HospitalInspections.org

Based on interview and record review the facility failed to follow their observational policies and procedures for one patient (#5) of 11 patients reviewed requiring a safe environment, resulting in the potential for 2 patients (#'s 9 and 11) losing their rights.
(See A-144)

1. The facility failed to ensure staff performed one to one (1:1) staff to patient ratio observational monitoring for one (#5) of one patient reviewed for 1:1 monitoring resulting in patients (#9 and #11) being subjected to unsafe sexual activities that were reported by patient #5.

Based on interview and record review, the facility failed to ensure staff performed one to one (1:1) staff to patient ratio observational monitoring according to their policy and procedure for one (#5) of one patients reviewed for 1:1 monitoring resulting in patients (#9 and #11) being subjected to unsafe sexual activities that were reported by patient #5. Findings include:

On 12/10/19 at 0945 review of patient #5's closed electronic medical record was conducted with Registered Nurse Educator Staff I and the following was revealed:
Patient #5 was 25 year -old male admitted to the facility (11/26/19-12/6/19). The patient presented with delusions, paranoia and was responding to voices.
A physician's order dated 11/29/19 at 1354 for patient #5 documented: "Place patient on 1:1 staff-nursing observation for unpredictable/threatening/aggressive behavior."

A review of physician's progress notes dated (11/29/19-12/3/19) documented the following:

On 11/29/19 at 0007: "Current Progress and Condition: Patient found pacing hall, signing, talking loud, unpredictable, labile continues needing 1:1 observation. Continued Interventions/Medications: Continue to monitor patient for changes in behavior and condition. Prompt him toward appropriate behaviors and responses."

On 11/30/19 at 1650: "Current Patient Progress: "He is reported to be intrusive with peers and sexually inappropriate with peers. His thought process is flight of ideas at times he is med seeking...Continuing Assessment/Justification For Continued Hospitalization: Remains agitated and psychotic. Interventions/Medication Plan: Continue Depakote, Ambilify and Buspar." However, there were no orders to continue or discontinue 1:1 staff to patient monitoring.

On 12/1/19 at 2314: "He is reported to be intrusive with peers and sexually inappropriate with peers. His thought process is with flight of ideas but today his anxiety is improved...Continuing Assessment/Justification for Continued Hospitalization: Remains agitated and psychotic. Interventions/Medication Plan: Continue Depakote, Ambilify and Buspar." However, there were no orders to continue or discontinue 1:1 staff to patient monitoring.

On 12/2/19 at 1025: Chief complaint reason for admission:
"Covering for (name of attending physician). The patient is currently loud, agitated, approaches me several times, intrusive, shouting...He is noted continues sexual inappropriate as noted this weekend..." However, there were no orders to continue or discontinue 1:1 staff to patient monitoring.

On 12/3/19 at 1354: Chief complaint reason for admission:
"Covering for (name of attending physician)...Last night RN called me regarding patient's severe agitation on the unit...He is being transferred from the 2nd floor to the 3rd floor because of sexually acting-out behaviors on the unit...He is placed on one-to-one, having discussed with the treatment team for sexually acting-out..."

A review of nursing notes dated 12/3/19 at 1034 documented: "Patient verbalized to staff that he had sex with 2 females on the unit during the midnight shift (when 2 different admits came to the hospital)..."
Further record review revealed the patient was only monitored every 15 minutes by staff. There were evidence in the medical record that documented the patient was on 1:1 monitoring by nursing staff.

On 12/10/19 at 1130 an interview was conducted with the Chief Nursing Officer Staff A. When queried regarding patient #5's self-reporting of having sex with 2 different female patients as aforementioned she (Staff A) explained she was immediately notified by staff, as well as the physician, recipient rights officer and the local law authorities. She said the patient's (#9 and #11) were assessed and interviewed by staff separately. Staff A said consensual sexual contact was prohibited by their facility. Staff A said both patients (#'s 9 and 11) said the sexual acts were consensual. Staff A explained both patients were counseled about the risks that were associated with the sexual incidents. She said both patients were transported to a local acute care emergency department for treatment and testing according to their policy/procedure. Staff A explained the local law authority were granted a search warrant on 12/4/19 for the collection of patient #5's "buccal DNA" (swabbing of the inner lining of cheek for genetic testing).

On 12/10/19 at 1220 an interview and record review was conducted with Medical Doctor Staff J. She said the reported incident had been brought to her attention. She explained the patient was unpredictable. She stated, "the patient should have been on continuous 1:1 observations at least while awake and if he continued to exhibit those type of unpredictable behaviors.

A review of the facility's "Observation Policy and Procedures" policy Number 2.12, dated September 2013 documented:
I. Purpose
To provide a procedure for ongoing or continuous observation of a patient's specific behavioral problems, to ensure a safe and therapeutic environment for the patient(s).
IV. Definitions
2. 1:1- ONE-to ONE close observation necessitating continuous supervision with staff no more than an arms-length away and in constant view of the assigned member for specific behavior(s).