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Based on a review of medical records, facility's policies and procedure, and staff interviews it was determined that the facility's governing body failed:

1. To ensure the the facility's emergency department delivered safe and effective care for of Patient #1.
2. To protect and promote the right of Patient #1 to receive care in a safe environment.

This failure resulted in harm to Patient #1 who was sexually assaulted by another patient on 04/08/19 in the behavioral health pod (BHP) of the facility's ED.

Findings were:

Cross refer to A1100-Emergency Services as it relates to the failure of the facility to continuously monitor of Patient #1 while on an involuntary hold in the behavioral pod of the facility's Emergency Department.
Cross refer to A0115-Patient Rights - as it relates to the failure of the facility to protect the right of Patient #1 to receive care in a safe environment.

Based on a review of medical records, facility's policies and procedure, and staff interviews it was determined that the facility failed to protect the right of Patient #1 to receive care in a safe environment by failing to continuously monitor a developmentally disabled patient (Patient #1) while the patient was on a 1013 (involuntary mental health hold). This failure resulted in harm to Patient #1 who was sexually assaulted by another patient on 04/08/19 in the behavioral health pod (BHP) of the facility's ED.

Findings:

Cross refer to A0043-Governing Body as it relates to the failure of the governing body:
1. To ensure the the facility's emergency department delivered safe and effective care for of Patient #1.
2. To protect and promote the right of Patient #1 to receive care in a safe environment.
Cross refer to A1104-Emergency Services as it relates to the failure of the facility to continuously monitor of Patient #1 while on an involuntary hold in the behavioral pod of the facility's Emergency Department.

A review of Patient #1's medical record revealed that the 48-year-old patient presented to the Emergency Department (ED) on 04/08/19 at 7:40 p.m. via ambulance from a group home for violent behavior towards staff, left ankle pain, and suicidal ideation. Documentation revealed that Patient #1's chief complaint was aggressive, bizarre behavior associated with psychosis, and left ankle pain. The ED physician noted that Patient #1 had a history of schizophrenia, mental retardation or developmental disability, and bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks). The ED physician's physical assessment notes further revealed that Patient #1 was oriented x 3 (oriented to person, place, and situation), maintained normal speech, and had no motor deficits. Patient #1 was tearful, hyper-verbal, delusional, and tangential (diverging from the topic). The ED physician signed a 1013 (involuntary admission into a healthcare facility for mental health treatment) on 04/08/19 at 7:52 p.m. and a behavioral health consult was ordered on 04/08/19 at 7:55 p.m.

The consent to treat was signed by Patient #1 on 04/08/19 at 8:23 p.m. however the Acknowledgement of Notice of Patient Rights and Responsibilities and the Advance Directives area were blank. A witness signed the last page of the consent form, verifying that the patient was unable to sign.

The medical record for Patient #1 revealed that on 04/08/19 at 11:29 p.m. the nurse called in a request for a behavioral health (BH) assessment.

On 04/09/19 at 4:14 a.m. nurse's notes revealed that the Development Disability Team (DDT) requested that Patient #1 be treated for psychosis. The nurse further noted that she was unable to complete a full assessment of Patient #1 due to Patient #1's developmental disability.

A review of the telehealth Behavioral Health Consult on 04/09/19 at 9:00 a.m. described Patient #1 as tearful, manic (wild or hysterical), and disorganized with loose associations. The assessment further revealed that Patient #1 was angry, combative, threatening, with delusions that other people were trying to harm her. The assessment revealed that Patient #1 asked if the assessor could get someone to sleep with her when it was time for sleep. The summary of the behavioral consult revealed that Patient #1 should remain on a 1013 and be referred for inpatient treatment.

On 04/09/19 at 10:14 a.m. the nurse's notes revealed that the DDT member assessed Patient #1 and consulted a Medical Doctor. The DDT member recommended that Patient #1 remain on a 1013 and be referred for inpatient treatment.

On 04/09/19 at 6:51 p.m. the nurse's notes revealed that Patient #1's stepmother/legal guardian called and stated that Patient #1 needed a shot of her medicine due the next day and that Patient #1 is better when the medication is received.

On 04/10/19 at 12:33 a.m. documentation revealed that Georgia Crisis and Access Line (GCAL) stated that Patient #1 was on two (2) behavioral health boards for pending discharge.

On 04/10/19 at 1:07 a.m. the nurse's notes revealed that the police officer (assigned to continuously monitor surveillance video) noticed on video that Patient #1 made physical contact with another patient (Patient #2). Patient #2 was removed and put in seclusion. Patient #1 was placed on continuous monitoring, and a counseling appointment was made for Patient #1.

Review of the sexual assault consult (MOSAIC GA-a facility designed and equipped to provide confidential and specialized services to meet the distinct needs of sexual assault victims) on 04/10/19 revealed that the consult was ordered to determine if any injuries were present which required treatment; or if there was residual from a previous injury. The consult was also ordered to provide medication(s) for the prevention or treatment of infection or the prevention of pregnancy (Per ED). A urine HCG test (human chorionic gonadotropin - a urine pregnancy test) was checked, with no result indicated.
The following medications were ordered:
Zithromax (antibiotic) 1 gram orally x 1 dose
Metronidazole (antibiotic) 2 grams orally x 1 dose
Rocephin (antibiotic) 250 mg intramuscular x 1 dose and
Ella (Ulipristal Acetate- birth control and hormone) 30-milligram tab orally as soon as possible.
No additional documentation was provided regarding the consult.

Review of the continuous observation monitoring logs revealed that the 15-minute checks of Patient #1 started on 04/08/19 at 7:00 p.m., through 04/15/19 at 2:15 a.m.
On 04/10/19 at 1:00 a.m. the monitoring log revealed the behaviors/activities and location of Patient #1 was documented as:
· The patient's safety/dignity 1=Yes
· Behavior Code 1=calm and cooperative
· Activity Code A=awake
· Location Code R=room
o On 04/11/19 from 1:45 p.m. to 2:45 p.m. the continuous observation monitoring log indicated' lunch' with no other activity codes written for patient observation.
o On 04/12/19 from 3:15 a.m. to 3:30 a.m. the continuous observation monitoring log indicated' lunch' with no other activity codes written for patient observation.
o On 04/13/19 from 4:30 a.m. to 4:45 a.m., the continuous observation monitoring log indicated 'break' with no other activity codes written for patient observation.
o On 04/13/19 from 1:00 p.m. to 1:15 p.m. the continuous observation monitoring log indicated 'break' with no other activity codes written for patient observation.
o On 04/14/19 from 2:30 a.m. to 2:45 a.m. the continuous observation monitoring log indicated 'break' with no other activity codes written for patient observation.
o On 04/14/19 from 1:00 p.m. to 1:15 p.m. the continuous observation monitoring log indicated 'lunch' with no other activity codes written for patient observation.
o On 04/15/19 from 2:00 a.m. to 2:15 a.m. the continuous observation monitoring log indicated 'break' with no other activity codes written for patient observation.

Patient #1 was discharged from the facility with her guardian and group home director on 4/15/19 at 3:35 p.m.

A review of two (2) hours and 10 minutes of surveillance video footage captioned in the ED's behavioral health area on 04/23/19 at 12:52 p.m. in the conference room with the day shift ED manager (Ed Manager EE), Risk Manager (RM BB), and the manager of hospital security (SM HH) revealed the following:
--On 04/10/19 at 1:00 a.m. the video revealed a police officer (Officer NN) sitting in front of the ED and behavioral health cameras on a cell phone.
Patient #2 is sitting in his room (room 24) and Patient #1 is sitting in her room (room 23) across the hall from each other.
· At 1:03:35 a.m., Patient #2 is seen walking into Patient #1's room.
· At 1:04 a.m., Patient #1 and Patient #2 are seen hugging and kissing each other.
· At 1:04 a.m., Patient #2 lies on top of Patient #1 and in between Patient #1's legs.
· At 1:06:54 a.m., Officer NN sitting in front of the cameras notes the situation on camera and goes into room 23 at 01:07:05 and puts Patient #2 back in room 24 and locks the door.
Further review of the video footage revealed that the ED manager, nursing supervisor, and several county police officers and investigators arrived at the scene.
· At 2:58 a.m. a tele-cart was placed in Patient #2's room for his behavioral health consult.
Patient #1 and Patient #2 were not physically assessed until 04/10/19 at 3:10 a.m.

Officer NN was observed walking away from cameras often throughout the two (2) hour and 10-minute segment.

A review of the medical record for Patient #2 revealed that the 77-year-old was admitted to the facility on 4/9/19 at 9:34 p.m. with a chief complaint of '1013 from a detention center'. Review of the 1013 form revealed that Patient #2 had a history of PTSD (post-traumatic stress disorder), current delusional thoughts, was refusing treatment and presented with unprovoked threats of harm to self and others. The history and physical revealed that Patient #2 was a 71-old male with a past medical history of anxiety and diabetes mellitus. He presented with complaint of medication refill. According to police, Patient #2 was brought in from a detention center for aggressive behavior and a 1013 was signed in the field. Upon arrival, Patient #2 reported that he needed a medication refill, which he did not have access to while he was recently in the hospital. Patient #2 denied suicidal ideation, homicidal ideation, or aggressive behavior.
After the incident with Patient #1 on 4/10/19, Patient #2 was placed in a law enforcement non-violent enclosure restraint. A new 1013 dated 4/10/19 was created for 'attempted molestation of a patient'. The 1013 form indicated that Patient #2 was mentally ill, and presented a substantial risk of imminent harm to self and others as manifested by recent overt acts or recent, expressed threats of violence which present a probability of physical injury to self or other persons. Patient #2 was subsequently discharged to jail/court in police custody on 04/10/19 at 12:45 a.m.

A tour of the ED was conducted on 04/23/19 at 11:15 a.m. with the ED manager (Ed Manager EE) and the Patient Safety Director (PSD II). The ED had a total of 66 beds which included six (6) rooms in the Behavioral Health (BH) pod. The behavioral health rooms included three (3) additional rooms outside of the established behavioral health pod (rooms 21, 22 and 34). Room #24 had an ED stretcher, a long call light, vents on the ceilings with holes and a TV encased in a box with rectangular openings. The unit led to an open door and then a restroom. The restroom had a loose shower water gauge plate and a protruding light fixture above the sink. The ED manager stated that staff stand outside of the restroom whenever the patient was using the restroom. A nurse's station was located directly in front of the BH pod. An officer was sitting in front of multiple cameras that monitored areas of the ED, including the ED beds and BH pod.

An interview was conducted on 04/23/19 at 1:54 p.m. in the north tower conference room with the day shift ED manager (Ed Manager EE). Ed Manager EE stated she had worked at the facility for 20 years. Ed Manager EE stated that a root cause analysis was completed on the incident related to Patient #1. It was observed that the officer (Officer NN) was on the phone and got up several times while watching the monitors. It was identified that the staff needed more education and training surrounding continuous observation of the cameras and the care of behavioral health patients. An attestation was put in place for all staff to ensure that cellphones were not in use and cameras were watched continuously. Ed Manager EE stated that a policy was being implemented regarding physician re-evaluation of the behavioral health patients. Ed Manager EE stated that the nurses in the ED are floated throughout the ED and have learned about taking care of behavioral health patients as they go. The ED nurses received CPI (Crisis Prevention Institute/Prevention training) and restraint training. The ED manager (ED Manager EE) stated that the ED does not have sitters. The ED does not have training for seclusion, but the ED has police officers for the 1013 patients.

An interview was conducted on 04/23/19 at 2:19 p.m. in the north tower conference room with the night shift ED manager (Ed Manager DD). Ed Manager DD stated that the night of the incident involving Patient #1 and Patient #2, the house supervisor was notified immediately. The on-call administrator was also notified, and Officer NN called his Lieutenant. The ED manager stated that the Lieutenant determined that the area and incident was a crime scene. ED Manager DD further stated that the Lieutenant called investigators. ED Manager DD stated that ED Physician FF was notified immediately after the incident by the charge nurse. The police officers told the staff to keep Patient #1 locked in his room. ED Manager DD stated that the facility attempted to notify Patient #1's guardian but was not able to get in touch until the morning.

An interview was conducted on 04/24/19 at 7:38 a.m. in the north tower conference room with Charge RN (RN AA). RN AA stated she had worked at the facility for 17 (seventeen) years and worked the 7:00 p.m. to 7:00 a.m. shift. RN AA stated that her primary role in the ED was to be a resource for the staff, address any complaints or concerns, and address patient safety. She typically does not have a patient assignment and is usually mobile throughout the entire ED for the 12-hour shift. She was required to round on 20 patients each shift, which signified entering patient rooms and asking the patients if the nurses explained the plan of care and if they had any complaints or concerns. RN AA stated that she is sometimes stationed at the BH pod but occasionally sits at the pod for a short amount of time. RN AA stated that she remembered Patient #1 and that Patient #1 was known to the ED because of previous visits earlier in the year. RN AA recalled that on the night of the incident 04/10/19, RN AA was sitting at the BH pod when she heard Officer NN say 'Oh No'. RN AA stated that the officer sounded distressed. RN AA glanced at the cameras and saw a patient on top of another patient. Officer NN rushed to the BH pod, at that time Patient #2 backed up from Patient #1 and Officer NN placed Patient #2 back in Patient #2's room. Officer NN stated that Officer NN locked Patient #2's room door. RN AA stated that she looked in Patient #1's room to check on her and Patient #1 said that she loved Patient #2 and that she did not want anyone to hurt Patient #2. Charge RN AA went to notify the ED Manager DD. RN AA stated that ED Manager DD notified the Nursing Supervisor. Charge RN AA stated that the video footing capturing the incident was then replayed, and Officer NN stated that he needed to notify his Lieutenant. When the Lieutenant arrived, the Lieutenant requested to see the video and began making calls to have detectives come out to watch the video. The Lieutenant explained to the staff that the incident looked like a criminal act had taken place. RN AA stated that the Nursing Supervisor called the administrator on call. RN AA stated that after the detectives arrived and watched the video they advised staff and law enforcement not to speak to the patients. RN AA stated she believed law enforcement set up for the MOSAIC Nurses to come to speak to Patient #1 due to her developmental disability. RN AA recalled that Patient #1 went up to the front door of the BH pod after the incident and stated she 'made love, sweet love'. The physician was notified immediately after the incident, but RN AA believed the physician was also advised not to touch Patient #1 by law enforcement. RN AA made a request approximately three (3) hours later that Patient #1 be transferred out of the BH pod. RN AA obtained a sitter around 4:00 a.m. to watch Patient #1 1:1 (one-on-one) in one of the BH rooms outside of the pod. RN AA stated that patients are monitored by the police officers via the video monitoring system and the 15-minute monitoring logs are filled out by the police officers. The police officers accompany the nurses inside the BH pod if medications are to be given or if the nurse needs to go back for any reason. This is due to previous experience where nurses have been attacked by patients. RN AA stated that adolescents, fall risk patients and elderly patients are not placed in the BH pod. RN AA stated that there were issues with the video monitoring system because police officers would get up frequently and the video would be unattended.

An interview was conducted on 04/24/19 at 8:13 a.m. in the north tower conference room with a Staff RN (RN CC). RN CC stated that she had worked at the facility for about five and a half (5 1/2) years in the ED, on the 7:00 p.m. to 7:00 a.m. shift. RN CC stated that usually when she came in for her shift she would receive her assignment and float throughout the ED including the BH pod. RN CC floated to the BH pod often and was familiar with the area by learning on the job. RN CC received CPI and BERT training annually. RN CC stated that she was aware that a 1013 meant a patient was held against his/her will if the patient is not safe (trying to harm oneself or others). RN CC stated that 24/7 monitoring of the video is required for the BH patients which included the police officers filling out the 15-minute check monitoring logs. If a nurse needed to go back to the BH pod, the officer always needed to be with that nurse; at that time no one would be watching the cameras. RN CC stated that only ambulatory (able to walk) patients should be in the BH pod and that those patients use the restroom by themselves. RN CC remembered the night of the incident on 04/24/19. RN CC recalled Patient #1 was continuously going back and forth from her room to the BH pod front door requesting snacks. Around 1:00 a.m. RN CC walked to another area of the ED to retrieve a snack for Patient #1. RN CC stated that when she returned, she saw RN AA but no officer in the nurse's station. RN CC was updated by RN AA and that everyone was in the process of being notified. RN CC stated she went to notify the physician and asked for a seclusion order. RN CC stated that law enforcement told her not to touch Patient #1 and that Patient #2 was locked in his room. Staff RN CC did not remember the physician examining Patient #1 and that Patient #1 was removed from the BH pod at approximately 4:30 a.m.

A review of facility policies and procedures included but was not limited to the following:

1. Hospital Policy on Patient Rights and Responsibilities, revised 09/2013, revealed the policy's purpose was to assure that certain rights are preserved for their patients. The policy indicated that individuals shall be accorded impartial access to treatment or accommodations that are available or medically indicated, regardless of race, creed, sex, national origin, or sources of payment for care. The patient/parent/guardian has the right to expect that within its capacity the hospital must make reasonable response to the request of patient services. The hospital must provide evaluation, service, and/or referral as indicated by the urgency of the case. The patient/parent/guardian has the right to considerate, respectful care at all times and under all circumstances, with recognition of his/her personal dignity. The policy further indicated the patient/parent/guardian has the right to expect reasonable safety in so far as the hospital practices and environment are concerned. Any allegations, observations or suspected cases of abuse, neglect or exploitation that occur in the hospital will be investigated by the hospital and referred to the appropriate authorities for investigation if necessary. This includes allegations against staff, students, volunteers, other patients, visitors, and/or family. The policy further revealed the patient/parent/guardian has the right to reasonable informed participation in decisions involving his/her health care and to receive from his/her physician information necessary informed consent prior to the start of any procedure and/or treatment.

2. Continuous Observation for Behavioral Health Patients Outside the Behavioral Health Environment, revised 04/2019, revealed the policy's purpose was to provide a safe, secure, and monitored area for behavioral health patients in the medical-surgical environment that could potentially or have attempted to harm themselves or others. The policy further revealed the patients will be cared for on the diagnosis appropriate unit by Registered Nurses (RNs) and patient safety attendants or other employees who have completed Crisis Prevention Intervention (CPI) training and/or Building Emergency Response Teams (BERT) training. Staff assigned to these patients must have been educated on the process for maintaining a secure room and must attend a de-escalation class within 90 days of hire. The policy further indicated (for 1013 order patients) a patient safety sitter will monitor these patients by direct 1:1 observation. The policy indicated when patients require toileting, the staff assigned to the area would remain inside the bathroom with the patient. The policy revealed continuous observation monitoring form will be completed every 15 minutes by assigned staff. The documentation would include the patient location, behavior, activity, and maintenance of the patient's safety and dignity.

Based on a review of medical records, facility's policies and procedure, and staff interviews it was determined that the facility failed to ensure that the emergency needs of Patient #1 to be continuously monitored while on a 1013 (involuntary mental health hold) were met in accordance with hospital policies and procedures. This failure resulted in harm to Patient #1 who was sexually assaulted by another patient on 04/08/19 in the behavioral health pod (BHP) of the facility's ED.

Findings were:

Cross refer to A0043-Governing Body as it relates to the failure of the governing body:
1. To ensure the the facility's emergency department delivered safe and effective care for of Patient #1.
2. To protect and promote the right of Patient #1 to receive care in a safe environment.
Cross refer to A0115-Patient Rights - as it relates to the failure of the facility to protect the right of Patient #1 to receive care in a safe environment.