HospitalInspections.org

Based on record review and interviews, the facility failed to protect one (1) patient (#1) of the ten (10) sampled patients.



Cross refer for details: 482.13(c)(2) Patient Rights

Based on record review and interviews, the facility failed to provide protection for one (1) patient (#1) of the ten (10) sampled patients.

Findings include:

Review of the medical record for patient #1 revealed an admission date of 2/14/14 with a diagnosis of Schizophrenia exhibiting increased agitation, threatening behaviors and homicidal ideation. The patient was responding to internal stimuli and a history of Mental Retardation and Sleep Apnea.

Review of the physician admission orders dated 2/14/14 revealed patient #1 was to be assessed/monitored every fifteen (15) minutes, due to the Potential for Suicidal/Self Harm.

Review of a form titled, "The Risk Management Worksheet/Incident Report" dated 3/1/14 at 12:50 a.m. revealed a Mental Health Assistant (MHA) #6 found patient #1 and patient #4 in the quiet room together. MHT #6 reported to Registered Nurse (RN) #5.

RN #5, assessed both patients. Patient #4 informed RN #5 they had oral sex. RN #5 separated patients #1 and #4, and instructed them not to go around each other. Patient #1 informed RN #5 that patient #4 threatened to beat him/she if he/she did not pull his/her pants down.

Review of medical record for patient #1 on the 24 hour Observation Sheets revealed patient #1 observation status was changed from every 15 minutes to Constant (within eyesight/or within fifteen (15) feet) observation status on 3/4/14 at 7:15 a.m. The patient was checked as a Potential for Sexual Aggression added on 3/4/14 in addition to Potential for Suicidal/Self Harm already listed on 2/14/14.

Review of a Video, dated 3/1/14 from 12:30 a.m. to 1:00 a.m. revealed on the Geriatric Unit hallway, however the video did not include the quiet room area. Per the video observation patient #1 and patient #4 were passing each other in the hallway then sitting and talking to each other fully dressed wearing their personal clothing. Patient #1 got up from sitting in the hallway and walked into another patient's room for a few minutes then exited the other patient's room and handed something to patient #4. A few minutes later patient #1 went into the quiet room, 20-30 seconds later patient #4 went into the quiet room.

Continued review of the video revealed MHA #6 checking patients' rooms, looking in the quiet room for a minute when passing the room, then checked a few other rooms and a couple minutes later returning to the quiet room with the RN #5.

Continuous review of the Video revealed RN #5 standing outside the quiet room. looking inside the room talking. A few minutes later patient #1 and patient #4 came out of the quiet room into the hallway. Patient #4 walked towards the nursing station and patient #1 went in the opposite direction into a room.

Interview on 6/17/14 at 3:15 p.m. with RN #5 revealed MHT #6 reported that patient #4 stated having oral sex in the quiet room with patient #1. Patient #1 reported that patient #4 threatened physical harm if patient #1 did not remove his/her pants. RN #5 stated both patients were assessed with no apparent injury. RN #5 confirmed failure to increase the observation status for patient #1 and #4 due to sexual behavior.

Review of the facility policy entitled, Patient Sexual Familiarity Prevention Guidelines", revised 6/14 indicated, response to alleged sexual familiarity occurrences staff would take all reports seriously and patients who alleged sexual assault would be placed on 1:1 observation., and that 1:1 observation would be discontinued by a physician.

Thus the facility failed to protect patient #1 even after observation of a sexual act, and the patient expressing fear, the MHT failed to immediately intervene, then the facility failed to increase observation status of patient #1, until three (3) days after the occurance.

Based on record review, the nursing staff failed after an alleged unwanted sexual act for patient #1, failed to provide observation to protect the patient from the alleged offender.


Cross refer for details:
482.13 Patient rights: Care in a safe setting
482.23 (b ) (4 ) Nursing Care Plan

Based on record review and interview, the facility staff failed to develop and implement a safety plan for a patient who had alleged an unwanted sexual act, and fear from the alleged offender for one (1) patient (#1) of the ten (10) sampled patients.

cross reference for details: 482.13(c)(2)

Findings include:

Review of the medical record for patient #1 revealed an admission date of 2/14/14 with a diagnosis of Schizophrenia exhibiting increased agitation, threatening behaviors and homicidal ideation. The patient was responding to internal stimuli and a history of Mental Retardation and Sleep Apnea.

Review of the admission physician orders revealed patient #1, was to be observed every fifteen (15) minutes. Review of the treatment plan revealed patient #1 at risk for Suicidal/Self Harm.

Review of a form titled, "The Risk Management Worksheet/Incident Report" dated 3/1/14 at 12:50 a.m. revealed a Mental Health Assistant (MHA) #6 found patient #1 and patient #4 in the quiet room together. MHT #6 reported to Registered Nurse (RN) #5.

RN #5, assessed both patients. Patient #4 informed RN #5 they had oral sex. RN #5 separated patients #1 and #4, and instructed them not to go around each other. Patient #1 informed RN #5 that patient #4 threatened to beat him/she if he/she did not pull his/her pants down.

Review of the 24 hour Observation Sheets revealed patient #1 observation status was changed from every 15 minutes to Constant (within eyesight/or within fifteen (15) feet) observation status on 3/4/14 at 7:15 a.m. three (3) days after the allegation of a sexual encounter.

According to the Treatment Plan Problem Sheet initiated on 2/14/14 thru patient #1's discharge on 3/7/14 included self- harming thoughts and behavior with no evidence of for sexual aggression.

Interview on 6/17/14 at 3:15 p.m. with RN #5 confirmed that above findings.

Review of the facility policy entitled, Patient Sexual Familiarity Prevention Guidelines", revised 6/14 indicated, response to alleged sexual familiarity occurrences staff would take all reports seriously and patients who alleged sexual assault would be placed on 1:1 observation., and that 1:1 observation would be discontinued by a physician.