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Based on policy review, medical record review, incident and grievance log reviews, and staff and physician interviews the hospital failed to ensure a patient's right to be free from abuse by failing to investigate an allegation of patient to patient sexual abuse per policy for 1 of 1 allegations reviewed (Patient #3).

The findings included:

Review of a policy titled "Reporting and Investigating Patient Neglect, Abuse, and Exploitation", review date 01/2019, revealed "...It is the policy of (name) to prohibit the abuse, neglect or exploitation of patient in any manner from staff, patients or visitors....DEFINITIONS....1. Abuse a....Examples include....sexual offense (sexual boundary violation, sexual assault)....2. Special Situations: Outside Phone Call or Discharged Patient/Family Complaining of Abuse, Neglect or Exploitation....iii. If an employee receives a direct call, he/she shall report it to the supervisor and initiate an occurrence/incident report. The supervisor will contact the Risk Manager or designee, who will in turn make contact to gather further information as outlined in this policy....k....If the supervisor receives a report of suspected abuse, neglect or exploitation after normal business hours, he/she will immediately relay the information to the House Supervisor who will report the incident to the administrator on-call and attending physician. The Nurse Supervisor will then provide the occurrence/incident report form to the PI (Performance Improvement) Director/Risk Manager's office. The PI Director/Risk Manager will notify the Patient Advocate. ..."

Medical Record review, on 07/16-17/2019, revealed Patient #3 was admitted on 05/16/2019 for worsening depression, alcohol withdrawal and anxiety. Review of the RN (Registered Nurse) Admission Note, dated 05/16/2019 at 2235, revealed the patient was admitted for alcohol detox and was involuntarily committed (IVC) for suicidal ideation with a plan. Review of the Psychosocial Assessment revealed the Patient #3 had a past medical history including physical, emotional, and sexual abuse. Review of a Nurse Progress Note, dated 05/18/2019 at 1437, revealed "...At approx (approximately) 1345 a phone call was received ....The caller .... wanted to speak to the highest ranking person in the building. (First and Last Name), Nursing Supervisor was present when the call was answered. She deffered (sic) to this staff member due to lack of familiarity with the patient.... stated that a male patient had exposed himself to (patient) and asked (patient) 'how she like the size of that xxx.' Says (patient) was touched and held by a male peer. States that the other patient's called her a 'princess' and that she 'better get over it.' I informed (family member) that patient had not reported any of this to staff but it was extremely concerning and I would talk with (patient) to get details about the allegations. (Family member) expressed concern that the patients would retaliate against her. Assured .....that (patient's) safety is of paramount importance to us.... At the conclusion of the call I engaged (patient) in a 1:1 discussion to obtain additional information about the alleged occurances (sic) Informed patient about the phone call with (family member) & ... concern for her safety and appropriate actions would be taken. (Patient) stated her (family member) is older & very protective.... doesn't believe I can take care of myself.' Assured (patient) that we were concerned for her safety & we would like to hear what happened so we could address the issue. Pt (Patient) stated that no one had exposed themselves to her or discussed their genitals with her. 'One of the guys was slouched down in the chair and had his hands in his pocket. There was some movement but that's it.' Stated no one had touched her or held her. Says no one called her princess. Stated that one of the peers was 'teasing' her roommate (sic) and calling her roommate (sic) Princess but never her. Agreed it could get loud in the Day Area near the phones and occasionaly (sic) inuendos (sic) were made. 'When things get too loud I go to my room & read.' ....Again assured (patient) of our concerns for (patient's) safety. Encouraged .... not to hesitate to seek out a staff member if at any time.... feels unsafe. Verbalized understanding. Following 1:1 discussion I notified (name) RN/ Nsg (Nursing) Supervisor of details of both conversations. Discussed concerns r/t (related to) possible inappropriate sexual behavior by patient with staff members and requested vigilance. Message left on Internal Communication sheet for Dr. (Name). ... " Review of handwritten notes on "Inpatient Physician Note" form, dated 05/19/2019 at 1130 revealed "...Had mentioned last night to staff someone had shown her penis (as written). Later on denied.... can consider abilify if.... (next handwritten word is not clear) paranoid ....(word written after paranoid is not identifiable) says it was a flashback from past. ..." Review of the Daily Nurse Progress Notes, on 05/19/2019 at 1314, revealed "....appears anxious....Feels unsafe due to milieu....Pt has been in and out of room for meals & visitation. Refused to come out for medications; Requested that medications be delivered to room. Reports history of PTSD (post traumatic stress disorder) that was triggered by incident in milieu 'It was like I was right there again'... ." Review of the Discharge Summary, dated 05/20/2019, revealed "...On May 20, 2019, the patient requests her discharge ASAP as the patient reports feeling triggered by other patients on the unit. The patient has had a history of PTSD and the patient appears very anxious, irritable, reports further inpatient stay would not be beneficial for the patient .... also reports further inpatient stay would be detrimental, would cause more anxiety.... so a decision is made to discharge the patient. ..." Review of Nursing Notes revealed Patient #3 was discharged home on 05/20/2019 at 1641.

Review of the incident report log and grievance log revealed no incident or grievance was filed related to the family member's allegation of sexual abuse.

Interview with Nursing Supervisor #1 (Supervisor #1), on 07/17/2019 at 1320, revealed Supervisor #1 recalled Patient #3 . Interview revealed the Supervisor did not speak with the family member on 05/18/2019. Interview revealed the Supervisor did speak with the family member face to face on 05/19/2019. Interview revealed the family member stated someone had exposed himself to the patient. Supervisor #1 stated she did not ask the patient about the incident, that the nurse indicated the patient denied any of it happened. Interview revealed when a family member calls with a complaint like this, they (the staff) go to the patient to see what the patient says/ feels. The interview revealed Supervisor #1 did not notify the Administrator on call, stating the supervisor would notify the Administrator on call if the patient stated the same thing as the family member.

Interview with a Patient Advocate on 07/17/2019 at 1415 revealed the advocate was not aware of this allegation. Interview revealed on the weekends the Supervisors "are in my place", but the advocate would generally be made aware of the issue on Monday. Interview revealed if she had been aware she would have followed up with the patient and family member.

Interview with MD #1 (the attending Psychiatrist for Patient #3), on 07/17/2019 at 1455, revealed MD #1 was not aware of the family member's complaint or request for a phone call. Interview revealed MD #1 did not speak with the family member and did not discuss the allegation with the patient because "I was not aware". Interview revealed MD #1 only read the communication sheet when it was flagged and generally relied on verbal reports from nursing.

Interview on 07/17/2019 at 1530 with RN #2 revealed the RN received a phone call from the family member who stated Patient #3 was sexually abused by another patient at the facility. Interview revealed the patient had not voiced any concerns or complaints, so the RN talked with the patient one on one and asked if there were any problems/ concerns. Patient #3 said no, interview revealed, so RN #2 asked specifically about the family member's allegation. The patient said the family member was "overblowing things". RN #2 stated she notified both the Supervisor and the weekend physician and put a note on the internal communication sheet. Interview revealed Patient #3 was secretive in her phone conversations and RN #2 continued to check in to be sure the patient was okay. RN #2 stated that she did not recall if she did an incident report. Interview revealed RN #2 was not aware of what the abuse policy said. RN #2 stated she notified the supervisor of the concern of possible patient to patient abuse to find out what she should do and did what she was instructed.

Interview on 07/17/2019 at 1615 with a Clinician / Therapist (LCSWA) revealed she completed a family session with the patient and family member prior to discharge on 05/20/2019. Interview revealed the Clinician was not aware of any issues that happened on the weekend.

Telephone interview on 07/17/2019 at 1830 with the weekend rounding psychiatrist (MD #2) revealed the MD sees every patient on weekends when rounding. Interview revealed MD #2 did not recall what the patient said to him. MD #2 read the Progress Note dated 05/19/2019 at 1130 and revealed it indicated the staff member said the patient denied it. Interview revealed that based on the Progress Note MD #2 believed the incident was discussed with Patient #3 and the patient did not "elaborate" and/or was elaborating it as a flashback. Further interview revealed MD #2 did not speak with a family member. MD #2 stated the priority was to talk with the patient to determine what was relevant.

Interview with Administrator #1, on 07/18/2019 at 1245, revealed there was only one abuse and neglect policy. Interview revealed an incident report should have been completed on the family member's allegation. Interview revealed the Communication Sheet was an appropriate form for staff to note a request for a physician to contact a patient's family member. Administrator #1 stated physicians should review the Communication Sheet. Interview revealed that after reviewing the record, if Administrator #1 had seen an incident report on this concern, it would have triggered a full investigation. Interview revealed any videos that would have been available at the time were no longer available. Interview revealed "We did drop the ball".

Based on policy review, medical record review and staff interviews, the facility failed to fax discharge information to patient's follow-up providers prior to their first follow-up appointment, for 3 of 12 medical records reviewed (Patient #10, #15, #4).

The findings included:

Review on 07/16/2019 of a policy titled "Discharge Planning/Discharge Summary" last revised 02/2019, revealed "...5. The Discharge Plan should:... e. Include timely and direct communication with and transfer of information to other programs, agencies, or individuals who will be providing continuing care..."

1. Closed medical record review of Patient #10, revealed a 48 year old patient admitted on 06/28/2019 for suicidal ideations with a plan. Review revealed Patient #10 was discharged on 07/03/2019 and had a follow-up appointment scheduled for 07/05/2019 at 1440. Review of the "Transition Discharge Cover Sheet" revealed Patient #10's physician discharge summary, safety crisis plan, multidisciplinary discharge planning form, discharge medication reconciliation form, prescription copy, patient advance directives acknowledgement form, and any applicable advance directive documents were sent to the follow-up provider on 07/08/2019 at 1421 (3 days after the scheduled follow-up appointment).

Interview on 07/17/2019 at 1435 with a Medical Records Assistant, revealed after discharge, patient charts were taken to the medical records office. Interview revealed the Medical Records Assistant looked at the "Multidisciplinary Discharge Planning Form" to know where patient's medical information should be faxed. Interview revealed normally, medical records staff were able to fax information the same day. Interview revealed the Medical Records office was open during business hours and when there were holidays they were closed. Interview revealed they did not work during the weekend.

Interview on 07/18/2019 at 1345 with the Director of Clinical Services revealed there was no specific policy about faxing medical record information to patient's follow-up providers. Interview revealed normally information was faxed within 24 hours of discharge. Interview revealed this was during a holiday.

2. Closed medical record review of Patient #14, revealed a 44 year old patient admitted on 04/22/2019 for detoxification from alcohol and suicidal ideations. Review revelaed Patient #15 was discharged on 04/25/2019, and had a follow-up appointment scheduled on 04/26/2019 at 0830. Review of the "Transitions Discharge Cover Sheet" revealed Patient #15's physician discharge summary, safety crisis plan, multidisciplinary discharge planning form, discharge medication reconciliation form, prescription copy, patient advance directives acknowledgement form, and any applicable advance directive documents were faxed to the follow-up provider on 04/26/2019 at 1308 (4 hours and 38 minutes after the scheduled follow-up appointment).

Interview on 07/17/2019 at 1435 with a Medical Records Assistant revealed after discharge, patient charts were taken to the medical records office. Interview revealed the Medical Records Assistant looked at the "Multidisciplinary Discharge Planning Form" to know where patient's medical information should be faxed. Interview revealed normally, medical records staff were able to fax information the same day. Interview revealed the Medical Records office was open during business hours and when there were holidays they were closed. Interview revealed they did not work during the weekend.

Interview on 07/18/2019 at 1345 with the Director of Clinical Services revealed there was no specific policy about faxing medical record information to patient's follow-up providers. Interview revealed normally information was faxed within 24 hours of discharge.

3. Closed medical record review of Patient #4, revealed a 55 year old patient admitted for suicidal ideations and detoxification from alcohol on 05/16/2019. Review revealed Patient #4 was discharged on 05/24/2019, and had a follow-up appointment scheduled on 05/28/2019 at 1320. Review of the "Transition Discharge Cover Sheet" revealed Patient #4's physician discharge summary, safety crisis plan, multidisciplinary discharge planning form, discharge medication reconciliation form, prescription copy, patient advance directives acknowledgement form, and any applicable advance directive documents information was faxed on 05/28/2019 at 1414 (54 minutes after the scheduled follow-up appointment).

Interview on 07/17/2019 at 1435 with a Medical Records Assistant revealed after discharge, patient charts were taken to the medical records office. Interview revealed the Medical Records Assistant looked at the "Multidisciplinary Discharge Planning Form" to know where patient's medical information should be faxed. Interview revealed normally, medical records staff were able to fax information the same day. Interview revealed the Medical Records office was open during business hours and when there were holidays they were closed. Interview revealed they did not work during the weekend.

Interview on 07/18/2019 at 1345 with the Director of Clinical Services revealed there was no specific policy about faxing medical record information to patient's follow-up providers. Interview revealed normally information was faxed within 24 hours of discharge. Interview revealed this was during a holiday.

NC00151865, NC00152436