HospitalInspections.org

Based on medical record review and staff interviews it was revealed the nursing staff failed to notify the physician after patient #1 complained of an inappropriate conduct occurring with another patient. This failure was identified in one (1) of four (4) medical records reviewed for the Behavioral Health Unit (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed patient #1 was in the adolescent unit at the time of the incident. At 12:22 p.m. on 1/1/20 patient #1 came to the nurse's station and stated someone had touched his private area. The Registered Nurse (RN) documented patient #1 was a one (1) to one (1) observation and the incident did not occur. Patient monitoring sheet reflects patient #1 was only on fifteen (15) minute checks when the incident occurred. An order was obtained from the primary care physician for a pediatric physician to examine the patient. The order was obtained on 1/2/20 at 11:04 a.m. A pediatrician examined the patient on 1/2/20 at 2:29 p.m. The nurse failed to notify the primary physician when the incident occurred.

2. A telephone interview was conducted with the Director of the Behavioral Unit on 6/30/20 at 1:30 p.m. He verified patient #1 was not on one (1) to one (1) observation at the time of the incident due to the personal care assistant also documenting on another patient's monitoring sheet at the same time as patient #1. He stated there is no proof patient #1 was on one (1) to one (1) observation at the time of the incident. When asked what his expectation was for the nurses he stated, "They should have called the doctor if they didn't know the patient was sexually assaulted." When informed the nurses did not notify the physician for twenty-three (23) hours and eighteen (18) minutes he stated, "If that is the case, I don't have an answer for that."

3. An interview was conducted with the Chief Executive Officer (CEO) on 7/1/20 at 11:24 a.m. When the CEO was asked about patient #1 he stated the on-call pediatrician expected the child to go to the Emergency Department (ED) to be evaluated. The CEO stated another pediatrician showed up and saw the patient. The CEO stated if the on-call physician had been called from the ED he would have shown up. The pediatrician who saw the patient did not know about the issue of the patient going to the ED. The staff on the Behavioral Unit did not think it happened so they contacted another physician to see him instead of sending him to the ED. When informed the nurses did not notify anyone of the incident at the time it occurred per documentation, the CEO stated they should have been notified. When informed, the surveyors were told the patient was one (1) to one (1) observation but there was no evidence to prove the patient was one (1) to one (1). He stated the patient probably wasn't one (1) to one (1) but direct observation. The CEO stated, "When that allegation was made doctor should have been notified and the child sent to the ED or if doctor is there, will say I will see patient there. Nursing dropped the ball."