HospitalInspections.org

Based on document review and interview the facility failed to ensure that care was provided in a safe setting for two of two patients who were reported as having a sexual encounter that was not consensual after reports of being harassed was noted in the patients' medical records, Patients #1 and #2.

Findings Include:
1. The policy Patient Rights and Responsibilities, policy number ADM-RI-1-P, last revised/approved 7/18/16 indicated patients have the right to care in a "...safe environment, free from any form of abuse, neglect, or harassment...", and a right "To an environment and practices that will provide reasonable safety."

2. Review of the medical record for patient #1 indicated:
A. On 9/24/16 at 10:26 PM: "Overheard by peers and staff making sexually explicit remarks to a...peer. Pt. stated 'I don't have on underwear and it just might have to fall out for you.'...peer was also being fliratous (sic) and engaing (sic) in inappropriate conversation. Pt instructed about unit rules prohibiting this behavior and separated from this peer. Both individuals were compliant with instructions."
B. On 9/25/16 at 8:28 AM: "[another] Pt on unit came to nursing station complaining about said Pt sexually harassing [them] during breakfast and would not leave [them] alone. Pt was asked to go back to SRA (stimulus reduction area), Pt initially went and then returned to dayroom stating [pt] did not have to do what we said, Pt. visibly agitated. Pt. was given PRN (as needed) medications and took them PO (orally), Pt returned to SRA with security standing by without incident."

3. Review of the medical record for patient #2 indicated:
A. On 9/24/16 at 11:07 PM: "Out on the unit laughing and flirtatious with...peer to the extend (sic) of engaing (sic) in sexual indueno (sic) and inappropriate sexual statesment (sic). Pt observed and hear (sic) to be laughing and stating 'you really have a big one.' Instructed on appropriate behavior/speech as well as asked to move away from...peer. Pt. became sullen and quiet refusing to engage in conversation with staff for a short period of time...Not currently on birth control but has been heard to comment [pt] is interested in sex with peer."
B. On 9/25/16 at 1:30 PM: "Pt sitting back in SRA upset and tearful. Sitting beside...peer. Redirected that there is to be no contact between patients. Pt. complyed.(sic)."
C. On 9/27/16 at 9:45 PM: Tech was doing [their] 15 minute checks. Pt. was back in SRA and was not seen on camera. Tech went back to SRA and knocked on the bathroom door next to the exam room. [Pt. #2] was in the bathroom and stated it was just [them] in there. Tech then checked the other rooms and bathrooms for [pt.#1]. [Tech] then went back to the shower room bathroom and unlocked the door. [Pt. #2] was coming out fully clothed and the [other] pt. (#1) was pulling their pants up and adjusting [themselves]. Pt's were separated. [Pt. #2] intially (sic) denied sexual activitey (sic) [pt. #2] stated 'I in the bathroom and that [pt.#1] just came in there to use the bathroom. [Pt. #2] then stated [they] wanted to tell the truth about what really happened. [Pt. #2] stated that [pt. #1] followed [them] into the bathroom and asked if they could have sex. [Pt. #2] stated [they] said No, and then [they] said 'Well we can try it but it's not a good idea.' [Pt. #1] then proceeded to pull down [pt. #2's] pants. Pt. (#2) was taken out of SRA. Charge nurse notified."
D. On 9/27/16 at 10:00 PM: "Spoke with pt. about what happened with [pt. #1] in BR area. Pt said that [pt. #1] asked [pt] to have sex with [them] while they were both in SRA area. [Pt. #2] said that [pt #2] told [pt. #1] [they] did not want to have sex with [them]. [Pt. #2] then went to the BR and said pt. (#1) came into the BR a few minutes later. Pt said [pt. #1] was telling [them] how beautiful [pt] is and that [pt. #1] wanted to have sex with [pt. #2]. Pt said [they] said no again, but [pt #1] persisted and kept saying how beautiful [pt] is and then pulled [their] pants down. Pt. said [they] then told [pt #1] okay, and they had sex. Pt said [pt. #1] told [them] to say that [pt. #1] was not in the BR with [pt. #2], but [pt #2] told [Pt. #1 they] could not lie about this. Pt. (#1) said that [they] did not physically attack [pt. #2]. Pt. (#2) was moved out of the SRA area, and on call manager [staff member #54] was notified about the incident."

4. At 9:05 AM on 10/26/16, interview with the nurse manager of the Psych 2 nursing unit, staff member #53, confirmed that they "can't answer" why patient #2 wasn't separated from patient #1 previous to 9/27/16 when the medical records indicated by staff notes that patient #2 was flirtatious with patient #1 and engaged in sexual innuendo and inappropriate sexual statements on two different dates (9/24/16 and 9/25/16) and had been heard to comment they were interested in sex with a peer. Staff member #53 stated that they had been unaware of this documentation.

Based on document review and interview the nursing staff failed to update the patient's plan of care (Master Treatment Plan) after a reported sexual encounter occurred for 1 of 1 patient reporting the event, Patient #2.

Findings Include:
1. The policy Multidisciplinary Treatment Plan - Psychiatry, policy number PSY-024-P, last revised/approved 6/17/14 indicated under "Procedure", in item 4.: "The MTP (master treatment plan) is reviewed and/or revised at least every 7-10 days by the treatment team."

2. Review of the medical record for Patient #2 indicated:
A. The patient was admitted on 9/22/16 and had a MTP created on 9/23/16.
B. A tech note at 9:45 PM on 9/27/16 indicated the patient reported a sexual encounter with another patient that at first was stated as consensual, but later stated was rape and wanted the other patient "prosecuted".
C. The MTP was noted as reviewed related to "Goal #2" on 9/30/16 and 10/17/16 and signed off by one staff member.
D. There was no addition or update to the MTP related to the patient's event of 9/27/16 and any safety precautions that might have been implemented to ensure the prevention of such an event in the future.

3. At 9:05 AM and 11:15 AM on 10/26/16, interview with the nurse manager of the Psych 2 nursing unit, staff member #53 confirmed that:
A. The multidisciplinary team rounds each day to discuss patients, their goals and their progress, but this is not documented clearly in patient charts.
B. There was no update to the treatment plan for Pt. #2 related to the reported rape on 9/27/16 and the safety precautions implemented.

4. At 12:20 PM on 10/26/16, interview with the director of quality/risk, staff member #52, confirmed that:
A The Treatment Plan policy is not specific about additions/changes/updates that need to be made to treatment plans with changes in patient events or needs while on the unit.
B. The policy indicated (in item #4) that the treatment team would review/revise the plan every 7 to 10 days, but only one member of the team signed off on the treatment plan for patient #2 on 9/30/16 and 10/7/16 as having reviewed the MTP.
C. There is no documentation to indicate the treatment team, as a whole, is reviewing/revising MTPs.

Based on document review and interview the nursing supervisor failed to ensure staffing, as per facility requirements, during the week of 9/18/16 to 9/24/16 and during the time of the reported sexual contact with 2 patients on 9/27/16, Patients #1 and #2,

Findings Include:
1. Review of the BMH (Ball Memorial Hospital) Adult staffing matrix indicated:
A. The day shift (Nursing Shift 1) was to have 2 nurses for 10 patients and 3 for 11 to 16 patients, the evening shift was to have 2 nurses for 10, 11 and 12 patients with 3 for 13, 14,15 and 16 patients, the night shift was to have 2 nurses for 1 to 16 patients.
B. At least one RN must be present on each shift.

2. Review of the staffing grid provided by the facility indicated staffing was not per the Staffing matrix as only 1 nurse was present on both 9/19/16 and 9/20/16 with 10 anand 11 patients respectively on the night shift, and there are to be 3 nurses on the day shift with 11 or more patients with 9/20/16 only having 2 present for 11 patients.

3. Review of the medical record for patient #2 indicated: On 9/27/16 at 9:45 PM: Tech was doing [their] 15 minute checks. Pt. (#2) was back in SRA (stimulus reduction area) and was not seen on camera. Tech went back to SRA and knocked on the bathroom door next to the exam room. [Pt. #2] was in the bathroom and stated it was just [them] in there. Tech then checked the other rooms and bathrooms for [pt.#1]. [Tech] then went back to the shower room bathroom and unlocked the door. [Pt. #2] was coming out fully clothed and the [other] pt. (#1) was pulling their pants up and adjusting [themselves]. Pt's were separated. [Pt. #2] intially (sic) denied sexual activitey (sic) [pt. #2] stated 'I in the bathroom and that [pt.#1] just came in there to use the bathroom. [Pt. #2] then stated [they] wanted to tell the truth about what really happened. [Pt. #2] stated that [pt. #1] followed [them] into the bathroom and asked if they could have sex. [Pt. #2] stated [they] said No, and then [they] said 'Well we can try it but it's not a good idea.' [Pt. #1] then proceeded to pull down [pt. #2's] pants. Pt. (#2) was taken out of SRA. Charge nurse notified."

4. Review of the RCA (root cause analysis) document (performed after the 9/27/16 incident) indicated action items included: Action Item #4: Verify staffing concerns identified in the investigation - no RN on the Psych 2 unit and only 2 staff left for 10 patients for at least 20 to 25 minutes. Requirements will be reported to risk management. (Due date = 10/11/16)

5. At 12:30 PM on 10/26/16, interview with the director of quality/risk, staff member #52, confirmed that:
A. A RCA was done with action items determined including one related to staffing concerns that were identified in the investigation that the one RN (registered nurse) and one tech had left the unit and only two staff were present for at least 20 to 25 minutes.
B. A phone call with the director of the unit indicated the RN left the unit to go to another nursing unit to assist staff with a computer question/issue and a tech left the unit to escort an elderly volunteer to their car in the parking garage. This left only one LPN (licensed practical nurse) and one tech to care for the patients on the unit at that time.
C. The tech who left the unit was the staff member monitoring the video feed in the SRA so that no one was observing patients #1 and #2 (by video) who were housed in that area for a period of time.
D. Staffing was not maintained as per expectations and policy with no RN on the unit and no staff were monitoring the video continuously, as required.