HospitalInspections.org

Based on a review of facility documentation, observation, and staff interviews, the facility failed to implement its own policy related to sexual acting out precautions, including staff awareness of patient precaution orders and appropriate patient room assignments, for 2 of 10 patient [Patients #1-2]. As a result, staff left unaware of physician-ordered precautions, and inappropriate room assignments made upon admission, may have contributed to a sexual encounter between two mental health patients with possible significant physical and mental health consequences for each [Patients #1-2].


Findings were:

Review of the facility's "Patient's Bill of Rights ...Basic Rights for All Patients" revealed the following:
" ...3. You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs, and are treated with respect and dignity..."


Facility policy #9351145 entitled "Sexual Acting Out and Sexual Victimization Prevention," last approved 03/2018, included the following:
" ...POLICY:
Austin Lakes Hospital shall implement a policy for patient/residents for protective measures the facility shall take for those who are vulnerable to sexual victimization by other patients who are on sexual precautions and receiving treatment in the facility. Patients shall not have sexual contact with one another. Patients are assessed for risk of sexual acting out behavior or of being sexually victimized.

PURPOSE:
Provision of a safe, therapeutic environment of care includes the prevention of patient to patient sexual incidents.

PROCEDURE: ...
B. Observation: ...
b. Sexual Acting Out precautions will be documented on the Patient Observation Sheet, the Twenty Four Hour Nursing Assessment, and the Staffing Board.
c. Program Staff will use the information from the Admission process when considering room placement/roommate assignment on the unit. This will include sexual aggression and sexual victimization risk issues and history, Physical size, Mental status, Cognitive abilities, sexual behaviors/verbalizations on the unit ..."


Patient #2 was admitted to Austin Lakes Hospital on 9/2/21 at 10:10 p.m. He was placed on sexual acting out precautions upon admission on 9/2/21 at 11:00 p.m. Physician orders for Patient #2 were as follows:
Admission Orders: " ...Precautions: Suicide (SP) ...Sexual Acting Out (SAO) ..."

A Psychiatric Evaluation on 9/3/21 at 3:10 p.m. included the following:
" ... Placed in ED (emergency detention) as lacking capacity for voluntary admit ... Psychiatric Diagnosis - Major Depressive d/o [disorder], severe w/ psychotic features ..."

The order for sexual acting out precautions for Patient #2 repeated on 9/6/21 at 8:21 p.m. and read as: "Sexual Acting Out Precautions."

These precautions were erratically noted by nursing staff on the 24-Hour Nursing Assessment and the Mental Health Tech Daily Notes. For example:

24-Hour Nursing Assessments:
- 9/3/21 on the 7-1900 (day shift), only suicide precautions were checked.
- 9/3/21 1900-700 (night shift), only suicide precautions were checked.
- 9/4/21 on the 7-1900 (day shift), only suicide precautions were checked.
- 9/4/21 1900 - 700 (night shift), no precautions checked at all.
- 9/5/21 on the 7-1900 (day shift), no SAO (sexual acting out) precautions were checked.
- 9/5/21 1900-7 (night shift) - no SAO precautions were checked.
- 9/6/21 on the 7-1900 (day shift), only assault precautions were checked.

Mental Health Tech Daily Notes (patient observation sheets) each covered a 24-hour time span and included:
- 9/4/21 - only suicide precautions were checked.
- 9/5/21 - only suicide precautions were checked.
- 9/6/21 - only suicide precautions were checked.


A review of the medical record of Patient #1 revealed she was admitted to Austin Lakes Hospital on 9/11/21. A Psychiatric Evaluation dictated on 9/11/21 at 12:03 p.m. included the following:
"This is a 37-year-old Caucasian female admitted her on a voluntary basis, brought by her husband ... Mental Status Exam: ... Thought process is poorly organized ... Denies to have any paranoia with me, but history indicated that she has some paranoia ... Her insight is intact, as she agreed to sign in voluntarily. Judgment appears to be fair ... Her memory appears to be intact, but formal testing was not done as the patient was not cooperative ...
DIAGNOSES:
Psychiatric Diagnosis: Psychosis, not otherwise specified ..."

A nursing note from the medical record of Patient #1 on 9/11/21 at 10:05 a.m. included the following:
"Pt very isolative, in room under covers most of shift. When awake, pt very soft spoken. Pt does not appear in imminent danger to self or others ... - At about 1700, tech reported to nurse that she found this pt & another male patient having oral sex and this pt was naked. I immediately tended to the pt and asked her what happened. Pt said that another female patient told her that she should have sex w/one of the male patients. Pt went into male room and no one was in there. She walked in the hallway to confirm with female which male she was supposed to have sex w/. During that time, male walked back in his room. Pt noticed this and went into his room and said, "Are we supposed to ...?" to which male pt shrugged and nodded. Pt states she wasn't sure so she walked out of the room. She describes feeling "okay" and "good" about it. So she went back in because she felt that was what she was "supposed to do." Pt and male then had a quick discussion about what they wanted to do. Pt then gave male oral sex. He ejaculated in her mouth, which was visualized and stated. They continued w/oral sex and she states he thrusted himself into her, which made her choke and feel like she was dying. He stopped and again, asked each other what they wanted to do. Male motioned sex, so he tried to insert himself into her. Patients were standing against wall. Male patient indicated to pt that he wanted anal sex and she helped insert himself into her anus. They had anal sex for moments before they stopped. Staff said they walked in during oral sex so it is unclear as to when the anal sex occurred. Nurse had pt go to the bathroom to assess for any obvious injury. Pt was not bleeding, but there was fecal matter in underwear and around bottom, substantiating pt's claims. Pt was tearful, apologetic, saying she felt 'he deserved it because he's a good man' but that she 'didn't want to ...' Pt denied pain & was immediately transferred to 3rd floor. Pt exhibited delusional thought processes as she though a man in the elevator was her husband ..."


A further review of the medical record of Patient #2 revealed he had at least one sexual encounter with another female patient prior to 9/11/21. A nursing progress note on 9/6/21, signed on 9/7/21 read as follows:
" ...[MD ] ordered a one-time dose of Zyprexa zydis 10 mg then female pt asked for a pencil and while female pt asked for a pencil and while the staff was looking for one [Patient #2] said that he has a pencil (per staff report) the pt followed [Patient #2] on the hallway and [Patient #2] stood by his door, pulled his pants down and show [sic] her his private part, both patients were followed by a tech, no touching happened per staff report. The female pt got very upset called her family and made other calls reporting the incident, pt became upset and threatened to kill the patient, pt was very angry and almost hit the female pt, staffs intervened to stop him no hold done only verbal de-escalation ..."


During a tour of the patient unit on the morning of 9/21/21 with Staff #2, the Director of Clinical Services, the unit was noted to be an L-shaped area with 2 hallways forming a right angle. A mental health tech was stationed at the common corner of the two hallways. Staff #2 indicated the doorways of the 2 patient rooms she believed Patient #1 and Patient #2 had been housed. The rooms were toward the end of one of the hallways, side-by-side and in a slightly-recessed alcove. Approximately 4 feet separated the doorways.

In a telephone interview with Patient #1 on 9/23/21 at approximately 10:30 a.m., she was asked if she could remember where the room had been in which the sexual encounter had occurred. She said, "It was right next door to mine. I know it was ... this one was right next door. I thought it was my room, so I was confused when he [Patient #2] told me I was walking toward the wrong bed. I was just so confused. I thought I was in my room ..."

Based on a review of facility documentation and staff interviews, the facility failed to ensure an individualized treatment plans as patient specific interventions to prevent sexual aggression and victimization for 1 of 2 patients on sexual acting out precautions [Patient #2] were not included on his treatment plan.


Findings were:

Review of the facility's "Patient's Bill of Rights ...Basic Rights for All Patients" revealed the following:
"...26. You have the right to a treatment plan for your stay in the hospital that is just for you. You have the right to take part in developing that plan, as well as the treatment plan for your care after you leave the hospital ..."

Facility policy #9351145 entitled "Sexual Acting Out and Sexual Victimization Prevention," last approved 03/2018, included the following:

" ...POLICY:
Austin Lakes Hospital shall implement a policy for patient/residents for protective measures the facility shall take for those who are vulnerable to sexual victimization by other patients who are on sexual precautions and receiving treatment in the facility. Patients shall not have sexual contact with one another. Patients are assessed for risk of sexual acting out behavior or of being sexually victimized.

PURPOSE:
Provision of a safe, therapeutic environment of care includes the prevention of patient to patient sexual incidents.

PROCEDURE: ...
B. Observation: ...
3. Treatment plans reflect patient specific interventions to prevent sexual aggression/sexual victimization ..."

Facility policy #9350950 entitled "Active & Individualized Treatment," last approved 09/2020, included the following:
" ...POLICY ...
It is the policy of Austin Lakes Hospital to provide care and a model of active treatment for all patients hospitalized at the facility.

Active treatment services provided must be: ...
Provided under and individualized treatment plan ...

PROCEDURE ...
2. Active Treatment interventions identified in the Master Treatment Plan and Treatment Plan Updates are delivered to patients and documented in each patient's record in such a manner as to assure all active therapeutic efforts are included ...
9. The treatment team will review and revise the treatment plan as often as needed, but at a minimum every seven (7) days ..."


Patient #2 was admitted to Austin Lakes Hospital on 9/2/21 at 10:10 p.m. He was placed on sexual acting out precautions upon admission on 9/2/21 at 11:00 p.m. Physician orders for Patient #2 were as follows:
Admission Orders: " ...Precautions: Suicide (SP) ...Sexual Acting Out (SAO) ..."

A Psychiatric Evaluation on 9/3/21 at 3:10 p.m. included the following:
" ... Placed in ED (emergency detention) as lacking capacity for voluntary admit ... Psychiatric Diagnosis - Major Depressive d/o [disorder], severe w/ psychotic features ..."

The order for sexual acting out precautions for Patient #2 repeated on 9/6/21 at 8:21 p.m. and read as: "Sexual Acting Out Precautions."

A review of the medical record of Patient #1 revealed she was admitted to Austin Lakes Hospital on 9/11/21. A Psychiatric Evaluation dictated on 9/11/21 at 12:03 p.m. included the following:
"This is a 37-year-old Caucasian female admitted her on a voluntary basis, brought by her husband ... Mental Status Exam: ... Thought process is poorly organized ... Denies to have any paranoia with me, but history indicated that she has some paranoia ... Her insight is intact, as she agreed to sign in voluntarily. Judgment appears to be fair ... Her memory appears to be intact, but formal testing was not done as the patient was not cooperative ...
DIAGNOSES:
Psychiatric Diagnosis: Psychosis, not otherwise specified ..."

A nursing note from the medical record of Patient #1 on 9/11/21 at 10:05 a.m. included the following:
"Pt very isolative, in room under covers most of shift. When awake, pt very soft spoken. Pt does not appear in imminent danger to self or others ... - At about 1700, tech reported to nurse that she found this pt & another male patient having oral sex and this pt was naked. I immediately tended to the pt and asked her what happened. Pt said that another female patient told her that she should have sex w/one of the male patients. Pt went into male room and no one was in there. She walked in the hallway to confirm with female which male she was supposed to have sex w/. During that time, male walked back in his room. Pt noticed this and went into his room and said, "Are we supposed to ...?" to which male pt shrugged and nodded. Pt states she wasn't sure so she walked out of the room. She describes feeling "okay" and "good" about it. So she went back in because she felt that was what she was "supposed to do." Pt and male then had a quick discussion about what they wanted to do. Pt then gave male oral sex. He ejaculated in her mouth, which was visualized and stated. They continued w/oral sex and she states he thrusted himself into her, which made her choke and feel like she was dying. He stopped and again, asked each other what they wanted to do. Male motioned sex, so he tried to insert himself into her. Patients were standing against wall. Male patient indicated to pt that he wanted anal sex and she helped insert himself into her anus. They had anal sex for moments before they stopped. Staff said they walked in during oral sex so it is unclear as to when the anal sex occurred. Nurse had pt go to the bathroom to assess for any obvious injury. Pt was not bleeding, but there was fecal matter in underwear and around bottom, substantiating pt's claims. Pt was tearful, apologetic, saying she felt 'he deserved it because he's a good man' but that she 'didn't want to ...' Pt denied pain & was immediately transferred to 3rd floor. Pt exhibited delusional thought processes as she though a man in the elevator was her husband ..."

A further review of the medical record of Patient #2 revealed he had at least one sexual encounter with another female patient prior to 9/11/21. A nursing progress note on 9/6/21, signed on 9/7/21 read as follows:
" ...[MD ] ordered a one-time dose of Zyprexa zydis 10 mg then female pt asked for a pencil and while female pt asked for a pencil and while the staff was looking for one pt [Patient #2] said that he has a pencil (per staff report) the pt followed [Patient #2] on the hallway and [Patient #2] stood by his door, pulled his pants down and show [sic] her his private part, both patients were followed by a tech, no touching happened per staff report. The female pt got very upset called her family and made other calls reporting the incident, pt became upset and threatened to kill the patient, pt was very angry and almost hit the female pt, staffs intervened to stop him no hold done only verbal de-escalation ..."

A review of the medical record of Patient #2 revealed a Master Treatment Plan of 9/5/21 with only the following problems:
Psychiatric Problems:
"Mood Instability w/SI (suicidal ideation) and response to internal stimuli ..."
And Psychosocial and Environmental Problems of:
"No housing
No social support ..."

An update to the treatment plan on 9/10/21 included the following:
" ...Changes to precautions/observation level: ... Yes ... 9/6/21 sexual acting out precautions 9/11/21 assault precautions." Patient #2 had been ordered on sexual acting out precautions upon admission.

The treatment plan included no problem, and thus no interventions related to preventing sexual aggression and/or victimization.