Las Vegas Sun

March 28, 2024

Psychiatric hospital fined for absence of precautions in alleged rape of patient

Police probing claims against man known to be violent

State investigators have fined the state’s psychiatric hospital in Las Vegas for not protecting a female patient who was reportedly raped by a male patient with known violent tendencies.

The staff at Rawson-Neal Psychiatric Hospital knew the man had bipolar and antisocial personality disorders and was prone to violence but failed to put protections in place to prevent him from harming others, according to the state’s investigation of the incident, released Thursday. It was one of three alleged rapes at the state’s two mental hospitals since 2005.

The medical records of the male patient, who was referred to only as “Pedro,” age 33, revealed he had “many incidents in which he was aggressive and threatening to staff and peers,” investigators from the Nevada Health Division’s Licensure and Certification Bureau wrote in their report.

Five weeks before the alleged rape, a psychological assessment concluded that Pedro was “a violent risk and care should be exercised in dealing with him. He is not amendable to behavioral interventions and will likely become agitated in reaction to any denial of what he feels entitled to.”

In October, Pedro threw a cup of orange juice at a female patient because she would not talk to him, the investigation found.

About a month later, he allegedly raped a different woman.

According to the state’s investigation, a mental health technician making a routine room check Nov. 14 saw Pedro leaving the 45-year-old woman’s room. The female patient told the facility’s staff that she had kissed Pedro willingly, but that even though she told him to stop he “forced himself into me.” Pedro claimed it was consensual sex.

Patients are closely monitored at Rawson-Neal, but patients are not locked in their rooms. They have been admitted because they are considered a danger to themselves or others. Many have violent or unstable tendencies, officials said.

The hospital’s director of nursing told state investigators that the facility’s policy is to have a staffing ratio of five patients per employee. At the time of the incident, there were nine patients — including the alleged perpetrator and victim — and two staff in the unit, the director of nursing told investigators.

The state Licensure and Certification Bureau, which licenses the hospital, fined Rawson-Neal $1,000 for failing to protect the female patient — the amount that’s designated by Nevada law for such an infraction.

The alleged rape was reported immediately to the state and to Metro Police, which is still investigating. Pedro has not been arrested, police officials said. It has also been reported to the Centers for Medicare & Medicaid Services and the Joint Commission, which monitors hospital quality, officials said.

Harold Cook, administrator of the state’s Mental Health and Developmental Services Division, the state agency responsible for the hospitals, said his internal investigation concluded that the 234-bed Rawson-Neal lacked the internal systems to protect the patient. Everyone who comes into the facility is assessed for risk, Cook said, and in this case staff saw the risk presented by Pedro.

“The difficulty is when you don’t have a protocol in place to translate that recognition of risk into preventive action,” Cook said. “If you don’t have a formal protocol then it gets forgotten or overlooked sometimes.”

Cook said the state has now put processes in place to protect patients when it’s determined that other patients are high risk.

Less than a week after the rape, on Nov. 20, there was another sexual assault at Rawson-Neal. A male patient who was known to be aggressive, but had no known history of sexual abuse, allegedly raped his male roommate, the Licensure and Certification Bureau reported. But in this case investigators determined there were no deficiencies by the hospital.

Cook said every patient shares a room and that there was no prior warning that the man would attack his roommate. But he added that the hospital should have done a better risk assessment to alert staff of potential danger.

Rapes are rare occurrences in mental hospitals, according to Cook and other local mental health experts. In April 2005 Cook was the administrator at the other state-run facility, Dini-Townsend Mental Hospital in Sparks, when a sexual assault took place that resembled the alleged incident Nov. 14.

In that case, a female patient was lying in bed heavily sedated when she was raped by a male patient who had a history of physical assault and uncooperative behavior with staff, the Licensure and Certification Bureau’s investigation showed. There was no documentation that the hospital’s staff had performed a mandatory room check just before the woman was raped, and it’s estimated the man may have been alone in her room for as long as 30 minutes, the investigation found.

At that time, Cook submitted a corrective action plan to ensure that the proper systems were in place to prevent such incidents.

Recalling the April 2005 incident, Cook said that even though the state runs both agencies he does not know how many of the lessons learned in Northern Nevada in 2005 were applied to the Southern Nevada mental hospital.

“In hindsight when you take a look at it there were things that could have been done to prevent it,” Cook said of the sexual assault allegations against Pedro. “I’m sorry we didn’t, but we’ll learn from this and move on.”

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