HospitalInspections.org

Based on documentation review, observation and interview, facility nursing staff failed to maintain patient personal privacy and dignity during and after toileting, failed to keep patient free from sexual abuse, failed to increase sexually acting out precautions, and failed to report patient abuse to a government agency per policy. See tags A0143 and A0145.

The cumulative effects of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on documentation review, observation and interview, facility nursing staff failed to maintain the personal privacy and dignity during and after toileting for 1 of 10 medical records reviewed. (P1)

Findings Include:

1. Facility policy titled "Patient Rights and Responsibilities", PolicyStat ID 13517670, last approved 04/2023, indicated under PROCEDURE: You have the right to: 1. Receive considerate ethical behavior and respectful treatments, services, and business practices. You have the right to made comfortable and be treated with dignity. You have the right to be respected for your personal beliefs and values including cultural, psychosocial, and spiritual values and beliefs. 3. Have your privacy, confidentiality and security needs respected by the organization. 14. Have personal privacy respected. Case discussion, consultation, examination and treatment are confidential and should be conducted discreetly. You have the right to be told the reason for the presence of any individual and adequate information about the person(s) responsible for the delivery of your care, treatment and services.

2. MR review for P1 indicated the following:
Psychiatric Progress Note documentation dated 9/3/24 indicated P2 reportedly went into P1's room and inserted his/her finger into P1's rectum. P1 claimed the incident with P2 took place in his/her bathroom while he/she was on the toilet.

3. MR review for P2 indicated the following :
Daily Nursing Narrative documentation dated 9/2/24 at approximately 7:00 pm indicated nursing staff reported P2 put his/her finger in P1's rectum. P2 stated he put his/her finger in P1's rectum because "he (P2) was a dog". MR for P2 lacked documentation in increased observation precautions and/or implementation of sexually acting out precautions. Social Service Documentation Progress noted dated 9/9/24 at 10:00 am indicated the investigation between P1 and P2 had found that both patients state the allegations happened.

4. Video footage reviewed with A2 (Director of Quality and Risk Management) on 9/10/24 at approximately 11:30 pm for 9/2/24 indicated as follows:
At 18:52:51 hrs. (hours) P2 can be seen getting out of his/her wheelchair and ambulating into P1's room.
At 18:55:36 hrs. P2 was seen being brought out of P1's room by BHA1 (Behavior Health Associate) in wheelchair placing P2 in the hallway directly facing P1's room.
At 18:56:53 hrs. P2 can be seen leaving his/her wheelchair again and entering P1's room.
At approximately 18:57 hrs. BHA2 (Behavior Health Associate) can be seen entering P1's room, leaves P1 to retrieve P2's wheelchair and then can be seen wheeling P2 out of P1's room into the hallway directly in front of P1's door.
At 18:58:52 hrs. P2 ambulates from his/her wheelchair into P1's room.
At approximately 18:59 hrs. nursing staff can be seen entering P1's room.
At 19:00 hrs. P2 is brought out of P1's room and placed in his/her wheelchair directly in front P1's door.
At 19:04 hrs. P2 ambulates from the wheelchair into P1's room.
At 19:05 hrs. P2 removed from P1's room to wheelchair in hallway directly in front of P1's room.
At 19:07:28 hrs. P2 can be seen looking around before exiting his/her wheelchair and entering P1's room at 19:07:55 hrs.. Staff members to P1's room at 19:08:41 hrs. At 19:11 hrs. P2 was brought out into the hallway to wheelchair directly across P1's door.
At 19:15:29 hrs. P2 ambulated into P1's room. At 19:18 hrs. staff can be seen entering/leaving P1's room. At 19:19 hrs. P2 can bee seen leaving P1's room and ambulating the length of both hallways to dispose of a white cloth onto a pile of what appeared to be dirty linen on the floor then ambulating back into P1's room.
At approximately 19:20 hrs. BHA2 and P1 can be seen leaving P1's room.

5. Incident Report notes dated 9/3/2024 at approximately 3:15 pm, indicated A2's interview with BHA1: BHA1 said P2 liked helping to the point of getting out of his/her wheelchair. P1 was calling for help because he was cleaning up his own mess and P1 was denying he/she could clean up the mess. P1 continued to ask for help and P2 wanted to help. BHA1 then heard P1 yell "GET OUT" to P2. P1 then told BHA1 that P2 put his/finger up P1's rectum. BHA1 noted that P1 was seated in his/her walker with his/her pants on. BHA1 stated that they removed P2 from P1's room redirecting P2 but efforts were unsuccessful.

Based on documentation review and interview, the facility failed to keep patients free from sexual abuse for 1 of 10 medical records (MR) reviewed (P1); and failed to increase sexually acting out precautions for 1 of ten medical records reviewed (P2); and failed to report patient abuse to a government agency per policy for 1 of 10 medical records reviewed. (P2)

Findings include:

1. Facility policy titled, "Patient Rights and Responsibilities", PolicyStat ID 13517670, last approved 04/2023, indicated under PROCEDURE: You have the right to: 18. Receive care in a safe setting, free from verbal or physical abuse or harassment. You have the right to access protective and advocacy services including notifying agencies of neglect, abuse, or exploitation.

2. Facility policy titled, "Sexually Acting Out (SAO) Precautions", PolicyStat ID 12195131, last approved 08/2022, indicated under RESPONSIBILITIES: A. Responsibilities of ALL Staff: 1. To understand and follow hospital policy. 3. Attempt to protect patients who may be particularly vulnerable to being sexually abused by other patients. 5. To respond appropriately to questions or concerns that patients may have regarding sexual issues or behaviors. 6. To redirect or restrict patients who may be demonstrating sexual behaviors towards other patients.

3. Facility policy titled, "Critical Incident Reporting to Department of Mental Health & Addiction (DMHA)", no policy number, last revised 05/2024, indicated under PROCEDURE: The procedure for incident reporting will be followed, as defined in Policy lll-B.11 "Incident Reports." The Risk Manager or designee will determine which incidents require notification to the Department of Mental Health and Addiction (DMHA) per the guidance below; The facility shall also submit a written report, to the division within ten (10) working days of the occurrence of any of the following: Any patient abuse occurring within the facility.

4. MR for P1 indicated in Daily Nursing Narrative documentation dated 9/2/24 at approximately 7:10 pm, indicated P1 stated P2 put his/her finger in P1's rectum.

5. MR review for P2 indicated Psychiatric Progress Note dated 8/20/24 indicated while on every 15-minute patient observation checks, P2 expressed sexual interest in another same sex peer. The peer was against the sexual advances and the two patients were kept separated. Psychiatric Progress Note dated 8/30/24 indicated P2 was found naked in another patient's room while the patient was in the shower. Mental Status Examination indicated P2 was noted to be sexually acting out. Daily Nursing Narrative dated 9/2/24 at approximately 7:00 pm indicated nursing staff reported P2 put his/her finger in P1's rectum. P2 stated he put his/her finger in P1's rectum because "he (P2) was a dog". The MR for P2 lacked documented of increased SAO precautions from behaviors displayed on 8/20/24, 8/30/24, and 9/2/24 by P2.

6. In interview on 9/10/24 at approximately 1:00 pm with LS 1 (Licensed Staff) confirmed P2 should have been placed on SAO precautions after his/her actions on 8/30/24 but was not. It would have been prudent to place P2 on SAO precautions, P2 should have been placed on a bed block but was not, bed blocks are discouraged by corporate leadership and 1:1 (one on one) level of observations orders are to be avoided if possible and discouraged by H1 corporate leadership.

7. In an interview on 9/10/24 at approximately 4:10 pm with A2 (Director of Quality & Risk Management) confirmed the incident that took place between P1 an P2 was not reported to G1(Government Agency) because the internal investigation completed by facility was unsubstantiated after speaking with P1, P2, reviewing video footage and conducting staff interviews.

Based on document review and interview, facility nursing staff failed to complete incident reports related to sexually acting out behaviors for 1 of 10 medical records reviewed. (P2)

Findings Include:

1. The facility policy titled, Incident Reports, PolicyStat ID 13033981, last revised 1/2023, indicated under PURPOSE: It is the policy of the hospital to support a culture of shared accountability for the identification, reporting and management of patient events that may impact the quality of care provided. An incident is defined as: any event which is not consistent with the routine operation of the hospital and that adversely affects or threatens to affect the well-being of the patients, employees, medical staff, visitors, consultants, or property of, regardless of whether and actual injury is involved or not. Any hospital staff member who witnesses, discovers or has direct involvement in and/or knowledge of an event must complete an incident report, or give a detailed report to the person completing the incident report.

2. MR review for P2 indicated Psychiatric Progress Note dated 8/20/24 indicated P2 expressed sexual interest in another same sex peer. The peer was against the sexual advances and the two patients were kept separated. No change to P2's level of observation was made after this incident. Psychiatric Progress Note dated 8/30/24 indicated P2 was found naked in another patient's room while the patient was in the shower. The MR for P2 lacked documented incident reports filed for behaviors displayed by P2 on 8/20/24 and 8/30/24.

3. In an interview on 9/10/24 at approximately 4:10 pm with A2 (Director of Quality & Risk Management) confirmed incident reports related to P2 sexually acting out on 8/20/24 and 8/30/24 were not filed and should have been.