HospitalInspections.org

Based on review of security reports, staff interviews and policy and procedures it was determined that the facility failed to ensure that care was provided in a safe setting for one (P#1) of five sampled patients when P#2 repeatedly entered P#1's room without permission. During one such incident, P#2 inappropriately touched P#1 on 4/17/23.
Findings include:

Review of medical record revealed P#1 was a 79 -year-old female with past medical history of Lupus (a disease that occurs when your immune system attacks your own tissues and organs) , Diabetes (high blood sugar levels), deep vein thrombosis (a blood clot forms in a deep vein) , Lung Disease, and Gastrointestinal Reflux Disease (GERD- a condition where stomach acid repeatedly flows back into the esophagus causing irritation and discomfort) who presented to the Emergency Department (ED) on 3/31/23 at 7:00 p.m. for evaluation of gradual worsening moderate weakness that started multiple months ago. The patient further reported appetite decrease, fatigue, weight loss, cough, shortness of breath, and inability to walk due to weakness.

On 4/18/23 lung medicine saw P#1 and noted that the treating team provided psychiatry evaluation today 4/18/23 to P#1 following yesterday's assault incident; Doctor's progress notes stated revealed P#1 seemed to be coping well and is eager to go home with family.

On 4/18/23 at 12:38 p.m. P#1 was discharged home with palliative care with instructions for follow-up with outpatient Psychiatric, Pulmonology, and Nephrology services.

Review of a facility report dated 4/16/23 revealed that a male patient (P #2), was observed wandering from his assigned room to other patient's rooms. Facility security was called for assistance. Security staff informed P#2 that his unacceptable behavior would not be tolerated.

A review of an incident report revealed that on 4/17/23 at approximately 11:30 a.m. P#2 entered P#1's room, exposed himself and attempted to grab P#1. Security and assigned RN intervened.

Review of facility document titled "Safety/Security Event" dated 4/17/2023 revealed P#2 repeatedly gained access to P#1's room. P#2 was observed self-pleasuring, reached under P#1 gown, and grabbed P#1 in the genital area.
During an interview on 4/22/24 at 11:15 a.m. with the Director of Public Safety (DPS) AA in a conference room, DPS AA stated that he has been employed with the facility for 12 years. DPS AA said that when security is called to a unit for patient disturbances, security would speak with the patient and remind the patient of facility policy regarding patient safety and responsibility. DPS AA stated that it is not security's responsibility to sit with patients who require continuous observation. If a patient requires continuous observation, patient sitters should be requested by a charge nurse through the carelink department. DPS AA said that for every encounter security is called to, a report is written up. When the City Police Department was called, facility security added the officer's name, badge number, and case number to the facility security report.

During an interview on 4/22/24 at 2:00 p.m. with Risk Manager (RM) BB in a conference room, RM BB stated that she was notified of the sexual assault event involving P#1 on 4/17/23 while the events were unfolding in real-time. RM BB along with her team responded immediately to the incident. She said when security arrived on the unit, they did not go straight to P#1's room, they followed the nurses back to the nurse's station to obtain the patient's face sheets and that was when P#2 had the opportunity to sexually assault P#1 for a second time. RM BB said that her first order of business was to ensure that P#1 was okay. She added that P#1 wanted to press charges against P#2 and the facility called the City Police Department to assist in the investigation. RM BB added that the facility put a hold on P#1's financial account and offered to move P#1 to another room. She said that P#1 did not want to move rooms and felt comfortable staying because P#2 was being arrested. RM BB added that risk management decided not to conduct a root cause analysis (RCA) because there had not been any harm to P#1. RM BB added that there had not been penetration or skin-to-skin contact and that P#2 had grabbed P#1's crotch through her gown and sheet therefore the facility did not feel there had not been any harm to P#1. RM BB further stated that P#1 made a joke about the incident which further solidified to RM BB that P#1 was okay and not harmed. She added that since the incident occurred the facility had begun conducting threat assessments immediately following any reported risk of violence. Prior to the event, threat assessments would be conducted within several hours or days after a reported risk of violence was reported. RM BB said that the facility has educated staff during staff huddles on the importance of identifying and reporting any incident of violence promptly.

An interview with Lead Investigator for Campus CC took place on 4/22/24 at 2:10 p.m. in the conference room. Investigator CC said he remember the incident in question. Investigator CC said he received a call from dispatch, and it was a floor RN that placed the call. He heard the call and went to the floor. The nurse reported to him that P #2 was going to P #1's room and was sexually aggressive and exposing himself. Investigator CC said he secured P #2 and called the Police (APD). Investigator CC said security remained on the unit until the police arrived and took the patient into police custody. Lead Investigator CC said prior to the incident involving P #1, there were two incidents/complaints with P #2 and security had been to the floor to talk to and redirect P #2. Lead Investigator CC explained that in the two incidents security explained the expectations as far as patient's behavior was concerned. Lead Investigator CC said P #2 was never seen as a threat by staff, he needed more to be redirected that anything else. Lead Investigator CC said when it came to patient and staff safety, they had zero tolerance and they never hesitated to call the police when a patient's behavior threatened safety.

During an interview on 4/22/24 at 2:55 p.m. with Clinical Manager (CM) JJ in a conference room, CM JJ stated that she has been employed with the facility for seven years. She said that she was not made aware of the prior incidents involving security being called to P#2's room on 4/14/23 and 4/16/23. She was made aware only of the event that occurred on 4/17/24 while it was happening in real time. CM JJ said that she notified risk management of the incident immediately. CM JJ said that sexual assault or battery is a crime, and she expects her staff to report it immediately. She further stated that it is especially important to report any type of abuse to staff because if it can happen to staff, it can happen to patients.

During an interview with Charge Nurse DD on 4/22/24 at 3:15 p.m. in the conference room, Charge Nurse DD said that P #2 (male patient) was confused and was not in his full mental state. Charge Nurse DD said P #1 was confined to her room because of her illness. Charge Nurse DD said P #2 was so confused that he was constantly getting out of his bed and was found frequently in the hallway. Charge Nurse DD said on one occasion, P #2 crossed over to a female patient's (P #1) room and exposed himself to the patient (P #1). CN DD said staff called security immediately and reported the incident to campus security. CN DD said security arrived within minutes and took control of the environment until police arrived. CN DD said P #1 never realized what happened because of his dementia. Charge Nurse DD said the nursing staff never considered P #2 a high risk. CN DD said staff was more concerned for P #2's safety because he would not stay in his room, and he was very mentally confused but never displayed sign of violence. CN DD said the main challenge was how to keep that P #2 in his room. CN DD said after the incident they educated staff about detecting hidden risk behavior and how to be more proactive by reporting all events, small or major before they escalated to more unfortunate incidents. They educated staff about what level of behavior was unacceptable regardless of mental states.

During an interview with Public Safety Officer EE on 4/22/24 at 3:50 p.m. in the conference room, Officer EE said he recalled the incident with P #1 and P #2. Officer EE said during that weekend, security was called to the unit in regard to the male patient (P #2) inappropriate language toward staff. Officer EE said when he went to the floor, he talked to P #2 and explained the behavior expectations to him as an inpatient. Officer EE said he was not sure P #2 understood the conversation because he was just looking at him and did not have any reaction nonetheless, he took the time to explain the unit rules to him. Officer EE said staff did not express any safety concerns because P #2 was only using language that was inappropriate other than that he was not a high risk.

During an interview with Public Safety Officer/Lieutenant FF on 4/22/24 at 4:02 p.m. in the conference room, Lieutenant FF said he recalled the incident with P #1 and P #2. Officer EE said during that weekend he responded to a dispatch call on Friday when security was called to the unit in regard to the male patient (P #2) inappropriate and sexual language toward staff. Lieutenant FF said he along with other officers went to the unit and talked to the male patient (P #2) about what was expected from him and the type of behavior that would not be tolerated. Lieutenant FF said he basically explained the policy and procedures related to safety on campus and on the units to P #2. Lieutenant FF said P #2 clearly did not seem able to process policy and procedures, but he tried his best to explain the code of conduct in clear terms to him. Lieutenant FF said it was not reported as sexual assault, but he was more like harassing a female nurse and the nurse did not feel threatened. Lieutenant FF said they had a zero tolerance for sexual assault. If it reported as sexual assault, they would have detained the patient and called City Police to arrest him. Lieutenant FF said the policy was cut and dry when it came to sexual assault and physical threat; they just made sure the police came to apprehend the person. Lieutenant FF said he was a public safety Officer with the facility for five years.

An interview with Public safety Officer GG took place on 4/22/24 at 4:30 p.m. in the conference room. Officer GG said when the call came in on the radio, he and other officers went to the unit, and he saw the male patient with a confused look on his face. Officer GG said P #2 was unable to answer questions when they tried to talk to him. Officer GG said they spoke with the nurse (RN HH), and she said that P #2 was using inappropriate language to her as she entered his room. Officer GG said he specifically asked the nurse if the male patient (P #2) touched her, and the nurse (RN HH) said no he did not, but he was making sexual comment, and she was just upset about the nature of his comments. Officer GG said they spoke with the male patient (P #2) about his behavior and what the expectations were in term of conduct.

An interview with Registered Nurse (RN) HH took place on 4/23/24 at 10:30 a.m. in the conference room. RN HH confirmed that she was the staff that the male patient (P #1) was making sexual comment to and was trying to grab a hold of. RN HH said all the staff nurse and herself including considered the male patient harmless; he was like a child and was not acting at his age level at all. RN HH said P #2 did not even know the time of the day and that he only responded to his name when you called him. RN HH said P #2 had dementia and could not remember a conversation that took place a minute ago. RN GG said as he entered the patient's room to care for wounds he had on his hand, he was talking to her in gross sexual terms; and considered the language inappropriate. RN HH said P #2 touched her in the buttocks and she called security. RN HH said security arrived right away. RN HH said security talked to the patient and the security officer that was in the room followed her to the nurse station to get a face sheet to write the incident report. RN HH said they heard female patient (P #1) yelling and they rushed to her room and saw the male patient (P #2) standing in the patient's room exposing himself. RN HH said at that point, the officer got P #2 out of the room, called the city Police, and remained on the unit until police arrived. RN HH said P #1 said P #2 touched her in her gown, but he did not grab her. RN HH said they contacted P #1's family member, the provider, and reported the incident to the Charge Nurse who then reported all incidents to the Nurse Manager. RN HH said she did think P #2 knew what he was doing and that she was not upset but just wanted him to see security and that would make him stop. RN HH said they talked to P #1 (female patient), and she appeared to be fine, and she was not upset about it. RN HH said P #1 was not in any distress when she talked to her. RN HH said the facility instructed them to report all incidents and not to hesitate to call security whenever they felt unsafe. RN HH said security patrolled the unit and she always saw their presence. RN HH said security was always available and responded to call in a timely manner.

A review of the facility's policy titled, "Rights and Responsibilities of Patients Policy", last revised 2/6/23, revealed that all patients have the right to considerate, respectful care at all times and under all circumstances, with recognition of their personal dignity and autonomy. Piedmont Healthcare will develop, implement, and adhere to policies intended to assure practices that will respect the rights of all patients regardless of race, creed, sex, sexual orientation, gender identity or expression, national origin, religion, age, disability, diagnosis, or sources of payment for care
A patient's right to personal, visual, and auditory privacy will be honored to the extent reasonable and possible. A patient's right to privacy may be limited when the patient must be continuously observed (at risk of harming self or others).
Safety/Security
The policy delineated that "The patient has a right to the provision of care in a safe setting"
. The Patient Safety Committee, Environment of Care Committee, Infection Control Committee, the Security Department, and PHC Risk Management Programs seek to eliminate risks to the patient.
A review of the facility's policy titled, "Targeted Violence and Threats of Violence Policy", last revised 9/13/21, revealed that it was the policy of the facility that all persons have the right to an environment free of harassment, threat, and violence. Threats of violence and acts of violence, whether expressed or implied, will not be tolerated. All reports of and / or observations of workplace violence would be taken seriously and addressed as such.
Procedures
The three major functions of a threat assessment are identification of the perpetrator(s), assessment of the risks of violence posed by a given perpetrator at a given time, and management of both the subject and the risks that he or she presents to a given target. The level of threat will help determine the scope and timing of the response.
Threat Levels: There are four defined threat levels used to indicate the level of protection needed with a specific person or incident. Each threat level is color-coded to help with ease of visual recognition by staff.
o Low-Level Threat (Yellow): A subject or incident that presents minor disruptions to normal facility operations and presents a low threat of violence.
o Medium Level Threat (Orange): A subject or incident that presents major disruptions to normal operations and presents the possibility for violent action.
o High-Level Threat (Red): A subject or incident that presents major disruptions to normal operations and has a verified history of violent action.
o Critical Level Threat (Black): A subject or incident that presents a known and immediate threat of significant bodily harm or death to patients, staff, or visitors.

The entity procedure should identify the responsibility of staff to report any risk of targeted violence to Public Safety as quickly as possible so the threat can be assessed, and preventative measures can be initiated.
o Protocols should be in place to require reporting of threats where personal safety may be at risk.
o All identified threats of targeted violence should be treated seriously, in accordance with entity procedure, and assessed through a process that analyzes the threat and recommends the appropriate level or type of intervention to be initiated.
o The entity's Public Safety Leader should play a leading role in the threat assessment process and the design of any safety plan.
o Where appropriate, the Public Safety Leader will collaborate with Risk, Compliance, or Employee Relations as dictated by the situation.
o Entity staff involved in assessing the threat to determine the appropriate level and type of intervention required should receive training for this role.
o Where warranted by the risk of violent action within specific circumstances, the Entity should Targeted Violence and Threats of Violence Policy.

The policy delineated that "The safety of the individuals, including the potential target, staff, patients, and visitors should be always of primary concern."