HospitalInspections.org

The Hospital was out of compliance for the Condition of Participation for Patient Rights.

Findings included:

The Hospital failed to ensure one (Patient #1) of 11 sampled patients were free from all types of harassment.

Cross Reference: A-0145

Based on interviews and records reviewed, the Hospital failed to ensure patients were free from all types of harassment for one of eleven sampled patients (Patient #1); Patient #1 was a pediatric patient with mental illness in the Hospital 's Emergency Department (ED) and was engaged in inappropriate communication via texting by an adult Hospital staff member following ED visits to the Hospital.

Findings include:

Review of Patient #1 's medical records, indicated that he/she presented to the Hospital ED via police due to suicidal ideation on 11/21/23. Patient #1 has a history of depression and schizophrenia (a disorder that affects a person ' s ability to think, feel, and behave clearly).

Review of the Hospital 's Patient Rights and Responsibilities Policy, effective 12/17/2021, indicated that patients have the right to receive care in a safe setting free from all forms of abuse and harassment.

Review of the Hospital 's Quality Assessment and Performance Improvement Plan dated 2/2024, indicated that communication and education on improvement philosophy, strategies, and tools in multiple venues throughout the organization may include but not limited to: new employee orientation, formal management education in terminology, strategies and tools, regularly scheduled computer-based training on improvement initiatives impacting their clinical accountability and departmental in-service programs tailored to meet the needs of a specific group. The policy further indicated that the Director of Quality, Patient Safety and Regulatory (QPS-R) is an integral member of the Senior Leadership Team focused on evaluating the delivery of care, developing an infrastructure for improvement, and promoting a safety culture. The Director, QPS-R is responsible for collaborating with executives and engaging clinicians in shared accountability for quality and safety.

Review of the Progress Note documented by the Attending Physician, dated 11/21/23 at 2:42 P.M., indicated that Patient #1 was focused on coming to the Hospital due to an alleged relationship with an adult staff member. The note further indicated that Patient #1 was hyper fixated on and believed that by coming to the Hospital he/she would be able to see the staff member, later identified as Patient Observer #1. Further review of the medical record indicated Patient #1 had multiple ED visits to the Hospital prior to 11/21/23. Patient Observer #1 had previously been assigned for constant observation for Patient #1 in September 2023.

During an Interview on 3/13/24 at 10:00 A.M., the Risk Manager said the Hospital did not perform a Root Cause Analysis (RCA) on the event involving Patient #1 as this was a Human Resources (HR) investigation and would be handled by that department.

During an interview on 3/13/24 at 11:09 A.M., the Director of Emergency Services and Critical Care Services said she was called by an outside community service organization notifying her that one of the Hospitals staff members, a patient observer (Patient Observer #1), was sending inappropriate text messages to one of their patients. She said she called the Chief Nursing Officer to make him aware and Patient Observer #1 was put on administrative leave immediately. She said HR was involved in the majority of the investigation. She said the Hospital identified an opportunity for education on code of conduct and patient rights with the patent observers. She said she has been educating ED staff during staff meetings and with staff individually. The Director of Emergency Services and Critical Care Services was unable to provide documentation to support education was fully implemented. She said the Hospital would also be adding this education during Hospital orientation for new hires but was unsure if it had been implemented. She said she was also involved with the education of new patient observers and has added the education to her portion of their orientation but was unable to provide documentation that this was implemented. The Director of Emergency Services and Critical Care Services said she oversees the patient observers who mainly work in the ED. She said patient observers have a review on performance every 2 years.

During an interview on 3/14/24 at 10:03 A.M., the Employee Relation Partner from HR indicated that the Director of Emergency Services and Critical Care Services made her aware of a staff member texting inappropriate/suggestive messages to a patient that was previously in the Hospital 's care. She said this prompted an HR investigation. She said that Patient Observer #1 admitted to texting with Patient #1. She said Patient Observer #1 disclosed messages sent to Patient #1 during his interview with HR; the text messages were inappropriate and Patient Observer #1 admitted it was wrong what he was doing and should not have engaged in messaging the Patient. The Employee relation partner indicated the investigation also identified another patient observer (Patient Observer #2) who aided Patient #1 in texting Patient Observer #1. The Employee Relation Partner indicated that the investigation resulted in Patient Observer #1 and Patient Observer #2 being terminated from their position at the Hospital. The Employee Relation Partner said as part of her investigation, video footage from the ED was reviewed and Patient Observer #2 could be seen using her personal phone, putting it between her and Patient #1, and Patient #1 was visibly distressed when the call ended. The Employee Relation Partner said it was identified during the Hospital investigation that the call on Patient Observer #2 ' s phone was placed to Patient Observer #1 to facilitate communication with Patient #1 and Patient Observer #1. She said there was a meeting after the investigation which identified opportunities for improvement and the need for more robust education on boundaries between Hospital staff and patients. She indicated that she recommended that the education be rolled out system wide.

During an interview on 3/14/24 at 11:33 A.M., the Chief Compliance and Privacy Officer indicated that she was involved in the investigation with Human Resources. She said there was a meeting that was held on 2/27/24 with HR to discuss the investigation. She said the Hospital identified a need for more education on code of conduct and that training would be added to yearly required education for all employees as well as for new employees during orientation. She said that the Director of Quality was not involved in this meeting. The Chief compliance and Privacy Officer indicated that the education has not been implemented.

The Hospital failed to ensure Patient #1 was free from harassment of the Hospital staff and the Hospital failed to implement interventions to prevent a like occurrence.