HospitalInspections.org

Based on document review and staff interview it was determined the facility failed to ensure all patients were kept free from all forms of abuse or harassment for one (#2) of ten sampled patients from a census of 22 patients on the Behavioral Health Unit.

Findings include:

Review of documentation revealed the facility was made aware of an allegation of sexual abuse by another agency on 2/13/2015. On 2/10/2015 a representation from the other agency presented to the BHU (Behavioral Health Unit) concerning the allegation.

On 3/3/2015 at 9:50 a.m. the Charge Nurse on the BHU, that had contact with agency staff member, was interviewed. She stated she spoke with the agency member on 2/10/2015. The agency staff member interviewed another staff member, obtained the contact information of two other staff members and left the unit. The Charge Nurse stated the agency member did not disclose the name of the patient or the nature of the allegation. The Charge Nurse stated she did not notify risk management the agency member was on the BHU on 2/10/2015.

On 2/13/2015 the agency staff member called the BHU and spoke to the Charge Nurse. At that time the agency staff member informed the nurse a patient alleged sexual abuse by two staff members while a patient in the BHU on 1/25/2015. The Charge Nurse immediately notified risk management of the allegation.

Interview with the risk manager on 3/2/2015 at approximately 11:50 a.m. revealed the facility initiated an investigation and the two alleged staff members placed on suspension.

On 2/24/2015, approximately fourteen days after the initial contact with the agency staff member, the Charge Nurse reviewed the video of the alleged date and found concerns. On 2/26/2015, approximately sixteen days after the initial contact, the risk manager reviewed the video and found concerns. One of the staff members also admitted to seeing the patient "on the streets" and exchanging phone numbers.

Review of the patient's record revealed the patient had been adjudicated incompetent and the patient's parent was appointed guardian by the court. During a 2/25/15 meeting with the patient and guardian the patient's phone was reviewed by the team resources manager. The review revealed text message exchanges between one of the staff members and the patient. The conversation was initiated by the staff member and the content of the text messaging was inappropriate and sexual in nature. The staff member requested inappropriate pictures of the patient.

Review of the facility documentation and staff interview with the risk manager and BHU manager revealed no evidence the facility reviewed any other video footage to ensure all patients were kept safe while in the care of the alleged staff members, the rationale for a delay in a viewing the video or why the initial staff member did not notify risk management of the agency staff member visit on 2/10/15.