Severe reports

At 4:12 AM, the patient was found unresponsive. [...] Staff called Emergency Medical Services (EMS), and they arrived around 2:50 AM. EMS took the patient’s vitals, and the patient refused to be transported to the ER. [...] Staff called 911 and administered Narcan to the patient. [...] The document showed that EMS responded and worked on the patient for 15 minutes and got a pulse. The patient was stabilized and transported to the local hospital. [...] Law enforcement responded to the scene and investigated the incident.

Failure to monitor access and egress to the facility can result in a lack of oversight of the facility and poor patient outcomes, including death. [...] The document showed that Emergency Medical Services (EMS) responded and worked on the patient for 15 minutes and got a pulse. The patient was stabilized and transported to the local hospital.

From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-337-080 – Resident care services (2)(h)(i)(ii) The licensee must address serious illness, medical emergencies, or threat to life; WAC 246-337-075 – Resident rights (2)(g) Each resident has the right to have a safe and clean environment.. "[...]" marks text left out between sentences.

In plain words: A child in the program reported that a staff member made sexual comments, flirted, and touched them inappropriately. Another staff member reported the allegations to child protective services and law enforcement. The state report notes that the staff member was later charged with two counts of child molestation. Our summary of the state's report. The state's own wording follows.

Review of a facility document titled, “Incident Report”, dated 08/23/23, showed that Staff B, Milieu Manager, contacted CPS to report sexual assault allegations made by Patient #1. [...] It showed that Staff Q captured detailed statements Patient #1 was making to law enforcement about the alleged sexual assault by Staff A. e. [...] 19. Review of an email exchange between Investigator #1, Staff D, Executive Director of Intensive Youth Services, and Individual #2, Detective, on 01/02/24, showed: “[Staff A] has been charged with two counts of Child Molestation in the 3rd Degree”. [...] On or around 08/19/23, Patient #1 disclosed during a “casual conversation” with a milieu staff that Staff A had inappropriately touched them. b. [...] On a second occasion, there was an inappropriate touching event with Staff A in the facility’s laundry room.

Law enforcement determines whether a crime was committed and therefore the facility may not limit or prohibit external reporting activities. [...] 12. During an interview with Staff D, on 09/21/23, they stated that no one from the facility had contacted law enforcement to report the sexual assault allegations made by Patient #1 on 08/18/23. They stated that after a conversation with Staff L, Chief Administrative Officer, they realized that they had the responsibility of reporting allegations of sexual assault to law enforcement.

The documents contained the following information: a. “[Staff A] has been making sexual comments like, “age is just a number” and [they] slap my ass. [They] also been looking down girls' shirts and has been making all of us uncomfortable.” b. “[Staff A] flirts with us kids. [They] tell them age is just a number, winks at them, touches them in places like their butts, gives them flowers, and overall is just really taken. [They] need to not work in a place where people have been sexually assaulted.

From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-337-075 Resident rights.; WAC 246-337-065 Safety and security.; WAC 246-337-048 Quality improvement program.; WAC 246-337-048 Quality improvement program.. "[...]" marks text left out between sentences.

In plain words: A child in the program reported that a staff member made sexual comments and touched them inappropriately. Another child made a similar report and called law enforcement, and records showed staff failed to report the first allegation to the police. Our summary of the state's report. The state's own wording follows.

On or around 08/19/23, Patient #1 disclosed during a “casual conversation” with a milieu staff that Staff A had inappropriately touched them. b. [...] The documents contained the following information: a. “[Staff A] has been making sexual comments like, “age is just a number” and [they] slap my ass. [They] also been looking down girls' shirts and has been making all of us uncomfortable.” b. “[Staff A] flirts with us kids. [They] tell them age is just a number, winks at them, touches them in places like their butts, gives them flowers, and overall is just really taken. [They] need to not work in a place where people have been sexually assaulted. [...] On 09/05/23 law enforcement responded to a lewd conduct call [lewd conduct is a type of criminal charge] from Patient #2 after they reported they’d been inappropriately touched by Staff A. b.

12. During an interview with Staff D, on 09/21/23, they stated that no one from the facility had contacted law enforcement to report the sexual assault allegations made by Patient #1 on 08/18/23. They stated that after a conversation with Staff L, Chief Administrative Officer, they realized that they had the responsibility of reporting allegations of sexual assault to law enforcement. [...] 9. A Teams message exchange between Staff D, Executive Director, and Staff E, Counselor, dated 09/28/23, showed Staff D messaging Staff E, saying “The detectives are wanting the documentation around your conversation about the sexual misconduct.

5. During an interview on 09/21/23 at 09:15 AM, Staff D, Executive Director of Intensive Youth Services, stated that an allegation of staff sexual misconduct was made by Patient #1 on or around 8/18/23. [...] 7. Review of law enforcement records and internal facility records showed that Patients #1 and #2 repeatedly reported they were prevented from using the telephone to call 911 and the non-emergency law enforcement number to report sexual misconduct by a staff inside the facility 8.

Staff S wrote:” Did anyone tell [Patient #4] that a DCR [designated crisis responder] would be coming to assess [them] and that due to [their] recent self-harm and blade to [their] neck indicating suicide risk that [they] would be likely detained for 6.5 months? [...] PYR will determine which outside entity needs to be reported to (DOH, Law Enforcement, CPS) and will determine the next steps.

From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-341-0600 Individual rights.; WAC 246-341-0410 Agency administration—Administrator key responsibilities.; WAC 246-341-0420 Agency policies and procedures.; WAC 246-341-1133 Evaluation and treatment services—Service standards.. "[...]" marks text left out between sentences.

A. Respondent has obstructed external oversight and intervention by impeding Program investigations and failing to cooperate with DCYF/CPS and law enforcement in connection with complaints of employee misconduct, child abuse and neglect, and criminal acts at the facility. [...] M2022-552 (lead) M2022-553 (consolidated) C. Respondent has demonstrated a pattern of indifference to the mental and physical well-being of patients by failing to report sexual abuse and professional misconduct. Furthermore, individuals in supervisory capacities, in at least two instances, attempted to cause credentialed providers to downgrade serious conduct such as “grooming” and “sexual assault” to protect the agency from external scrutiny.

From the state's report. Findings of fact, summary action order. "[...]" marks text left out between sentences.

A. Respondent has obstructed external oversight and intervention by impeding Program investigations and failing to cooperate with DCYF/CPS and law enforcement in connection with complaints of employee misconduct, child abuse and neglect, and criminal acts at the facility. [...] M2022-552 (lead) M2022-553 (consolidated) C. Respondent has demonstrated a pattern of indifference to the mental and physical well-being of patients by failing to report sexual abuse and professional misconduct. Furthermore, individuals in supervisory capacities, in at least two instances, attempted to cause credentialed providers to downgrade serious conduct such as “grooming” and “sexual assault” to protect the agency from external scrutiny.

From the state's report. Findings of fact, summary action order. "[...]" marks text left out between sentences.

For example, the Program has identified that three (3) former employees of DYS Brush Prairie have — allegedly engaged in professional boundary violations, including sexual misconduct, with three (3) minor patients.

From the state's report. Findings of fact, summary action order.

For example, the Program has identified that three (3) former employees of DYS Brush Prairie have — allegedly engaged in professional boundary violations, including sexual misconduct, with three (3) minor patients.

From the state's report. Findings of fact, summary action order.

1. During an interview on 04/12/22 at 1:00 PM, Staff A, Licensing and Compliance Manager, stated that the alleged sexual assault incident was only reported to the Department of Children, Youth and Family (DCYF) and was not reported to DOH.

3. Review of the “Root Cause Analysis”, dated 03/07/22, showed that Patient #3 had gone into the room of Patient #1, #2 and #4 on the night of the alleged sexual assault incident.

Based on staff interview, the agency failed to report to the Department of Health an incident of sexual abuse for 1 or 4 patients reviewed (Patient #3).

From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-341-0420 (13)(a), Agency policies and procedures.; WAC 246-337-075 (2)(a)(g) Resident rights.; WAC 246-337-065 (5)(a) Safety and Security..

3. Review of the “Root Cause Analysis”, dated 03/07/22, showed that Patient #3 had gone into the room of Patient #1, #2 and #4 on the night of the alleged sexual assault incident.

Based on staff interview, the agency failed to report to the Department of Health an incident of sexual abuse for 1 or 4 patients reviewed (Patient #3). [...] 1. During an interview on 04/12/22 at 1:00 PM, Staff A, Licensing and Compliance Manager, stated that the alleged sexual assault incident was only reported to the Department of Children, Youth and Family (DCYF) and was not reported to DOH.

From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-337-075 (2)(a)(g) Resident rights.; WAC 246-337-065 (5)(a) Safety and Security.. "[...]" marks text left out between sentences.

In plain words: A child in the program reported that another child grabbed her left breast while she was in a facility van and later grabbed her crotch at a YMCA pool. Our summary of the state's report. The state's own wording follows.

Critical Incidents/ as appropriate state body overseemg that Health/ Department of Social and Health (MCO)/ and regional Administrative events when appropriate after consultation (CCO/ CAO/ Risk Manager/ or supervismg below: COMPREHENSIVE HEALTHCARE POLICIES AND PROCEDURES will report and follow-up with the appropriate email/ withm one busmess day any Critical below) or as otherwise specified m the will report to the Department of Health Healthcare s premises/ of any individual of receiving notice of the individuaFs https://fortress.wa.gov/doh/opu'do/s?s=OTPDeathReportmg Director or VP/ or designee of Residential of Health and other appropriate agencies incidents that involve serious or undesirable inpatient hospital stay; and through internal or external emergency or BHA Critical Incident Reporting webpage: https://forti'ess.wa.gov/doh/opmio/s?s=ComplamtFormHPF Director or VP/ or designee of Residential notify DSHS/Residential Care Service suicide/ relocation to a hospital or other or designee in an Assisted Living resident s physician/ and other individual(s) is a significant change in the resident's health care facility; or the resident dies.

1.Review of police report, titled “Supplemental Narrative”, dated 10/23/19, showed that Patient #1 reported sexual assault and harassment to the police. “TPatient #1] confirmed that there have been several incidents and |] asked [Patient #1]to tell me [Police Detective] about the first time that something happened. [Patient #1] told me they were in a facility van coming back from an outing...[Patient #2] reached through a ‘crease’ in the and he grabbed van the left side of her body, under her shirt... [Patient #1] told me [Patient #2}] grabbed her left breast when he reached through her shirt’.” “I [Police Officer] told [Patient #1] | heard about something happening at the YMCA pool... [Patient#1] told me that she was swimming back and forth and [Patient #2] grabbed her crotch...[Patient #2] placed his hand down the back of her pants and then got out of the pool...” 2.

From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-341-1126(l)(b) Mentai health inpatient services - Policies and procedures "Adult.; WAC 246-341-1126(1}(b) Metal health inpatient services Policies and procedures Adult..

Critical h-icidents/ as appropriate state body overseeing that Health/ Department of Social and Health (MCO)/ and regional Administrative events when appropriate after consultation (CCO/ CAO/ Risk Manager/ or supervising below: COMPREHENSIVE HEALTHCARE POLICIES AND PROCEDURES will report and follow-up with the appropriate email/ within one business day any Critical below) or as otherwise specified in the will report to the Department of Health Healfchcare s premises/ of any mdividual of receiving notice of the individuals https://forti'ess.wa.gov/doh/opuTio/s?s=OTPDeathReportmg Director or VP/ or designee of Residential of Health and other appropriate agencies incidents that mvolve serious or undesirable mpatient hospital stay; and through internal or external emergency or BHA Critical Incident Reporting webpage: https://forh'ess.wa.gov/doh/opuuo/s?s=Con'iplaintFormHPF Director or VP/ or designee of Residential notify DSHS/Residential Care Service suicide/ relocation to a hospital or other or designee m ai\ Assisted Living resident's physician/ and other individual(s) is a significant change in the resident's health care facility; or the resident dies.

From the state's report. Deficiency cited, complaint investigation. Cited: WAC 246-337-075(2)(a) Resident Rights..

Onor about February 8, 2023, the Program received a second complaint alleging a counselor (Stowe) employed at DYS Brush Prairie was arrested for having — a sexual relationship with Patient #10.

The notice explained that the Program would comply with the conditions in Part 2 to protect covered records and information obtained from DYS Brush Prairie. — The records request letter explained that the investigation had to do with allegations of staff sexual misconduct with patients and with a failure of facility systems to ensure patient safety.

Swope also engaged in nonconsensual sexual contact with Patient #11 during an outing from DYS Brush Prairie.

2023-2056) the Program became aware of allegations that another counselor at DYS Brush Prairie (Swope) had engaged in sexual contact with Patient #11 within — DYS Brush Prairie’s facility and while Patient #11 was admitted to DYS Brush —- — Prairie.

Further, Patient #9 reported to the Program and DYS Brush Prairie that the incidents — with Reinmuth resembled how they felt when they were raped by a teacher.

During this phone call, Patient #9 reported they had been in communication with Reinmuth since being discharged, and that Reinmuth had been communicating with another patient of DYS Brush Prairie outside of the facility. — Patient #9 reported the conduct of Reinmuth had triggered a manic episode due to past trauma when Patient #9 had been raped by a teacher.

While admitted to DYS Brush Prairie, Patient #9 had frequent contact — with Reinmuth, including disclosing to Reinmuth that Patient #9 was raped by a teacher.

From the state's report. Findings of fact, notice of intent.

On or about February 8, 2023, the Program received a second complaint alleging a counselor (Stowe) employed at DYS Brush Prairie was arrested for having — a sexual relationship with Patient #10.

From the state's report. Findings of fact, notice of intent.

The notice explained that the Program would comply with the conditions in Part 2 to protect covered records and information obtained from DYS Brush Prairie. — The records request letter explained that the investigation had to do with allegations of staff sexual misconduct with patients and with a failure of facility systems to ensure patient safety.

From the state's report. Findings of fact, notice of intent.

Swope also engaged in nonconsensual sexual contact with Patient #11 during an outing from DYS Brush Prairie.

From the state's report. Findings of fact, notice of intent.

2023-2056) the Program became aware of allegations that another counselor at DYS Brush Prairie (Swope) had engaged in sexual contact with Patient #11 within — DYS Brush Prairie’s facility and while Patient #11 was admitted to DYS Brush — — Prairie.

From the state's report. Findings of fact, notice of intent.

Further, Patient #9 reported to the Program and DYS Brush Prairie that the incidents — with Reinmuth resembled how they felt when they were raped by a teacher.

From the state's report. Findings of fact, notice of intent.

During this phone call, Patient #9 reported they had been in communication with Reinmuth since being discharged, and that Reinmuth had been communicating with another patient of DYS Brush Prairie outside of the facility. — Patient #9 reported the conduct of Reinmuth had triggered a manic episode due to past trauma when Patient #9 had been raped by a teacher.

From the state's report. Findings of fact, notice of intent.

While admitted to DYS Brush Prairie, Patient #9 had frequent contact — with Reinmuth, including disclosing to Reinmuth that Patient #9 was raped by a teacher.

From the state's report. Findings of fact, notice of intent.