HospitalInspections.org

Based on interview and document review, it was determined the facility staff failed to inform the juvenile patient's representative (Parents) that the patient was assaulted by another patient.

The findings include:

A review of the Psychiatric Progress Note from 5/20/2022 at 1055 a.m. for Patient #1 contained the documentation "...Staff reported that [Patient #1] laughed at someone, who was self-harming [other patient] and that person got angry and had swing [sic] at [Patient #1], hit [Patient #1] on the face ..."

A review of the Social Services Note from 5/24/2022 at 11:30 a.m. for Patient #1 contained the documentation "...Pt [patient] reported being slapped and staff not doing anything. Pts [family] reported was not told and thought Pt was just dealing another PTs behaviors. Thx [therapist] sent an email to Adolescent unit manager [SM7] regarding incident occurring with another Pt slapping [patient]. PT reported not feeling safe at the hospital and preferring to transfer to [a psychiatric treatment facility]. PT reported [patient] was ok with plan for RTC but continued reporting concerns with being on the unit. Pt walked out of family meeting before it ended."

During an interview on 8/29/2022 at 11:43 a.m., SM1 stated if a safety event occurs involving an adolescent patient, the patient's family is notified that shift, as soon as possible.

During an interview on 8/30/2022 at 10:41 a.m., SM7 stated that parents of the adolescent patients are always notified if there is an incident with the patient, and it is documented in a patient note and in the event report. SM7 stated that if the parent does not answer, SM7 will leave a message. SM7 stated staff will try to contact another family member if there is more than one contact person listed on the patient's face sheet. SM7 stated that the staff contact the family as soon as possible after the incident.

On 8/30/2022, SM10 reviewed Patient #1's medical record and confirmed that there was no documentation of the event when Patient #1 was hit by another patient, and no documentation that Patient #1's parents were notified of the event.

A review of the facility's policy titled, Serious Safety Events (SSE), states in part:
...Patient Safety Event: An event, incident, or condition that could have resulted or did result in harm to a patient. A Patient Safety Event can be, but is not necessarily, the result of a defective system or process design, a system breakdown, equipment failure, or human error. Patient Safety events also include Adverse Events, No-Harm events, Close Calls, and Hazardous Conditions. (The Joint Commission, Sentinel Event Chapter. 2018)
...Ideally, the initial patient/patient's representative/family and/or support person disclosure should be conducted as soon as possible after the determination of the SSE occurrence. The patient and/or patient's representative/family and/or support person, should be notified in a place appropriate for exchange of confidential clinical information. Disclosure should include discussion of the unanticipated outcome of care, treatment and services that relate to the SSE when the patient and/or patient's representative/family and/or support person is not already aware of the occurrence. An adequate amount of time should be allocated for the disclosure, an apology and the patient and/or patient's representative/family and/or support person to ask questions and express concerns, if any should arise in the course of this discussion.
...After disclosure, an entry will be made in the medical record and authenticated by the practitioner who notified the patient and/or patient's representative/family and/or support person of the event. The names of other caregivers present for the discussion, including language interpreter, will be noted. Respectful disclosure occurs not only at the time of the event but as a component in ongoing support, resolution, and improvement processes...

The above concerns were discussed at the exit conference on 8/30/2022 at 11:20 a.m.