HospitalInspections.org

Based upon Health Care Personnel Registry review, policy and procedure reviews, medical record reviews, staffing assignment reviews, and staff interviews, the hospital failed to be in compliance with Federal and State laws by not reporting an allegation of staff to patient sexual abuse for 1 of 1 patient (#6).

The findings include:

Health Care Personnel Registry general information review revealed when allegations of suspected patient abuse, listed in North Carolina General Statue 131E-256 (a)(1), involving unlicensed health care workers, health care employers are required to submit reports to the Health Care Personnel Registry (HCPR) Investigations Branch.

Policy and procedure reviews on 07/16/2014 revealed the hospital had neither a "24-hour" nor a "5-day working" policy to ensure allegation(s) of abuse were reported in accordance with Federal and State laws.

Closed medical record review on 07/17/2014 revealed the patient, #6, a 38-year-old voluntarily presented to Hospital XXX emergency department on 05/13/2014 at 1814 with complaints of visual hallucinations and suicidal thoughts without a plan to inflict self-harm. Review revealed the patient's past medical history included schizophrenia (abnormal thought process). Further review revealed the patient was monitored for safety and at 1920, a physician from Unit #1 was consulted. Review revealed on 05/14/2014 at 1219, the patient was transferred from the emergency department to Unit #1 with an admitting diagnosis of schizoaffective disorder (abnormal thought processes with mood disorder). Further review revealed at 1437, the ordering physician ordered suicide monitoring with every fifteen (15) minutes visual checks. Further review revealed the patient was monitored for suicide precautions by a female staff members on 05/14/2014, 05/15/2014, and 05/17/2014. Further review revealed on 05/16/2014 from 0636 to 1901, the patient was monitored for suicide precautions by male staff #1. Further review revealed on 05/18/2014 from 1900-2100, the patient was monitored for suicide precautions by male staff #2. Further review revealed from 05/18/2014 at 2220 until 05/20/2014 at 1145, the patient was monitored for suicide precautions by contract staff (male and female).
Review revealed on 05/19/2014 at 1517, Counselor #1 "Met with patient per pt [patient] request. Pt stated that [patient] needed to contact the pt advocate. Stated that one of [patient's] 1:1 care givers had sexually abused [patient]. The patient stated that [staff unknown] displayed [staff body part] to the [patient], then later, while [patient] was using the bathroom, [staff unknown] forced [patient] to perform [sexual act]." Further review revealed Counselor #1 instructed the patient "to wait until [patient] was well enough to make a rational decision..." Review revealed no documentation that Counselor #1 reported the allegation of sexual abuse in accordance with State and Federal laws.
Review revealed on 05/21/2014 at 1204, Counselor #1 informed Psychiatrist #1 of the alleged sexual attack during the 05/20/2014 treatment team meeting. Further review revealed the patient "reported [first name of male staff #1] sexually attacked" [patient]. Further review revealed Psychiatrist #1 met with the patient, at which point in time the patient explained (male staff #1) "insisted" that the patient leave the bathroom door open while the patient used the bathroom. Further review revealed Psychiatrist #1 described the patient as "construed in [patient] own delusional way that is akin to sexual assault. [Patient] did not report [male staff #1] because [patient] was afraid that hospital will be hard on [patient] to protect one of their own. ..." Further review revealed Psychiatrist #1 explained to the patient that leaving the bathroom door open was a precaution and part of the 1:1 monitoring policy. Further review revealed Psychiatrist #1 explained to the patient "that no action will be taken against [male staff #1]" and encouraged the patient to report the next time "anything happened. ..." Review revealed no documentation that Psychiatrist #1 reported the allegation of sexual abuse in accordance with State and Federal laws.

Interview on 07/17/2014 at 1348 with Counselor #1 revealed on 05/19/2014, the patient requested to speak with Counselor #1 related to a "1:1 worker forced a patient to perform (sexual act). Further interview revealed the patient stated the first name of the alleged abuser. Further interview revealed the patient had not reported the alleged sexual act and the Counselor #1 was the first staff member informed of the incident. Further interview revealed Counselor #1 spoke with the patient's assigned nurse and notified the Director of Unit #1. Further interview revealed Counselor #1 described the patient as "delusional" (unrealistic) because the patient wanted to file a civil law suit. Further interview revealed Counselor #1 stated to the patient "to wait until mental state was clearer before filing a complaint." Interview revealed Counselor #1 failed to report an allegation of sexual abuse in accordance with State and Federal laws.

Interview on 07/17/2014 at 1409 with the Unit Director revealed on 05/19/2014, Counselor #1 informed this staff of the alleged sexual abuse. Further interview revealed the Unit Director informed Psychiatrist #1 of the alleged sexual abuse the same day. Further interview revealed Psychiatrist #1 "felt the patient was delusional." Further interview revealed the Unit Director thought the alleged sexual assault occurred 05/19/2014 when the patient was monitored by a male contract staff. Further interview revealed the Unit Director failed to perform a comprehensive staff assignment review for the patient's entire hospitalization which would have revealed on 05/16/2014, male staff #1 was assigned 1:1 monitoring for the patient. Interview revealed the Unit Director failed to report an allegation of sexual abuse in accordance with State and Federal laws or according to HCPR guidelines.

Telephone interview conducted on 07/21/2014 at 1551 with Health Care Personnel Registry revealed Hospital XXX administrative staff had not filed a twenty-four (24) hour nor a five (5) day working report concerning male staff #1 related to the alleged staff to patient abuse.

Based upon policy and procedure reviews and medical record reviews, the hospital staff failed to provide a behavioral health patient privacy during personal hygiene for 1 of 1 patients (#6).

The findings include:

Review of the Hospital XXX policy, "Therapeutic Environment" with a revision date of 12/01/2013 revealed "APPLICABILITY: ...POLICY: ...PURPOSE: ...and privacy in a therapeutic setting. ..."

Closed medical record review on 07/17/2014 revealed the patient, #6, a 38-year-old voluntarily presented to Hospital XXX emergency department on 05/13/2014 at 1814 with complaints of visual hallucinations and suicidal thoughts without a plan to inflict self-harm. Review revealed the patient was monitored for safety and at 1920, a physician from Unit #1 was consulted. Review revealed on 05/14/2014 at 1219, the patient was transferred from the emergency department to Unit #1 with an admitting diagnosis of schizoaffective disorder (abnormal thought processes with mood disorder). Further review revealed at 1437, the ordering physician ordered suicide monitoring with every fifteen (15) minutes visual checks. Further review revealed the patient was monitored for suicide precautions by a female staff members on 05/14/2014, 05/15/2014, and 05/17/2014. Further review revealed on 05/16/2014 from 0636 to 1901, the patient was monitored for suicide precautions by male staff #1. Further review revealed on 05/20/2014, Psychiatrist #1 met with the patient, at which point in time the patient explained (male staff #1) "insisted" that the patient leave the bathroom door open while the patient used the bathroom. Further review revealed Psychiatrist #1 explained to the patient that leaving the bathroom door open was a precaution and part of the 1:1 monitoring policy. Review revealed no documentation that the patient was provided privacy during hygiene care.

Based upon policy and procedure reviews, medical record reviews, staffing assignment reviews, and staff interviews, the hospital staff failed to ensure a behavioral health patient was not abused by failing to report an allegation of staff to patient sexual abuse for 1 of 1 patient (#6).

The findings include:

Policy and procedure reviews on 07/16/2014 revealed the hospital failed to provide a policy for reporting any incidents of abuse.

Closed medical record review on 07/17/2014 revealed the patient, #6, a 38-year-old voluntarily presented to Hospital XXX emergency department on 05/13/2014 at 1814 with complaints of visual hallucinations and suicidal thoughts without a plan to inflict self-harm. Review revealed the patient's past medical history included schizophrenia (abnormal thought process). Further review revealed the patient was monitored for safety and at 1920, a physician from Unit #1 was consulted. Review revealed on 05/14/2014 at 1219, the patient was transferred from the emergency department to Unit #1 with an admitting diagnosis of schizoaffective disorder (abnormal thought processes with mood disorder). Further review revealed at 1437, the ordering physician ordered suicide monitoring with every fifteen (15) minutes visual checks. Further review revealed the patient was monitored for suicide precautions by a female staff members on 05/14/2014, 05/15/2014, and 05/17/2014. Further review revealed on 05/16/2014 from 0636 to 1901, the patient was monitored for suicide precautions by male staff #1. Further review revealed on 05/18/2014 from 1900-2100, the patient was monitored for suicide precautions by male staff #2. Further review revealed from 05/18/2014 at 2220 until 05/20/2014 at 1145, the patient was monitored for suicide precautions by contract staff (male and female).
Review revealed on 05/19/2014 at 1517, Counselor #1 "Met with patient per pt [patient] request. Pt stated that [patient] needed to contact the pt advocate. Stated that one of [patient's] 1:1 care givers had sexually abused [patient]. The patient stated that [staff unknown] displayed [staff body part] to the [patient], then later, while [patient] was using the bathroom, [staff unknown] forced [patient] to perform [sexual act]." Further review revealed Counselor #1 instructed the patient "to wait until [patient] was well enough to make a rational decision..." Review revealed no documentation that Counselor #1 ensured the patient was not abused.
Review revealed on 05/21/2014 at 1204, Counselor #1 informed Psychiatrist #1 of the alleged sexually attack during the 05/20/2014 treatment team meeting. Further review revealed the patient "reported [first name of male staff #1] sexually attacked" [patient]. Further review revealed Psychiatrist #1 met with the patient, at which point in time the patient explained (male staff #1) "insisted" that the patient leave the bathroom door open while the patient used the bathroom. Further review revealed Psychiatrist #1 described the patient as "construed in [patient] own delusional way that is akin to sexual assault. [Patient] did not report [male staff #1] because [patient] was afraid that hospital will be hard on [patient] to protect one of their own. ..." Further review revealed Psychiatrist #1 explained to the patient "that no action will be taken against [male staff #1]" and encouraged the patient to report the next time "anything happened. ..." Review revealed no documentation that Psychiatrist #1 ensured the patient was not abused.

Interview on 07/17/2014 at 1348 with Counselor #1 revealed being approached by the patient while in the hallway on 05/19/2014. Interview revealed the patient requested to speak with Counselor #1 related to a "1:1 worker forced patient to perform (sexual act). Further interview revealed the patient stated the first name of the alleged abuser. Further interview revealed the patient had not reported the sexual abuse and the counselor was the first staff member informed of the incident. Further interview revealed Counselor #1 spoke with the patient's assigned nurse and notified the Unit Director. Further interview revealed Counselor #1 described the patient as "delusional" (unrealistic) because the patient wanted to file a civil law suit. Further interview revealed Counselor #1 stated to the patient "to wait until mental state was clearer before filing a complaint." Interview revealed Counselor #1 failed to ensured the patient was not abused.

Interview on 07/17/2014 at 1409 with the Unit Director revealed on 05/19/2014, Counselor #1 informed this staff of the alleged sexual abuse. Further interview revealed the Unit Director informed Psychiatrist #1 of the alleged sexual abuse the same day. Further interview revealed Psychiatrist #1 "felt the patient was delusional." Further interview revealed the Unit Director thought the alleged sexual assault occurred 05/19/2014 when the patient was monitored by contract staff. Further interview revealed the Unit Director was unable to confirm the identity of the alleged abuser. Interview revealed the Unit Director failed to comprehensively review the nursing assignment for the entire patient's hospitalization. Interview revealed the Unit Director failed to ensure the patient was not abused.

Interview on 07/17/2014 at 1551 with Hospital Administration staff #1 revealed the Hospital Administration was unaware of the alleged sexually abuse prior to DHSR (Division of Health Service Regulation) survey. Further interview revealed Hospital Administration staff #1 learned the alleged sexually abuse during the DHSR survey staff interviews. Further interview revealed staff were encouraged to report "everything" via the non-punitive electronic incident reporting system. Interview revealed no documentation that an electronic incident report was processed related to the alleged staff to patient abuse.

NC00097614