Samaritan Behavioral Center

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 50223 Based on observation, interview, and record review the facility failed to ensure that an allegation of patient-to-patient sexual abuse was fully investigated and that the grievance process was implemented in accordance with facility policy and regulatory requirements following a patient-to-patient sexual incident involving two patients (P1 and P11) of 12 patients reviewed. Findings include: A review of P1s medical record revealed P1 was admitted to a co-ed adult unit of an acute care psychiatric hospital on 8/20/25 at 2106 on a petition and a clinical certification from the emergency room with an admitting diagnosis of Bipolar/Schizoaffective Disorder. P1 lives in a group home and has a court appointed legal guardian. P1 was discharged back to the group home on 9/17/25. A review of P11s medical record revealed P11 was admitted to a co-ed adult unit of an acute care psychiatric hospital on 8/5/25 2114 on a petition and clinical certification from the emergency room with an admitting diagnosis of Schizoaffective disorder, depressed type . P11 was discharged to a shelter on 8/22/25 at 1224. On 10/28/25 at 1534 a review of the complaint and grievance log indicated a complaint for P1 “type: boundaries patient/patient”. Opened 8/27/25 and closed 8/29/25 and listed as unsubstantiated. At this time Recipient Rights Advocate staff M explained that they received several complaints from P1’s family member one of which was regarding an alleged sexual assault by another patient. Staff M explained that they did not substantiate that any patient rights were violated. Staff M explained that they interviewed Staff K who confirmed that they witnessed P1 with their legs open and P11 on top of them and that Staff K reported the incident to the nurse on duty. Staff M explained that they did not investigate P11 and did not know P11 had sexually acting out precautions (SAO) in place. Staff M also confirmed that they viewed the video footage which showed P11 entering P1s room at 0359, Staff K entering P1s room at 0409 and then P11 exiting the room. On 10/29/25 at 0958 Staff M was again interviewed and explained that the incident involving P1 and P11 was classified as a complaint because it was peer to peer and that rounds were done in a timely fashion, so it was opened as a neglect case and was unsubstantiated. Staff M explained that police involvement would be up to the patient’s legal guardian. The facility administrator staff A who was present at the time of this interview confirmed that P1 could not competently consent to sexual activity and has a legal guardian. Staff A confirmed that the incident involving P1 and P11 should be classified as abuse and explained that P1s legal guardian was notified and police were called. Staff M confirmed that P11 was discharged without being interviewed and that the nurse was also not interviewed by them. Staff B explained that both patients denied sexual contact and stated that it wasn’t until after P1’s return from the emergency room did they know that any sexual contact had occurred. A review of P11’s medical record revealed that they were discharged on 8/22/25 at 1224 before interviews and investigations were completed. A review of the complaint investigation revealed the nurse on duty, Staff S was never interviewed. An interview was conducted on 10/27/25 at 1024 with the Director of Risk staff C confirmed that they interviewed P1 who stated “I wanted to make love I was lying down. I performed oral sex and I wanted to.” Staff C indicated that their review concluded that they couldn’t find anything that the facility could have done to prevent the incident from occurring or reoccurring except for possibly posting an employee in the hallway. Staff C verified that no corrective-action plan was completed. A review of the grievance and complaint log revealed that the patient’s sister had filed repeated concerns but the facility did not document a written grievance response, status letters, or follow-up communication as required by policy. When asked to provide letters, the facility provided a receipt for a certified letter dated 10/26/25. No letters were provided. A review of the facility’s policy titled “Patient Rights” revealed the following: “Each patient has the right neither to be physically, sexually or otherwise abused (including sexual harassment) nor to be neglected.” A review of the facility’s policy titled “Identifying Abuse and Neglect” revealed the following: Abuse Class I: A non-accidental act, or provocation of another to act by an employee volunteer, agent of a provider, or another patient that caused or contributed to death, or sexual abuse of, or serious physical harm to a recipient ...Sexual Abuse: is any of the following: (i) Criminal sexual conduct as defined by section 520b to 520e of 1931 PA 318, MCL750.520b To MCL750.520e involving an employee, volunteer, or another patient, of a provider and a recipient. (ii) Any sexual contact or penetration involving an employee, volunteer, or another patient of a department operated hospital or facility and a recipient. (iii) Any sexual contact or sexual penetration involving an employee, volunteer or another patient of a provider and a recipient whom the employee, volunteer or agent provides direct services ...IV. Procedures. A.Employee: ANY employee who witnesses, discovers or are notified of an incident concerning patient abuse or neglect including verbal and written reports in accordance with the MNC 1723, will: a)Immediately take actions to protect, comfort, and assure treatment of the patients as necessary b) Verbally notify the charge nurse and recipient rights office immediately. If Charge Nurse not available notify, CEO, CAO, NEO, or Medical Director c) File an incident report in Clarity before the end of the shift and complete a Recipients Rights Compliant Form (including patient statement), being as descriptive as possible (including observations and statements heard relating to the allegation of abuse or neglect) A Compliant may be from any of the following a.The patient who thinks he/she has been a victim b. A family member of the patient; c. Another patient who may have witnessed the incident, or d. Any responsible citizen who may have witnessed the incident. B. Charge Nurse: 1. Assesses the patient, notifies the attending psychiatrist, and takes whatever action is necessary to provide for the patient’s immediate medical needs, and other safety measures including moving the patient to other unit or room as applicable. 2. Investigate allegation o Interview staff and/or client who reported allegation of abuse or neglect o Interview the clients involved in the allegation, either as a witness, via hear-say, or as a participant. Interviews shall be conducted with no other clients present. oReview patient monitoring procedures o Review applicable hospital policies 3. Mandatory reporting of o Allegations of Abuse or Neglect must be immediately reported to a) The rights office b) Administration -Chief Executive Officer, Chief Administrative Officer, Nursing Executive Officer, Risk Manager and Medical Director c) Other agencies as required by law [MHC 1752 (1)] o Each individual staff member with knowledge of the allegation of abuse or neglect must submit an incident report. (see Hospital Policy MH-35” Incident Reports”) o Ensure the patient statement of allegation of abuse or neglect (as descriptive as possible) completed on Recipient Rights Complaint For 4. Documentation o Any patient care issue is documented in the patient’s medical record, including allegations of sexual assault or sexual familiarity. oNever use another patient’s name in a patient’s medical record. o Document the staff’s response to the allegation, specific actions to maintain safety of the patient’s involved. oDo not reference incident report in medical record. oDocument contact made to physicians, and guardiansoTreatment team shall revise the treatment plans as applicable for the safety and care of the client’s involved. 5 Sends the patient to the nearest Emergency Room if rape is suspected/or alleged, for a complete rape examination. C. Recipient Rights Advisor: 1. Investigates the alleged abuse/neglect complaint. (Investigative process outlined in “Patient Complaints” Policy MH-01) 2. Maintains a record of the investigation and the recommendations of the report in accordance with the Recipient Rights Reporting Policy. 3. The rights office will provide a prompt and thorough review of charges of abuse that is fair to both the recipient alleged to have been abused and the charged employee, volunteer, or agent of a provider. D.Director of Nursing: 1.Investigation Upon receipt of an Incident Report, telephone notification, Recipient Rights notification, the Director of Nursing for reasons including, most importantly, the protection of patient rights, will investigate any allegations of abuse and/or neglect. In addition, investigations are conducted to assure safety, to find causes, to prevent similar occurrences and to protect company interests. A copy of resolution will also be shared with Recipient Rights Advisor, Human Resources, Chief Executive Officer and Medical Director. 2. If the incident involved a staff, the Director of Nursing will sign the “Notification of Abuse and Neglect” Sheet and initiate the “Suspension of Staff during Recipient Rights Investigation” procedure. See Policy MH 47 for full reference. 3.If the incident involved another patient, the Director of Nursing will summarize its clinical interventions using the “Clinical Leadership Assessment of Peer-to-Peer Abuse” form. The Office of Recipient Rights will include these findings in its investigative report.E. CEO: 1. Upon receipt of a Incident Report or Recipient Rights Complaint Form that alleges patient abuse or neglect that has not been resolved at the lower level, will meet with the Recipient Rights Advisor and may establish a fact-finding committee, or directly determine the next course of action. 2. If indicated, determines who will sit on the ad-hoc fact-finding committee to investigate the allegation of patient abuse/neglect. This committee shall include the Recipient Rights Advisor. a.shall review all data in relation to allegations of patient abuse/neglect.b.shall interview all staff involved, or who have knowledge of the allegations of patient abuse/neglect and ascertain if the patient’s rights have been violated. c.shall make a recommendation to the CEO. 4.For incidents involving peer against peer abuse, the CEO will review the “Clinical Leadership Assessment of Peer-to-Peer Abuse”, and determine the appropriateness of nursing leadership’s interventions.”

“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: 50223 Based on interview and record review, the facility failed to protect one patient (P1) of 12 patients reviewed from sexual abuse by another patient resulting in a violation of the patient’s right to care in a safe environment. Findings include: A review of P1s medical record revealed P1 was admitted to a co-ed adult unit of an acute care psychiatric hospital on 8/20/25 at 2106 on a petition and a clinical certification from the emergency room with an admitting diagnosis of Bipolar/Schizoaffective Disorder. P1 lives in a group home and has a court appointed legal guardian. P1 was discharged back to the group home on 9/17/25. A review of P11s medical record revealed P11 was admitted to a co-ed adult unit of an acute care psychiatric hospital on 8/5/25 at 2114 on a petition and clinical certification from the emergency room with an admitting diagnosis of Schizoaffective disorder, depressed type . P11 was discharged to a shelter on 8/22/25 at 1224. A review of P11s medical record revealed nursing notes from 8/12/25 noted: “Patient threatening to come behind the nurses station to physically and sexually assault writer.” A nursing note by RN staff Q dated 8/18/25 revealed “Patient is sexually inappropriate with female staff. Placed on SAO (sexually acting out) precautions.” A review of P11s care plan revealed that SAO was added to their treatment plan on 8/18/25. Review of P1s medical record revealed a nurses note dated 08/22/2025 04:42 revealed the following: “At approximately 4:10 AM during routine rounds, the technician observed the patient with another patient positioned on top of her. When questioned, the patient denied any inappropriate activity and became verbally loud and disruptive.” An interview on 10/29/25 at 1157 with mental health technician (MHT) staff K confirmed they witnessed P1 and P11 engaged in a sexual act and immediately reported the incident to the Registered Nurse staff S, who is no longer employed by the facility. Staff K stated P1 had been exhibiting sexually inappropriate actions and comments prior to this event which Staff K had reported to Staff S. Interview on 10/29/25 at 1230 with RN Staff Q revealed that they obtained the order for SAO for P11 due to P11 exhibiting sexually inappropriate behaviors and comments to Staff Q and other staff. Staff Q explained that sexually acting-out patients should be under constant visual observation and not permitted in rooms with peers. During an interview on 10/29/25 at 1020 the Director of Nursing Staff H explained that when a patient is on SAO precautions, they should be placed on one-to-one observation or moved closer to the nurses’ station. Staff H confirmed that a one-to-one order requires a physician’s signature, but additional measures such as moving a patient to a single room could be initiated by nursing leadership when the risk is known. Staff H confirmed that P11 was not on one to one observation nor was his room moved away from a female vulnerable patient despite being on SAO. Review of staffing assignments showed that the MHT on duty was responsible for the entire 20-bed unit during the time the incident occurred. On 10/28/25 at 1557 review of the video footage 8/22/25 03:58-04:00p confirmed that P11 entered P1’s room and remained inside for approximately 10 minutes before the MHT entered the room and P11 exited. A policy regarding sexually acting out precautions was requested on 10/28/25 at 1300, and on 10/29/25 1217 and was not provided by the conclusion of the survey. A review of the facility’s policy titled “Identifying Abuse and Neglect” revealed the following: “Sexual Abuse: is any of the following: (i) Criminal sexual conduct as defined by section 520b to 520e of 1931 PA 318, MCL750.520b To MCL750.520e involving an employee, volunteer, or another patient, of a provider and a recipient. (ii) Any sexual contact or penetration involving an employee, volunteer, or another patient of a department operated hospital or facility and a recipient. (iii) Any sexual contact or sexual penetration involving an employee, volunteer or another patient of a provider and a recipient whom the employee, volunteer or agent provides direct services.”