HospitalInspections.org

Based on record review and interview, the facility failed to develop and provide a comprehensive treatment plan when it did not include Patient #1's risk of being sexually victimized following a reported recent sexual assault prior to admission and during the admission, in the treatment plan, placing the patient at risk for being sexually victimized, physically and psychologically injured, including being raped.

Findings include:

Review of the facility provided policy Multidisciplinary Treatment Planning Process (revised 12/9/20) reflected, "Each patient will have an individual written treatment plan which best meets his/her biopsychosocial needs. This plan is developed by a treatment team composed of all major disciplines (or designee in his/her absence) under the direction of the psychiatrist. Each discipline plays an active role in the treatment planning process and is responsible for carrying out the treatment action plans. Included in each discipline role is an assessment of the patient and prescribed interventions to best meet the needs of the patient."

Review of Patient #1's medical records reflected a 23-year-old-female, admitted on 9/18/22, for psychosis. The patient's medical records reflect the facility was aware the patient had made statements of a recent sexual assault. Patient #1 had made sexual comments during her admission intake, asking a male nurse about sexual intercourse.

During an interview, on the morning of 11/29/22, in the administrative conference room, Staff #1, Director of Nursing (DON) stated, "Patient #1 wanted to press charges; we called the police, they arrived and did an investigation. Patient #2 was not arrested; he was moved to another unit and placed on a one-to-one observation ..." When asked about patient #1's admission intake, indicating a sexual assault 6 days prior, and if the facility assessed her for a risk for being sexually victimized, Staff #1, DON stated, "We have a precaution levels assessment; the assessment is for the aggressor."

Review of the facility provided blank treatment plan form (undated) for Sexual Acting Out or Risk of Sexual Victimization reflected for the writer to indicate if the patient had a history of sexual victimization/trauma.

During an interview, on the morning of 11/29/22, in the administrative conference room, Staff #5 Behavioral Health Manager stated, "My team is definitely involved in assessing patients at risk." When asked if Patient #1 had been assessed for risk of sexual victimization, Staff #5 stated, "It should have been included in the treatment plan." Staff #5 confirmed the assessment was not completed.

During an interview, on the afternoon of 11/29/22, in the administrative conference room, when asked to review the hall video, during the time of the incident Staff #1, DON stated, "We no longer have the video, it was over 30 days ago. I had reviewed the camera, they can be seen walking down the hall together, they are in the room for 10 minutes. They were not holding hands, when they passed a staff member in the hall. Patient #1 did not speak to the staff member and the staff is not around when they enter her room."