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Based on observation, interview and document review, the hospital failed to ensure all patient rights were protected when a patient became pregnant while at the facility.

A condition level deficiency was issued. See A0144.

An IJ was identified 4/8/22, related to patients receiving care in a safe setting. The IJ was removed on 4/11/22, at 4:24 p.m., but the hospital remained out of compliance at the Condition of Patient Rights. See A0144

Based on interview and document review, the hospital failed to provide care in a safe setting for 2 of 16 patients (P1, P2) reviewed for patient rights when staff failed to provide adequate supervision and safety checks and P1 and P2 engaged in sexual activity. The sexual activity between P1 and P2 resulted in P1 becoming pregnant while a patient in the hospital.

The IJ began on 3/17/21, when patient P1 reported to her county case worker (CW)-A she thought she was pregnant and requested a pregnancy test. P1 admitted to CW-A she had been sexually active with P2 and had sex three times while hospitalized. CW-A emailed the facility on 3/18/22, with P1's allegations. P1's foster family brought her in for a pregnancy test to be on 3/22/22, where she had a positive pregnancy test. CW-A emailed the facility again on 3/22/22, when P1's pregnancy test came back positive. The chief executive officer (CEO), regulatory and quality improvement registered nurse (RQI), senior director of quality (DQ), chief nursing officer (CNO), Vice President of Operations (VPO), Vice President of Nursing Practice and Clinical Education (VPNP), Supervisor of Behavioral Health (BHS), and Administrative Assistant (AA) were notified of the IJ finding on 4/8/22, at 8:32 a.m.
The immediacy was removed on 4/11/22, at 4:24 p.m. but the Condition of Participation of Patient Rights remained out.

Findings include:

P1's medical record indicated P1 admitted to the facility 12/6/21, and discharged on 3/16/22. P1's diagnoses included traumatic brain injury, neurodevelopmental disorder, cognitive disorder, history of sexual abuse as a child, anxiety, and major depressive disorder. P1 was 18 years old and was under a Mental Illness Civil Commitment in her county of residence, as well as having a county child protection service (CPS) worker assigned to her. P1's medical record indicated P1 was a vulnerable adult due to her lower intellectual functioning and her history of being sexually assaulted and sexually abused as a child.

P1's psychiatric evaluation completed on 12/7/21, included P1's need for a safe environment. The evaluation also revealed P1's history included substantial history of sexual abuse.

P1's Person-Centered Master Treatment Plan initiated on 12/8/22, included for P1 to be monitored on routine precautions as ordered for safety.

P1's Vulnerability Risk Prevention Plan completed on 12/6/21, Identified P1 as a vulnerability risk related to trauma history and vulnerability to abuse by others. P1 declined to discuss, but according to collateral information patient has a history of abuse and trauma as a child.

P1's progress notes indicated the following:

On 2/21/22, at 9:50 a.m. P1 requested to have a pregnancy test completed, although P1 was informed that she had one done on 12/8/21 that was negative. P1 denied any sexual activity since that time.

On 2/24/22, at 11:51 a.m. P1 appeared to be paranoid as she wanted a pregnancy test ordered from the medical provider. P1 denied any sexual contact since admission, and was informed she had a pregnancy test when she was admitted to this hospital.

On 2/25/22, at 10:00 a.m. P1 was requesting a pregnancy test. P1 acknowledged having sexual relations prior to admission, but denied having any sexual interactions since her admission. P1 denied any physical symptoms associated with pregnancy, and confirmed she has had her menstrual cycle during this hospitalization. P1 indicated although she had a negative pregnancy test initially after admission, she would like another test as she continued to worry and remain preoccupied with concerns for pregnancy. P1 appeared to be responding to internal stimuli and appears to have a relationship/ friendship interest to young man on the unit.

On 2/28/22, at 8:28 a.m. P1 tended to keep to herself, but continued to seek out a male peer. Staff continued to
provide redirection, as she often followed him around the unit and sat directly next to him.

On 3/1/22, at 9:51 a.m. P1 continued to seek out a male peer on the unit, and staff need to provide redirection.

On 3/1/22, at 4:20 p.m. P1 reported to staff she thought she was pregnant. The progress note further revealed P1 had been following a male peer around the unit. The note continued to add P1 had a pregnancy test completed last week with negative results.

On 3/9/22, at 3:15 p.m. P1 required a lot of redirection related to continuing to follow a male peer around the unit. P1 had poor boundaries, staff were struggling to maintain appropriate distance between the two.

On 3/10/22, at 3:15 p.m. P1 continued to need redirection regarding boundaries with peers.

On 3/11/22, at 8:04 a.m. P1 has remained focused primarily on a select male peer this past treatment week, with many of her comments being focused on him.

On 3/11/22, at 2:05 p.m. P1 arrived late to group, and was quite disruptive as she was attempting to have a conversation with a male peer who was listening attentively in group. P1 continued to be interested in this male peer, she has been noted to be following this peer around the unit and staring at him.

On 2/22/22, P1's communication morning team meeting notes indicated staff had been directed to watch P1 closely while she was with P2. On 2/24/22, P1's communication morning team meeting notes indicated P1 still worried about getting a pregnancy test performed. On 2/27/22, P1's communication morning team meeting notes indicated P1 continued to seek out P2. On 3/6/22, P1's communication morning team meeting notes indicated P1 continued to have boundary issues, and it was difficult to redirect and maintain distance between P1 and P2.

Review of P1's medical record indicated P1 had a urine pregnancy test completed on 12/8/22, and 2/25/22, with both tests indicating negative test results.

P2

P2's medical record indicated P2 was admitted to the facility on 2/14/22, and discharged on 3/14/22. P2's diagnosis included schizophrenia.

On 3/6/22, P2's communication morning team meeting notes indicated staff had been directed to watch P1 closely while she was with P2.

On 4/6/22, at 1:10 p.m. P1's county case worker (CW)-A was interviewed. CW-A stated P1 called her on 3/17/22, and stated thought she was pregnant, she had sex with a man who was three years older than her at the facility, and gave the other patient's name. CW-A stated P1's foster family was not able to have her seen for a pregnancy test until 3/22/22, and she had a positive pregnancy test on that date. CW-A stated she had emailed the facility on 3/18/22, with the allegations P1 made. CW-A stated she also emailed the facility when P1's pregnancy test came back positive. CW-A stated P1 would not be able to handle a pregnancy, and she would not be able to care for a child. CW-A stated P1 was also on some serious medications, and these could affect an unborn child. CW-A stated the facility never updated her when P1 requested a pregnancy test at the hospital, and she would have wanted to know that.

On 4/6/22, at 3:26 p.m. the administrator was interviewed and stated P1 had a pregnancy test when she was admitted, and again during her hospital stay. The administrator stated P1 said she was not sexually active. The administrator stated she had been notified by CW-A of P1's statements of being sexually active while in the facility, and her request for a pregnancy test. The administrator stated CW-A notified them of P1's positive pregnancy test. The administrator stated she notified the facility's Quality Assurance (QA) staff who advised them not to do anything until P1 had an ultrasound done to see when she may have become pregnant. The administrator stated the facility had not started an investigation into the allegation, had not reported this to the state agency (SA), and had not contacted the police.

On 4/7/22, at 8:39 a.m. P2 was interviewed and stated he had been sexually active while at the facility. P2 stated it was consensual and declined to give any further details.

On 4/7/22, at 10:32 a.m. human services technician (HST)-A was interviewed and stated P1 had an infatuation with P2. HST-A stated there were times she would have to separate P1 and P2 from sitting too close together, but she had not observed them having physical contact. HST-A stated physical contact of any form was not allowed between patients.

On 4/7/22, at 10:59 a.m. licensed practical nurse (LPN)-A was interviewed and stated P1 and P2 liked to walk together, but she never observed any physical contact. LPN-A stated physical contact of any form was not allowed between patients.

On 4/7/22, at 11:41 a.m. registered nurse (RN)-A was interviewed and stated P1 had liked P2. RN-A stated P1 had boundary issues, and staff had been instructed to keep close eyes on P1. RN-A stated he never observed physical contact between P1 and P2, but could tell P1 liked P2 by the way she would just stare at him. RN-A stated physical contact of any form was not allowed between patients.

On 4/7/22, at 11:58 a.m. psychiatrist (MD)-A was interviewed. MD-A stated P1 had asked him for pregnancy tests, but he had never asked her if she was sexually active. MD-A stated P1 was delusional while at the facility. MD-A stated once he was informed P1 was pregnant, he contacted her foster home and the pharmacist, and made medication changes.

On 4/7/22, at 12:34 p.m. social worker (SW)-A was interviewed. SW-A stated during the facility morning huddles, they discussed concerns and staff were instructed to keep an eye on P1 and P2 because they liked each other. SW-A stated P1 and P2 had an attraction towards each other. SW-A stated on 3/18/22, he had received the emails from CW-A indicating P1 had reported having a sexual relationship and could be possibly pregnant. SW-A stated he received another email from CW-A on 3/22/22 which indicated P1 had a pregnancy test completed, with positive results. SW-A stated he forwarded the emails to the administrator.

The facility's undated Welcome letter provided to new patients, indicated patients should expect to be safe from any sexual contact as it was not permitted. This included hugging, kissing, holding hands, etc.

The facility policy Therapeutic Observations, dated 11/2/21, directed staff to provide for the safety of clients whose clinical presentation warrants supervision, observation and/or restricted access to potentially dangerous items. The level of observation, supervision or restriction identified is the least restrictive or intrusive necessary.

The IJ was removed on 4/11/22, at 4:24 p.m. when it could be verified the hospital had submitted and implemented an acceptable removal plan which included education related to initiating therapeutic observations, re-assessing all patients to determine risk for sexual activity and potential pregnancies, reeducating all current patients and providing education to new admissions that sexual contact is not allowed. This was verified through observation, interview and policy review. All current patients were assessed to ensure they were not sexually active, and ensuring identified risks were included in treatment plans.