 07/15/2026 at 2:15 PM, a video of P-1 in the seclusion room on 03/19/2026 through 03/20/2026 was reviewed and the following observations were noted: 03/19/2026 - At 10:48 PM, P-1 had a bowel movement on the floor - At 10:49 PM, P-1 smeared feces against the inside door of the seclusion room - At 10:51 PM, Behavioral Health Associate Staff D checked P-1 but did not take action to address the feces - At 10:53 PM, P-1 had a second bowel movement and smeared feces on the wall and door - At 11:10 PM, P-1 smeared feces on floor and kicked door while naked . 03/20/2026 - At 12:54 AM (2 hours and 6 minutes after P-1 defecated in the seclusion room), Staff D obtained paper towels and instructed P-1 to clean the feces - At 1:03 AM, P-1 exited the seclusion room and area Director of Quality Staff B confirmed the observations at the time of video review. According to the facility’s policy “SECLUSION,” dated 2/23/2025, “A patient in seclusion will be offered food, beverages, and hourly access to toileting. The patient will remain clothed unless his/her actions make it impractical or inadvisable; shall be kept in sanitary conditions; and will be provided a bed or mat to sit on or lie down on unless is/her actions make it impractical or inadvisable.” According to the facility’s “HOUSEKEEPING MANAGEMENT PROGRAM,” dated 2/23/2025, for patient rest rooms, “Clean toilets. Use a bowl mop on the inside of the toilet. Use a disposable cloth, abrasive pad, lotion cleanser, and a spray bottle of germicidal detergent solution to remove soil from the exterior of toilets and adjacent wall and partition surfaces. Dry the toilet seat and bright metal surfaces to prevent water spotting.” The policy also revealed for daily quiet room cleaning, “Spot clean walls, doors, door facings, columns, and other building surfaces to remove handprints, smudges, and other obvious soil. Use a cloth and germicidal detergent solution from a spray bottle.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to ensure patients in seclusion were monitored according to facility policy for 3 (P-1, P-4, P-5) of 4 patients reviewed resulting in the increased likelihood of undesirable outcomes and loss of patient’s rights for the patients. Findings include: On 07/14/2026 at 12:45 PM, P-1’s medical record was reviewed. On 03/19/2026 at 9:50 PM, P-1 had separate orders for “Seclusion” and “Flowsheet documentation of continuous observation no less than every 15 minutes while in seclusion and restraint.” On 03/19/2026 at 10:13 PM, P-1’s Medical/Non-Violent Restraint Flowsheet documented by Behavioral Health Associate Staff D revealed on 03/19/2026 at 10:12 PM, P-1 was “lying or sitting.” There were no additional observations recorded on P-1’s flowsheet even though P-1’s order required continuous observation no less than every 15 minutes. On 03/20/2026 at 2:54 AM, Nurse Staff J signed a Note for a “Form: Seclusion/Restraint Flowsheet” and that flowsheet revealed: P-1 entered the seclusion room on 03/19/2026 at 9:32 PM and exited the seclusion room at 03/20/2026 at 1:12 AM. The Patient Monitoring section of the flowsheet revealed two entries recorded by Staff J. On 03/19/2026 at 9:32 PM, P-1 had behaviors of “Cursing; Yelling/Screaming; Uncooperative; Threatening; and Combative” with an intervention “Continuous in-person monitoring.” On 03/20/2026 at 1:12 AM, P-1 had a behavior of “Quiet” with an intervention “Discontinue seclusion/restraint.” There were no additional observations recorded on P-1’s flowsheet while P-1 was in seclusion even though P-1’s order required continuous observation no less than every 15 minutes. On 07/14/2026 at 1:22 PM, P-4’s medical record was reviewed. On 06/23/2026 at 9:45 PM, P-4 had separate orders for “Seclusion” and “Flowsheet documentation of continuous observation no less than every 15 minutes while in seclusion or restraints.” On 06/24/2026 at 3:36 AM, P-4’s nursing note revealed “pt placed on seclusion for about 2 hours for safety.” A review of P-4’s medical record revealed that there was no seclusion flowsheet monitoring form created to document the continuous observation monitoring of P-4. On 07/14/2026 at 2:00 PM, P-5’s medical record was reviewed. On 04/22/2026 at 9:22 PM, P-5 had separate orders for “Seclusion” and “Flowsheet documentation of continuous observation no less than every 15 minutes while in seclusion and restraint.” A review of P-5’s medical record revealed that there was no seclusion flowsheet monitoring form created to document the continuous observation monitoring of P-5. Chief Nursing Officer Staff C confirmed the findings at the time of discovery. On 07/15/2026 at 1:26 PM, Staff C was queried if they expected staff to follow the facility policies and procedures, Staff C revealed “Yes, I do.” According to the facility’s policy “Seclusion,” dated 03/25/2025, “The patient shall be monitored and reassessed through continuous in-person observation. Staff monitoring the patent will document the monitoring in 15-minute intervals. If a behavioral health associate (BHA) BHA is monitoring the patient, he/she will notify the assigned registered nurse (RN) immediately of any abnormal behaviors. The assigned RN will assess the patient immediately and will document their findings in the electronic health record (EHR).””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 48772 Based on record review and interview, the facility failed to ensure nursing staff adhered to the policies and procedures of the facility for 1 (P-2) of 11 patients reviewed, resulting in possible negative outcome. Findings include: P-2 has a past medical history of absence seizures (brief lapse in awareness with sudden cessation of all activity with a blank look/staring off into space), major depressive disorder, generalized anxiety disorder, and gender dysphoria. P-2 was admitted to the facility on 5/4/26 for inpatient behavioral health treatment after suicide attempt with intentional fluoxetine ingestion (medication used to treat major depressive disorder). During record review on 7/14/26 at 1:00 PM, it was noted that the “Intake” documentation indicated P-2 arrived at the facility on 5/4/26 at 3:10 PM and the “initial nursing assessment” indicated P-2 arrived at the adolescent unit at 6:00 PM. A review of the nursing progress note, by licensed practical nurse (Staff U) dated 5/5/26 at 5:48 AM, stated, “Resident alert and responsive. Resident was in the room when observed lying in the bed and noted having a seizure. Patient developed stiffening of the right arm followed by some jerking. Patient eyes rolled upward and foaming at the mouth. Time at 2335 (11:35 PM) the seizure stop at 2337 (11:37 PM). Seizure precaution in place. Patient was lethargic with some confusion noted. Patient fully oriented at 2340p (11:40 PM) time 3. Doctor was on the scene, Family [name] notified times 4 no answer. Will maintain observation and report any changes.” [sic] An interview was conducted on 7/15/26 at 11:30 AM with the resident physician (Staff S) who was called to examine P-2 post seizure. Staff S stated that she was contacted by the nursing unit earlier that evening when P-2 approached the nurse’s station and “was concerned about seizure medication.” Staff S stated that she looked into the chart and was made aware of the seizure medication ethosuximide, but the pharmacy had left for the night. Staff S stated that around 11:45 PM, she was notified of seizure activity that was witnessed by staff. Staff S stated that seizure activity had ceased within a few minutes and before Ativan could be administered. An interview was conducted with Pharmacist (Staff P) on 7/15/26 at 9:24 AM. Staff P was queried on the process for verifying home medication and stated home medications can be used when medications are not on the facility formulary. Staff P stated the admissions team would collect the medication from the patient and release it to the pharmacy. The pharmacy would then verify the drug, dose, and frequency and print a new label with the directions and send it to the unit. Staff P stated there is a pharmacist on duty until 8:00 PM on weekdays and until 3:00 PM on weekends. Staff P was questioned on the process when a patient is admitted after the pharmacy is closed and replied that nursing would obtain a one-time order to administer the medication prior to pharmacy review where two nurses would verify the medication prior to administration. Staff P was asked to review P-2’s seizure medication and stated there was a pharmacist on duty until 8:00 PM on 5/4/26. Staff P stated the order for ethosuximide 500mg twice daily was verified on 5/5/26 at 9:06 AM. Staff P stated that twice daily medications are administered at 9:00 AM and 9:00 PM and confirmed that the PM dose on 5/4/26 was not administered and P-2 had one dose administered on 5/5/26 at 9:24 AM. An interview was conducted with the Chief Nursing Officer (Staff C) on 7/15/26 at 1:13 PM. Staff C stated the medication history process is conducted once the patient is on the floor and the nurse would identify the medication is not on formulary. Staff C was queried on the “Medications from Home” policy and if seizure medication is considered urgent and replied it would be considered urgent use. Staff C acknowledged staff did not follow the policy. Policy: Patient Medications from Home (Issued 4/15/25). States: Medications brought in should be inventoried and recorded in the patient’s belongings list in the Electronic Health record (EHR). Medications brought in by the patient that will be used during the hospital stay will be retrieved from Intake by healthcare personnel. If during normal business hours a pharmacist will obtain the medication from Intake. The pharmacist will verify the home medication, put it in a “Home-Medication” bag and take to the unit. The medication will be placed in the patient specific bin in the Pyxis machine for the nurse to retrieve to use for the patient. If after normal business hours, nursing will need to get the medication from Intake. If non-urgent use, the pharmacist will verify the next business day. If medication is needed before the next business day, the medication will need to be verified by a healthcare professional (i.e., physician, nurse practitioner).”

“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: 47415 Based on observation, interview, and record review, the facility failed to provide monitoring for 3 (P-1, P-2, P-7) of 10 patients reviewed, resulting in: inappropriate patient to patient contact, injury to a patient, and the potential for poor outcomes for all patients. Findings include: P-7 During facility tour of adolescent unit on 3/10/25, at 0945 P-7 with orders for 1:1 observation (elopement risk),was observed exiting the activity room to the left of the nursing station, entering the hallway and entering the day room in front of the nursing station and sitting down in a chair. Another staff member was in the dayroom, P-7 was not accompanied by her assigned 1:1 observer at the time of observation. Director of Clinical Services Staff E present during unit tour, confirmed the observation in an interview conducted in conference room on 3/10/25 at 1530. P-1 Record review for P-1 revealed safety orders on 2/15/25, were for rounding observations every 15 minutes and a 1:1 observer. On 2/15/25, the 1:1 observer for P-1 (per review of video footage) left the day room at 1350, leaving P-1 without a 1:1 observer. P-1 assaulted another patient (P-4) after the 1:1 sitter walked away. P-4 sustained a carpet burn to the left arm. On 3/11/25 at 1330 an interview with Chief Medical Officer (CMO) Staff U revealed it is his expectation that staff follow policy and procedures of the facility. Review of policy titled, “Observations, Patient” provided at time of survey, dated 2/23/25, revealed: “To maintain patient health and safety ...1:1 team member is assigned to one patient. The assigned team member must remain close enough to intervene if the patient attempts inappropriate behaviors. This was not done. 50585 P-2 On 3/11/2025 at 0845, Risk Manager Staff D and Director of Quality Staff C reviewed an alleged incident between P-1 and P-2. According to the facility’s description of the incident, “on 2/8/2025” (P-1) “reported to staff that patient (P-2) was in (their) bathroom and touched (their) breast and exposed (themselves). According to the incident report investigation, the outcome revealed that “Patients were interviewed, video footage was reviewed. The following timeline was established and substantiated the sexual misconduct/boundary allegation.” 1600 Both patients (P-1 and P-2) can be seen talking with another patient outside (P-1’s) door. 1604 (P-2) is in (their) room and (P-1) and another patient can be seen talking to (P-1) from the doorway. 1609 P-2 can be seen sitting outside (another patient’s room) with P-1 and 2 other patients. 1612 Both patients (P-1 and P-2) enter (P-1’s) room (P-1) just ahead of (P-2) and door closes. 1613 (P-1) steps out of room and back in 1614 Different female patient enters room and both females leave 1615 (P-1) reenters room 1618 (P-1) seen at doorway of room 1619 - 1620 (P-2) leaves (P-1’s) room and goes into room across from (P-1) fully clothed, BHT (Behavioral Health Technician) can be seen looking for him for locates him for observation. On 3/11/2025 at 1120, a video review of the hallway activities outside P-1’s with Risk Manager Staff D confirmed the timeline and activities as described in the description of the alleged incident. According to the facility’s interview of P-1 following the alleged incident, P-1 revealed that P-2 “went into my bathroom along (sic) and no one else was present. (They) was sitting on the toilet when I came in (they) began touching my breast I had on my shirt at that time. (They) pulled down (their) pants and I saw a drop of semen fall from (their) penis. The semen drop on the floor and I cleaned it up. I asked (them) to get out of my room and (they) did.” According to the facility’s interview of P-2 following the alleged incident, P-2 revealed “I went into P-1’s bedroom because (they) asked me too. I thought (they) was going to suck my dick. I remember being in the bathroom (they) ask me to pull down my pants. She got upset and asked me to leave (their) bedroom which I did. Patient very confused (they) reported I don’t remember the whole thing but I did not touch (them) at all.” According to P-2’s patient observation sheet for 2/8/2025, P-2 was observed by Behavioral Health Technician Staff V at 1606 and 1634 and documented as P-2 being in their bedroom. There was a 28-minute gap between the two recordings at 1606 and at 1634. Staff C was queried if an every 15-minute safety check was missing for P-2 and Staff C confirmed there was a missing 15-minute check during the time of the sexual misconduct allegation between P-1 and P-2. On 3/11/2025 at 1125, a video review with Risk Manager Staff D of the unit and patients walking the hallways revealed that on 2/8/2025 at 1606, Staff V was sitting in a chair in the day room and P-2 was down the hallway and may or may not have been in their room (unable to determine from video). Staff D was asked whether staff could verify the safety check even though it appeared Staff D could not see P-2 and Staff D explained there was a proximity report that would tell the distance at the time of recording. On 3/11/2025 at 1130, the proximity report for P-2’s safety check at 1606 was requested. On 3/11/2025 at 1215, CNO Staff F revealed they were unable to produce the proximity report on their computer that would reveal the distance between Staff V and P-2 at 1606. Staff V was asked to be interviewed on 3/11/2025 at 0900 and was not available. On 3/11/2025 at 1250, the facility’s policy “Electronic Patient Observations Using (DEVICE),” dated 2/23/2025 revealed that “Documentation of the observation is to be completed once the patient has been observed. If the beacon is not registering or the patient refuses to wear a beacon, the round may still be entered but the patient must be observed before it is completed.” The policy also revealed that for “Q 15 Minute Rounds,” “All patients are monitored at minimum once in every 15-minute block of time.””

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 47415 Based on record review and interview, the facility failed to protect one patient (P-4) from 2 physical assaults by peers and failed to follow facility policy regarding observation levels for abuse and neglect occurrences on unit, resulting in physical abuse and mental anguish to P-4 and the potential for harm to all patients served by the facility. Findings Include: On 02/13/25, the medical record for P-4 was reviewed. P- 4, a 15-year-old female was admitted to the facility on 1/13/25, with diagnoses of disruptive mood dysregulation disorder and attention-deficit/hyperactivity disorder (ADHD, combined type). Review of records revealed P-4 was physically assaulted twice in the day room (video review conducted at time of survey and confirmed the following events). The first assault occurred on 2/13/25 at 1819, by 2 peers (P-1 and P-3). P-1 hit P-4 in the head, and then P-3 started hitting P-4. Patients were separated by facility staff at 1820. P-4 complained of head pain after the assault on 2/13/25. The second physical assault to P-4 occurred on 2/15/25 at 1350:41, by 2 peers (P-1 and P-5), both peers started hitting/kicking P-4. Patients were separated by facility staff at 1350:49. P-4 sustained carpet burns to her left arm after the assault on 2/15/25. Record review for P-3 revealed that rounding observations and orders remained at every 15 minutes after physical altercation with P-4 on 2/13/24. No changes in observation level noted on 2/13/25, they were not increased to every 5 minutes nor was a 1:1 sitter assigned. Record review for P-1 revealed orders on 2/15/25, were for rounding observations every 15 minutes and a 1:1 observer. On 2/15/25 1:1 observer for P-1 (per review of video footage) left the day room at 1350, leaving P-1 without a 1:1 observer. P-1 assaulted P-4 after 1:1 sitter walked away. Record review for P-5 revealed that rounding observations and orders remained at every 15 minutes after physical altercation with P-4 on 2/15/25. No changes in observation level noted on 2/13/25, they were not increased to every 5 minutes nor was a 1:1 sitter assigned. On 3/11/25 at 1330 interviews with Chief Executive Officer (CEO) Staff A, Chief Nursing Officer (CNO) Staff F, and Chief Medical Officer (CMO) Staff U revealed nursing can always add observations or increase observation levels for the safety of patients, they are not allowed to decrease observation orders. CMO Staff U stated it is his expectation that staff follow policy and procedures of the facility. Review of recipient rights policy titled, “Abuse and Neglect” provided at time of survey dated 2/23/25, revealed under heading “Abuse: a. If a patient commits abuse the registered nurse will place the patient committing the offense on Q5 minute observations or 1:1 observation. Review of policy titled, “Observations, Patient” provided at time of survey, dated 2/23/25, revealed: “To maintain patient health and safety ...1:1 team member is assigned to one patient. The assigned team member must remain close enough to intervene if the patient attempts inappropriate behaviors ... The RN may increase the level of observation if the patient’s condition changes. The psychiatric practitioner will be contacted as soon as possible for notification of the change in condition and to obtain an order for the observation level ...The RN may add a precaution if the patient’s condition changes. The psychiatric practitioner will be contacted as soon as possible for notification of the change in condition and to obtain an order for the new precaution.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 47415 Based on record review and interview, the facility failed to provide the Important Message from Medicare (IMM) to 3 (#1, #5, #6) of 5 patients whose medical records were reviewed for the provision of the Important Message from Medicare document, resulting in the failure to inform the patient or patient’s representative of the right to appeal discharge and potential loss of rights for the patient. Findings include: On 11/14/24, during initial facility tour, review of open medical records and insurance information, for P-5 and P-6 revealed the IMM was not provided or signed by the either patient on admission. At time of discovery, Staff D confirmed the documents were not in the record. On 11/14/24 at 1300, review of closed medical record for P-1 revealed the IMM was not provided or signed by patient on admission. On 11/14/24 at 1000 interview with Staff I revealed the registration staff is responsible to provide the IMM to patients with Medicare insurance. Monthly audits reveal that the provision of this document on admission is lower than goal.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 47415 Based on interview and record review, the facility failed to follow policy by failing to initiate a prompt and through investigation in 1 (P-1) of 3 patients reviewed for sexual abuse allegations resulting in an increased risk of harm for all patients. Findings include: On 5/22/24 record review for P-1 revealed note by Staff K on 5/18/24 at 1704 that stated physician from the emergency room called to inform writer that P-1 reports she was raped last night at sending facility”. On 5/23/24 at 1000 in conference room, interview with RN Staff K confirmed she received the report call from the emergency room physician on 5/18/24 regarding P-1’s allegation of an alleged rape occurring (at sending) facility last night, and she immediately reported it to House Supervisor Staff S. On 5/22/23 at 1530 an interview with house supervisor Staff S reveled she was notified of the allegation and immediately notified Nurse Manager Staff E on 5/18/24 (Saturday). On 5/23/24 at 1100 a review of the Grievance Log found no entry for an alleged rape reported for P-1 occurring on 5/18/24. On 5/23/24 at approximately 1120 interview with Recipients Rights Officer Staff L revealed he was not notified of a rape allegation involving P-1 on 5/18/24, and to date no recipient’s rights investigation has been initiated. On 5/23/24 record review of policy titled “Patient to Patient Sexual Assault Allegation Policy”, dated 4/26/22 revealed under policy, “It is the policy ...to investigate all allegations of ... sexual assault. An allegation of ...sexual assault is a serious matter and a consistent approach must be applied to ensure that all allegations are investigated immediately and concluded as soon as possible, with an effective and caring response” and under section titled, “Immediate Action Protocol ... f. Clinical Staff will notify the Recipient Rights Officer of the patient’s allegation.” On 5/23/24 record review policy titled, “Recipient Rights - Abuse and Neglect” dated 6/20/23 revealed under procedure, “Immediately after receiving a report of an apparent or suspected abuse or neglect ...the Recipient Rights Officer will begin an investigation into the matter.””