HospitalInspections.org

Based on review of facility policies, review of facility documents, review of medical records (MR), review of facility video surveillance, and interviews with staff, it was determined that the hospital failed to ensure that patients received care in a safe setting, with the potential to negatively impact all 84 patients at the facility.

Cross Reference:
482.13(c)(2) Patient Rights: Receive care in a safe setting

On August 16, 2024 at 10:30 AM, as a result of this failure, Immediate Jeopardy (IJ) was identified. The immediate interventions implemented by the facility included staff re-education, review and assesment of all current patients needs, and increased monitoring. The IJ was removed on August 19, 2024 at 2:00 PM after the State Survey Agency completed onsite verification that the facility implemented the corrective actions addressing the IJ.

Based on review of facility policies, review of facility documents, review of medical records (MR), review of facility video surveillance, and interviews with staff, it was determinted that the facility failed to implement an increased level of observation for a patient that sexually assaulted another patient, per hospital policy. This deficient practice resulted in the hospital's inability to protect patient rights and provide services in a safe setting. This deficiency had the potential to impact all 84 patients within the facility.

Findings include:

Review of facility policy "Patient's Rights Bill of Rights" effective April 2007, reviewed October 2023, revealed, " ...The patient has the right to receive care in a safe setting ..."

Review of facility policy "Sexual Precautions (perpetration/victimization)" effective December 2006, reviewed April 2024, stated, " ...When a patient is regarded as a risk for sexual misconduct, or at risk of being a victim of sexual misconduct the physician's orders will specify "Sexual Precautions" ...In the event of serious intent and overt attempt/act, the patient will be placed on 1:1 [level of observation] ... Constant, continuous, and effective observation and supervision is an effective method of prevention ..."

Review of MR #1 "Psychiatric Assessment" dated July 21, 2024 revealed " ...Patient is acutely psychotic, aggressive, agitated and belligerent ...patient is currently admitted under involuntary status for psychosis and aggression. [He/She] has made multiple suicidal and homicidal threats in general ...Q [every] 15-minute safety checks will suffice ...however, we will continue to monitor patient closely; if needed, [he/she] can be on one-to-one for safety ..."

Review of MR #1 "Final Ancillary Orders" revealed physician orders were placed on July 21, 2024, at 2:16 AM (time of admission) for "Sexual Aggression Risk" precautions.

Review of facility document "Incident Investigation Summary", no date, revealed that Patient # 2 reported a sexual assault by Patient #1 on the evening of 7/21/2024 that occured in Patient # 2's room, witnessed by Patient # 2's roommate.

Review of MR # 2 "Discharge Summary", dated July 23, 2024 revealed that Patient # 2 was admitted to the hospital on July 20, 2024, and discharged July 22, 2024 with a diagnosis of unspecified mood disorder and intellectual disability. "...Significant Finding...According to staff, patient was sexually molested by another patient on the unit..."

Review of MR # 3 "Physician Discharge Orders/Plan" dated July 31, 2024 revealed, discharge diagonses of unspecified psychotic disorder and intellectual disability.

Review of facilty document "Daily Census" dated July 21, 2024 revealed that Patient # 1 and Patient # 3 were roommates on July 21, 2024.

Review of facility document "Daily Census" dated July 22, 2024 revealed that Patient # 1 and Patient # 3 remained roommates on July 22, 2024.

Interview on August 16, 2024 at 10:20 AM with Employee # 2 revealed that Patient # 1 was moved to a private room on July 22, 2024 at 1:47 PM. It was confirmed that an open patient room was available on July 21, 2024, however, Patient # 1 was not moved until the next afternoon. Patient # 2 and Patient # 3 were both close in age and both had intellectual disabilities. No evidence was found that the facility took action to address this situation appropriately.

Review of MR #1 "Daily Physician Progress Note" dated July 22, 2024 revealed that the patient was hypersexual and sexually inappropriate with another patient.

Review of MR #1 "Daily Physician Progress Note" dated July 29, 2024, revealed " ...tried to sexually assault another patient today but staff intervened ..."

Reveiw of MR #1 "Patient Observation Record" from July 21, 2024 and July 31, 2024, revealed that the patient was on a Q15 minute safety check level of observation.

Interview with Employee # 3 and Employee # 4 on August 16, 2024 between 5:45 PM and 6:15 PM revealed that Patient # 1 moved to a private room on July 22, 2024 as an intervention after the report of sexual assault. It was confirmed that Patient # 1 had ongoing inappropriate sexual behaviors throughout thier hosptial stay, Employee #3 and Employee #4 were unable to indicate whether a discussion occurred to evaluate the need for increased supervision for Patient # 1 after the incident, and no documentation relating to an evaluation of the need for increased supervision was found.

Based on review of facility policies, review of facility documents, review of medical records (MR), and interviews with staff, it was determined that the hospital failed to revise the interdisciplinary care plan to reflect current patient needs for 1 out of 4 patients (Patient # 1) reviewed in the sample.

Findings include:

Review of facility policy "Interdisciplinary Patient-Centered Care Planning" effective July 2024, revealed, " ...It is the policy ...to provide therapeutic services based upon a patient- centered, individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family/representative to collaboratively identify the patient's assessed needs to be addressed during treatment team and develop appropriate goals and interventions ...must include ...Identification of problems to be treated and the specific behavioral manifestations of those problems in the patient ...The treatment team ...will complete a review of the treatment plan as clinically indicated, or at a minimum every (7) days. Identified problems will be summarized, progress towards goals will be reviewed, new goals and interventions identified, as well as discharge considerations will be updated. A treatment plan revision can be completed any time the treatment team decides to alter the proposed strategies based upon the patient's needs. Reviews of the treatment plan are documented on the appropriate treatment plan forms in the medical record. The following would be cause for conducting a review of the plan and developing a revision ...A new impairment/problem or significant information about an existing impairment is identified ..."

Review of facility document "Incident Investigation Summary", no date, revealed that Patient # 2 reported a sexual assault by Patient #1 on the evening of 7/21/2024.

Review of MR # 1 "Individual Treatment Plan" dated July 21, 2024 did not contain any short term or long-term goals related to sexual acting out behaviors.

Review of MR # 1 "Interdisciplinary Master Treatment Plan" dated July 21, 2024 did not contain any information relating to sexual acting out behaviors.

Review of MR #1 "Final Ancillary Orders" revealed physician orders were placed on July 21, 2024, at 2:16 AM (time of admission) for "Sexual Aggression Risk" precautions.

Review of MR #1 "Daily Physician Progress Note" dated July 22, 2024 revealed that the patient was hypersexual and sexually inappropriate with another patient.

Review of MR #1 "Daily Physician Progress Note" dated July 23, 2024 revealed that the patient was very hypersexual.

Review of MR #1 "Daily Physician Progress Note" dated July 29, 2024 revealed " ...tried to sexually assault another patient today but staff intervened ..."

Interview with Employee # 3 and Employee # 4 on August 16, 2024 between 5:45 PM and 6:15 PM revealed that Patient # 1 had ongoing inappropriate sexual behaviors throughout their hospital stay, including successful and attempted sexual assaults. It was confirmed that patient's care plan was not updated to reflect current patient needs.

Based on review of facility policies, review of medical records (MR), and interview with staff, it was determined that the facility failed to adhere to the policies and procedures of the hospital for 1 out of 4 patients (Patient # 2) reviewed in the sample.

Findings include:

Review of facility policy "Timeliness of Initial Assessments" effective December 2002, revised January 2021, revealed that a nursing assessment is required to be completed within 8 hours of admission. A preliminary treatment plan is required withing 24 hours of admission.

Review of facility policy "Plan for the Provision of Patient Care" effective December 2006, revised May 2022, revealed, " ...Assessment of Patients ...On arrival, patients receive a nursing assessment to include physical status and functioning. The nursing assessment is completed within the first 8 hours ..."

Review of facility policy "Interdisciplinary Patient-Centered Care Planning" effective July 2024, revealed, " ...It is the policy ...to provide therapeutic services based upon a patient-centered, individualized treatment plan ... The nurse completing the Nursing Assessment or designee shall develop the Initial Treatment Plan within eight (8) hours of admission ..."

Review of MR # 2 revealed no evidence of a completed nursing assessment within eight (8) hours of admission.

Review of MR # 2 revealed no evidence of an initial treatment plan within 24 hours of admission.

During an interview on August 14, 2024 between 11:52 AM and 12:00 PM with Employee # 3, these findings were confirmed.