HospitalInspections.org

Based on medical record (MR) review, hospital policy and document review, and staff (EMP) interview, it was determined that the hospital failed to provide care in a safe setting (refer to A144); and failed to keep patients free from abuse (refer to A145); The cumulative effect of these deficient practices resulted in the hospital's inability to protect patient rights and ensure that patients received care in a safe setting.


Cross reference:
482.13(c)(2) Patient Rights: Care in a Safe Setting
482.13(c)(3) Patient RIghts: Free From Abuse/Harassment

Based on medical record (MR) review, policy review and staff (EMP) interview, it was determined that the hospital failed to ensure the safety of patients by failing to identify any potential causes or initiate measures to prevent re-occurrence of patient elopement during fire drills, thus potentially affecting the safety of all patients at the hospital. Findings include:

Hospital document titled "All-Hazards Emergency Response Plan", dated 4/25/22, stated, "...Evacuation ...If evacuation is required, employees and patients evacuate to the outside area designated for their unit or program. Hospital employees conduct a count of patients and personnel and notifies' the Safety & Security Officer immediately if they believe any persons were not successfully evacuated or may be trapped in the building ..."

Hospital policy titled "Inpatient Precautions - Elopement Precautions", revised 4/19, stated, " ...Staff shall provide appropriate assessment and observation of inpatients who have either verbally or non-verbally expressed a desire to elope ...The psychiatric practitioner shall order observation and precautions consistent with the assessed level of risk ...A patient on Elopement Precaution must be maintained on a 1:1, Line of Sight (LOS), or a Unit Restriction ..."

Hospital policy titled "Risk Management Incident Reporting Policy", reviewed 1/23, stated, " ...The Incident Report will help ...in identifying and analyzing potential areas of risk and implementing measures to improve the overall quality of care and promote a culture of safety throughout the facility ...5.0 Responsibility ...Facility Risk manager will investigate and will document the investigation's findings ...Facility Risk Manager will collect data for statistical analysis and trending as deemed appropriate ..."

Review of MR1 "Admission Psychiatric Evaluation" revealed Patient 1 was admitted on 8/8/23 voluntarily with diagnoses of bipolar affective disorder and alcohol use disorder.

Review of MR1 "Hospital Admission Order" dated 8/8/23 at 8:48 PM listed "Level of Observation" every 15 minutes, and precautions for seizure, fall, and moderate suicide risk.

Review of MR1 "High Risk Notification Form" dated 8/8/23 at 9:13 PM stated, " ...Elopement Risk ...N/A ..."

Review of MR1 "Narrative Daily Progress Note" dated 8/10/23 at 10:50 PM stated, " ...Pt irritable, agitated and impulsive. Snapping and verbally abusive to staff during dinner. Pt wanted to be D/C [sic] and became angry when told we did not have authority to do so. Pt proceeded to lie on the table in dayroom. During fire code, pt eloped, then was D/C'ed AMA ..."

Review of MR1 "Progress Note" dated 8/10/23 and timed 9:32 PM revealed the fire alarm sounded between 7:45 and 8:00 PM.

Nursing "Progress Note" dated 8/10/23 at 9:32 PM stated, "During the fire code ...while in hallway with other pts [patients], pt continued to go through doors against staff advice ...Pt ran along facility's hallway via the geriatric unit, then continued to front of facility to the lobby. Although pt was interrupted by staff, pt refused to be redirected, then went through the exit. At approximately 2056 hours [8:56 PM], Nursing Coordinator reported that [psychiatrist] was called and authorized pt to be D/C'ed [discharged] AMA [Against Medical Advice]. Police was [sic] also called, but ...did not do anything because pt signed into facility voluntarily."

During an interview on 9/26/23 at 2:50 PM, EMP4, Director of Risk stated an incident report was completed for this event/elopement. It was assigned as a "Level 3" risk score.

The hospital was asked to provide a copy of the investigative materials concerning this event. Materials included parts of the medical record and witness statements from nursing staff.

"Witness Statement" provided by EMP7, Behavioral Health Associate (BHA), stated, "...The fire alarm sounded. In route to go to the courtyard [Patient 1] ran through the hallway and out the door. He refused to come back in and because of the alarm and having a yard full of patients I couldn't force him to come into the courtyard."

EMP4, Director of Risk, did not include specific investigative findings in the documents provided. EMP4 stated this incident was classified as a "Level 3". "Level 3" investigation includes gathering witness statements and summarizing the incident. There was no evidence that the hospital's investigation included examining for possible causes of the elopement, or that the hospital implemented additional measures to prevent future elopements during fire drills.

During an interview on 9/26/23 at 3:35 PM, EMP2, Chief Nursing Officer (CNO), stated during a fire drill, each unit evacuates to a designated area, usually one of the courtyards. When the alarm sounds, all doors in the hospital automatically unlock. Staff on each unit are responsible for their patients and do head counts. No one is specifically assigned to watch exit doors. EMP2, CNO, stated, that during each fire drill, he/she worries because if all the patients wanted to leave at once, staff could never stop them.

Hospital policy "Fire Response Plan", dated 5/22, stated, "...Upon direction or immediate danger, hospital staff shall relocate the patients...to exterior secure courtyards. Staff will announce unit name and location once they arrive...Staff and Patients shall remain in these locations under staff control...".

Based on medical record (MR) review, hospital policy and document review, and staff (EMP) interview, it was determined that the Hospital failed to institute interventions to prevent sexual acting out in one patient (MR3), thus endangering 3 of 5 (MR2, MR4, MR5) patients sampled for sexual abuse. Findings include:


Hospital policy titled "Treatment Planning", revised 9/2016, stated, " ...The Multidisciplinary treatment plan will be individualized and identify the specific needs and goals of the patient and the specific interventions to be conducted by the staff to promote ongoing recovery ...Each clinical discipline develops the specific intervention(s) that they will utilize to support and assist the patient in achieving the objective by which the patient will advance toward a successful discharge and return to the community ..."

Hospital policy titled "Inpatient Room Assignment", reviewed 10/2016, stated, "...Procedure ...A. Clinical criteria ...Some of the issues that may impact on a decision to house two inpatients in the same room or separately include ...The assessed risk to carry out assaultive or sexually aggressive behavior ...Potential for sexual activity generally ...Any history of sexual or physical victimization ...The developmental age of the two potential roommates ...D. Reassessment ... Whenever patients are involved in assaultive incidents or other behaviors that put others at risk and/or any other new clinical information is received by the team that may impact on the clinical safety of the patients involved, the room assignment is re-assessed ..."

Hospital policy titled "Separation of Age Groups in Programs", reviewed/revised 10/2012, stated, " ...Room assignments are based on age. Children of the same gender ages 6-12 may share a room and adolescents of the same gender ages 13-17 may share a room. In special circumstances, mature 12 year olds may be roomed with adolescents ..."

Hospital policy titled "Inpatient Precautions - Sexual Acting Out Precautions" last reviewed/revised 4/2019, stated, " ...Sexual contact between patients while in the hospital, is against hospital policy for the following reasons ...to protect patients who may lack the cognitive capacity to consent to having sexual contact ...To protect patients who could be vulnerable to victimization or exploitation ...To prevent harm and promote safety, patients engaging in sexually abusive behavior may be subject to ...Placement in a room near the nursing station ...Placement in a room without a roommate ...Placement on LOS, 1:1 observation status or Unit Restriction ..."

Hospital policy titled "Risk Management Incident Reporting Policy", reviewed 1/23, stated, " ...The Incident Report will help ...in identifying and analyzing potential areas of risk and implementing measures to improve the overall quality of care and promote a culture of safety throughout the facility ...5.0 Responsibility ...Facility Risk manager will investigate and will document the investigation's findings ...Facility Risk Manager will collect data for statistical analysis and trending as deemed appropriate ..."



A review of MR3 revealed Patient 3 had a history of emotional, physical, and sexual abuse per the "Admission Psychiatric Evaluation" from 8/22/23 at 2:38 PM.

A review of MR3, "Psychosocial Assessment", dated 8/22/23, revealed, under the section "Sexual Orientation/Identity", Patient 3 identifies as bisexual, but prefers males.

Per review of MR3, a "Progress Note", dated 8/25/23 at 12:40 PM, stated, " ...Staff was made aware that this pt [patient] had a hickey and [patient] was seen coming from the bathroom near room...Incident report created. Pt now on SAO [sexually acting out] precautions and Q5 [every 5 minutes observation] while awake ...Pts separated ..."

Review of hospital document, "Incident Report Log", showed this incident was said to have occurred on 8/25/23 at 9:00 AM, and was assigned a severity index of "Level III - Minor".

When the hospital staff was asked to provide investigative materials for the 8/25/23 incident with Patient 3 and Patient 4, EMP4, Director of Risk, provided staff witness statements and the Incident Report log. No witness statements from Patients 3 & 4 were provided.

In an interview on 9/26/23 at 2:50 PM, EMP4 revealed that this incident was classified as "Level 3," and that "Level 3" investigations include gathering witness statements and summarizing the incident. There was no documented evidence of a review of facility procedures that may have contributed to the incident or any corrective actions that could prevent the recurrence of similar incidents.

Review of MR3 Practitioner Orders on 8/25/23 revealed orders for every 5 minutes observation and Sexually Acting Out precautions.

On 8/28/23, EMP8, Nurse Practitioner, discontinued every 5-minute observation and ordered every 15-minute observation - the minimum observation level for any patient at the hospital. Patient 3 remained on SAO precautions.

In an interview on 9/26/23 from 3:38 to 3:47 PM, EMP8, Nurse Practitioner, stated the criteria for discontinuing SAO precautions for Patient 3 included the discharge of Patient 4. When asked if interventions for SAO were discussed at Patient 3's multidisciplinary treatment meetings, EMP8 stated many of the therapeutic groups address boundary issues. Psychiatry would discuss impulse control.

In an interview with EMP2 on 9/26/23 between 12:40 and 2:50 PM, EMP2 confirmed the Interdisciplinary Treatment Plan for MR3 was not updated at this time to include SAO precautions.

Per the hospital document "Interdisciplinary Treatment Plan", the treatment plan typically lists long-term and short-term goals that are both measurable and individualized. The treatment plan also includes interventions that staff will use to assist the patient in achieving these goals.

MR3 revealed a similar incident occurring on 9/5/23. Hospital staff were asked to provide all investigative materials regarding the 9/5/23 incident. These included the Incident Report log and witness statements from Patient 3 and Patient 5. Patients 3 and 5 were the same gender.

Per the Incident Log, this event occurred on 9/5/23 at approximately 7:30 PM. The summary of the investigation stated, "Staff noticed a mark on [Patient 3's] neck ...Staff examined [his/her] neck and saw 2 bite marks. [Patient 3] admitted the marks were from [Patient 5] biting [his/her] neck. [Patient 3] stated this occurred during shower time in a room, but denied anything else inappropriate happened ...MD notified, pts both Q5 now".

"Witness Statement" dated 9/6/23 by Patient 3 stated, "Me and [Patient 5] were chilling in their room and ...they wanted to kiss me ...A kiss lead to more ...I broke up with them cause [sic] they kept dragging me to the shower to have sex ..."

"Witness Statement" dated 9/5/23 by Patient 5 stated, "Me and [Patient 3] are dating ...I broke up ...I got back together and [he/she] wanted me to bite [his/her] neck...[He/she] wanted me to be more sexual and stuff."

Review of MR3 revealed "Practitioner's Order" on 9/5/23 by EMP8, Nurse Practitioner, revealed an order for every 5-minute observation. On 9/6/23, EMP8, Nurse Practitioner, changed the order to every 5-minute observation while awake and every 15-minute observation while asleep.

In an interview on 9/26/23 from 3:38 to 3:47 PM, EMP8 was asked why Patient 3 had a roommate, and why the level of observation decreased to every 15 minutes while asleep, after two separate incidents of sexually inappropriate behavior. EMP8 assumed this was a safe situation as both roommates were of the same gender. EMP8 stated, "Obviously we were wrong."

On 9/12/23, EMP8, Nurse Practitioner, discontinued every 5-minute observation and reverted to the standard of every 15-minute observation.

During an interview on 9/26/23 at 3:38 PM, EMP8, Nurse Practitioner (NP), it was stated that Patient 3 was placed back on every 15-minute observation on 9/12/23 when Patient 5 was discharged from the hospital.

A review of MR3 revealed the Interdisciplinary Treatment Plan was again not updated to include SAO precautions after the second incident on 9/5/23. Patient 3 also remained with a roommate.

The hospital self-reported an incident occurring on 9/18/23 between Patient 3 and Patient 2.

Hospital staff were asked to provide investigative documents for the 9/18/23 incident. Hospital staff provided full investigative materials, including Governing Body Meeting minutes and recommended actions.

The hospital document "Witness Statement", obtained by hospital administration, and made by EMP11, nurse, stated, "During shift report on 9/18/23 the BHA [Behavioral Health Associate] came in and said [Patient 2] and [Patient 3] should be separated so...went out and moved [Patient 3] from the room to separate them."

The hospital document "Witness Statement", obtained by hospital administration, and made by EMP13, BHA, stated, " ...9/18 when I walked past their room [Patient 2] was pulling [his/her] pants up coming out of the corner behind the cabinet. [Patient 3] was also fixing [his/her] clothes ..."


A review of MR2 "Psychosocial Assessment" dated 3/2/23, revealed Patient 2 had an IQ score of 52. Per the hospital document "MeadowWood Hospital Intake Tier System", undated, " ...Profound IDD [intellectual and developmental disabilities] ..." is a " ...Tier 4 - Patient in this category have been determined by the medical staff to be outside the capability to provide care for the facility ..."

Interview of Patient 2 on 9/19/23, obtained by hospital administration, stated, " ...[Patient 3] was begging me saying [he/she] wanted to kiss me, and have sex with me. I said yes b/c [because] I didn't wanna [sic] hurt [his/her] feelings and [he/she] kissed me... and had sex with me ...". When Patient 2 was asked how this made them feel, [he/she] said, " ...Uncomfortable ...". When asked if Patient 2 felt safe, they stated, " ...No keep [Patient 3] away from me ..."

Interview of Patient 3 by hospital administration occurred on 9/19/23, in which Patient 3 stated, " ...It happened last night after 10...we kissed ... then I touched [Patient 2] ...it was consensual ..."

The hospital document "Witness Statement" from Patient 2 on 9/20/23 stated Patient 3 "...had sex with me...told me not to tell anyone but I told them anyways [sic] ...I told [him/her] no but [he/she] did it anyways ..."

A review of MR2, "Progress Note", on 9/19/23, revealed, "Pt being sent to ED for further evaluation of... pain and burning ..."

Both Patients 2 and 3 were placed on every 5-minute observations and SAO precautions on 9/19/23. Patient 3 was evaluated by EMP8, NP, and ordered "No roommate" on 9/19/23.

During an interview on 9/26/23 at 3:47 PM, EMP8, NP, stated they were not aware of Patient 3's sexual preference. EMP8 routinely asks patients if they are in an active relationship, but doesn't address sexual preference.

Review of MR3 revealed an "Interdisciplinary Treatment Plan" for SAO (Sexually Acting Out) precautions, instituted on 9/19/23.

Review of MR3 "SAO" Interdisciplinary Treatment Plan, dated 9/19/23, revealed the "Long Term Goal" "...will decrease overall intensity and frequency of angry feelings and increase ability to recognize and appropriately express angry feelings as they occur. Refrain from SAO". "Short Term Goals" read, " ...[Patient 3] will verbalize feelings of anger in a controlled, assertive way, refraining from SAO behaviors" The "Interventions" listed for physician, nursing, therapist, and activity therapist addressed medication effectiveness, monitoring behaviors to prevent harm to self or others, helping to develop techniques to deal with anger, and teach alternate techniques to handle angry feelings."

During an interview with EMP2, Chief Nursing Officer (CNO), on 9/26/23 from 12:40 to 2:50 PM, it was confirmed that the Interdisciplinary Treatment Plan did not contain individualized and specific goals for SAO precautions, and stated the plan seemed to address anger, not SAO behaviors.

An ad-hoc Governing Body meeting was held on 9/22/23 to address the alleged sexual assault.

Review of facility document "Governing Board Meeting Minutes," dated 9/22/23, revealed "The governing board reviewed the RCA [root cause analysis] and agreed that patients on sexual acting out precautions should be observed on Q5 minute [every 5 minutes] checks until further policy review and amendments occur...The CEO and Director of Quality will identify an appropriate evidence-based tool for review by the medical staff and quality council. At that point, policy revision and further staff training will occur by 10/15/23."

A review of the hospital document "Governing Board Meeting Minutes" dated 9/22/23, and a review of the proposed, unapproved hospital policy "Sexual Safety Precautions" revealed the amendments have yet to be finalized.