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Based on observation, interview and record review it was determined that Immediate Jeopardy was identified on 03/18/10 at 482.13 condition of Participation Patient Rights.
Based on the findings of the complaint investigation concluded on 03/18/10, it was determined the Condition of Participation: Patient ' s Rights was not met. The facility failed to implement policy and procedures to provide a safe environment. It failed to adequately monitor patients in the Emergency Department who were on security holds to prevent injury to the patients and others. Following sexual assault of one patient (Patient #1) by another (Patient #2), both on security holds, and elopement of two other patients (Patient #10, and #11) on security holds, the hospital failed to implement measures to prevent reoccurrence. In addition, Patient #1 was restrained when assaulted and was not provided an emotionally safe environment in the manner of restraint.
Under Condition of Participation 482.13
Refer to Standard Tag A144

Based on observation, interview and record review it was determined the hospital failed to provide patients with the right to receive care in a safe setting to ensure both physical and emotional safety. A patient who was being held on a security hold in the ED, restrained and in low level of consciousness, was sexually assaulted by another patient in the ED (also being held on a high security hold). The victim-patient was held in a seclusion room with visual access by staff, patients and visitors in a high-traffic area of the ED. However, the lights were turned off and the security staff monitoring the room with a fixed camera was unable to properly visualize the patient. Security staff did not monitor the victim or perpetrator-patients per hospital policy. Neither patient had sensor bands per hospital policy.

Following discovery of the assault in progress by a hospital staff member, the hospital implemented no additional measures to provide adequate security to prevent reoccurrence nor reeducate all staff .In addition, two (2) other patients being held in the ED eloped from the hospital without knowledge of staff or security personnel. One of the elopements occurred six (6) days after the sexual assault.

The findings include:

Review of the hospital policy entitled, " Procedure: Security Detention Patients (revised February, 2010) revealed that patients involuntarily held against their will by a psychiatric or medical decree are considered to be on " security detention hold " . Once the patient is placed on a security hold the patient is placed under the control of the Security Department and becomes the responsibility of the department to insure the patient remains in the hospital until either admission or discharge. A security dispatch will notify a security officer (rover) to escort the patient to either the ED or Emergency Psychiatric Services. The patient is to have an EXI HALO sensor (electronic sensor band) placed on the wrist or ankle before leaving the Triage area.

Review of the hospital policy entitled, " Policy: Standard Operation Procedure Emergency Room Rover Patrol " revealed a shift corporal is responsible for conducting the ED rover patrols to check on security detention and MIW (Mental Inquest Warrant) patients every fifteen minutes and are to initial a check sheet after doing so.

Review of the Physician Clinical report on Pt. #1 ( 03/12/10) revealed Patient #1 was admitted to the ED on 03/10 at 15:18 with complaints of abdominal pain, nausea and vomiting and was under the influence of alcohol. Laboratory tests revealed a blood alcohol level of 471

Review of the Nursing Progress notes revealed the patient was assessed in the ED and admitted to having drunk thirty (30) beers that day. At 3:15pm the patient ambulated to a room in the ED lethargic and intoxicated. The patient was placed in bed and an IV was started to administer fluids and medication. At 7:53pm the record reported the patient was repeatedly told to stay in bed and was ordered by the physician to have nothing by mouth. At 8:24pm the patient was reported to be out of bed again and was ordered by the physician to be placed in four (4) point restraints for safety and increased risk of falls ( " Medical Restraints /Method : Hard Plastic " ). At 10:22pm an ED technician (ED tech.) reported that, upon entering the patient ' s room, he " discovered another patient performing what appeared to be oral sex on the patient in room 29. The patient (Patient #2) immediately stood up and returned to (his/her) room. " At 10:30pm Patient #1 was reported standing in the doorway of the room with unsteady gait and having pulled the IV out. When staff asked the patient if someone removed (his/her)restraints, the patient said " yes " . The patient was placed back in bed and the gown (bloody from the IV being pulled out) was changed. A sexual assault nurse performed a sexual assault exam the following morning at 4:26am. At 6:30am the patient began having intermittent, generalized seizure activity. Patient #1 was medicated, suctioned, and received respiratory treatment. At 9:44am he/she continued to seize and required intubation. Patient #1 was transferred to the intensive care unit and continued to receive treatment there when interviewed on 03/17/10.

Review of the medical record of Patient #2 revealed the patient was voluntarily admitted to ER on the evening of 03/11/10 for complaints of , depression, suicidal ideation, having taken " a lot of drugs " and having drunk a half gallon of alcohol . Lab results confirmed the patient ' s blood alcohol level to be362 at 8:55pm. The patient reported history of Paranoid Schizophrenia and Bipolar Disorder. Patient #2 was placed on hospital Emergency Dept. Security Detention ( " hold " ) at triage due to suicidal threats, falls potential, disorientation and confusion.

Review of the hospital ' s occurrence report regarding Patient #2 ' s sexual assault on Patient #1 revealed that, at 9:45pm, a security guard conducting fifteen-minute checks on the security hold patients in the ED reported Patient #2 missing from Room 26. A forty-minute perimeter search was conducted for the patient, both inside and outside of the building. The patient was found in seclusion room #29 sexually assaulting Patient #1. Security responded to a panic alarm activation at 10:45pm from the ED, Room 26, where staff were attempting to put Patient #2 in four-point restraints. At this time, the patient yelled out, " You guys are just restraining me because I ate her pussy " . The patient admitted to staff that he/she went into Patient #1 ' s room, took the patient out of restraints, and performed oral sex on the patient.

Interview on 03/16/10 at 3:00pm with the Risk Manager revealed Patient #2 was placed in the seclusion room (Room 29) upon admission to the ED because it was available but later was switched to room 26. Patient #1 was screaming, cursing and frightening other patients so was moved to the more distant room 29 used for seclusion.

Observation of the ED on 03/16/10 at 4:00pm revealed both Rooms 26 and 29 to be on the same end of the square room. In the middle of the square was the nursing station from which all staff could record documentation on computers. Room 29, a seclusion room, was located on the corner of the square, nearest two (2) main entrances to the ED. The room contained a fixed camera monitor in the front left corner near the ceiling. Room 26 was part of a four (4) bay area to the rear of the ED (four beds divided by curtains). This area was approximately thirty (30) feet from Room 29. The ED was very busy. Room 29 contained a male patient seated unrestrained on the bed with the door open and lights on.

Interview with the Director of the Emergency Department on 03/16/10 at 4:00pm revealed Room 29 was to have the door closed and lights on when being used as a seclusion room. However, when used as a " calming effect " (as for Patient #1), the lights would be turned off and door left open. The director further stated the ED was busy that evening and a major trauma had taken staff out of the ED. None of the staff knew how or why the assault happened, according to the director. Neither patient could safely be chemically restrained due to their high blood alcohol levels.

Interview with RN #2 on 03/16/10 at 4:30pm revealed this nurse was assigned to both patients but was actually assisting with a trauma event in an adjoining area when the incident occurred. When absent, a float nurse took over. However, all staff helped each other during a trauma event, according to RN #2. The nurse stated she learned of the incident after returning from the trauma area and had to redirect Patient #2 two (2) additional times from attempting to go to Patient #1 ' s room. The nurse said the float nurse and ED techs were supposed to check on patients and there was enough staff that evening to provide care.

Review of the hospital policy entitled, " Restraints and Seclusion " revealed the following: " ...nursing staff must monitor the patient according to the patient ' s needs and release the patient form restraints and clinically assess the patient at a minimum of every 2 hours. Monitoring includes: 1. Physical and emotional (psychological )well-being. 2. Maintenance of their individual right and dignity. ..5. Assessment and reassessment of the patient ' s overall well-being. 6. Assessment and reassessment for signs and symptoms of injury ... " .

Interview with ED tech. #1 on 03/17/10 at 8:20am revealed he redirected Patient #2 when the patient refused to stay in bed. When the tech noticed a bag of belongings on the nurses ' station in front of Room 29, he assumed they must belong to whoever was in the room. When he opened the closed door to the darkened room he discovered Patient #2 on his/her knees with the upper half of the body laying on the lower half of the stretcher (face down). Patient #2 looked up, got up, and exited the room. Patient #1 lay on the bed with the knees up and the genitals completely exposed.

Further interview with ED tech #1 revealed that rooms occupied by patients were to have doors open and lights on. He stated the security department had come to the ED in the past and told staff they could not have the door to the seclusion room closed and lights off if a patient was in the room.

Interview with Physician #4 on 03/17/10 at 10:25am revealed he was the attending physician for Patient #1. He said he told the patient three or four times to stay in bed due to being a falls risk and needing fluid restriction. He restrained the patient first and then decided to move the patient to the seclusion room because the cursing and yelling disturbed others. Physician #4 stated he went back " hourly " to check on the patient but did not see the patient after the incident took place. The physician stated the door was closed and the light was off. He stated he considered this to be a safe situation for the patient.

Interview on 03/17/10 at 8:52am with the Security guard who served as " rover " on 03/10/10 revealed he checked on Patient #1 in Room 29 at 9:30pm and 9:45pm. He stated the lights were off in room 29, which was not unusual, and the door was opened about two (2) feet. He observed patient #1 lying quietly in bed with restraints on the hands and feet. He discovered Patient #2 missing at approximately 9:45pm, checked the area including the bathroom, and radioed to security that the patient on security hold was missing. The guard was directed to do a four-block perimeter search of the area outside of the building. When returning to the front of the building he received a radio message that Patient #2 was found inside in a bathroom. The guard further stated he did not always get to do the required fifteen-minute rounds on security hold patients because of other duties but would mark on the rounds sheets that he did so. He stated this was " a flaw in the system " because of short staffing.

Interview by phone on 03/17/10 at 5:10pm with the Security Dispatcher who monitored the security camera monitors at the time of the incident revealed he came on duty at 10:00pm. He assumed Room 29 was empty because the lights were off and the door was closed. The dispatcher stated the previous dispatcher had failed to document that the patients on security hold had changed locations. The dispatcher was responsible for observing approximately sixty (60) monitors from cameras in the interior and exterior of the hospital and the two (2) other buildings on campus. The dispatcher said security hold patients did not always have electronic bracelets. He stated, " It ' s hit and miss. We may not have enough on hand or patients don ' t wear them " . He said the bands alarmed at exit points of the ED area: at the ambulance bay, the triage area, and the radiology area.

Observation of the recorded videotape from the seclusion room camera on 03/10/10 at 10:00pm revealed a darkened area with a patient visible on a stretcher wearing a hospital gown, restrained at the hands and feet, and with a blanket over the patient ' s midsection. At 10:18 the patient moved as if to try to sit up. It was apparent that this was visible from ambient light reflecting on the light surfaces in the room because the rest of the area appeared dark. At 10:20 a shadow appeared and the room became dark. At 10:31, the room brightened up.

Interview with the Director of Security on 03/17/10 at 9:40am revealed the Security Department established time lines from observing the darkened images on the video. The timeline established that someone entered the room at 10:02 and immediately exited. The door reopened twelve (12) seconds later. The door opened again at 10:11:35 and a person is observed coming in and out. Someone entered the room at 10:20 and was " caught " at 10:29:26. The director stated that, during the security department search for Patient #2, part of the time the patient would have had to have been in Patient #1 ' s room. He said it was nursing practice to leave the lights off. He said the dispatcher had " a multitude of jobs-it ' s one of many cameras, one of many duties. " He stated both patients should have had electronic bands on and did not know if either had them.

Additional Interviews with the Director of ER 0n 03/17/10 at 10:20 and on 03/18/10 at 9:30amrevealed the ER did not follow the hospital policy of electronic bands because patients removed them. She said the hospital was considering a new policy of different color gowns to identify patients on security hold but this had not gone into effect yet. The director stated that, when the patient was put into restraints, no one noticed the lights were out and the door was shut. She said she felt that, if the light had been left on, a gown and a sheet would provide adequate dignity based on " how the (ED) is constructed at this time " . She said she thought that rounding was not done appropriately. However, she said she believed that a better practice would be to have disruptive patients together in the ED and have a security guard there to monitor them.

Interview with Charge Nurse #3 on 03/18/10 at 8:15am revealed she was present during the incident and assisted Patient #1 following the assault. She also redirected Patient #2 back to the assigned room when the patient stood at the nurses desk in front of room 29 and strained his/her neck to see Patient #1 after being caught assaulting him/her. The nurse stated the lights should have been on and, since the patient was in four-point restraints, it was the hospital policy for the door to be secured. The nurse admitted that, even with the door open and the lights off, the patient was visible to public view. In addition, Charge Nurse #3 said the security department staff should have known Patient #1 was in the seclusion room because they assisted in putting him/her into it.

The hospital could produce no evidence of reeducation of staff prior to initiation of the investigation. Interviews with supervisory staff (Charge Nurse #1 at 3/16 on 5:40pm; Charge Nurse #2 on 03/17/10 at 8:00am; Director of ED on 03/16/10 at 4:45pm; Charge Nurse #4 on 03/18/10 at 8:55am) revealed managers were supposed to talk to staff about restraint policies and that ED staff had been educated on a 1:1 basis and in small groups. The Director of the ED stated on 03/16/10 at 4:50pm that a mandatory staff meeting for all ED staff was to be held on April 19, 2010.

However, interviews with RN #4 and RN #5 (03/16/10) and RN#7, ED Tech #2, RN #8, and RN #10 (03/18/10) revealed they were not reeducated following the incident.

Review of the list of occurrence reports in the ED over the prior three (3) months revealed two (2) additional elopements of patients on security holds. These patients exited the building without nursing staff or security staff ' s knowledge. On 01/23/10, a patient on a security hold eloped while he/she waited for security staff to escort the patient to Emergency Psychiatric Services. On 03/16/10 (six days after the event in which Patient #2 was found missing) another hold patient went missing from the hospital campus and was not found.

Interview with the Director of the Security Department on 03/18/10 at 11:00am revealed he did not know how the patient got out on 01/23/10. Regarding the elopement of the patient on 03/16/10, he stated, " A lot of folks come and go. He was on a hold. We did the process after we found the patient missing. It ' s very easy to get out. "