HospitalInspections.org

Based on interview and record review the hospital failed to ensure a safe environment was provided for 1 of 1 employee (Personnel #9) and 1 of 1 patient (Patient #6).

1) On 09/25/16 at 1100 (Patient #7) a male patient was found unclothed in female (Patient #6's) room. (Patient #6) alleged she was sexually assaulted. (Patient #7) was not placed on a higher level observation after the event.

2) On 09/25/16 at 1400 (Patient #7) attacked Personnel #9 and attempted to sexually assault her. Patient #7 was not placed on 1:1 until 09/25/16 at 1745.

Findings included:

1) Patient #7's Detention Warrant dated 09/25/16 reflected, "Unable to answer questions...believes people are stealing his money, stabbing him and taking him to Mexico ...spoke continually...was physically aggressive with his family...sees demons..."

The physician admission order dated 09/25/16 timed at 1007 reflected, "Schizoaffective Disorder...standard Q15 minutes for Aggressive Behavior..."

The Nursing Progress Note timed at 09/25/16 timed at 1100 reflected, "Patient found in female patients' room without any clothes on. Patient removed from the room and redirected ...monitored closely..."

The 09/26/16 timed at 1730 physician order reflected, "Late entry for 09/25/16 timed at 1745...patient to be monitored with 1:1 continuous supervision due to sexual inappropriateness and aggression...noted at 1730..." Patient #7 was not placed on a higher level of observation after the above event.

The Intake Assessment dated 09/26/16 timed at 2020 reflected, "Per unit staff patient is sexually inappropriate and trying to rape female patients'..."


Patient #6's Psychiatric Evaluation dated 09/20/16 reflected, "Increased depression, suicidal ideations...feeling hopeless helpless and worthless...decreased concentration and low self-esteem, increased anxiety and depression..."

The 09/25/16 progress note timed at 1100 reflected, "Notified that a male patient was found in female patients' room...nude and on the roommates bed...staff reported she was across the hall from the scene knocking on the patients' door and called her name...the female patient opened the door to look out and this is when the nude patient was observed...the patient shut the door before staff was able to speak to her...staff entered the room and at this time male patient told to get dressed...escorted to his room...1140...approached her once again to query her about the alleged rape...I don't feel safe..."

The 09/25/16 physician order timed at 1130 reflected, "Transfer patient to...unit for safety..."

On 11/02/16 at 1230 Personnel #7 reviewed Patient #6's medical record and verified a 1:1 was not ordered after the above event between (Patient #6)
and (Patient #7).

2) Patient #7's Detention Warrant dated 09/25/16 reflected, "Unable to answer questions...believes people are stealing his money, stabbing him and taking him to Mexico ...spoke continually...was physically aggressive with his family...sees demons..."

The physician admission order dated 09/25/16 timed at 1007 reflected, "Schizoaffective Disorder...standard Q15 minutes for Aggressive Behavior..."

The Nursing Progress Note dated 09/25/16 timed at 1400 reflected, "Patient attempted to be sexually inappropriate with staff in the nutrition room when he pushed the door closed behind him...placed on 1:1 for safety." The medical record revealed no order for 1:1 monitoring until 09/25/16 at 1745.

The Intake Assessment dated 09/26/16 timed at 2020 reflected, "Per unit staff patient is sexually inappropriate and trying to rape staff members..."

On 11/01/16 at 1726 Personnel #9 was interviewed by telephone. Personnel #9 stated she was one of the technician's on the unit. Personnel #9 stated (Patient #7) was found naked in a female patients' room earlier on the morning of 09/25/161. The female was sent to a different unit. Personnel #9 was asked if the male patient was placed on a 1:1. Personnel stated the patient was not until after he attempted to sexually assault her while she was in the nutrition room. Personnel #9 stated the patient pushed his way into the room and the door shut. The patient was touching her all over her body and she started screaming when he put his hand over her mouth. The staff heard her scream and came into the the room. Personnel #9 stated she did not feel safe.

Based on record review and interview, the hospital nursing staff failed to evaluate the nursing care for one of one patient (Patient #3) according to her needs. Patient #3 was assessed to be at high risk for suicide upon admission. On 10/27/16 Patient had a fresh scratch wound on her arms. In addition, she wrapped a pair of scrub pants tightly around her neck. There was no evidence of nursing assessment of potential injuries related to the incident and/or the scratch wound on the patient's arm.

Findings included:

Patient #3's Admission Nursing Assessment dated 10/20/16 at 0100 reflected an admission diagnosis of Major Depressive Disorder.

Intake Assessment dated 10/20/16 at 0005 reflected a chief complaint of "feeling suicidal." The patient was assessed to be at "high risk" for suicide with acute risk factors that included a clear intent, feelings of hopelessness and "severe current stressors."

Behavioral Health Progress Notes dated 10/27/16 at 1930 reflected staff entered the patient room. Patient #3 showed staff a "scar" she had scratched on her arm. The notes reflected that "staff checked on patient every five minutes ...after about ten minutes later, staff walked in ...[and] ...[Patient #3] had a pair of scrub pants double wrapped around pt's neck pulled tight ...allowed staff to take it from neck."

Nursing Progress Notes dated 10/27/16 timed at 1944 reflected that Patient #3 had "fresh scratches" on her right forearm and had scrub pants "pulled tightly around her neck ...[physician] notified ...orders for patient to be placed on 1:1 [staff to patient observation] ...will continue to monitor closely." There is no evidence of nursing assessment of the patient self-injurious arm wound or the potential injuries after the patient had wrapped the scrub pants around her neck.

During an interview on 10/28/16 at 1400, Employee #7 denied awareness that Patient #3 had wrapped scrub pants tightly around her neck less than 24 hours ago.

Based on interview and record review the hospital failed to ensure 2 of 10 patient careplans were complete and addressed inappropriate sexual behavior which occurred during (Patient #6 and Patient #7's) hospital stay. (Patient #7's) careplan further did not address (Patient #7's) sexual assault for 1 of 1 employee (Personnel #9).

Findings included:

1) Patient #7's Detention Warrant dated 09/25/16 reflected, "Unable to answer questions...believes people are stealing his money, stabbing him and taking him to Mexico ...spoke continually...was physically aggressive with his family...sees demons..."

The Nursing Progress Note timed at 09/25/16 timed at 1100 reflected, "Patient found in female patients' room without any clothes on. Patient removed from the room and redirected ...monitored closely..."

The Intake Assessment dated 09/26/16 timed at 2020 reflected, "Per unit staff patient is sexually inappropriate and trying to rape female patients' and staff..."

The undated Initial Nursing Treatment Plan for Patient #7 revealed no initial treatment concerns. The document did not address the patients' sexually inappropriate behavior nor his aggression. The document was left blank.

On 11/02/16 from 1145 to 1245 Personnel #7 was interviewed. Personnel #7 was asked to review Patient #7's medical record. Personnel #7 verified Patient #7's treatment plan did not address his sexually inappropriate behavior.

2) Patient #6's Psychiatric Evaluation dated 09/20/16 reflected, "Increased depression, suicidal ideation's...feeling hopeless helpless and worthless...decreased concentration and low self-esteem, increased anxiety and depression..."

The 09/25/16 progress note timed at 1100 reflected, "Notified that a male patient was found in female patients' room...nude and on the roommates bed...staff reported she was across the hall from the scene knocking on the patients' door and called her name...the female patient opened the door to look out and this is when the nude patient was observed...the patient shut the door before staff was able to speak to her...staff entered the room and at this time male patient told to get dressed...escorted to his room...1140...approached her once again to query her about the alleged rape...I don't feel safe..."

The Interdisciplinary Master Treatment Plan dated 09/23/16 revealed no documentation and/or update regarding sexually inappropriate behavior which occurred in the patients' room which involved a male patient.

On 11/02/16 at 1230 Personnel #7 reviewed Patient #6's medical record and verified the treatment plan did not address and/or was updated with the alleged sexually inappropriate behavior Patient #6 experienced from (Patient #7) on 09/25/16.

The policy and procedure entitled, "Treatment Planning" with a revision date of 06/2015 reflected, "The treatment plan is the tool used by the physician and interdisciplinary treatment team to formulate and document the medical, psychiatric, nursing, and counseling/social services interventions...the treatment plan shall be an accurate and dynamic representation of patients' treatment experience...treatment team assess the patients' current clinical status, progress toward treatment plan goals and make necessary modifications..."