HospitalInspections.org

Based on the scope and severity of deficiencies related to Patient Rights, the facility failed to substantially comply with this condition.

The findings include:

During the course of the complaint investigation, through medical record review, interviews and document reviews, the surveyor determined that a patient verbalized a sexual assault allegation to multiple staff members. The staff members documented the allegation in the medical record; however, failed to report it to authorities as required by the facility's policy and state law. In addition, the facility failed to investigate the allegation at the time it was made by the patient. This led to the identification of an immediate jeopardy on 10/11/2023 at 11:54 a.m.

On 10/12/23 at 10:29 a.m., the facility presented the surveyor with a removal plan which was reviewed and found acceptable. The surveyor verified implementation of measures outlined in the removal plan while on site which included; a safety alert transmitted to all staff regarding compliance with reporting of patient allegations of abuse, in-service training for staff on mandatory reporting, team huddles to reinforce patient safety and reporting allegations of abuse, and weekly tracer audits with added elements of abuse/neglect added to behavioral health units. The IJ was removed on 10/12/23 at 1:00 a.m.

This condition level non-compliance could impact all patients in the facility, but specifically, those patients with allegations of abuse involving facility staff. These allegations may not be investigated properly and potential abuse may occur unabated.

See tags:

A-0145

Based on medical record review, staff interviews and facility document review, it was determined the facility staff failed to report and respond to a patient's allegation of sexual assault.

A-0168

Based on medical record review, staff interview and facility document review, it was determined the facility staff failed to apply restraints in accordance with the physician's order for one (1) of five (5) patients sampled for restraint/seclusion review.

Based on medical record review, staff interviews and facility document review, it was determined the facility staff failed to report and respond to a patient's allegation of sexual assault.

The findings include:

In the afternoon of 10/10/23, the surveyor conducted medical record reviews with SMs #9 and #10. SM #6 was also present during the review. During the review of patient #3's medical record, the surveyor located two (2) progress notes dated 9/13/23; one (1) by SM #15 and the other by SM #13.

SM #15's progress note at 2:13 p.m. documented the patient reported to SM #15 they were sexually assaulted at the facility but the patient did not want to discuss the matter further.

SM #13's progress note at 2:40 p.m. documented the patient reported to SM #13 they were sexually assaulted at the facility and did not feel safe.

The surveyor inquired if the allegation had been reported by the staff and requested to see any related documentation. SMs #6, 9 and 10 were unaware if the allegation had been reported. SM #3 advised the surveyor that (SM #3) would research and contact the appropriate staff members to determine if there was a report and follow-up.

On 10/11/23 at 9:45 a.m., the surveyor met with SMs #1, 2 and 3. SM #3 said that leadership "talked with the team (psychiatric care team)" (afternoon/evening of 10/10/23) and was informed that "the team had a meeting after seeing the patient on 9/13/23. The team agreed that the patient's disease, mania, delusions were responsible for the patient's accusation". According to SM #3, the team said "the patient had never said anything prior or after about the accusation." Additionally, "the patient had made other comments/statements" during the stay that "supported the patient was experiencing delusions and mania". SM #2 acknowledged that there was a "breakdown" in the reporting and that it is an "opportunity". SM #1 agreed that the "breakdown is in the failure to report". SM #3 advised that the incident had been reported as of 10/10/23 at 5:00 p.m. (after the surveyor made the facility aware of the allegation).

At 10:10 a.m., the surveyor met with "the team". Included in "the team" were SMs #11, 12, 13, 14, 15 and 16. SM #16 (Psychiatrist) advised the psychiatric care team did meet as reported to discuss the patient's care and determined the sexual assault allegations to be part of the patient's psychosis. SM #16 acknowledged that the clinical director did not further investigate the accusation and it was not reported on that day (9/13/23). It should be noted, Patient #3's medical record did not contain documentation of the meeting or that the psychiatric care team determined the sexual assault allegation to be unfounded.

The facility's policy titled, Abuse, Neglect or Exploitation of Patients within [name of facility]: Witnessed or Alleged, Sexual or Physical, was reviewed and reads, in part: "... To assure understanding of an compliance with regulatory and/or legal requirements for reporting witnessed or alleged patient sexual or physical abuse or neglect... Definitions:... FACT - Forensic Assessment and Consultation Team... Policy Description: This policy provides guidance on dealing with witnessed and unwitnessed sexual or physical abuse, neglect or exploitation of patients that occur within the hospital. The following steps will be taken in instances when someone witnesses or when staff are made aware of allegations of unwitnessed sexual or physical abuse, neglect or exploitation involving a patient while in the hospital... 1. Take appropriate measures to protect the patient. Security personnel and/or a sitter may be utilized to safeguard the patient. 2. Assess the patient for harm and treat as necessary. Notify the physician's attending physician. 3. If the allegation is directed against a current healthcare provider or staff member, another healthcare provider or staff member will be assigned to care of the patient. 4. Notify the charge nurse or immediate supervisor who will notify Senior Leadership, Security (if not already notified to safeguard the patient) and Risk Management. After hours, weekends and holidays, Risk Management can be contacted by calling... 5. The patient or family member/guardian will be given the option to notify law enforcement at any point. 6. Staff will contact FACT when sexual abuse occurs following the guidance below: 1. If a competent adult, contact FACT after patient makes decision regarding notification of law enforcement. 2. If a minor, contact FACT after notifying Child Protective Services. 3. If an adult covered by Adult Protective Services (18 years and over with incapacitation and 60 and over), contact FACT after notifying Adult Protective Services... 7. Inform the patient that [name of facility] will investigate the matter. 8. Staff member (s) will cooperate with all investigations conducted by Security, Risk Management and outside law enforcement (if notified)...".

A facility document titled, Abused, Neglected or Sexually Assaulted Individuals and Patients, was reviewed and reads, in part: "... 1. General Guidelines... B. The hospital Case Management department shall be notified when a patient is suspected of or known to be a victim of abuse (to include strangulation), neglect or sexual assault. i. The Case Management department will assist staff through the reporting process and will notify the attending physician. ii. If a Discharge Planner is not available, the staff member identifying the abuse, neglect, or sexual assault should contact the appropriate law enforcement agency and/or child protective services (CPS) or Adult Protective Services (APS) when applicable.

SM #3 informed the surveyor that when an allegation is reported, the leadership team (consisting of, but not limited to, nursing leadership, security, quality and risk) is notified immediately and an investigation is started. SM #3 said that "risk" reviews the allegation (prior to reporting to law enforcement) for any confidentiality or patient safety concerns.

As of the end of the survey, the allegation identified during the investigation (involving patient #3) was being reviewed by "risk". The facility did not start the aforementioned process until the surveyor notified the facility of the sexual assault allegation during the onsite survey.

The events of the survey and the identified deficiencies were reviewed with SMs #1, 2, 3, 5 and 6 during the exit conference on 10/13/23.

Based on medical record review, staff interview and facility document review, it was determined the facility staff failed to apply restraints in accordance with the physician's order for one (1) of five (5) patients sampled for restraint/seclusion review.

The findings included:

In the afternoon of 10/11/23, the surveyor reviewed medical records with the assistance of SM #17. Five (5) of the ten (10) records were sampled to review restraints/seclusion. The medical record for #10 indicated the patient presented to the emergency department on 10/5/23 with acute respiratory distress. At 3:10 a.m. on 10/5/23, the physician ordered a violent restraint. The restraint read "Limb Restraint. Left Wrist. Right Wrist". The Registered Nurse (RN) documented at 3:15 a.m. that the following non-violent restraints were "started:" Freedom Sleeve (R), Freedom Sleeve (L). The RN documented that freedom sleeves were discontinued on 10/6/23 at 3:10 a.m.

On 10/23/23, SMs #18 and 19 reviewed the medical record again with the surveyor. SM #18 explained that since non-violent restraints were applied, the order was "likely meant to be for non-violent restraints" and "it's just the wrong order was clicked in the system". The surveyor inquired if there was any documentation to show the physician was contacted by staff to clarify the order prior to applying the restraints. SM #18 and 19 were unable to locate any documentation in the record. The surveyor inquired about the monitoring documentation for violent restraints; SM #18 and 19 were unable to locate the documentation; however, there was documentation in the record for non-violent restraint monitoring.

The facility's policy, IHS Restraints and Restraint Alternatives Policy was reviewed and reads, in part: "... 1. Use requires an active order by an appropriately privileged physician or licensed practitioner... 3. Patients are monitored, assessed and reassessed at specific intervals during use...".

The above noted deficiency was reviewed with SMs #1, 2, 3, 5 and 6 during the exit conference on 10/13/23.