HospitalInspections.org

Based on record review and interview, the hospital failed to ensure there was documentation in a patient's medical record about a discussion of and consent for a medication to stop conception for 1 (#2) of 5 patients sampled.

Findings:
Review of the Hospital's policy titled Informed Consent revealed in part:
It is the policy of theis hospital to respect the patient's right to be informed of medical procedures and interventions which are to be rendered and the patient's right to accept or refuse such procedures and/or interventions. Informed consent must be obtained and documented.

Review of Patient #2's medical record revealed she was admitted on 07/17/2021 and discharged on 07/22/2021. Her principal diagnosis was listed as Paranoid Schizophrenia and secondary as generalized anxiety disorder and cannabis use.

Review of Patient #2's PEC dated 07/16/2021 at 7:50 p.m. revealed she was determined to be suicidal, dangerous to self and unwilling.
Review of Patient #2's CEC dated 07/17/2021 at 10:00 a.m. revealed she was determined to be suicidal, dangerous to self and unwilling.

Review of Patient #2's Incident Report dated 07/19/2021 at 8:10 a.m. revealed the following: Summary of Events: Patient approached the nurse's station and informed the nurses that a peer took her into the bathroom to have sex.

Review of physician's orders for Patient #2 revealed an order dated 7/19/21 at 9:46 a.m. for Plan B X 1 dose today as soon as available - pregnancy prevention.

Review of Patient #2's MAR revealed a dose of Plan B X 1 dose had been given on 7/19/21 (no time listed).

Review of Patient #2's medical record revealed no documentation that the psychiatrist had discussed the use, benefits or side effects of the Plan B pill or that Patient #2 had consented to take the pill.

In an interview on 08/16/2021 at 4:30 p.m. with S2DON, he verified there should be documentation in Patient #2's medical record of informed consent to take a pill to stop conception.

Based on record reviews and interviews, the hospital failed to ensure patients were free from abuse or harassment. This deficient practice is evidenced by failing to ensure a female patient that alleged a male patient exposed himself to her was placed in a different unit for safety from potential harassment for 1 (#5) of 5 (#1, #2, #3, #4, #5) sampled patients.

Findings:

1. Failing to ensure a female patient that alleged a male patient exposed himself to her was placed in a different unit for safety from potential harassment.

Reviews of Patient #5's medical record revealed she was admitted to the hospital on 06/30/2021.

Review of a note by S6Advocate dated 07/07/2021 revealed the following: The husband of Patient #5 called to report his wife did not receive discharge paperwork and stated that his wife had been sexually harassed while in the facility.

Review of a statement by S7LPN that was attached to an incident report (not a permanent part of the medical record) for Patient #5 revealed the following:
Patient arrived on unit and after admission was complete she noticed another patient that was being admitted she proceeded to tell this writer that the patient exposed himself to her while the both of them were waiting to be assessed in intake.

Review of Patient #5's medical record revealed there was no documentation of sexually inappropriate behavior or allegations of another patient exposing themselves to her. Further review revealed neither she nor the person she alleged sexually harassed her were removed from the same unit.

In an interview on 08/13/2021 with S4MD, he said he was familiar with Patient #5. He said he was told after the fact that a male had sexually harassed her in intake and she asked not to be on his unit and was not moved. He said he was not made aware until after Patient #5's discharge. He said the nurse should have informed him of her complaint about being harassed in intake by a male patient. He said he would have separated the patients into different units.

In an interview on 08/16/2021 at 1:33 p.m. with S7LPN, she said she remembered Patient #5. She said she remembered when Patient #5 walked on the unit she pointed to a guy and said that's him right there, he exposed himself to me in intake. S7LPN reported Patient #5 had told her she was scared. She said she told S8RN and asked her if they should move her to another unit. S8RN told her no. They told her if she felt she was in harm at any time to let them know and they would move one of them. She also reported neither she nor the RN had called the physician.

Based on observation, interview and record review, the hospital failed to ensure there was adequate staffing to observe patients as ordered for 1 (C) of 6 units (A, B, C, D, E, F).

Findings:

Review of the hospital's staffing matrix revealed with 18 patients the technicians should have 9 patients each assigned to them.

Review of the hospital's census sheet for Unit C revealed there was currently 2 technicians and 18 patients. 12 of the patients were to be observed every 15 minutes and 6 of the patients were to be observed every 5 minutes.

In an observation on Unit C on 08/13/2021 at 9:05 a.m. there were 2 mental health technicians making observations on the 18 patients. The 18 patients were in multiple common areas and in bedrooms. S5MHT was assigned to do every 15 minute observations on 11 patients and every 5 minute rounding on 5 patients. Upon viewing the documentation on the observation sheets, Patient #R1 was supposed to be observed every 5 minutes but he was documented as being observed every 15 minutes. Patients #R2 and #R3 were also every 5 minute observations and had not been documented on since 8:45 a.m. (20 minutes).

In an interview on 08/13/2021 at 9:10 a.m. with S5MHT, she reported she had several other tasks to do in addition to observing the patients as ordered. She said the other MHT is new so he only had 2 patients to observe. When asked, S5MHT said it was not realistic that she could watch all of her patients as ordered.

In an interview on 08/16/2021 at 4:30 p.m. with S2DON, he said it is not possible for 1 MHT to make observations on 16 patients with 11 every 15 minutes and 5 every 5 minutes. He said that did not meet the staffing matrix.

Based on record review and interview, the hospital failed to ensure a physical exam was documented after a patient alleged sexual assault for 1 (#2) of 5 sampled patients (#1, #2, #3, #4, #5).

Findings:

Review of Patient #2's Incident Report dated 07/19/2021 at 8:10 a.m. revealed the following: Summary of Events: Patient approached the nurse's station and informed the nurses that a peer took her into the bathroom to have sex.

Review of Patient #2's medical record revealed no assessment by a nurse after the alleged sexual assault.

In an interview on 08/16/2021 12:51 p.m. with S8RN, she said she remembered Patient #2. She said around 8:00 a.m., Patient #2 came to the nurses' station with another patient and Patient #2 was sobbing. The other patient said Patient #2 had been raped in the bathroom.
When asked if she did an assessment on Patient #2 and documented it in the nurse's notes after the reported assault she replied, "No".

In an interview on 08/16/2021 at 1:44 p.m. with S7LPN, she said she was familiar with Patient #2. She said when she came in on Monday Patient #2 made a statement that Patient #1 had penetrated her and she didn't want it to happen. When asked if she had performed and documented an assessment of Patient #2 she said at this hospital the RN documents in the nursing note, the LPN's do not.

In an interview on 08/16/2021 at 4:30 p.m. with S2DON, he said there should have been an assessment after Patient #2's allegation of sexual assault.

Based on record review and interview, the hospital failed to ensure medical records were accurate and complete. This deficient practice was evidenced by failing to document in a patient's medical record an alleged incident that a peer exposed himself to her while in intake and she was uncomfortble being in the unit with him for 1 (#5) of 5 (#1, #2, #3, #4, #5) sampled patients.

Findings:

Review of the hospital's poicy titled Documentation Protocol revealed in part:
Facility records, reports, charts and documents are to be accurate, truthful and complete.

Review of a note by S6Advocate dated 07/07/2021 revealed the following: The husband of Patient #5 called to report his wife did not receive discharge paperwork and stated that his wife had been sexually harassed while in the facility.

Review of a statement by S7LPN that was attached to an incident report (not a permanent part of the medical record) for Patient #5 revealed the following:
Patient arrived on unit and after admission was complete she noticed another patient that was being admitted she proceeded to tell this writer that the patient exposed himself to her while the both of them were waiting to be assessed in intake.

Review of Patient #5's medical record revealed there was no documentation of sexually inappropriate behavior or allegations of another patient exposing themselves to her.