HospitalInspections.org

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Based on medical record review, and interview, it was determined the facility failed to provide care for its patients in a safe setting. Specifically, the facility failed to maintain close monitoring of patients on the Behavioral Health Unit (BHU). This finding was noted in two (2) of 11 medical records reviewed. (Patient #s 1 and 2).

These failures may result in harm to patients.

Findings include:

(1) Patient #2 is a 21- year-old male who presented to the ED on 9/21/19 at 1:09 AM with a complaint of hallucinations, disorganized thoughts, and hypersexual behavior. The Emergency Department (ED) nurse reported at 1:09 AM that Patient #2 walked around the ED unit with his pants down, exposed his penis and requested pictures of the female staff's breasts. The ED nurse noted the patient was placed on close observation. The psychiatrist noted on 9/21/21 at 12:32 PM, that Patient #2 was admitted for safety and stabilization of his symptoms.

The Behavioral Health Unit (BHU) nurse noted on 9/23/19 at 7:39 PM that Patient #2 stated he wanted to have sex with one of the Patient Care Technicians (PCT's). On 9/24/19 at 11:36 PM a nurse documented that Patient #2 was reminded of maintaining boundaries and making inappropriate comments towards the female staff. A nurse noted on 9/28/21 at 9:23 PM that Patient # 2 was observed interacting inappropriately with female patients and entering their personal space.

On 9/29/21, a nurse noted that Patient #2 was brushing against female peers and behaving inappropriately. A nurse charted that the patient was reminded to maintain boundaries.
A nurse noted on 9/30/21 at 7:20 AM, that the patient was found in Patient #1's room by a staff while making rounds. Patient #1 reported that Patient #2 told her to "touch it". The medical record indicates "no injuries or physical contact was made between the two patients."

On 9/30/21 at 3:46 PM, a nurse noted that Patient #1 reported that a male peer (Patient #2) walked into her room and solicited for sex. The nurse noted that the patient reported she would feel safe if Patient #2 was not allowed to approach her again.

A Social Worker noted that Patient #1 reported the following: Patient #2 entered her room at approximately 10:30 PM while her roommate was absent from the room. Patient #2 exposed his penis and asked her to touch it while making sexual comments. A Patient Care Technician (PCT) opened her door while making rounds and she did not see Patient #2 who was hiding behind the door of her room. She was afraid to tell the PCT that Patient #2 was in her room, due to the fear that he might retaliate. Once the PCT closed the door, Patient #2 resumed sexual solicitation and touched her clothed thigh. Patient #2 ran out of her room once her roommate entered the room. She felt some anxiety and fear that Patient #1 would return to her room.

There was no documented evidence that Patient #2 who had disorganized thoughts and a frequently documented hypersexual behavior was closely monitored. Even though Behavioral Health Unit hallway was continuously monitored, staff was not aware that Patient #2 had entered a female patient's room.

These findings were shared with Staff A, Senior Director Quality Behavioral Health on 5/26/21 at 3:00 PM.

Based on medical record review, document review and interview, in two (2) of 11 medical records reviewed, it was determined the facility failed to investigate and analyze incidents to improve patient safety. This was evident in medical records #1 and 3.

Findings include:

Review of the facility's "2020 Performance and Improvement Safety Plan" which was last revised 2/2021 revealed, the "Quality and Patient Safety Department shall assist departments with activities to improve safety, the quality of care delivered and to improve organizational performance."

Review of medical record for Patient #4 revealed the patient assaulted Patient #3 on 5/7/21. Patient #3 sustained a fractured nose, a deviated septum and he bled profusely from these injuries.

During an interview conducted on 5/26/21 at 12:30 PM, the Nurse Manager for the Behavioral Health Unit (BHU) stated Patients #3 and #4 had a dispute earlier during their hospitalization which was settled prior to the day of the assault. Although the Security Department completed its investigation of the incident, the clinical staff had not initiated an investigation.

There was no documented evidence of an investigation of the incident and corrective actions to maintain safety of all patients.

The clinical staff reported during an interview on 5/26/21 at 12:30 PM that they deferred their investigation until after the police has completed their investigation.

Review of medical record for Patient #1, a female patient revealed that on 9/29/19, while in the Behavioral Health Unit, she reported that Patient #2, a male patient made sexual advances to her in her room. A Patient Care Technician (PCT) opened her door while making rounds and she did not see Patient #2 who was hiding behind the door of her room. Patient #1 stated she was afraid to tell the PCT that Patient #2 was in her room, due to the fear that he might retaliate. Once the PCT closed the door, Patient #2 resumed sexual solicitation and touched her clothed thigh. Patient #2 ran out of her room when her roommate entered the room.

There was no documented evidence that the clinical staff initiated or conducted investigations of these incidents or identified any measures to prevent or minimize similar occurrences.

These findings were acknowledged during an interview conducted on 5/26/21 at 2:45 PM with Staff B, the Nurse Manager for the BHU.