HospitalInspections.org

Based on document review and interview, the facility failed to ensure care in a safe setting on 1 (Unit 100) of 3 areas toured (see tag 144) and failed to ensure patients are free from abuse/harassment in 1 (Unit 100) of 3 area toured (see tag 145).

The cumulative effect of these systemic problems resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review and interview, the facility failed to ensure care in a safe setting in 1 (Unit 100) of 3 areas toured:

Findings include:

1. Policy/procedure, Patient Rights and Responsibilities, 1-A.9, revised/reviewed 6/18 indicated on page 3: "Receive care in a safe setting, free from verbal or physical abuse or harassment".

2. Policy/procedure, Patient Observation, 11-C.113, revised/reviewed 1/18 indicated on page 2: "Line of sight observation: 1. Staff will maintain routine visual observation with the patient".

3. Review of patient 1's MR indicated the patient was sent to F1 for evaluation after the patient's roommate reported that he/she had had a sexual encounter with the patient. The nurse found that the patient's pants were down when he/she assessed him/her so patient was sent out to be evaluated for possibly sexual assault. Review of Nursing Reassessment dated 10/17/18 0340 hours per staff N1 indicated: "Patient was observed to have pants pulled down and incontinent pad found in shower. Patient unable to state what happened or if anything happened. Roommate questioned and stated he/she had sex all night long. Review of Nursing Reassessment dated 10/18/18 at 1100 hours indicated: "Resident transferred out to F1 for further evaluation.

4. Review of patient 2's MR indicated the patient shared a room (room 1010) with patient 1 and occupied bed 2. Review of patient 2's MR indicated the patient was admitted to the facility on 9/25/18 for bipolar affective disorder and inappropriate sexual behavior. Review of physician admitting orders dated 9/25/18 indicated: "Precautions: Line of sight observation. Assault. Sexual acting out". Review of Every 15 Minute Patient Observation Monitoring forms lacked documentation Line of Sight Observation had been implemented per nursing staff starting daily on 9/25/18 through 10/17/18. Review of Behavioral Health Progress Note dated 10/5/18 per staff N2 indicated: "Clinician observed patient attempting to kiss a direct care staff member on the mouth today. Direct care staff report from night shift said patient was naked and attempted to have sex with another male resident". Review of Psychiatric Progress Note dated 10/5/18 per medical staff D2 indicated: "...nursing staff reported that patient's mood has been labile, impulsive at times, and that patient has been making sexual inappropriate comments towards the roommate and was naked standing over the roommate last night...". Review of Behavioral Health Progress Note dated 10/17/18 per staff N2 indicated: "Patient has a one-to-one (1:1) assigned to him/her today. Direct care staff report patient stuck his/her hands down a male/female patient's diaper". Review of Psychiatric Progress Note dated 10/17/18 per medical staff D2 indicated: "He/she reportedly told one of the Certified Nursing Assistants (CNA) that he/she had sex with his/her roommate. Upon further assessment, his/her roommate was found early this morning with his/her pants pulled down. At 0700 hours this morning, nursing staff notified this clinician about the incident last night, verbal order was given to move patient to a new room and place patient on 1:1 observation for safety". Patient 2's MR lacked documentation an increased observation level was initiated by nursing staff as ordered by the physician on 9/25/18 due to patient 2's history of sexually acting out behavior.

5. On 10/29/18 at approximately 1030 hours, staff N6 (Chief Executive Officer) was interviewed and confirmed patient 1 and patient 2 shared room 1010 from 10/16/18 to 10/17/18. Staff N6 confirmed patient 2 was moved to another room on 10/17/18 after an incident that occurred on 10/17/18 involving potential sexual assault. Staff N6 confirmed patient 2 reported to staff that he/she sexually assaulted patient 1. Staff N6 confirmed medical staff D2 ordered patient 2 to be transported to F1 on 10/18/18 for medical assessment due to incident. Staff N6 confirmed patient 2's admission orders included a Line-of-Sight Observation Level. Staff N6 confirmed nursing staff failed to implement Line-of-Sight Observation Level.

Based on document review and interview, the facility failed to ensure patients were safe from abuse/harssment in 1 (Unit 100) of 3 areas toured:

Findings include:

1. Policy/procedure, Patient Observation, 11-C.113, revised/reviewed 1/18 indicated on page 2: "Line of sight observation: 1. Staff will maintain routine visual observation with the patient".

3. Review of patient 1's MR indicated the patient was sent to F1 for evaluation after the patient's roommate reported that he/she had had a sexual encounter with the patient. The nurse found that the patient's pants were down when he/she assessed him/her so patient was sent out to be evaluated for possibly sexual assault. Review of Nursing Reassessment dated 10/17/18 0340 hours per staff N1 indicated: "Patient was observed to have pants pulled down and incontinent pad found in shower. Patient unable to state what happened or if anything happened. Roommate questioned and stated he/she had sex all night long. Review of Nursing Reassessment dated 10/18/18 at 1100 hours indicated: "Resident transferred out to F1 for further evaluation.

4. Review of patient 2's MR indicated the patient shared a room (room 1010) with patient 1 and occupied bed 2. Review of patient 2's MR indicated the patient was admitted to the facility on 9/25/18 for bipolar affective disorder and inappropriate sexual behavior. Review of physician admitting orders dated 9/25/18 indicated: "Precautions: Line of sight observation. Assault. Sexual acting out". Review of Every 15 Minute Patient Observation Monitoring forms lacked documentation Line of Sight Observation had been implemented per nursing staff starting daily on 9/25/18 through 10/17/18. Review of Behavioral Health Progress Note dated 10/5/18 per staff N2 indicated: "Clinician observed patient attempting to kiss a direct care staff member on the mouth today. Direct care staff report from night shift said patient was naked and attempted to have sex with another male resident". Review of Psychiatric Progress Note dated 10/5/18 per medical staff D2 indicated: "...nursing staff reported that patient's mood has been labile, impulsive at times, and that patient has been making sexual inappropriate comments towards the roommate and was naked standing over the roommate last night...". Review of Behavioral Health Progress Note dated 10/17/18 per staff N2 indicated: "Patient has a one-to-one (1:1) assigned to him/her today. Direct care staff report patient stuck his/her hands down a male/female patient's diaper". Review of Psychiatric Progress Note dated 10/17/18 per medical staff D2 indicated: "He/she reportedly told one of the Certified Nursing Assistants (CNA) that he/she had sex with his/her roommate. Upon further assessment, his/her roommate was found early this morning with his/her pants pulled down. At 0700 hours this morning, nursing staff notified this clinician about the incident last night, verbal order was given to move patient to a new room and place patient on 1:1 observation for safety". Patient 2's MR lacked documentation an increased observation level was initiated by nursing staff as ordered by the physician on 9/25/18 due to patient 2's history of sexually acting out behavior.

5. On 10/29/18 at approximately 1030 hours, staff N6 (Chief Executive Officer) was interviewed and confirmed patient 1 and patient 2 shared room 1010 from 10/16/18 to 10/17/18. Staff N6 confirmed patient 2 was moved to another room on 10/17/18 after an incident that occurred on 10/17/18 involving potential sexual assault. Staff N6 confirmed patient 2 reported to staff that he/she sexually assaulted patient 1. Staff N6 confirmed medical staff D2 ordered patient 2 to be transported to F1 on 10/18/18 for medical assessment due to incident. Staff N6 confirmed patient 2's admission orders included a Line-of-Sight Observation Level. Staff N6 confirmed nursing staff failed to implement Line-of-Sight Observation Level.

Based on document review and interview, the facility failed to ensure nursing staff documented incidents and transport of patients as per facility policies/procedures in 2 of 10 medical records (MR) reviewed:

Findings include:

1. Policy/procedure, Incident Reports, 111.B.11, revised/reviewed 1/16, indicated: "Incident reports shall include documentation of the following elements: head to toe assessment performed if applicable. Attending provider notified within 1 hour of incident/injury involving their patient.

2. Policy/procedure, Transfer and Transport of a Patient, 1-C.73, revised/reviewed 6/18, indicated: "Prior to transport, and upon returning, the Registered Nurse will document a patient assessment, condition on the Continuation of Care Form. The following forms are required to be completed when transporting the patient: Transfer/Transport Consent/Order; Continuing Care Transfer Information".

3. Review of patient 1's MR lacked documentation by nursing of Continuation of Care Form, Transport Consent and patient assessment/condition prior to transport to F1 on 10/17/18. Review of patient 1's MR lacked documentation of a complete head to toe assessment by nursing post incident on 10/17/18. Review of patient 1's MR lacked documentation the patient's attending physician was notified of incident within 1 hour post incident on 10/17/18.

4. Review of patient 2's MR lacked documentation by nursing that the patient's attending physician was notified within 1 hour of incident that occurred on 10/17/18.

5. Review of facility incident/occurrence report dated 10/17/18 involving patient 1 and 2 lacked documentation a head to toe assessment of patient 1 was completed post incident and lacked documentation patient 1 and 2's attending physicians were notified within 1 hour of the 10/17/18 incident.

6. Staff N6 confirmed nursing staff failed to document incident investigation per facility policy/procedure. Staff N6 confirmed nursing staff failed to document patient 1's transport to F1 per facility policy/procedure. Staff N6 confirmed nursing staff failed to document the incident that occurred on 10/5/18 related to patient 2's sexual behavior towards another patient.