HospitalInspections.org

Based on review of facility documents, review of medical records and staff interview, the facility failed to ensure patients had the right to receive care in a safe setting.

Findings included:

Facility policy titled "patient rights" stated in part, "Cross Creek Hospital policy is to provide the best possible treatment to all patients at all times, under all circumstances ...
Basic Rights for all patient
...e. You have the right to a clean and human environment in which you are protected from harm, have privacy with regard to personal needs, and are treated with respect and dignity.
...5. You have the right to be free from mistreatment, abuse, neglect, and exploitation."

Facility patient rights document stated in part, "You have the right to a human and safe environment that affords reasonable protection from harm. You have the right to be free from mental and/or physical abuse and free from chemical and physical restraints, except when necessary to protect you from injury to yourself or other."

Facility policy titled "Incident Reporting" stated in part, "Purpose: The Incident Report is a risk management tool that notifies the facility of potential areas of loss. It enables the facility to manage risk, reduce the losses, and improve the quality of health care provided in the facility through risk control intervention and monitoring the effectiveness of the interventions and corrective action plan.
The responsibility for completed an Incident Report rests with any facility staff member who witnesses, discovers, or has direct knowledge of an 'incident.' An 'incident' is an unanticipated happening which was not consistent with the routine care and/or operation of the facility and may have occurred due to a violation of policy and procedure ...
1.0 Procedure: Any facility staff member who witnesses, discovers, or has direct knowledge of an incident must complete an Incident Report as soon as practical after the incident is witnessed or discovered, before the end of the shift/work day.
...1.3 If the incident involves a resident, staff must chart relevant information in the patient's medical record. When documenting incidents in the medical records, staff will chart precisely what happened ...
2.0 Definitions on incident report form:
...4.0 Sexual Allegations:
Boundary - Any action or relationship between patient to patient, patient to staff, or patient to visitor that would interfere with a safe, therapeutic environment and care at the facility.
...3.0 Responsibility:
...3.2 The Shift Supervisor or Facility Designated Individual will conduct a preliminary incident review ..."

Facility policy titled "Sexual Acting Out Precautions" stated in part, "I. Scope: This policy establishes the guidelines for staff to follow when treating a patient who ... exhibits sexual behavior during the course of treatment.
II. Purpose: The purpose of this policy is to provide a safe environment for all patients and staff.
...IV. Policy: Cross Creek Hospital is committed to providing a safe environment for all patients and staff ... Patients who are not identified as having a history of sexually acting out behavior, but exhibit sexual behavior during the course of their treatment at Cross Creek Hospital will be assessed and managed in accordance with this Policy and Procedure.
...V. Procedure:
...B. SAO Incident during Treatment
1. During regular business hours, the staff having knowledge of the incident should notify the House Supervisor, who will notify the Risk Manager and the attending Physician. The incident will be entered in the progress notes, and an Incident Report will be completed ...
3. If the patient is a minor or has a guardian, the Unit Nurse or therapist will contact the patient's legal guardian as soon as possible but no later than 24 hours after the discovery of the incident.
...5. The facility's response to sexual allegations or actual events includes as appropriate:
a. Separation of patients ...
b. Evaluation/ER visit
c. STD Testing
d. Rape Kit
e. Pregnancy Testing
6. The Risk Manager will conduct a preliminary investigation to determine the reporting requirements to the stat; agency caseworkers; law enforcement; and/or other external agencies, and UHS risk Management."

Facility Policy titled "Abuse, Neglect, and Human Trafficking" stated in part, "Definitions: Abuse: Abuse is defined as the willful infliction of injury ... with resulting ... mental anguish. This includes staff neglect or indifference ...
Sexual Abuse - Any touching, directly or through clothing, of any individual by an employee for sexual purpose or for a sexual manner. This includes but is not limited to: kissing, touching the genitals, buttocks or breasts ... failing to intervene or not attempting to stop inappropriate sexual activity or performance between individuals; and/or encouraging inappropriate sexual activity or performance between individuals.
...Procedure
1. An employee/contractor, or medical staff who has received information or has observed evidence that would reasonably cause him/her to believe that a patient has been, is, or will be adversely affected by abuse, neglect, or human trafficking from any person will immediately report the information to the CEO or his/her designee, and the attending provider or his/her designee ...
a. If reporting individual had documenting privileges, he/she is responsible for documenting all relevant information in the medical record. Relevant information will also be reported to CEO or designee, Director of Nurses, Director of Social Services, attending practitioner or designee and Risk Manager. Reporting individual will document all persons notified.
b. All relevant information will be documented in the medical record including quotes as appropriate, observed physical/behavioral status, the patient's statement and interventions made.
...4. Report of Suspected Sexual Abuse of a Minor:
a. Cross Creek Hospital is required to report a victim of abuse who is a minor under 14 years of age who has engaged in sexual activity with any individual to whom the minor is not married ..."

*Medical record for patient #1 revealed a psychiatrist progress note dated 4/12/18 at 12:45 pm that stated in part, "Pt [patient] was very upset. This am b/c [because] another peer touched her inappropriately ..."
Nursing progress note dated 4/12/18 at 3:30 pm stated in part, "Pts dad [name omitted] notified of pts [sic] report that she was touched inappropriately by male pt."
Discharge Summary dated 4/16/18 at 3:50 pm stated in part, "Course of Treatment: ...There was an incident of inappropriate touching by another peer which made her upset but later on staff doubted if that incident was ever occurred [sic].
There was no incident report completed. There was no documentation or evidence the alleged incident was followed-up on or investigated.


*Medical record for patient #7 revealed a psychiatrist progress note dated 4/12/18 at 12:30 pm that stated in part, " ...Staff denies any issue except noticed some SAO [Sexually Acting Out] (touching girl peers) ... Placed sexual precaution."
Discharge Summary dated 4/13/18 stated in part, "Trough staff reported some sexually acting out behavior in his part along with another male peer towards female peers. Pt was placed on sexual precaution ..."
There was no incident report, investigation, or follow-up for this incident. There was no indication the patient's family was notified of the incident.

*Medical record for patient #9 revealed a psychiatrist progress note dated 4/12/18 at 10:50 am that stated in part, "Pt became extremely angry after confronted on his inappropriate behavior w/ [with] another female pt - touching her inappropriately ..."
Activity Therapy group progress note dated 4/12/18 at 11:08 am stated in part, "[Patient #9] was inappropriate at the beginning of grp [group], needed multiple re-direction to maintain appropriate physical boundaries w/ peers was asked to leave group for a break when he wouldn't comply."
Discharge summary dated 4/17/18 at 11:30 am stated in part, "1:1 [one to one] started after reports by other pt's that he was sexually inappropriate when staff left and this was continued until discharge for safety/peace of mind of other patients ..."
There was no incident report, investigation, or follow-up for this incident. There was no indication the patient's family was notified of the incident.

*Medical record for patient #12 revealed a nursing note dated 4/29/18 at 5:00 pm that stated in part, "Pt reported being touched by other male pt to her private part of the body. Nobody witnessed. Details see incident report ..." There was no documentation the patient's family was notified of the incident.

With no investigation or follow-up on these alleged sexual incidents, all patients are at risk for receiving care in an unsafe setting.

The above was confirmed in an interview with the director of performance improvement/risk management on the afternoon of 6/13/18.

Based on review of facility documents, review of medical records and staff interview, the facility failed to ensure patients had the right to be free from all forms of abuse.

Findings included:

Facility Policy titled "Abuse, Neglect, and Human Trafficking" stated in part, "Definitions: Abuse: Abuse is defined as the willful infliction of injury ... with resulting ... mental anguish. This includes staff neglect or indifference ...
Sexual Abuse - Any touching, directly or through clothing, of any individual by an employee for sexual purpose or for a sexual manner. This includes but is not limited to: kissing, touching the genitals, buttocks or breasts ... failing to intervene or not attempting to stop inappropriate sexual activity or performance between individuals; and/or encouraging inappropriate sexual activity or performance between individuals.
...Procedure
1. An employee/contractor, or medical staff who has received information or has observed evidence that would reasonably cause him/her to believe that a patient has been, is, or will be adversely affected by abuse, neglect, or human trafficking from any person will immediately report the information to the CEO or his/her designee, and the attending provider or his/her designee ...
a. If reporting individual had documenting privileges, he/she is responsible for documenting all relevant information in the medical record. Relevant information will also be reported to CEO or designee, Director of Nurses, Director of Social Services, attending practitioner or designee and Risk Manager. Reporting individual will document all persons notified.
b. All relevant information will be documented in the medical record including quotes as appropriate, observed physical/behavioral status, the patient's statement and interventions made.
...4. Report of Suspected Sexual Abuse of a Minor:
a. Cross Creek Hospital is required to report a victim of abuse who is a minor under 14 years of age who has engaged in sexual activity with any individual to whom the minor is not married ..."


*Medical record for patient #1 revealed a psychiatrist progress note dated 4/12/18 at 12:45 pm that stated in part, "Pt [patient] was very upset. This am b/c [because] another peer touched her inappropriately ..."
Nursing progress note dated 4/12/18 at 3:30 pm stated in part, "Pts dad [name omitted] notified of pts [sic] report that she was touched inappropriately by male pt."
Discharge Summary dated 4/16/18 at 3:50 pm stated in part, "Course of Treatment: ...There was an incident of inappropriate touching by another peer which made her upset but later on staff doubted if that incident was ever occurred [sic].
There was no incident report completed. There was no documentation or evidence the alleged incident was followed-up on or investigated.

*Medical record for patient #12 revealed a nursing note dated 4/29/18 at 5:00 pm that stated in part, "Pt reported being touched by other male pt to her private part of the body. Nobody witnessed. Details see incident report ..." There was no documentation the patient's family was notified of the incident.

These patients were subject to abuse while inpatient at the facility. The facility staff did not protect these patients by following facility policy.

The above was confirmed in an interview with the director of performance improvement/risk management on the afternoon of 6/13/18.