HospitalInspections.org

Based on document review and interview the facility failed to ensure care in a safe setting related to an incident involving sexual contact between two youth patients in 2 (patient 7 and 8) of 10 medical records (MR) reviewed (see tag 144).


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

Based on document review and interview the facility failed to ensure care in a safe setting related to an incident involving sexual contact between two youth patients in 2 (patient 7 and 8) of 10 medical records (MR) reviewed:

Findings include:

1. Policy/procedure, 702.17, Sexual Acting Out and Victimization Risk Policy, revised/reviewed 11/19 indicated:
a. page 1: "Bloomington Meadows Hospital is committed to providing our patients with a sexually safe environment; free from perceived and real threats from visitors, staff and other patients. Patient who have been identified with risks associated with personal boundary issues, sexual victimization, or sexual aggression will be placed on Sexual Acting Out Precautions and assigned a level of observation".
b. page 2: "Safe boundaries will be maintained. General Guidelines in Preventing Sexually Acting Out: 1. Program rules include safe boundaries. 2. No touching others. 3. Only one patient in the bathroom at a time. 4.Staff needs to listen for conversations between patients that involve sexual connotation and intervene as indicated...".

2. Policy/procedure, 701.08, Abuse Assessment and Reporting, revised/reviewed 11/19 indicated: "Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation".

3. Policy/procedure, 702.10, Levels of Observation and Precautions, revised/reviewed 11/19 indicated:
a. page 1: "The Physician will order one of two levels of observation at time of admission and if the patient's condition warrants a change: a. every 15 minute b. One-to-one".
b. page 3: "A specified and dedicated staff member will stay within approximately one arm's length of the patient on 1:1 observation. This continuous direct visual observation will continue even when patients shower, change, or when they need to use the bathroom...due to the patient being a safety concern, the patient will remain on the unit for all meals while on a 1:1 observation. The nurse will order a meal tray for the patient to be delivered to the unit. The specified and dedicated staff member will document on a progress note every two hours regarding why they were placed on a 1:1 and their current behavior".

4. Policy/procedure, 702.22, Sexual Allegation Protocol, revised/reviewed 1/19 indicated on page 1:."Action Steps...2. Staff will observe the patient and document information obtained during the assessment concerning the assault...b. Staff will separate the patients involved in the allegation...staff will inform...appropriate agencies; i.e., Indiana Department of Child Services...".

5. Review of patient 8's MR lacked documentation of implementation of preventive guidelines after learning from another patient that patient 8 had intention of sneaking into male peer's room after bedtime as documented in Nursing Progress Note dated 12/7/19 at 0958 hours.

6. Review of patient 7 and 8's MR lacked documentation the patients were separated post sexual contact incident that occurred on 12/7/19.

7. Review of patient 8's Observation Rounds/Precautions Form dated 12/7/19 lacked documentation the patient was observed one-to-one starting on 12/7/19 at 1421 hours as per medical staff D5's order.

8. Review of patient 8's MR lacked documentation of a progress note every two hours regarding why patient 8 was placed on a 1:1 and his/her current behavior as indicated per policy/procedure,702.10, Levels of Observation and Precautions.

9. Review of patient 8's MR lacked documentation the nurse ordered a meal tray for the patient to be delivered to the unit so the patient could eat his/her meal on the unit while on a 1:1 observation.as indicated per policy/procedure, 702.10, Levels of Observation and Precautions.

10. Review of Event Report dated 12/7/19 at 1648 hours indicated: "Patient asked by staff N3 (Mental Health Technician [MHT]) to use the restroom while group was in dayroom. Staff N3 allowed for patient to go to bathroom. Approximately 5 minutes later, staff N3 called out for them to exit the bathroom, male/female patient exited first followed by patient a minute later. Patient stated that he/she and male/female peer had sex, and that the 'meet up' had been planned prior...Per surveillance review, male/female entered room at 14:50:02, male/female entered 16 seconds later at 14:50:18. Male/female is seen peering out of bedroom door, fully clothed, at 14:52:50. Staff entered room at 14:55:40, male/female peer exited with staff at 14:56:19, followed by patient at 14:56:41 hours".

11. On 12/16/19 at approximately 1230 hours, medical staff D5 (Nurse Practitioner) was interviewed and confirmed patient 8's MR indicated the patient had a history sexual abuse. Staff D5 confirmed an incident occurred on 12/7/19 at approximately 1450 hours involving youth patient 7 and 8. Medical staff D5 confirmed the incident involved sexual contact between patient 7 and 8 while in patient 7's bathroom.. Medical staff D5 confirmed after the incident, he/she observed staff N5 interviewing patient 8 but did not document an assessment himself/herself. Medical staff D5 confirmed he/she wrote a physician order for one-to-one observation on 12/7/19 at 1421 hours but patient 8's MR lacked documentation the the one-to-one observation level was implemented.

12. On 12/16/19 at approximately 1300 hours, staff N6 (Chief Nursing Officer) confirmed patient 8's MR lacked documentation the patient was being observed on a one-to-one status starting on 12/7/19 at 1421 hours as ordered per medical staff D5. Staff N6 confirmed patient 7 and 8's MR indicated both patients were located in the dayroom, dining room and gym at the same time on 12/7/19 from 1515 to 2115 hours post sexual contact incident that occurred on 12/7/19.

Based on document review and interview the facility failed to ensure nursing staff document patient care related to an incident involving sexual contact between two youth patients in 2 (patient 7 and 8) of 10 medical records (MR) reviewed:

Findings include:

1. Policy/procedure, 800.50, Transfer Out Of Facility, revised/reviewed 1/19 indicated on page 1: "If M.D.orders for the patient to be transferred, prepares the patient for transfer. a. Notifies receiving facility and confirms ability to accept the patient...c. Complete following forms: i. Memorandum of transfer ii. Copy from medical record to send to receiving facility...".

2. Policy/procedure, 702.17, Sexual Acting Out and Victimization Risk Policy, revised/reviewed 11/19 indicated on page 3: "...8. The Director of Risk Management, or designee, will notify all applicable external agencies and regulatory authorities on the next business day following notification and initiation of the investigation".

3. Review of patient 7's Observation Rounds/Precautions form dated 12/7/19 indicates the patient was in the Dayroom at 1445 hours however as per incident documentation and surveillance video timeline confirms patient 7 was in his/her room and not in the Dayroom as documented.

4. Review of patient 8's MR lacked documentation related to the patient's transfer to F2 on 12/7/19 post sexual contact incident that occured on 12/7/19 at 1450 hours.

5. On 12/16/19 at approximately 1300 hours, staff N6 (Chief Nursing Officer) was interviewed and confirmed patient 8's MR lacked documentation related to the patient transfer to F2 on 12/7/19.