HospitalInspections.org

The hospital failed 2 of 2 Patients (Patient #1 and Patient #2) by failing to ensure an ongoing program that shows measurable improvement in indicators for which there is evidence that it will analyze, and track adverse patient events. The hospital executives failed to ensure the hospital completed a medical assessment of both patients after adverse event and failed to report the event to the Department of Health and Human Services.

Findings Include:

Through record review the hospital Incident Report reflect that there was no apparent injury. The report does not address the mental state of patient after adverse event. The event does not address the patient was physical assessed by medical staff. It addresses that Patient #1 and Patient #2 was observed.

Through record review hospital Staff #3 recorded that Patient #1 reported feelings of 'disgust' after being sexually assaulted by Patient #2.

Through record review hospital Staff #3 recorded Patient #2 admitted to engaging in inappropriate sexual conduct with Patient #1.

Through interview with Staff #3, it is unknown if a medical assessment was completed. Staff #3 indicated that both Patient #1 and Patient #2 were interviewed and both admit that inappropriate sexual activity occurred between them. Staff #3 reported that Patient #1 was the victim, and did not consent to the behavior of Patient #2. Patient #2 climbed in the bed of Patient #1 and rubbed the body along the backside of Patient #1. Patient #2 then told Patient #1 multiple times to perform oral sex. Patient #2 then masturbated and ejaculated onto Patient #1. Patient #1 and Patient #2 had no noted history of Sexually Acting Out behaviors prior to this event. The patients were both on Q15 observations.

Through interview with Staff #4, it is unknown if medical assessment was completed. Staff #4 reported that there are no records that indicate a internal investigation was completed as a result of the adverse event. Staff #4 reported that there is no record that a Root Cause Analysis was completed in regards to this adverse event. Staff #4 reported that there is no evidence that this adverse event was reported to the Department of Health and Human Services for further investigation/survey.

Through Interview with Hospital Staff #4 reported the previous Risk Manager failed to follow its own policy by not informing administration of the occurrence of events of SAO behavior between Patient #1 and Patient #2.

Through interview with hospital Staff #1 reported, the hospital failed to follow its own Policy by not implementing protective measures for patients, by not advocating for those who are vulnerable to sexual victimization by failing to complete investigations to attempt to prevent future incidents.

Policy
The hospital Policy on Sexually Acting Out and Sexual Victim Prevention dated 07/17/2019 reflected, "Perimeter Healthcare shall implement a policy for patients for protective measures. The facility shall advocate for those who are vulnerable to sexual victimization by other patients who are on sexual precautions and residing in the facility. Patients shall not have sexual contact with one another. Patients are assessed for risk of sexual acting out behavior or be of being sexually victimized."

The hospital Policy on Incident Reporting dated 07/17/2019 reflected, "The incident report is a mechanism for informing administration of the occurrence of circumstances surrounding individual problematic events. An 'Incident' is defined as any happening that is not consistent with the normal or usual operations of the hospital and/or department. Injury does not have to occur. The potential for injury and/or property damage is sufficient for an event to be considered an incident. incidents are reviewed by the Perimeter Healthcare Performance Improvement Committee and referred to other committees as indicated by hospital policy or legal, regulatory or accreditation requirements;
Critical Incidents
I. Staff will inform the House Supervisor of all critical incidents as soon as possible.
A. Critical Incidents are any incident that causes or has the possibility of causing serious injury to a patient, staff,
or visitor such as:
ii. Rape/Sexual Assault
II. The CNO and or CEO upon his/her discretion will inform the Medical Director immediately or the next day as warranted.

The hospital Policy on Abuse dated 07/17/2019 reflected, "Perimeter Healthcare promotes and requires professional, ethical and legal conduct of staff. The advocacy role of health care is maximized when addressing issues of conduct of staff. Perimeter Healthcare assess the conditions of illegal, unethical and/or unprofessional conduct of staff. All health care service providers will immediately report to the appropriate supervisor, manager or department head any suspected illegal, unethical and/or unprofessional conduct by another individual, illegal, unethical and or unprofessional conduct by any healthcare service providers are prohibited and/or state regulatory and/or legal authorities as mandated by statuette, hospital policy and/or regulation(s). It is the responsibility of all staff members and healthcare professionals of Perimeter Healthcare to report concerns regarding illegal, unethical and/or unprofessional conduct to hospital administration.

The hospital Policy on Ethics of Patient Care dated 04/21/2021 reflected, "Perimeter Healthcare shall operate using the standards for organizational ethics related to patient care decisions making."

The hospital Policy on Nursing Services dated 08/2020 Reflected, "It is the policy of Perimeter Healthcare Nursing Services Department to proved the highest attainable quality of nursing care to all patients consistent with the mission, values vision and goals...Providing acute psychiatric care for children and adolescents. The ages range from 5-17. The goal of this unit is to stabilize acute episodes of psychiatric disorders, create an individualized plan of care that includes developmental and age specific interventions, group and individualized therapies, play therapy, family therapy, school and plans for discharge back to their family or to the community in the least restrictive environment possible."