HospitalInspections.org

Based on interviews and record review (RR), the hospital failed to provide evidence that a timely, thorough investigation was completed after one patient (P)1 reported she had been inappropriately touched by another patient. When P1 verbalized fear of a second male patient, the facility did not take a proactive approach to investigate her concern further or identify that patient. In addition, the facility was unable to provide documentation that criminal background checks had been completed for all employees at the time of hire. As a result of these deficiencies, there is the potential patients are not protected from potential abuse.

Findings include:

1) On 12/30/21 the Office of Healthcare Assurance (OHCA) received a facility initial report (FRI) that "Patient (P1) reported that she was touched inappropriately in the crotch area by a male peer [another patient]. On 01/07/22, OHCA received the completed report with the following information: " On 12/24/21 patient casually stated to Staff RN, "I wasn't gonna say anything, but I just thought you should know that about three days ago a male peer had thrust his hand on her medial buttocks towards the middle of her legs. Patient then stated that she told him (via the sign language she knows), to stop, that wasn't okay, and that the male peer then apologized. Patient was vague about when it happened, who was around, left out any details, and stated that she didn't' report it earlier because she didn't want to "bring it up and was just gonna let it go." No specific indication of why it was brought up at this time."

The FRI documented facility interventions implemented were: "Strict adherence to social distancing by all patients (at least 6 feet [COVID guidelines]), Q (every) 15 minute monitoring of all patients, Patients taught/reminded about personal boundaries (also that they have the right to enforce and create their own boundaries and not let others in their space."

RR revealed P1 was a 27-year old female with a history of post traumatic stress disorder (PTSD), severe anxiety, major depression disorder and history of suicide attempts. She was admitted via voluntary status to the hospital behavioral health unit (Molokini) on 12/07/2021 for suicidal ideation.

Reviewed the hospital policy titled "Abuse, Neglect and Exploitation" last revised date 09/2019. The policy statement included: "1.2 A suspicious or report of adult or child abuse, neglect or exploitation requires prompt investigation and reporting."
The procedure included:
"5.2.4 Appropriate Department Manager or designee and leadership team will investigate and gather facts about the patient care concern."
"5.2.5 Quality Management will assemble Advisory Core Team (Social Work Services, Human Resources, Risk Management to meet with the Department Manager to a. Review information. b. Provide feedback and guidance."
"5.2.7 Report findings to external authorities and protective agencies, as appropriate."

RR of progress notes revealed the following pertinent notes:
12/24/2021 at 04:50 PM by RN2: "At about 1630 (04:30 PM) pt (P1) reported to another RN(1), "About 3 days ago (a male peer) grabbed me in the crotch from behind." "I told him no, no please stop. That isn't OK. Then, he apologized." MD informed, Nurse Manager informed. Pt given MPD (Maui Police Department) non-emergency number and encouraged to file a report."
12/24/21 at 07:40 PM by RN2: "1 Maui Police officer arrived at 1910 (07:10 PM). Pt is currently in the conference room of the PHP (unlocked) unit to make the report; also accompanied by 1 RN and 1 security officer. ..."
12/28/21 at 06:17 AM by RN3: "...She (P1) had multiple complaints about how her PTSD has been triggered throughout the day and she has been "crying my eyes out." She states when other staff members attempted to give her suggestions, it just frustrated her more and felt it was not the appropriate response. She states she does not feel safe here, especially with a particular male peer. Reinforced that we will be checking on her frequently throughout the night when she stated she felt secure at night, it is only the daytime when everyone awake."

On 03/03/22 during an interview with the Quality Director (QD), requested all documentation of the facility investigation regarding P1's allegation. At that time inquired who interviewed P1 after the incident was reported. The OD she said the Social Worker (SW) was the one that interviewed P1. The facility provided emails regarding the OHCA report, and the facility unusual occurrence report, but there was no additional documentation of interviews or investigation findings.

On 03/03/22 at 01:15 PM, during an interview with the Charge Nurse (CN), he said he was made aware of the incident by another RN. Inquired if he spoke with or interviewed P1 or the RN she told about the incident, he said no. The CN said he could not recall all the details or if the manager was notified. When asked if he would consider this an allegation of abuse, he replied, "Yes, she was allegedly touched, sexually inappropriate." Inquired how you should protect the alleged victim (AV), the CN said it depends on the situation, we could go as far as a 1:1 sitter if needed. When asked if he knew who the alleged perpetrator (AP) was, he said no.

On 03/03/22 at 01:45 PM, during an interview with the SW, she said her role in the incident was to complete the OHCA report. When asked if she interviewed P1, she replied "no." The SW said she got the information for the OHCA report from the facility occurrence report and then shared the draft report with several individuals before sending it out.

On 03/04/22 at 11:30 AM conducted an interview with the Quality Director (QD) and Risk Manager (RM).
The QD said she did not have any direct involvement with this incident and said she was mistaken when she informed surveyor that the SW had done the interview with P1. The QD said she was sure the Unit Manager (UM) had investigated the event and referred to the documentation in the occurrence report.

The RM said she saw the occurrence report and notified the Unit Manager (UM) who coordinated the investigation. The UM was unavailable for interview as she was out on leave. The RM said the SW completed the OHCA report based on the information in the occurrence report, and then would touch base with the UM for more details for the completed (final) report. When inquired if the Advisory Core Team met regarding this incident, the RM said no, as didn't appear to require it.

The facility internal occurrence report was reviewed together with the QD and RM. It was noted there was a difference in the OHCA report and the internal occurrence report specific to the AP. The OHCA report said "by a male peer," and the occurrence report read "...I just thought you should know that about three days ago [male peer name] did this to me." The documentation did not include a name of the AP, and it could not be validated if the UM knew the name of the AP (peer/patient) or not. The RM said she thought the UM knew who the AP was, but could not say so definitively. If the AP was known, there was no documentation of follow-up with his MD, interview, interventions implemented or additional monitoring.

The QD and UM both agreed the investigation lacked documentation.

RR revealed there was no evidence P1 was interviewed by the UM or designee after the incident was reported. The facility did not interview RN1, who P1 reported the incident to, or the unidentified RN or security present during the police interview. In addition, there was no follow up after P1 reported being fearful of a second male patient. This patient was not identified and there was no further documentation of her concern.

2) Surveyor requested criminal background check information for four current staff (S1, S2, S3, and S4). The facility was able to provide documentation of background check for one (S1) of the four staff. In response to Surveyor request, an email dated 03/04/22 at 12:38 PM from the Human Resource Director to Quality Improvement read "We do not have access to Background Check information for any employees who transitioned from Hawaii Health System Corporation (HHSC), based on the legislative requirements that were put in place when HHSC transitioned to Maui Health System (MHS). The language mandated that MHS would neither redo nor conduct any Background Checks or Drug Screens for transitioning employees.