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The Condition of Participation has not been met.

1. Based on a review of clinical records, facility documentation, staff interviews and a review of policies, the hospital failed to reassess two (2) of four (4) patients' (Patient #16 and #14), observational status following an allegation of sexual abuse and/or followed the high alert policy to ensure a safe environment. Please see A-144.

2. Based on review of clinical records, hospital documentation, policies and procedures and staff interviews for 4 of 8 behavioral health patients who alleged to have been assaulted (Patient's #15, #18, #20, #24) the hospital failed to ensure that the allegations were thoroughly investigated and/or documented to promote and protect each patient's rights. Please see A-145

Based on a review of clinical records, facility documentation, staff interviews and a review of policies, the hospital failed to reassess two (2) of four (4) patients' (Patient #16 and #14), observational status following an allegation of sexual abuse and/or followed the high alert policy to ensure a safe environment. The findings include the following:

a. Review of the clinical record identified Patient #16 was admitted to the hospital on 8/21/16 with diagnosis that included schizophrenia, seizure disorder and a history of substance abuse. Review of facility documentation dated 9/5/15 identified Patient #15 reported that Patient #16 entered his/her room on 9/5/15 at 8:40 PM and touched him/her inappropriately. Both Patient #15 and #16 were on fifteen-minute checks during this period of time. A nurse's note dated 9/6/15 at 12:46 AM indicated that the patient was transferred to the Emergency Department on 9/5/15 at 11:00 PM for a medical evaluation due to complaints of abdominal pain. Patient #15 was medically cleared and transferred back to the hospital on 9/7/15.

Interview and review of the clinical record with Nurse Manager #1 on 10/4/16 at 11:15 AM indicated a risk assessment should have been conducted following the allegation of abuse to develop strategies and/or develop a plan to ensure the safety of all the patient's in the milieu. Based on the hospital policy, Patient #16 should have been placed on a high risk alert category three (3) for allegations of sexually inappropriate behavior and was not.

Further interview identified that Patient #16 remained on fifteen-minute checks until Patient #15 returned from the hospital on 9/7/16 and at that point, Patient #16 was placed on constant observation. Nurse Manager #1 stated Patient #16 should have been placed on constant observation immediately following the incident on 9/5/16 to minimize the risk to other patient's on the unit.

b. Review of the clinical record identified Patient #14 was admitted to the hospital on 3/15/16 on a physician's emergency certificate for acute psychosis. Patient #14 was placed on a high alert status, category two (2) on 3/15/16 for a known history of aggressive behaviors. Review of the facility documentation dated 4/23/16 identified Patient #13 and #14 were observed sitting in the hallway next to the room of Patient #14 talking with one another when observational checks were conducted at 5:35 PM. At 6:10 PM Patient #13 reported to the facility staff that Patient #14 pressured Patient #13 to perform a sexual act. Interview with the Manager of Security on 10/4/16 at 10:30 AM indicated video surveillance was conducted in the hallway of the inpatient unit and identified Patient #14 took the hand of Patient #13 and the two patient's entered Patient #14's room at 5:35 PM. Patient #13 exited from the room at 5:43 PM followed by Patient #14. Video surveillance was not conducted in the patient's room or bathrooms. Subsequent to the event Patient #14 was placed on constant observation. Patient #13 was sent to the hospital for a medical evaluation on 4/23/16 and on arrival back to the facility was admitted to an alternate unit.

Interview and review of the clinical record with Nurse Manager #1 on 10/4/16 at 11:00 AM indicated Patient #14's high risk alert category failed to be revised from a category two (2) to a category three (3) immediately following the allegation of sexual abuse on 4/23/16 until 4/26/16, three days after the event.

The hospital policy entitled high risk alert directed in part that all employees would be responsible to report all threats of violence, aggressive acts, intimidation and other volatile behaviors to their supervisor and the security office. An assessment would be made by clinical staff and an action plan taken to address the behavior. If the clinician determined that staff should be aware of high risk behaviors a request that the patient is placed on a high risk alert is made. The high risk form is completed and approved by the clinical manager and submitted to security. The form would be submitted into the Electronic Medical Record (EMR). The employee completing the high risk alert form must describe the behavior requiring placement on the high alert status and this form would be used to communicate to other clinicians or employees. It is the responsibility of the clinical staff to develop strategies for the high risk patient. These safety measures should be documented in the medical record and passed down to employees during safety huddles and shift changes. Stage two (2) behaviors included but not limited to making verbal and suicidal threats, conveying violent intentions, angry outbursts and aggressive behaviors. Category three (3) behaviors included assaultive behaviors, committing or attempting sexual assault and physical confrontations and altercations.

Based on review of clinical records, hospital documentation, policies and procedures and staff interviews for 4 of 8 behavioral health patients who alleged to have been assaulted (Patient's #15, #18, #20, #24) the hospital failed to ensure that the allegations were thoroughly investigated and/or documented. The findings include:

a. Review of the clinical record identified Patient #16 was admitted to the hospital on 8/21/16 with diagnosis that included schizophrenia, seizure disorder and a history of substance abuse. Review of the facility documentation dated 9/5/15 identified Patient #15 reported that Patient #16 entered his/her room on 9/5/15 at 8:40 PM and touched him/her inappropriately. Patient #15 was transferred to the Emergency Department on 9/5/15 at 11:00 PM for a medical evaluation due to complaints of abdominal pain. Patient #15 was medically cleared and transferred back to the hospital on 9/7/15.

Interview and review of the clinical record with RN #11 on 10/3/16 at 3:30 PM identified Patient #15 alleged at approximately 8:30 PM Patient #16 entered the patient's room three times and on one of those occasions rubbed Patient #15's clothed buttocks. Further interview with RN #11 indicated she did not observe Patient #16 enter Patient #15's room, she documented what was reported to her by the patient at 9:40 PM and by MHW #2.

Interview with MHW #2 on 10/6/16 at 10:00 AM identified she observed Patient #16 in the room of Patient #15 on one occasion after dinner at approximately 5:00 PM. MHW #2 indicated she informed Patient #16 to leave the room. Further interview with MHW #2 identified although a "round table" and/or group discussion was conducted on 10/5/15 with administration she was never interviewed regarding the event or asked the specific time of the incident.

Interview with the Manger of Security on 11/2/16 at 12:30 PM indicated video surveillance was reviewed of the inpatient unit and was viewed from 7:55 PM through 9:35 PM however failed to be viewed in the correct location as the documentation of the location and/or the time of the incident failed to be reflected on the occurrence report and/or reported to him correctly. Further interview with the Manager of Security indicated he did not review the surveillance tape prior to 8:00 PM because he was informed the time frame was 8:40 PM. The surveillance tape was no longer available for review.

A review of facility documentation, policies, and interview with the Associate Counsel/Director of Risk Management was conducted on 10/4/16 at 10:00 AM. The Associate Counsel/Director of Risk Management identified that the alleged incident was investigated as a safety event. It was not considered a Serious Safety Event under HPI Methodology or reviewable Joint Commission Sentinel Event as stated in AP Policy 200-47, therfore a 3 meeting RCA was not conducted. The Associate Counsel/Director of Risk Management advised that interviews for alleged incidents of sexual assaults are typically coordinated and conducted by Security, HR (Human Resources) and clinical leadership. Staff also participate in debriefing in Safety Huddles.

A request for documentation of staff interviews related to this incident was made, however could not be provided by the hospital.


b. Patient #18 was admitted to the behavioral health unit on 07/27/15 with diagnoses that included Mood Disorder, disorganized thinking, and ineffective coping. Review of the clinical record progress note dated 08/28/15 at 5:40 PM identified that Treatment Coordinator (TC) #1 was notified by Parole Officer (PO) #1 by phone on 08/27/15 that on 08/26/15 Patient #18 reported that he/she had been raped by a staff member. TC #1 and Unit Manager #9 met with a staff member from the public defender's office on 08/28/15 who identified that Patient #18 could not recall the date of the incident, but recalled that the incident occurred at 3:00 AM and involved a man with a specific first name and of a specific racial origin.

Review of the clinical record, including TC #1 documentation between 08/28/15 and discharge on 08/31/15 failed to identify any monitoring and/or further evaluation of the patient in regards to the rape allegation. Interview with TC #1 on 10/05/16 at 11:05 AM identified that he/she had reported the allegation to MD #18 and Unit Manager #9 on 08/28/16. TC #1 was unaware of any further investigation of the allegation and was not interviewed by any hospital personnel or asked to provide a written statement. TC #1 was unaware of any staffing changes or if other interventions were implemented to address the patient's allegation.

A behavioral health progress note dated 08/28/15 at 4:08 PM by MD #18 identified the patient's allegation of raped while in the hospital, and that an investigation was underway by State Agency #1 and the local police. The patient had refused to meet with the public defender on 08/28/15 and would not recant the allegation. MD #18's written plan included to continue to monitor and evaluate. Review of further daily notes documented by MD #18 through discharge on 08/31/15 failed to identify any monitoring and/or further evaluation of Patient #18's allegation of rape. Interview with MD #18 on 10/18/16 at 11:30 AM identified that, although Patient #18's clinical status was discussed daily in team meeting, he/she was not involved in the investigation as the investigation was typically the responsibility of the nurse and Unit Manager.

A progress note dated 08/28/15 at 6:02 PM by RN #10 identified that Patient #18 allegedly reported to PO #1 that he/she had been raped. RN #10 and Unit Manager #9, subsequently interviewed the patient who denied the rape. The patient's responsible party was notified and refused to consent to a rape kit examination. Review of nursing notes documented from 08/28/15 through discharge on 08/31/15 failed to identify that any monitoring and/or further evaluation of the patient occurred, specific to the allegation of rape.

Review of a Safety Event Entry (categorized as an alleged sexual assault) reported on 08/28/15 at 2:55 PM by Unit Manager #9, identified that following notification of Patient #18's allegation of rape on 08/28/15 an investigation was in progress and the alleged staff member (MHW #1) was transferred off the unit. A document dated 09/24/15 by Unit Manager #9 identified that there was an investigation in progress by State Agency #1 and the local police. Unit Manager #9 documented that the patient was interviewed following denial to meet with the police and State Agency #1 worker. The patient denied the event, but was being treated for acute psychosis and rule-out substance induced. Unit Manager #9 documented that the patient's family member had identified that the patient was upset with staff for multiple interventions provided. Patient #18 was transferred to a long term behavioral health treatment center on 8/31/15 for continued intensive care and treatment.
Nurse Manager #9's follow-up documentation dated 09/24/15 identified that the staff handled the patient per policy and procedure. It was identified that the patient's allegation correlated with an incident where the patient's behaviors necessitated a physical hold and a medication injection.

Interview with MHW #1 (identified as the alleged perpetrator) on 10/05/16 at 11:30 AM identified that he/she had not been interviewed about an interaction with Patient #18.

Interview with Unit Manager #9 on 10/13/16 at 11:35 AM identified that staff from the Quality Department and the Unit Manager would coordinate the investigation and details would be discussed in the team meetings. The TC would update the care plan and the MD should write a note about the occurrence.

c. P#20 was admitted on 5/5/16 for suicidal ideation. According to nursing documentation on 5/7/16 P#20 began complaining of vaginal pain and dysuria. The complaint escalated and on 5/7/16 at 10:06 AM the physician was notified and a urinalysis was ordered and completed. Urinalysis results were negative. P#20 received pain medication with "fair" effect. On 5/8/16 P#20 continued to complain of worsening vaginal pain and per physician order was sent to Hospital the Emergency Department (ED) for evaluation at 5:25 PM. On 5/8/16 at 9:00 PM the hospital was notified by the ED hospital that P#20 was being transferred to another hospital for a sexual assault evaluation. P#20 had reported that she had been inappropriately touched by a peer (P#22) in the unit hallway on the evening of 5/7/16 and it was after the assault that she began experiencing vaginal pain however P#20 initially complained of vaginal pain 5/7/16 at 10:06 AM and alleges the assault occurred on 5/7/16 in the evening. P#20 identified the perpetrator by his first initial "D" (P#22). P#20 had been placed on constant observation on 5/8/16 for other behaviors not related to this incident.

According to a facility Security Report dated 5/9/16 upon notification of the incident on 5/8/16 local law enforcement was notified and arrived at 9:10 PM. According to the report, security was to review recordings from 5/7/16 on the patient care unit P#20 resided on, in an attempt to locate the two involved patients and substantiate the allegation.

During an interview with the Director of Risk Management on 10/11/16 at 11:20 AM he/she could not confirm that security video tapes of the hallway where the alleged event occurred were reviewed.

During an interview with Executive Director of Security and the Security Manager on 10/13/16 at 11:00 AM the Security Manager indicated he/she had knowledge that some video review was conducted after the incident and the video did not substantiate the allegation. However he/she could not provide documentation to confirm what was viewed and when it was done. Security Guard #10 who was initially involved in the investigation was no longer employed by the facility and unavailable for interview at the time of the investigation.

During an interview with the DNS on 10/14/16 at 9:15 AM he/she indicated that documentation of interviews conducted as part of the investigation could not be provided. Interviews were conducted in conjunction with Human Resources and the HR employee involved no longer worked at the facility and his/her documentation of the interviews could not be located.

d. Patient #24 was admitted on 4/8/16 due to a threat of cutting him/herself and had a diagnosis of Disruptive Mood Dysregulatory Disorder. On 5/9/16 P#24 was sent to an acute care hospital ED for medial care. While in the ED, Patient #24 reported that he/she had been molested by a staff member at the treating hospital. At the time he/she could not identify the gender of the perpetrator or the date the incident occurred. Staff at the acute care hospital notified staff at the treating hospital and notified P#24's family of the allegation. A report was filed with State Agency #1 on 5/9/16 and local law enforcement was notified.

On 5/12/16 the State Agency Social Worker (SW) met with P#24 and his/her family. During the interview P#24 described the incident and indicated the incident occurred the previous week after 11:30 PM and he/she had not seen the staff member prior to or since the incident. P#24 provided a description of the alleged perpetrator. P#24 stated he/she remembers having been medicated earlier and the incident seemed real but may not have been because he/she had sleep paralysis (hallucinations) and has had similar incidents before. P#24 told police the incident "felt like a dream".

The State Agency Summary indicated during the investigation interviews were conducted with 12 staff members, all of whom worked a third shift in the week P#24 was allegedly assaulted. According to the investigative documentation, all staff members denied seeing any person who met the description of P#24's alleged perpetrator.

A review of the hospital investigation of the allegation was conducted with the Director of Risk Management, Director of Care Management, Vice President of Behavioral Health, Director of Nursing, Executive Director of Security and the Security Manager. The investigation identified that an initial Occurrence Report and Security Report were completed on 5/9/16. Local law enforcement and the acute care hospital notified State Agency #1 on 5/9/16. Electronic mail (e-mail) correspondence identified between 5/9/16 and 5/16/16 communication occurred between the State Agency, hospital administration and security staff to identify a potential date of the incident (specific date not identified) and which staff were involved. According to the E-mail, interviews with staff were to be conducted. Although the hospital identified that the allegation of the alleged sexual assault could not be substantiated, staff could not provide documentation of who was interviewed or when the interviews were conducted.

During an interview with the DNS on 10/14/16 at 9:15 AM he/she indicated that documentation of interviews conducted as part of the investigation could not be provided. Interviews are conducted in conjunction with Human Resources (HR) and the HR employee involved no longer worked at the hospital and his/her documentation of the interviews could not be located.







29049

Based on a review of clinical records, hospital documentation, policies and interviews for four of ten patients who alleged abuse (Patient #18, #15, #13, and #25), the hospital failed to develop and/or revise the plan of care to address the allegation. The findings include:

a. Patient #18 was admitted to the behavioral health unit on 07/27/15 with diagnoses that included Mood Disorder, disorganized thinking, and ineffective coping. Review of the clinical record progress note dated 08/28/15 at 5:40 PM identified that Treatment Coordinator (TC) #1 was notified by Parole Officer (PO) #1 by phone on 08/27/15 that on 08/26/15 Patient #18 reported that he/she had been raped by a staff member. TC #1 and Unit Manager #9 met with a staff member from the public defender's office on 08/28/15 who identified that Patient #18 could not recall the date of the incident, but recalled that the incident occurred at 3:00 AM and involved a man with a specific first name and of a specific racial origin.

Review of the clinical record, including TC #1 documentation between 08/28/15 and discharge on 08/31/15 failed to identify any monitoring and/or further evaluation of the patient in regards to the rape allegation. Interview with TC #1 on 10/05/16 at 11:05 AM identified that he/she had reported the allegation to MD #18 and Unit Manager #9 on 08/28/16. TC #1 was unaware of any further investigation of the allegation and was not interviewed by any hospital personnel or asked to provide a written statement. TC #1 was unaware of any staffing changes or if other interventions were implemented to address the patient's allegation.

A behavioral health progress note dated 08/28/15 at 4:08 PM by MD #18 identified the patient's allegation of raped while in the hospital, and that an investigation was underway by State Agency #1 and the local police. The patient had refused to meet with the public defender on 08/28/15 and would not recant the allegation. MD #18's written plan included to continue to monitor and evaluate. Review of further daily notes documented by MD #18 through discharge on 08/31/15 failed to identify any monitoring and/or further evaluation of Patient #18's allegation of rape. Interview with MD #18 on 10/18/16 at 11:30 AM identified that, although Patient #18's clinical status was discussed daily in team meeting, he/she was not involved in the investigation as the investigation was typically the responsibility of the nurse and Unit Manager.

A progress note dated 08/28/15 at 6:02 PM by RN #10 identified that Patient #18 allegedly reported to PO #1 that he/she had been raped. RN #10 and Unit Manager #9, subsequently interviewed the patient who denied the rape. The patient's responsible party was notified and refused to consent to a rape kit examination. Review of nursing notes documented from 08/28/15 through discharge on 08/31/15 failed to identify that any monitoring and/or further evaluation of the patient occurred, specific to the allegation of rape.

Review of a Safety Event Entry (categorized as an alleged sexual assault) reported on 08/28/15 at 2:55 PM by Unit Manager #9, identified that following notification of Patient #18's allegation of rape on 08/28/15 an investigation was in progress and the alleged staff member (MHW #1) was transferred off the unit. A document dated 09/24/15 by Unit Manager #9 identified that there was an investigation in progress by State Agency #1 and the local police. Unit Manager #9 documented that the patient was interviewed following denial to meet with the police and State Agency #1 worker. The patient denied the event, but was being treated for acute psychosis and rule-out substance induced. Unit Manager #9 documented that the patient's family member had identified that the patient was upset with staff for multiple interventions provided. Patient #18 was transferred to a long term behavioral health treatment center on 8/31/15 for continued intensive care and treatment.
Nurse Manager #9's follow-up documentation dated 09/24/15 identified that the staff handled the patient per policy and procedure. It was identified that the patient's allegation correlated with an incident where the patient's behaviors necessitated a physical hold and a medication injection.

Interview with MHW #1 (identified as the alleged perpetrator) on 10/05/16 at 11:30 AM identified that he/she had not been interviewed about an interaction with Patient #18.

Interview with Unit Manager #9 on 10/13/16 at 11:35 AM identified that staff from the Quality Department and the Unit Manager would coordinate the investigation and details would be discussed in the team meetings. The TC would update the care plan and the MD should write a note about the occurrence.

Review of the patient's written plan of care for Aggressive Behavior including history of making accusations against staff dated 7/28/15 and 07/29/15 failed to identify the allegation of abuse and/or corresponding staff interventions. Review of the Behavioral Health Master Treatment Plans dated 07/29/15, 07/30/15, 08/05/15, 08/11/15, 08/13/15, 08/20/15, and 08/24/15 failed to identify the allegation of abuse and/or corresponding interventions.

Interview with the Director of Care Management on 11/03/16 at 11:05 AM identified that the Social Worker is the gate keeper of the Master Treatment Plan. The registered nurse initiates the Interdisciplinary Plan of Care (IPOC) at the time of admission and all disciplines participate within 72 hours and the plan is formally updated every seven days.

The hospital policy for Interdisciplinary Treatment Planning identified, in part, that problems are identified based on interdisciplinary assessments, patient and family input, as well as written and/or verbal information provided by other providers/hospitals and/or ED records. Any significant change in a patient's medical, psychiatric or behavioral status that occurs prior to the scheduled review date, requires a supplemental treatment plan update. The supplemental update can be initiated by any member of the treatment team, but must be developed and signed by all disciplines.





29049

b. Review of the clinical record identified Patient #15 was admitted to the hospital on 9/2/15 for suicidal ideations and Opioid Dependence who presented for Opioid detoxification with a past history of sexual abuse. Facility documentation dated 9/5/15 identified Patient #15 reported that Patient #16 entered his/her room on 9/5/15 at 8:40 PM and touched him/her inappropriately. Patient #15 was transferred to the Emergency Department on 9/5/15 at 11:00 PM for a medical evaluation due to complaints of abdominal pain. Patient #15 was medically cleared and transferred back to the hospital on 9/7/15. Interview and review of the clinical record with Nurse Manager #1 on 10/4/16 at 11:45 AM indicated the facility failed to initiate a plan of care on 9/5/16 that included the allegation of sexually inappropriate behaviors with interventions that were individualized for Patient #15.

c. Review of the clinical record identified Patient #13 was admitted to the hospital on 4/21/16 after a suicidal attempt with diagnoses that included major depression, borderline personality disorder and an alleged recent sexual assault. Review of the facility documentation dated 4/23/16 identified Patient #13 and #14 were observed sitting in the hallway next to the room of Patient #14 talking with one another when observational checks were conducted at 5:35 PM. At 6:10 PM Patient #13 reported to the facility staff that Patient #14 pressured Patient #13 to perform a sexual act. Interview with the Manager of Security on 10/4/16 at 10:30 AM indicated video surveillance was conducted in the hallway of the inpatient unit and identified Patient #14 took the hand of Patient #13 and the two patient's entered Patient #14's room at 5:35 PM. Patient #13 exited from the room at 5:43 PM followed by Patient #14. Video surveillance was not conducted in the patient's room or bathrooms. Subsequent to the event Patient #14 was placed on constant observation. Patient #13 was sent to the hospital for a medical evaluation on 4/23/16 and on arrival back to the facility was admitted to an alternate unit. Interview and review of the clinical record with Nurse Manager #1 on 10/4/16 at 11:10 AM indicated the nursing plan of care should have been revised on 4/23/16 to include allegations of sexually inappropriate behaviors with interventions that were individualized for Patient #13.

d. Review of the clinical record identified Patient #25 was admitted to the hospital on a Physician's Emergency Certificate (PEC) on 5/19/16 for aggressive behaviors. On 5/20/16 at approximately 1:15 AM Patient #25 came out of his/her room questioning why his/her "pants were unzipped". Security and the local police department were notified and an investigation was conducted. The patient provided a description of the person whom he/she believed entered the room and according to the facility, the description of the person did not match another patient or staff member. The video camera of Patient's hallway where his/his room was located was reviewed at the time of the incident, interviews were conducted and the allegation was unsubstantiated by the facility. Interview and review of the clinical record with Nurse Manager #3 on 10/6/16 at 1:45 PM indicated the nursing plan of care should have been revised on 5/20/16 to include allegations of sexually abuse with interventions that were individualized for Patient #25.

The hospital policy entitled Documentation of Nursing Process in part directed data collection, analysis of the data and the formulation of patient problems. The next step consisted of defining goals for patient problems and then implementing orders and interventions to achieve the goals and resolve the problems. Based on initial and ongoing assessments of the patient and appropriate plan of care is developed in collaboration with clinical disciplines, patient and family. The plan of care would be established and an evaluation of the goals would be determined. When an outcome was not achieved, a variance exists and the plan of care may need to be changed or revised.