HospitalInspections.org

Based on hospital policy/procedure review, Behavioral Health and corporate administrative staff interviews, incident report review, Behavioral Health staff interviews, medical record review, tours and observations and video review, the hospital failed to have an effective Governing Body by failing to ensure a safe patient environment.

The findings include:

1. The hospital staff failed to ensure the patient's right for a safe environment by failing to have processes and systems in place for the monitoring and supervision of Behavioral Health patients.

~cross refer to 482.13 Patient's Rights Condition: Tag A115.

2. The hospital failed have an effective and organized nursing service ensuring a safe patient environment by failing to have processes and systems in place for the monitoring and supervision of Behavioral Health patients.

~cross refer to 482.23 Nursing Services Condition: Tag A0385.

Based on hospital policy/procedure review, Behavioral Health and corporate administrative staff interviews, incident report review, Behavioral Health staff interviews, medical record review, tours and observations and video review, the hospital staff failed to ensure the patient's right for a safe environment by failing to have processes and systems in place for the monitoring and supervision of Behavioral Health patients.

The findings incldue:

1. The hospital staff failed to ensure a safe patient environment by failing to have processes and systems in place for the monitoring and supervision of Behavioral Health patients.

~cross refer to 482.13(c)(2) Patient's Rights Standard: Tag A144.

Based on hospital policy/procedure review, Behavioral Health and corporate administrative staff interviews, incident report review, Behavioral Health staff interviews, medical record review, tours and observations and video review, the hospital staff failed to ensure a safe patient environment by failing to have processes and systems in place for the monitoring and supervision of Behavioral Health patients.

The Findings include:

Review of "Inpatient Behavior Health Program Patient Handbook" revised 02/28/2012 revealed, "Sexual acts or inappropriate physical contact between patients are not permitted. Violence of any sort is not tolerated...It is the responsibility of the staff to prevent harm from occurring to any patient...Provocative and distractive clothing is prohibited."

Interview with Behavioral Health administrative staff on 12/04/2013 at 1541 revealed the facility had a locked co-ed adult admissions Behavioral Health unit. The interview revealed the unit accepted patients on involuntary commitment (IVC). The interview revealed administrative staff recently reinforced with the Behaviorial Health unit nursing staff the policy of a staff member remaining in their assigned areas (300 and 400 halls) to monitor patients. Interview revealed all doors are locked on the unit except for the patient bedroom doors. Interview revealed all patients are on standard every 15 minute observation checks with documentation in the medical record. Interview revealed during freetime between groups and times in which there is no scheduled activity, patients can move freely between the two hallways. The interview revealed in October 2013 the administrative staff identified educational needs of the staff providing care on this unit. The interview revealed the hospital had an incident in November 2013 on the Behavioral Health adult unit when a male patient had allegedly raped a female patient. The interview revealed an investigation was conducted and concerns with the staff not being present in the assigned hallways was identified. The interview revealed corrective actions were implemented to include staff members must be in the assigned hallways at all times. The interview revealed the staff was not "picking" up on behaviors of the patients. The interview revealed after the incident a module for the "GUIDELINES for PERFORMING OBSERVATIONS & PRECAUTIONS" was added to the educational requirements for the staff. The interview revealed administrative staff had viewed video monitors to see if staff were observing the hallways. The interview revealed there had been times when the staff were observed not following the corrective action. The interview revealed there was no written policy or procedure for clothing for the Behavioral Health patients. The interview revealed the dress code was paper gowns the first 24 hours after admission, no strings, no belts, shoe laces, cords no suggestive clothing, no leggings or tank tops.

Review of the "FULL REPORT FOR EVENT" (the report completed by RN #1) revealed RN #1 completed documentation of the incident on 11/02/2013. Review of the "Patient Event Detail" section revealed,"This nurse went down to the roomon (room) the 400 hall after hearing a pt. scream. Patient #2 was hovering over Patient #1 on the bed. Patient #1 at this time was screaming 'stop leave me alone' and was fighting to keep her pants up. this nurse told pt. to stop and to leave her alone then this nurse grab his arm and Patient #2 pushed against this nurse and pushed me out way. then Patient #2 pulled pt onto the floor and pulled her pants down to mid-thigh, CNA #3 entered the room and we were able to get Patient #2 off of Patient #1 and also at this time CNA #1 and CNA #4 was in room as well, staff was able to get Patient #1 out the room and this nurse and CNA #1 came to the desk with Patient #1 and CNA #3 and CNA #4 stayed in the room with Patient #2.

Interview with RN #2 on 12/05/2013 at 1245 revealed RN #2 was the assigned charge nurse (CN) on the Behavioral Health unit on 11/02/2013 the date of the alleged rape. The interview revealed Patient #2 "definitely responding to internal stimuli and laughing inappropriately" prior to the incident. Interview revealed that Patient #2 was assigned to RN #2. Interview revealed, "I talked with Patient #2 several times that day and didn't feel something was a red flag or problem." Interview revealed RN #2 did not feel the need to change the observation status of Patient #2.

Closed medical record review of Patient #2 revealed a 22 year old male admitted as an IVC to the Behavioral Health Unit on 11/01/2013 at 1925 from the ED (emergency department) for psychosis nos (not of specific origin). Record review revealed documentation that Patient #2 was "masturbating in room in ED" at 1850. Record review revealed documentation that during the intake process, "pt (patient) was crying and then laughing hysterically. The pt. reports he was just trying to get a ride and laughed inappropriately throughout the interview and appeared to be responding to internal stimuli." Record review revealed documentation on 11/02/2013 at 1517 by RN#2, "Pt has been guarded and suspicious... pt laughing inappropriately and appears to be responding to internal stimuli."

Closed medical record review of Patient #1 revealed a 44 year old female admitted to the hospital on 10/30/2013 with an admission diagnosis of suicidal ideation, depressed mood, helpless and impaired insight. Record review revealed this patient was IVC. Record review revealed documentation on 11/02/2013 at 1730 staff responded to a room finding Patient #1 laying on the bed with Patient #2 standing over her. Record review revealed that Patient #1 was physically assaulted by Patient #2. Record review revealed documentation the patient was taken to the hospital ED for complaints of neck pain and back pain. Record review revealed the patient was placed on 1:1 observation until her discharge on 11/04/2013 due to patient's safety concerns.

Observations during the tour of the Behavioral Health Unit on 12/4/2013 at 1645 revealed a centralized nursing station with the 400 hall perpendicular to the nursing station to the left and the 300 hall perpendicular to the nursing station to the right. Each hallway had a dayroom area with chairs and TV. Observation revealed the doors into the nursing station were locked and required badged access to enter. Observation revealed staff standing in the nursing station and in the entry area (dayroom) outside of the 300 and 400 hallways. Multiple patients were observed walking from the 400 hall around the nursing station into the 300 hall co-mingling with other patients. Observation revealed an eraser board located outside the nursing station containing the name of the staff assigned to each respective hall. Observation revealed a patient wearing a low cut tank top with cleavage visible. Observation revealed a female patient sitting in the dayroom area wrapped in a blanket with inability to visualize hands. During the tour the patient was observed walking throughout both hallways wrapped in a blanket.

Observations during the staff completing the 15 minute checks revealed the CNA's (Certified Nursing Assistant's) starting at the first patient room on the right. The CNA stood at the doorway and identified one patient in the room and voiced the other patient assigned to the room was not in the room. Observation revealed the CNA continuing to walk down the hall visualizing the rooms from the doorways. Observation revealed the CNA did not enter any patient room. Observation revealed the CNA completed the 15 minute check by visualizing the patients in the day room area.

Interview on 12/4/2013 ay 1710 with CNA #1 revealed at the beginning of the shift the CNA goes into each patient room to check for contraband. The interview revealed staff do not routinely enter the patient rooms during the 15 minute checks. The interview revealed she visualizes her assigned patients only. The interview revealed she locates each assigned patient and documents the check and the location of the patient. The interview revealed if a patient is not seen during the check the CNA will leave the assigned area to find and visualize the assigned patient. The interview revealed patients are not to wear tank tops or revealing clothing. The interview revealed CNA #1 was not aware of a policy addressing the patient's dress code. The interview revealed a staff member should have asked the patient presently on the unit wearing a tank top to change clothing

Interview on 12/4/2013 at 1730 with CNA #2 revealed for the 15 minute checks she will leave her hall to find and visualize an assigned patient. The interview revealed she does not report off to anyone to monitor her assigned patients when she must go and locate a patient. The interview revealed patients are not to wear hoods, strings, jewelry, watches, hair pieces, belts and tank tops. The interview revealed the patient presently on the unit wearing a tank top staff should have spoken to the patient to change clothing. The interview revealed the patients are not to have blankets covering the body so hands can not be seen.

Interview with corporate administrative accreditation staff on 12/4/2013 at 1800 revealed there was not a system or process in place for monitoring and supervising psychiatric patients.

Interview on 12/05/2013 at 1002 with risk management revealed the facility had an event involving physical assault between a male and female patient on the behavioral health unit that occurred on 11/02/2013. Interview revealed risk management had closed the investigation since sexual activity did not occur. Interview revealed that the administrative staff was notified by the behavioral unit nursing staff that Patient #1 was transferred to the ED for complaints of neck and back pain after the physical assault. Interview revealed that Patient #2 was immediately placed in seclusion. Interview revealed that no staff member saw Patient #2 pick up Patient #1. Interview revealed the event was recognized by the staff when they heard noise from another patient, "Hey, need help." Interview revealed that RN #1 saw Patient #2 up over Patient #1 on the bed. Interview revealed that Patient #1 had her pants down and she was fighting to hold them up screaming "stop leave me alone." Interview revealed that RN #1 attempted to grab Patient #2. Interview revealed that Patient #2 pushed RN #1 off of Patient #2. Interview revealed that Patient #2 grabbed Patient #1 and pulled her off of the bed and onto the floor. Interview revealed that RN #1 was able to pull Patient #2 off of Patient #1 with the assistance of additional staff members. Interview revealed the hospital police were notified. Interview revealed that Patient #1 pressed charges against Patient #2. Interview revealed that Patient #2 was arrested and removed from the facility by law enforcement. Interview revealed that the conclusion of the investigation revealed that staff members were unaware of covert/overt signs and symptoms of psychiatric behaviors. Interview revealed the staff were in the nursing station and were not monitoring their assigned hall when the event occurred. The interview revealed the staff were given inservices and a module for "GUIDELINES for COMPLETING OBSERVATION and PRECAUTIONS" was added to the educational requirements. Interview revealed the educational requirements were initiated 10/09/2013 based on concerns identified by administrative staff prior to the alleged rape event. Interview revealed the educational module was added after the event. The interview revealed 77% of the staff had completed the module for "GUIDELINES for COMPLETING OBSERVATIONS and PRECAUTIONS" as of 11/2013.

Review of the incident/investigation/arrest report revealed the police received a report of "attempted rape" on 11/02/2013 at 1745 at the hospital's Behavioral Health Unit. Review revealed the attempted rape was documented at 11/02/2013 at 1732. Review of the report revealed the staff member advised, "they just had a patient that almost got raped." Further review revealed Patient #1 (the alleged victim) was on the 400 hall and Patient #2, also on the 400 hall, picked her up and carried her to another patient's room and pulled her pants down to her knees. Patient #1 stated she was, "kicking and screaming for help while she was being carried down the hall." Review revealed staff arrived in the room and got Patient #2 off of Patient #1. Further review revealed that after the NP (nurse practitioner) evaluated Patient #2, he was charged with attempted second degree rape, assault on a female and sexual battery.

Review of video taped footage of incident on 11/2/2013 revealed patients in the 400 hall dayroom at 1730. Video review revealed Patient #1 laying on the chairs supine (back) and Patient #2 sitting beside Patient #1. Further review revealed Patient #1 turning prone (onto her stomach) and speaking to Patient #2. Further review at 1732:43 revealed Patient #2 picking up Patient #1 and twirling her down the hall. Further review revealed Patient #2 attempted to go into a room on the right side of the hall. Further review at 1732:56 revealed Patient #2 entered the last room on the left side of the hall with Patient #1. Further review at 1733:10 revealed staff entering the room with Patient # 1 and Patient #2. Observation revealed the camera's on the unit only offer a retrospective view visible to administrative staff. Observation revealed the camera images on the monitors in the nurses stations are without sound and good visualization.

Based on administrative staff interview, hospital policy/procedure review, Behavioral Health and corporate administrative staff interviews, incident report review, Behavioral Health staff interviews, medical record review, tours and observations and video review, the hospital failed have an effective and organized nursing service ensuring a safe patient environment by failing to have processes and systems in place for the monitoring and supervision of Behavioral Health patients.

The findings include:

1. The hospital staff failed to ensure a safe patient environment by failing to have processes and systems in place for the monitoring and supervision of Behavioral Health patients.

~cross refer to 482.23(b)(3) Nursing Services Standard: Tag A0395.

Based on hospital policy/procedure review, Behavioral Health and corporate administrative staff interviews, incident report review, Behavioral Health staff interviews, medical record review, tours and observations and video review, the hospital staff failed to ensure a safe patient environment by failing to have processes and systems in place for the monitoring and supervision of Behavioral Health patients.

The Findings include:

Review of "Inpatient Behavior Health Program Patient Handbook" revised 02/28/2012 revealed, "Sexual acts or inappropriate physical contact between patients are not permitted. Violence of any sort is not tolerated...It is the responsibility of the staff to prevent harm from occurring to any patient...Provocative and distractive clothing is prohibited."

Interview with Behavioral Health administrative staff on 12/04/2013 at 1541 revealed the facility had a locked co-ed adult admissions Behavioral Health unit. The interview revealed the unit accepted patients on involuntary commitment (IVC). The interview revealed administrative staff recently reinforced with the Behaviorial Health unit nursing staff the unit's standard practice of a staff member remaining in their assigned areas (300 and 400 halls) to monitor patients. Interview revealed all doors are locked on the unit except for the patient bedroom doors. Interview revealed all patients are on standard every 15 minute observation checks with documentation in the medical record. Interview revealed during freetime between groups and times in which there is no scheduled activity, patients can move freely between the two hallways. The interview revealed in October 2013 the administrative staff identified educational needs of the staff providing care on this unit. The interview revealed the hospital had an incident in November 2013 on the Behavioral Health adult unit when a male patient had allegedly raped a female patient. The interview revealed an investigation was conducted and concerns with the staff not being present in the assigned hallways was identified. The interview revealed corrective actions were implemented to include staff members must be in the assigned hallways at all times. The interview revealed the staff was not "picking" up on behaviors of the patients. The interview revealed after the incident a module for the "GUIDELINES for PERFORMING OBSERVATIONS & PRECAUTIONS" was added to the educational requirements for the staff. The interview revealed administrative staff had viewed video monitors to see if staff were observing the hallways. The interview revealed there had been times when the staff were observed not following the corrective action. The interview revealed there was no written policy or procedure for clothing for the Behavioral Health patients. The interview revealed the dress code was paper gowns the first 24 hours after admission, no strings, no belts, shoe laces, cords no suggestive clothing, no leggings or tank tops.

Review of the "FULL REPORT FOR EVENT" (the report completed by RN #1) revealed RN #1 completed documentation of the incident on 11/02/2013. Review of the "Patient Event Detail" section revealed,"This nurse went down to the roomon (room) the 400 hall after hearing a pt. scream. Patient #2 was hovering over Patient #1 on the bed. Patient #1 at this time was screaming 'stop leave me alone' and was fighting to keep her pants up. this nurse told pt. to stop and to leave her alone then this nurse grab his arm and Patient #2 pushed against this nurse and pushed me out way. then Patient #2 pulled pt onto the floor and pulled her pants down to mid-thigh, CNA #3 entered the room and we were able to get Patient #2 off of Patient #1 and also at this time CNA #1 and CNA #4 was in room as well, staff was able to get Patient #1 out the room and this nurse and CNA #1 came to the desk with Patient #1 and CNA #3 and CNA #4 stayed in the room with Patient #2.

Interview with RN #2 on 12/05/2013 at 1245 revealed RN #2 was the assigned charge nurse (CN) on the Behavioral Health unit on 11/02/2013 the date of the alleged rape. The interview revealed Patient #2 was "definitely responding to internal stimuli and laughing inappropriately" prior to the incident. Interview revealed that Patient #2 was assigned to RN #2. Interview revealed, "I talked with Patient #2 several times that day and didn't feel something was a red flag or problem." Interview revealed RN #2 did not feel the need to change the observation status of Patient #2.

Closed medical record review of Patient #2 revealed a 22 year old male admitted as an IVC to the Behavioral Health Unit on 11/01/2013 at 1925 from the ED (emergency department) for psychosis nos (not of specific origin). Record review revealed documentation that Patient #2 was "masturbating in room in ED" at 1850. Record review revealed documentation that during the intake process, "pt (patient) was crying and then laughing hysterically. The pt. reports he was just trying to get a ride and laughed inappropriately throughout the interview and appeared to be responding to internal stimuli." Record review revealed documentation on 11/02/2013 at 1517 by RN#2, "Pt has been guarded and suspicious... pt laughing inappropriately and appears to be responding to internal stimuli."

Closed medical record review of Patient #1 revealed a 44 year old female admitted to the hospital on 10/30/2013 with an admission diagnosis of suicidal ideation, depressed mood, helpless and impaired insight. Record review revealed this patient was IVC. Record review revealed documentation on 11/02/2013 at 1730 staff responded to a room finding Patient #1 laying on the bed with Patient #2 standing over her. Record review revealed that Patient #1 was physically assaulted by Patient #2. Record review revealed documentation the patient was taken to the hospital ED for complaints of neck pain and back pain. Record review revealed the patient was placed on 1:1 observation until her discharge on 11/04/2013 due to patient's safety concerns.

Observations during the tour of the Behavioral Health Unit on 12/4/2013 at 1645 revealed a centralized nursing station with the 400 hall perpendicular to the nursing station to the left and the 300 hall perpendicular to the nursing station to the right. Each hallway had a dayroom area with chairs and TV. Observation revealed the doors into the nursing station were locked and required badged access to enter. Observation revealed staff standing in the nursing station and in the entry area (dayroom) outside of the 300 and 400 hallways. Multiple patients were observed walking from the 400 hall around the nursing station into the 300 hall co-mingling with other patients. Observation revealed an eraser board located outside the nursing station containing the name of the staff assigned to each respective hall. Observation revealed a female patient wearing a low cut tank top with cleavage visible. Observation revealed a female patient sitting in the dayroom area wrapped in a blanket with inability to visualize hands. During the tour the patient was observed walking throughout both hallways wrapped in a blanket.

Observations during the staff completing the 15 minute checks on 12/04/2013 at approximately 1630 revealed the CNA's (Certified Nursing Assistant's) starting at the first patient room on the right. The CNA stood at the doorway and identified one patient in the room and voiced the other patient assigned to the room was not in the room. Observation revealed the CNA continuing to walk down the hall visualizing the rooms from the doorways. Observation revealed the CNA did not enter any patient room. Observation revealed the CNA completed the 15 minute check by visualizing the patients in the day room area.

Interview on 12/4/2013 ay 1710 with CNA #1 revealed at the beginning of the shift the CNA goes into each patient room to check for contraband. The interview revealed staff do not routinely enter the patient rooms during the 15 minute checks. The interview revealed she visualizes her assigned patients only. The interview revealed she locates each assigned patient and documents the check and the location of the patient. The interview revealed if a patient is not seen during the check the CNA will leave the assigned area to find and visualize the assigned patient. The interview revealed patients are not to wear tank tops or revealing clothing. The interview revealed CNA #1 was not aware of a policy addressing the patient's dress code. The interview revealed a staff member should have asked the patient presently on the unit wearing a tank top to change clothing.

Interview on 12/4/2013 at 1730 with CNA #2 revealed for the 15 minute checks she will leave her hall to find and visualize an assigned patient. The interview revealed she does not report off to anyone to monitor her assigned patients when she must go and locate a patient. The interview revealed patients are not to wear hoods, strings, jewelry, watches, hair pieces, belts and tank tops. The interview revealed the staff should have spoken to the patient presently on the unit wearing a tank top to change clothing. The interview revealed the patients are not to have blankets covering the body so hands can not be seen.

Interview with corporate administrative accreditation staff on 12/4/2013 at 1800 revealed there was not a system or process in place for monitoring and supervising psychiatric patients.

Interview on 12/05/2013 at 1002 with risk management revealed the facility had an event involving physical assault between a male and female patient on the behavioral health unit that occurred on 11/02/2013. Interview revealed risk management had closed the investigation since sexual activity did not occur. Interview revealed that the administrative staff was notified by the behavioral unit nursing staff that Patient #1 was transferred to the ED for complaints of neck and back pain after the physical assault. Interview revealed that Patient #2 was immediately placed in seclusion. Interview revealed that no staff member saw Patient #2 pick up Patient #1. Interview revealed the event was recognized by the staff when they heard noise from another patient, "Hey, need help." Interview revealed that RN #1 saw Patient #2 up over Patient #1 on the bed. Interview revealed that Patient #1 had her pants down and she was fighting to hold them up screaming "stop leave me alone." Interview revealed that RN #1 attempted to grab Patient #2. Interview revealed that Patient #2 pushed RN #1 off of Patient #2. Interview revealed that Patient #2 grabbed Patient #1 and pulled her off of the bed and onto the floor. Interview revealed that RN #1 was able to pull Patient #2 off of Patient #1 with the assistance of additional staff members. Interview revealed the hospital police were notified. Interview revealed that Patient #1 pressed charges against Patient #2. Interview revealed that Patient #2 was arrested and removed from the facility by law enforcement. Interview revealed that the conclusion of the investigation revealed that staff members were unaware of covert/overt signs and symptoms of psychiatric behaviors. Interview revealed the staff were in the nursing station and were not monitoring their assigned hall when the event occurred. The interview revealed the staff were given inservices and a module for "GUIDELINES for COMPLETING OBSERVATION and PRECAUTIONS" was added to the educational requirements. Interview revealed the educational requirements were initiated 10/09/2013 based on concerns identified by administrative staff prior to the alleged rape event. Interview revealed the educational module was added after the event. The interview revealed 77% of the staff had completed the module for "GUIDELINES for COMPLETING OBSERVATIONS and PRECAUTIONS" as of 11/2013.

Review of the incident/investigation/arrest report revealed the police received a report of "attempted rape" on 11/02/2013 at 1745 at the hospital's Behavioral Health Unit. Review revealed the attempted rape was documented at 11/02/2013 at 1732. Review of the report revealed the staff member advised, "they just had a patient that almost got raped." Further review revealed Patient #1 (the alleged victim) was on the 400 hall and Patient #2, also on the 400 hall, picked her up and carried her to another patient's room and pulled her pants down to her knees. Patient #1 stated she was, "kicking and screaming for help while she was being carried down the hall." Review revealed staff arrived in the room and got Patient #2 off of Patient #1. Further review revealed that after the NP (nurse practitioner) evaluated Patient #2, he was charged with attempted second degree rape, assault on a female and sexual battery.

Review of video taped footage of incident on 11/2/2013 revealed patients in the 400 hall dayroom at 1730. Video review revealed Patient #1 laying on the chairs supine (back) and Patient #2 sitting beside Patient #1. Further review revealed Patient #1 turning prone (onto her stomach) and speaking to Patient #2. Further review at 1732:43 revealed Patient #2 picking up Patient #1 and twirling her down the hall. Further review revealed Patient #2 attempted to go into a room on the right side of the hall. Further review at 1732:56 revealed Patient #2 entered the last room on the left side of the hall with Patient #1. Further review at 1733:10 revealed staff entering the room with Patient # 1 and Patient #2. Observation revealed the camera's on the unit only offer a retrospective view visible to administrative staff. Observation revealed the camera images on the monitors in the nurses stations are without sound and good visualization.

NC00093471
NC00093483