HospitalInspections.org

Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to ensure patients received care in a safe environment and free from all forms of abuse for one (1) of twelve (12) sampled patients, Patient #12.

On 05/13/18 at 5:20 PM, Patient #1 was in the Admissions Assessment Area, a locked room, waiting to be evaluated by a Medical Provider, for possible admission. Staff escorted Patient #12 into the same locked Admissions Assessment Area. The Admissions Assessment Area was a locked area in which staff did not provide continuous supervision or monitoring and patients could not exit the room without staff unlocking the door to exit. While the area was locked and unmonitored by staff, Patient #1 touched Patient #12's left leg and left breast and attempted to lift his/her shirt. Patient #12 pushed Patient #1's arm away. Patient #1 attempted to touch Patient #12's left breast a second time and Patient #12 pushed Patient #1's arm away and banged on a window to get staff's attention.

The findings include:

Review of the facility's policy titled, Incident Management: Protection of Patients from Abuse, Neglect, Exploitation, Harassment, and Injury, undated, revealed the facility was committed to the provision of services in a caring and hospitable environment that was free from harm for the patient, the visitor and the staff. Per the policy, the Risk Management Program verified that patients, visitors and staff were protected from abuse, neglect, exploitation and harassment. Continued review revealed, the facility would verify that any incident of abuse was reported and analyzed in accordance with local, state or Federal law and that appropriate corrective, remedial or disciplinary actions occurred.

Review of the facility policy titled, Patient Supervision, undated, revealed the policy was for the supervision of patients admitted to the facility. The level of supervision required, as designated in the policy, was based on an assessment for 'at-risk' behaviors, with fifteen minute checks utilized when patients were at low risk for injury but had risk factors present. Continued review revealed, the physician or Advance Practice Registered Nurse (APRN) was responsible for determining patient risk for harm to self or others, and determined the level of supervision required.

Review of the facility's policy titled, Patient Rights and Responsibilities, undated revealed patients had the right to receive care in a safe environment, free from all forms of abuse.

Review of the medical record revealed, Patient #1 was in the Admission Waiting Area on 05/13/18 for a Manic State with being a danger to self and others. Continued review revealed the facility admitted Patient #1 for inpatient treatment. Review of the Admission History for Patient #1 revealed, upon being informed of the intent to admit him/her, Patient #1 became rageful, escalating to threatening and barricading himself/herself in the waiting room by placing couches in front of the doors. A team intervention was called, and the patient received an intramuscular injection of medication, eventually calming, but only after making threats to staff the doctors.

Review of the medical record revealed, Patient #12 was in the Admission Waiting Area on 05/13/18 for Suicidal Ideation. Continued review revealed, Patient #12 was not admitted to the facility for inpatient treatment.

Review of video (with no audio) of the Admissions Waiting Area, on 5/13/18, revealed Patient #1 was lying on a couch when Patient #12 entered at 5:20 PM and sat on a couch adjacent to Patient #1. Continued review of the video revealed, at 5:22 PM, Patient #12 got up and laid down on a couch across the room from Patient #1 at 5:23 PM. At 5:25 PM, Patient #12 sat up, and Patient #1 came over to sit next to him/her and to his/her left on the couch. The two shook hands. Per video, at 5:26 PM, Patient #1 rubbed Patient #12's leg mid-thigh while Patient #12 showed Patient #1 a tattoo on his/her left arm, and Patient #1 leaned in closer to see the tattoo. A few seconds later, still 5:26 PM, Patient #1 touched Patient #12's left breast through his/her clothes with his/her left hand. Per video review, Patient #12 pushed Patient #1's hand away. A few seconds after, still at 5:26 PM, Patient #1 attempted to touch Patient #12's left breast through his/her clothes again, and Patient #12 pushed his/her hand away, then proceeded to stand up. Patient #1 then laid down on the couch at 5:28 PM. Patient #12 sat down on a couch adjacent to Patient #1. A few seconds later, still at 5:28 PM, Patient #12 got up and was observed to be banging on the observation glass with his/her hands. Patent #12 was observed talking to someone through the glass, at which point, Patient #1 got up, and was observed throwing his/her hands in the air. Staff allowed Patient #12 through the door to the hallway leading to the examination rooms at 5:30 PM.

Review of the Admissions Waiting Room and Observation Area Record - 15 Minute Checks form, dated 05/13/18, revealed Mental Health Associate (MHA) #3 had observed the room at 5:15 PM and again at 5:30 PM.

Review of the facility's investigation and witness statements revealed, Patient #1 touched Patient #12's left breast and attempted to lift his/her shirt. Patient #12 pushed Patient #1's arm away and banged on the window to get staff attention. Patient #12 was moved to the examination room for safety and privacy. Per the report, the interview did indicate Patient #12 was upset and crying regarding the incident.


Observation of the admitting process on 05/23/18 at 8:35 AM, revealed the Admissions Waiting Area, was a locked room that required staff to unlock the door for awaiting patients to exit. Continued observation revealed, staff did not provide continuous supervision or monitoring, instead checking every fifteen minutes either through the glass or through the video footage and documenting these checks on the Admissions Waiting Room and Observation Area Record - 15 Minute Checks form. Observation revealed, an empty workstation beyond the admissions waiting room glass, with a clerk's area next to it separated by a wall, and a room designated to be the treatment planning room on a hallway just across from the clerk's area. Continued observations during the survey revealed, MHAs were present in the clerk's area at times, and in the treatment planning area with a nurse at other times.

Interview with MHA #2, on 05/22/18 at 11:37 AM, revealed he was present in admissions on the evening of 05/13/18, near the door in the treatment planning area, when he heard banging on the observation window to the admissions waiting area. He stated, he called out for MHA #3 and went to see what was going on. MHA #2 stated, he had a hearing deficit and could not hear what Patient #12 was saying at the time, although he heard later from MHA #3, who removed Patient #12 from the area, that Patient #1 was groping Patient #12. MHA #2 went on to state, staff check on the admissions waiting area every fifteen minutes, and also listen for any noises coming from the room. He revealed, the admissions waiting room could be viewed from a monitor in the treatment planning area.

Interview with MHA #,3 on 05/22/18 at 11:47 AM, revealed she was working in admissions on 05/13/18 when MHA #2 alerted her to a situation in the admissions waiting area. Continued interview revealed, she removed Patient #12 from the area to an examination room to get him/her away from the situation. She revealed, Patient #12 was crying when she got him/her in the examination room, and proceeded to tell her Patient #1 put his/her hand on his/her shirt but he/she pushed it away. Further interview with MHA #3 revealed, she kept Patient #12 in the examination room, and Patient #12 never had to return to the admissions waiting area. She revealed, Patient #1 had been calm and had not exhibited any inappropriate behaviors prior to the arrival of Patient #12. Additional interview with MHA #3 revealed, staff review available information obtained when the patients arrive, to include any information from police, security, and from observing and speaking with the patients prior to them entering the admissions waiting area, and if they exhibited any inappropriate or aggressive behaviors or made statements indicative of inappropriate or aggressive behaviors, they were kept separate from other patients. MHA #3 revealed, in addition to being able to hear in the admissions waiting area, they conduct fifteen minute checks to ensure potential patients are safe.

Interview with RN #1, on 05/22/18 at 10:41 AM, revealed she worked in admissions on the evening of 05/13/18. She revealed, MHA #3 called out to her from the hallway leading to the examination rooms, and reported Patient #12 stated he/she had been touched by Patient #1. She revealed, staff was with Patient #12 after that in an examination room. She revealed, she reviewed the video footage from the admissions waiting area, and revealed although patient #1 did initiate physical contact with Patient #12, he/she did not appear frightened or anxious, just got up and knocked on the observation window. RN #1 revealed, if there were any concerns based on available information, as well as observation and interview with potential patients, any aggressive or inappropriate patient were kept separate. She revealed, she couldn't remember if they had any information on Patient #1 or Patient #12 at the time of the incident.

Interview with RN #4, on 05/23/18 at 8:51 AM, revealed she frequently worked in admissions on weekends, and revealed they usually received some background information on patients coming in, although they didn't receive background information on potential patients being brought in on a police citation. She revealed, staff read police reports, and assessed potential patient behavior, to determine whether or not they were aggressive or cooperative. She revealed any patients who were cussing, posturing, or demanding to be let go were kept isolated from other patients for their safety as well as the safety of other patients. In addition, RN #4 revealed, although the room was locked and the patients could not leave without staff opening the door, they were able to hear people in the admissions waiting area. Per RN #4, patients were able to knock on the window if they wanted something. She revealed, staff lay eyes on potential patients every fifteen minutes, either through observation glass or on video monitor. She revealed, incidents or conflicts in the admissions waiting area were rare, as they were able to isolate potential aggressors prior to coming to the admissions waiting area.

Interview with the Director of Risk Management, on 05/23/18 at 7:55 AM and again at 10:54 AM, revealed although they were doing fifteen minute checks prior to a previous incident that was cited in October, as a result of that incident they started documenting their fifteen minute checks. She revealed, they also implemented a system in which they separated perpetrators from other potential patients when a situation arose. She discussed the admissions process, from intake through admission as a patient, describing security measures taken to ensure potential patients were kept safe. She revealed, staff did not sit at the observation window at all times, although on days with more patients they were more likely to be there. She revealed, both staff as well as security had access to video feed of the admissions waiting area. She revealed there was no formal protocol; however, if a patient came in on a violent offense, they knew before the patient ever came upstairs to admissions. She revealed, patients were admitted on fifteen minute checks unless they acted in a manner that necessitated closer observation, which was also their protocol for the admissions waiting area. She revealed patients with a violent history would either be monitored one on one, or segregated from other patients. She stated, during the admissions process, they didn't have as much information on patients as they do after the admissions process, and there was the potential for something to happen without staff present to witness it.