“Student #2 walked into student #1’s bedroom. At the time of the incident there were eight boys on the unit with three staff. One staff was assisting an upset student…The other two staff were in the day room with four students. The same staff member was responsible for both student #1 and #2’s observation sheets. When the staff member who was assisting with the upset patient returned to the dayroom he asked staff where patient #1 was located…Student #2 was found sitting on student #1’s bed and walked when staff walked in the room and found him. When questions about the incident student #1 admitted that student #2 performed oral sex on him.”The provider told DBHDS that the administrative team added more rounds and made more of a presence on the units. Additionally, they told DBHDS that nursing staff were notified of the importance of reviewing rounds sheets during each shift and supervisors received additional training on staff observations.
An investigation conducted by the Virginia Department of Behavioral Health and Developmental Services (DBHDS) determined that North Spring Behavioral “failed to provide adequate supervision” for residents. DBHDS found that two residents were left alone in a bedroom and engaged in oral sex while staff members were assisting other residents. DBHDS reported: