HospitalInspections.org

The hospital failed 2 of 2 Patients (Patient #4 and Patient #5) the right to receive care in a safe setting.

Finding Include:

During Observation of Video footage timeline reflected Patient #4 and Patient #5 were discovered behind a secured door for 10minutes and 25 seconds. The information reflects the door was closed and locked. It is actually unknown what transpired behind the closed locked door.

During Interview the Staff# 9 indicated that Staff#14 reported that the patients were told to get dressed and Patient #5 pants were not securely on pulled down mid waist and Patient #4 did not have on pants.

During Interview Staff #1 and Staff #9they were informed that this was not a safe environment. Can they explain staffing and staff issues. The unit was appropriately staffed, and rounding was being conducted as required, however the patients were able to walk down the hallway and enter into the room. Staff #9 reported two staff are now planted in the hallway in the blind spot corners. These staff are to monitor the hallway and the third mental health tech makes unit observations as required by the 15minute mark as scheduled.

During Record review Patient #4's High Risk Alert sheet did not reflect the Patient was Hypersexual and Impulsive. It was found on other documentation and later again discovered by the Treatment Team.

During the Interview with Staff #1 the hospital has implemented changes and continuously offered training to each staff to ensure patient safety.

During Interview with Staff #1 and Staff #2 it was reported we are not certain what exactly happened behind the closed doors. For the patients to be unfounded for 10 minutes and 25 seconds this is an unsafe environment. The staff agreed.

Policy:
The hospital Policy on Abuse dated 10/2021 reflected, "It is the policy of Millwood Hospital to report all incidents of Patient abuse, negelct and exploitation as soon aspossible after the time the incidnet is identified.

The hospital Policy on Healthcare Peer Review/Incident Reporting Process dated 11/2019 reflected, "The Healthcare Peer Review HPR/Incident Reporting Process is the reporting methodology used to track incidents, outcomes, or issues that potentially represent patient safety concerns or
quastionable clinical practices. The reporting process supports each facilitiy's patient safetty efforts and multi-disciplinary peer review process."

The hospital Policy on Patients Rights dated 02/2021 reflected, "It is the policy of Millwood hospital and Excel Centers to ensure that all patients receivee a copy of the Patient Handbook which includes the Patient Bill of Rights as well as an oral explanation of those rights both in their primary langage and in simple non-technical terms. We will strive to abide by and respect all patient rights without regard to race, religion, creed ethnicity, gender, age, sexual orientation, or handicap. Millwood Hospital and Excel Centers shall support and protect the fundamental human, civil constituational and statutory rights of the individual patient and recognize and respect personal dignity of the patient at all times."

The hospital Policy on Assault Observation Precautions:
Provision of a safe, therapeutic environment of care includes the prevention of Assult, as well as any threats of assault...To provide a plan for monitoring potentially aggressive...patients via Assault Precautions...Identifying early warning signs, and implementing interventions to prevent assault incidents, wile estblishing guidelines for the use of the "Code 10" and to minimize the disruption of the thrapeutic milleu as well as ensure the safety of all patients and staff."

The hospital Policy on Sexually Acting Out Policy reflected, "On admission to all levels of care, Millwood Hospital identifies patients with sexual aggression and/or victimization history /behaviors. Patients who have a history of sexual aggression or who are exhibiting sexual aggressive behvaior will be placed on an appropriate observation level and until precautions to provide for a safe, therapeutic environment. The admission clinican is responsible for completing the initial risk assessment regarding sexual aggression/victimization and documenting it on the admission assessment screen. The physician and nurse place the patient on the appropriate precaution and observation level. Patients should be educated regarding their responsiblity to report verbal or physical sexual threats, abuse and the consequences of prohibited behavior on the unit. PAtient at risk for sexual victimization shouldbe evaluated for level of functioning and need for additional protection, i.e., develo[mentally disabled, sedated, post-ECT, or medically compromised patients."

The hospital failed 2 of 2 Patients (Patient #4 and Patient #5 to be free from all forms of abuse.

Findings Include

During Record Review Patient #1 was diagnosised as being a Hyper-sexual and implusive. The Record High Alert failed to reflect this information and initially the patient was not placed on Sexual Acting Out Precautions. The hospital failed to follow its own policy.

Policy
The hospital Policy on Assault Observation Precautions:
Provision of a safe, therapeutic environment of care includes the prevention of Assult, as well as any threats of assault...To provide a plan for monitoring potentially aggressive...patients via Assault Precautions...Identifying early warning signs, and implementing interventions to prevent assault incidents, wile estblishing guidelines for the use of the "Code 10" and to minimize the disruption of the thrapeutic milleu as well as ensure the safety of all patients and staff."

The hospital Policy on Sexually Acting Out Policy reflected, "On admission to all levels of care, Millwood Hospital identifies patients with sexual aggression and/or victimization history /behaviors. Patients who have a history of sexual aggression or who are exhibiting sexual aggressive behvaior will be placed on an appropriate observation level and until precautions to provide for a safe, therapeutic environment. The admission clinican is responsible for completing the initial risk assessment regarding sexual aggression/victimization and documenting it on the admission assessment screen. The physician and nurse place the patient on the appropriate precaution and observation level. Patients should be educated regarding their responsiblity to report verbal or physical sexual threats, abuse and the consequences of prohibited behavior on the unit. PAtient at risk for sexual victimization shouldbe evaluated for level of functioning and need for additional protection, i.e., develo[mentally disabled, sedated, post-ECT, or medically compromised patients."