HospitalInspections.org

Based on document review and interview, it was determined, for 1 of 1 patient (Pt. #3) accused of sexual assault, the Hospital failed to provide protection to staff and patients from a potential sexually acting out patient.

Findings include:

1. On 12/19/16 at 2:00 PM, the Hospitals "Abuse Intervention Program Facility Procedures", with no effective date, was reviewed. The Procedures included, "Procedures for Prevention - V. Protection of Patients - The facility will take steps to prevent mistreatment while the investigation is underway. Patient who allegedly mistreated another patient will be removed from contact with the patient, during the course of the investigation. The accused patient's condition shall be evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety of other patients and employees of the facility. The procedure failed to include identifying the patient as a potential sexually acting out individual.

2. On 12/22/16 at 9:20 AM, Hospital policy titled, "High Risk - Precautions", revised 7/2014, was reviewed. The policy included, "A procedure that, if not planned for and/or implemented correctly, has a significant potential for affecting the safety of the individual served. All patients admitted to an inpatient behavioral medicine unit are considered to be at risk. In most cases the 15 minute precautions procedure is followed... This level of monitoring helps to de-escalate the environment and assures that each patient's needs are being monitored. The policy did not include instructions for sexually acting out (SAO) behavior.

3. On 12/19/16 at 12:15 PM, Pt. #3 ' s clinical record was reviewed. Pt. #3 was a 77 year old male, admitted on 9/11/16, with diagnoses of agitation, schizoaffective disorder, and dementia. Pt. #3 safety sheets included assault and fall precautions. On 9/16/16 at 10:50 AM, a nursing note (E #3) included, " Writer and Social Worker followed up with Patient regarding allegations [touching patient's breast] made by a female patient in which Patient denies. Patient informed he will be transferred to another unit as a precautionary measure and Patient agrees. Pt. #3 was transferred to 5C, the adult male psychiatric unit. However, Pt. #3 ' s safety precaution sheets from 9/16//16 through 9/20/16, were not amended to include sexually acting out (SAO) precautions.

4. Nursing notes on 9/16/16 at 6:57 PM, on 5C, included, " Patient is restless, needy, loud, hype-rverbal, and sexually preoccupied. Patient continues with inappropriate comments regarding female staff going through the unit ... "

5. On 12/21/16 at 10:30 AM, an interview was conducted with a MHC-Mental Health Technician (E #6). E #6 stated Pt. #3 should have been placed on SAO precautions after the allegation because there are female nurses and social workers on 5B, who could be offended. E#6 stated, "We need to know if a patient is on SAO precautions to be more aware of the patients' behaviors around female staff to ensure their safety".

6. On 12/21/16 at 12:00 PM, an interview was conducted with the Director of Behavioral Health (E #5). E #5 stated with any sexual behaviors that affect others (i.e.: inappropriate touching or sexual innuendos), the patient needs to be placed on SAO precautions for safety. E#5 stated there should been a doctor's order for SAO after Pt. #3 alleged sexual misconduct.