HospitalInspections.org

Based on review of complaint information, observation, record review, review of incident reports, and staff interview, the hospital failed to develop an abuse prohibition protocol to ensure patients are free from all forms of abuse, neglect, or harassment. The hospital failed to investigate allegations made by patients to determine if abuse occurred and/or the effects of the situation on patients involved. The hospital failed to investigate a sexual act between patients. (Refer to A0145). These failures violated patient's rights and placed all patients at risk of experiencing abusive situations.

Based on review of complaint information, observation, record review, review of incident reports, and staff interview, the hospital failed to establish a comprehensive procedure for abuse/neglect prohibition and failed to thoroughly investigate alleged sexual incidents involving 4 of 8 closed patient (Patient #27, #28, #29, and #30) records reviewed. Failure to develop a process to ensure all allegations of abuse are thoroughly investigated is a violation of patient rights and placed all patients at risk of physical and/or psychosocial harm.

Findings include:

Complaint information received by the Department alleged that one patient entered another patient's room and "touched my private areas twice." The allegation indicated the patient reported this incident to a nurse, and the hospital failed to address the patient's concern.

Upon entering the facility on the afternoon of 03/06/23, a request for information included policies to prohibit abuse and neglect, including the reporting and investigating process. Facility staff failed to provide policies/procedures to address the prohibition of abuse and neglect.

- Record review for Patient #27 occurred on March 7-8, 2023. This hospital admitted Patient #27 on 12/03/22 with diagnoses including depression, anxiety, and trauma related disorder. A Progress Note, dated 12/10/22 at 8:10 a.m., identified as part of "HISTORY OF PRESENT ILLNESS: Per nursing, patient had disrupted sleep as a peer entered into patient's room overnight . . . On interview today, patient reports that someone walked into her room and tried to sexually assault her . . ."

- Record review for Patient #28 occurred on March 7-8, 2023. This hospital admitted Patient #28 on 12/02/22. A 24-Hour Nursing Progress Note, dated 12/08/22, stated, ". . . He was sitting next to a peer and tried to touch her hand. Peer was moved away from him without incident. Later in the shift he was quietly sitting in the chair next to her. He reached over to her and grabbed her over the clothes between her legs. He was escorted away from the peer without incident . . ."

A Progress Note, dated 12/09/22 at 8:45 a.m., identified as part of "HISTORY OF PRESENT ILLNESS: . . . he [Patient #28] has been sexually inappropriate on a few occasions, he was trying to grab genital parts of a young patient and he required to be redirected and restrained and required to be given Haldol, Ativan, Benadryl combination to calm him down . . ."

A Progress Note, dated 12/10/22 at 8 a.m., identified as part of "HISTORY OF PRESENT ILLNESS: Per nursing, patient [#28] entered a female patient's room overnight, but was able to be redirected . . ."

During interview on the morning of 03/07/23, a Risk Management staff member (#6) confirmed Patient #27 is the patient who Patient #28 "was trying to grab genital parts of a young patient." Patient #27's room is also the room Patient #28 entered. Following this interview, a tour of the unit where these incidents occurred showed rooms in a semi-circle, all facing a nurse's station in the center. A television (tv) was affixed to the front of the nurse's desk. The staff member said Patients #27 and #28 sat in chairs facing the tv during the incident of inappropriate touching.

An interview occurred at 3:15 p.m. on 03/07/23 with a nursing staff member (#8) who worked during the incident on 12/08/22 when Patient #28 touched Patient #27. This nurse said she was seated at the nurse's station and looking directly into the area where Patients #27 and #28 sat watching tv. She could only see the upper body of the patients over the desk. This staff member said when the incident occurred, Patient #27 jumped up and was visibly upset. The nurse stated that due to Patient #27's past trauma, being upset when being touched was understandable. This nurse said Patient #28 did not deny touching Patient #27, when asked.

When asked for an investigation into these incidents, a Risk Management staff member (#6) provided untitled documents identified from the hospital's incident tracking system.

The document addressing Patient #28, dated 12/08/22, identified incident type as "Sexual Boundary Verbal/Physical Non-Aggressive Breach." Treatment or intervention was to "Place on Precautions, Increase Observation." The Comments section stated, "Patient was sitting in chair in the day room watching tv next to female peer. He reached over and touched the female peer on the outside of her pants in the crotch area. Patient is psychotic. Changed to Q8 [observe every 8 minutes]. Sexual aggression precautions added." The progress note regarding this incident indicated Patient #28 required a combination of Haldol, Ativan, Benadryl to calm him, and identified the incident as non-aggressive. This document lacked evidence of a facility investigation. The staff member (#6) failed to provide information regarding the incident when Patient #28 entered Patient #27's room on the night of 12/09/22.

The document addressing Patient #27, dated 12/08/22, identified incident type as "Sexual Boundary Verbal/Physical Non-Aggressive Breach." Treatment or intervention was "Voluntary Time Out." The Comments section stated, "Patient was sitting in chair in the day room watching tv next to female peer. He reached over and touched the female peer on the outside of her pants in the crotch area. Patient is psychotic. Changed to Q8. Sexual aggression precautions added." This document lacked evidence of a facility investigation. This staff member (#6) failed to provide information regarding the incident when Patient #28 entered Patient #27's room on the night of 12/09/22.

On the morning of 03/08/23, an interview occurred with a Risk Management staff member (#6). This staff member identified the above documents as the investigation into the incident of Patient #28 inappropriately touching Patient #27. This staff member said he was not made aware of the incident when Patient #28 entered Patient #27's room until after the hospital transferred both patients out of the facility.

When asked for evidence of training for the staff who failed to report this incident, a nursing staff member (#4) provided information to show nursing staff received education on 02/27/23. Facility staff failed to provide evidence the medical providers who were aware of the incident received education on the importance of reporting.

A review of incidents occurring in the past 30 days occurred on 03/07/23. This list included a sexual incident occurring between Patient #29 and Patient #30 on 02/15/23.

- Record review for Patient #29 occurred March 7-8, 2023. The hospital admitted Patient #29 on 12/19/22. A Progress Note, dated 02/16/23 at 9:30 a.m., identified as part of "HISTORY OF PRESENT ILLNESS: . . . Staff reported that the patient had a sexual misconduct with a female patient's [sic] last night and he was moved to another room and he is currently on sexual aggression precautions."

Review of the hospital's incident tracking system documentation for Patient #29 regarding the sexual incident found the incident type as "Sexual, Intercourse Pt/Pt [involving two patients]." The Treatment or intervention is identified as "N/A [not applicable]." The Comments Section identified, "MHT [Mental Health Technician] came behind the nurse's station and notice (sic) [Patient #30] giving [Patient #29] oral sex in the quiet room. He immediately intervened and separated the two patients."

Record Review for Patient #30 occurred March 7-8, 2023. The hospital admitted Patient #30 on 12/22/22. This hospital discharged Patient #30 on 02/16/23 at 11 a.m. (the morning after the incident). The record contained no documentation regarding the incident. The incident tracking system documentation for Patient #30 described the incident with no additional information provided.

During interview on the afternoon of 03/07/23, a Risk Management staff member (#6) failed to provide an investigation into the above incident.

The hospital failed to develop an abuse prohibition protocol to ensure patients are free from all forms of abuse, neglect, or harassment. The facility failed to investigate allegations made by Patient #27 against Patient #28 to determine if abuse occurred and/or the effects of the situation on Patient #27. The hospital also failed to investigate a sexual act between Patients #29 and #30.