HospitalInspections.org

Based on record review, policy review, document review, and interviews, the Hospital failed to promote and protect the Rights of each patient, by the failing to inform and provide all Patient Rights to patients or representatives and failed to ensure patients were free from all forms of abuse by staff failing to report and investigate an incident of potential abuse between patients.

The cumulative effects of these deficient practices place all patients at risk of insufficient information to make decisions directly affecting their choices of care and places patients at risk for abuse not identified and reported by staff.

Findings Include:

1. The Hospital failed to ensure all patients or patient's representative were informed of the Patient Rights to personal privacy; to receive care in a safe setting; and to be free from all forms of abuse or harassment; and the patient has the right to access their medical records, including current medical records, upon an oral or written request, in the form or format requested by the individual. (Refer to A-0117)

2. The Hospital failed to ensure all patients were free from all forms abuse by failing to ensure staff identified an incident as potential abuse, staff failed to follow hospital reporting requirements, leading to the hospital inability to investigate and respond to the potential abuse. (Refer to A-0145)

Based on document review, record review and interview the Hospital failed to ensure all patients or patient's representative were informed of the Patient Rights to personal privacy; to receive care in a safe setting; and to be free from all forms of abuse or harassment; and the patient has the right to access their medical records, including current medical records, upon an oral or written request, in the form or format requested by the individual, for four of four patient (Patients 1, 2, 3, and 10) records reviewed. Failure to inform patients or their representative of all Patient Rights places the patients or representatives at risk for not knowing all of their rights and making uninformed decisions about their care and services.

Findings Include:

Review of a hospital policy titled, "Patient's Rights and Responsibilities" revised 04/2014, showed, "To provide guidelines which outline patient rights and responsibilities; to recognize and promote personal safety and dignity; and acknowledge cultural, psychosocial and spiritual values which influence patients' perception of care and illness. Patients' rights apply to persons of all ages (neonates, children, adolescents, adults, and the elderly) and irrespective of race, creed, gender, sexual orientation, national origin or disability. Each patient will be informed of his or her rights and responsibilities in a method of communication that the patient understands. The patient may appoint a representative to receive this information should he or she so desire ... ...Privacy and Confidentiality: The patient has the right, within the law, to personal and informational privacy ... ...The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned, and to be free from verbal, physical, psychological, sexual or emotional abuse or harassment ... ... The patient has the right to be informed that [Hospital] is committed to high standards of care, safety and hospitality for patients and their families.
Review of a hospital policy titled, " Abuse, Neglect, Harassment and Exploitation within the Facility" reviewed 12/2021, showed PURPOSE: Providence Medical Center (PMC) and Saint John's Hospital (SJH) maintain a work and living environment that is professional and free from threat and or occurrence of harassment, abuse (verbal, physical, mental or sexual, involuntary seclusion, misappropriation of property) neglect or exploitation.

Review of a hospital document titled, "Patient Information Guide" provided to patients or representatives on admission, showed, the "Patient Rights" failed to include the Patient Rights to personal privacy; to receive care in a safe setting; to be free from all forms of abuse or harassment; and to access their medical records, including current medical records, upon an oral or written request, in the form or format requested by the individual."

Review of a hospital document titled, "Patient Handbook Senior Behavioral Health Center" provided to patients or representatives on admission to the Senior Behavioral Health Unit (SBHU), showed, the "Patient Rights" failed to include the Patient Rights to personal privacy; to receive care in a safe setting; to be free from all forms of abuse or harassment; and to access their medical records, including current medical records, upon an oral or written request, in the form or format requested by the individual."

Patient 1
Review of Patient 1's record showed a document titled, "Conditions of Admission and Financial Responsibility" ...22. PATIENT RIGHTS. I have been provided the hospital's policies regarding patient rights.

Patient 2
Review of Patient 2's record showed a document titled, "Conditions of Admission and Financial Responsibility" ...22. PATIENT RIGHTS. I have been provided the hospital's policies regarding patient rights.

Patient 3
Review of Patient 3's record showed a document titled, "Conditions of Admission and Financial Responsibility" ...22. PATIENT RIGHTS. I have been provided the hospital's policies regarding patient rights.

Patient 10
Review of Patient 10's record showed a document titled, "Conditions of Admission and Financial Responsibility" ...22. PATIENT RIGHTS. I have been provided the hospital's policies regarding patient rights.

During an interview on 04/20/22 at 1:00 PM, Staff A, Registered Nurse (RN), Director of Nursing (DON), confirmed, after reviewing the Patient Information Guide and Patient Handbook, the patient has the right to personal privacy; the patient has the right to receive care in a safe setting; and, the patient has the right to be free from all forms of abuse or harassment, and the patient has the right to access their medical records, including current medical records, upon an oral or written request, in the form or format requested by the individual, were no included in the Patient Rights documents provided to the patients or representatives on admission.

Based on record review, policy review and interview the Hospital failed to ensure all patients were free from all forms abuse by failing to ensure staff identified an incident as potential abuse, staff failed to follow hospital reporting requirements, leading to the hospital inability to investigate and respond to the incident for one of ten patient (Patient 3) records reviewed. Failure to identify and report all forms of abuse has the potential to place patients at risk for continued abuse and harm.


Findings Include:


Review of a hospital policy titled, " Abuse, Neglect, Harassment and Exploitation within the Facility" reviewed 12/2021, showed PURPOSE: Providence Medical Center (PMC) and Saint John's Hospital (SJH) maintain a work and living environment that is professional and free from threat and or occurrence of harassment, abuse (verbal, physical, mental or sexual, involuntary seclusion, misappropriation of property) neglect or exploitation.
Providing a safe environment for the patient is one of the most basic and essential duties of the facility ... ...Patients must not be subject to abuse by anyone, including but not limited facility staff other patients, consultants or volunteers, staff of other agencies serving the patient, family members or legal guardians, friends, or other individuals ...

...Internal Reporting suspected violations:

Any suspected, observed or reported violation of this patient safety policy will be reported to:
Department Director, Chief Nursing Officer and Risk Management ...

Procedure for investigation:

The Department Director and/or supervisor on duty will immediately assess the patient (including the size, location, etc., of any injury), and properly document the date, time, and location of the reported or suspected incident.

The supervisor will ensure that the patient is protected from harm during the investigations

A safety event report and investigation must be completed for any violation of this policy or injury of unknown origin using the facility safety event reporting system.

The physician and family will be notified as soon as possible, when appropriate ...

...All witnesses or involved parties will be interviewed giving their own description of the incident. These records will become part of the permanent investigation file.

The Department Director/Manager or supervisor on duty will interview the patients as well as all nursing, housekeeping, laundry, dietary, activity, or social service staff, any visitors or others who may have knowledge of the occurrence or who may have been in the vicinity at the time of the incident.

Patient 3

Review of Patient 3's medical record showed he was admitted on 02/15/22 with altered mental status and discharged on 03/07/22 with diagnoses of mild cognitive impairment, anxiety disorder, unspecified; major depression with psychotic features; Parkinson's disease, deep brain stimulatory implant, history of falls, gait impairment.

Review of the Nurses note dated 02/22/22 at 6:42 PM, showed Patient 3 was found in his room with a female patient who was sitting in a chair without her pants on and Patient 3 was on the floor with his hands on her knees. The nurse documented that on arrival to the room, Patient 3 was attempting to put a sweatshirt on the female patient, like a pair of pants. Other staff assisted the female patient with getting dressed. When asked what he was doing he said that her pants were wet, and the female stated the same. It was documented that the female patients' pants were dry. The female patient was escorted back to her room. Further reviewed of the nurse's notes showed on 02/23/22 it was documented that Patient 3 was following the female patient from the past incident. Nurse informed Patient 3 that he was to leave her alone completely and not talk to her due to his inappropriate behavior towards her. He verbalized to the nurse he would discontinue his inappropriate behavior. On 02/23/22 at 2:59 PM documentation showed Patient 3 was caught again sneaking into same female patients room right behind the patient, as soon as he saw staff was looking at him he turned around and said, "I didn't say anything to her." the note continued he was once again informed he needed to stay away. The female patient was placed in the day room with the door shut away from Patient 3, under staff supervision. On 02/23/22 at 11:19 PM it was documented, ..."No agitation, aggression, or sexually inappropriate behaviors noted thus far. 02/24/22 at 2:34 PM the nurse documented, "Pt is alert and oriented x 4, calm and cooperative. He has had no incidence thus far in the shift of violating boundaries with women on the unit" ... ..."still exhibits disorganized thoughts at times."


During an interview on 04/21/22 at 8:10 AM Staff D, Registered Nurse (RN), when asked about the incident that occurred on 02/22/22, with Patient 3 and a female patient, he stated that the incident was discovered by the aid and by the time he got to the room, Patient 3 was away from the female patient. When asked if the incident was reported to the supervisor, he stated no, from what they could gather, there was no sexual intent. He stated that the female patient had on a brief and Patient 3 had pants on. Staff D stated that a "verge" (hospital event/incident reporting system) report was not made. When asked why a report was not made, he stated that with this one there was no intent to harm and it was not sexually inappropriate. He stated that Patient 3 was trying to help get pants on the female patient even though it was a shirt Patient 3 had. He stated that he thought the female patient was Patient 10.


During an interview on 04/21/22 at 8:27 AM, Staff E, CNA, stated that she was doing 15-minute rounds she found the female patient in Patient 3's room. She stated that she notified the nurse immediately by radio and that both nurses came to the room to take care of the situation. She stated that it happened at the end of her shift and once she reported it to the nurse, she left. She stated that the female patient was sitting in the chair with her pants off, and Patient 3 was sitting on the floor, she stated that when she walked in, Patient 3 pushed himself back away from the female patient. She stated that Patient 3 said he was trying to help her get her pants on. Staff E stated that Patient 3 was dressed and had pants on. She stated that she feels nothing had happened at the time but if she hadn't gone in, potentially inappropriate activity could have happened. She stated that Patient 3 and the female patient had previously been seen holding hands, walking in the hall. She stated that she thinks the female patient was Patient 10.


During an interview on 04/21/22 at 9:24 AM, Staff BB, RN, stated that she worked the following day, morning shift. She stated that the incident between Patient 3 and the female patient was passed on in report. She stated that both patients had super disorganized thinking, but the male had a better grasp on things. She stated that she had seen him "lurking" around the door and he was redirected for inappropriateness. She stated that the female patient, who she thought was Patient 10, was more hyper-sexual than Patient 3. She stated that Patient 3 was put in line of site after the incident.

During an interview on 04/21/22 at 5:00 PM, Staff CC RN, who was schedule to work on 02/22/22 at 7:00 PM, stated that the incident with Patient 3 and a female patient happened before he got to work. He stated that the incident was passed on in report.


Patient 10

Review of Patient 10's medical record showed she was admitted to the SBHU from a nursing facility on 01/27/22 with increasing behavior problems including agitation, aggressive behaviors towards staff and other residents, angry, combative at times and delusional. Significant emotional lability and disoriented to her surroundings. Patient 10 was discharged back to her nursing facility on 02/28/22.

There was no documented evidence in Patient 10's medical record to show Patient 10 was involved in the incident that occurred with Patient 3 on 02/22/22.

Review of the event log showed there was no documented evidence of the incident involving Patient 3 and a female patient and there was no documented evidence of an investigation of the incident.


During an interview on 04/21/22 at 8:35 AM, Staff A, RN, Director of Nursing (DON) stated that this type of incident should have been reported to the supervisor and risk manager and the risk would have done an investigation.

During an interview on 04/21/22 at 8:53 AM, Staff C, Director of Risk Manager, stated that any event that is unusual, an unsafe condition, outside of normal conditions, an actual safety event or near misses would be reportable through the event reporting system. When asked if the incident that occurred with Patient 3 and the female patient would be an event that fell into those categories, she stated that yes, an example would be this incident. She stated that the unit manager would conduct interviews, would notify the appropriate people, physician, family, and decide on the next steps. She stated the patients would be put in different areas while a incident was investigated.