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Based on document review and interview, the Hospital failed to ensure patients were safe from ligature risks; failed to closely monitor patients on the Behavioral Health Unit and failed to conduct annual abuse training for employees. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to ensure patients' rooms were free of ligature risks (A144).

2. The Hospital failed to ensure monitoring of 2 of 2 patients (Pt #1 and Pt #2) to prevent inappropriate sexual behavior (A145 - A)

3. The Hospital failed to conduct annual abuse training for employees (A145 - B).

Based on observation, document review and interview, it was determined for 1 of 1 Psychiatric Unit (Male Behavioral Health), the Hospital failed to ensure patients' rooms were free from ligature risks. This could potentially affect 1 suicidal patient on census as of 12/26/18.

Findings include:

1. On 12/26/2018 at approximately 9:20 AM, an observational tour was conducted on the Male Behavioral Health Unit. There were 21 patients on the Unit during the tour. The Unit consisted of 13 patient rooms, of which there was 1 bathroom in each patient room. The room entrance doors and bathroom doors were all unlocked. The doorframes were square and the doors reached to the top of the frame. Of the 21 patients, 1 patient was on suicide precautions.

2. The CMS (Centers for Medicare and Medicaid Services) S & C (survey and certification ) Memo: 18-06- Hospitals, dated December 08, 2017, reviewed on 12/26/18 at approximately 9:00 PM included, "Memorandum Summary...Definition of a Ligature Risk: A ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include...door frames..."

3. On 12/26/18 at approximately 2:00 PM, an interview was conducted with the Senior Vice President of Quality (E #10). E #10 stated that the Hospital is aware of the ligature risks and sensors for each door have been ordered. E #10 stated that the sensors will have an alarm that will go off when any weight is applied to the door.

4. On 12/26/18, the Hospital presented a current Hospital census for the male Behavioral Health Unit. The census included: 21 patients with 1 patient on suicidal precautions.

A. Based on document review and interview, it was determined that the Hospital failed to ensure monitoring of 2 of 2 patients (Pt #1 and Pt #2) to prevent inappropriate sexual behavior. This failure resulted in an alleged incident of inappropriate sexual behavior between Pt #1 and Pt #2 in the community shower room on the Behavioral Health Unit.

Findings include:

1. On 12/26/18 at approximately 10:00 AM, the Hospital's policy entitled "Precautions" (revision date March 2017) was reviewed and indicated " ...The purpose of this policy is to ensure that appropriate precautions are implemented based on assessment and evaluation of each patient ...

2. On 12/26/18 at approximately 10:45 AM, Pt #1's medical record was reviewed. Pt #1 was a 20 year old male admitted to the Hospital's male Behavioral Health Unit on 11/11/18 with the diagnosis of unspecified psychosis. Pt #1's medical record noted that Pt #1 had a history of violent behavior and schizophrenia. Pt #1's record noted that on 11/11/18, Pt #1 was placed on close observation precautions. Close observation per Hospital policy is every 15 minute monitoring. Pt #1's medical record noted that on 11/12/18, Pt #1 reported the he had been sexually assaulted in the Behavioral Health Unit's shower room on 11/12/18. Pt #1's medical record noted that Pt #1 was transferred to the ER (Emergency Room) on 11/13/18 following the allegation of sexual assault for evaluation. On 12/26/18 at approximately 11:30 AM, Pt #1's Emergency Room medical records dated 11/13/18 at 1:12 PM were reviewed. Pt #1's emergency room record noted "Chief complaint - Sexual assault, Severity of chief complaint - Moderate. Pt #1 stated that he was rectally assaulted by male while in shower approximately 8 PM last night. States assailant placed penis in rectal area. Denies other penetration. Denies fall/injury, but noted some blood per rectum. Final Diagnosis - Alleged sexual assault. Discharge instructions - Consider repeat HIV/RPR tests 6-8 weeks. Doxycycline (antibiotic medication for syphilis [infection from sexual contact] 100 mg #14, Flagyl (antibiotic)500 mg #14. On 12/26/18 at approximately 11:35 AM, Pt #1's Medical Forensic Documentation Form was reviewed. The Emergency Room Nurse (E #2) documented " ...Pt #1 stated that he was in the shower on 4 South when he was approached by another patient and forced Pt #1 to have anal sex with him. After the sex, Pt #1 was told to come to assailant's room and did so, to room 447, when assailant attempted a second time to penetrate him in the anus and nurse came into the room and interrupted the act. The incident took place 11/12/18 around 8:00 PM per patient ..."
Pt #1's medical record dated 11/12/18 at 6:50 PM noted " ...At about 6:20 PM, the Nurse Technician (E #3) told the Registered Nurse (E #4) that while E #3 was making rounds, E #3 found Pt #1 of room 436-2, in the room of Pt #2 (447-2) having sex act and that Pt #1 was on top of Pt #2. E #3 informed the Nurse Manager (E #5) but was told to inform the Nursing Supervisor (E #6). E #6 came up and after telling E #6 what happened, E #4 asked if she needed to do rape kit, E #6 said let me go assess them, she went to them. After her assessment of both patients, E #6 said that two of them said that it was consensual sex act, that there were no problems, no injury seen, no bleeding noted, Pt #1 denied any pain. MD #2 & MD #3 were paged, resident doctors on duty, both doctors came together with E #4 and Pt #1 was assessed, evaluated. Pt #1 maintained that it was consensual act, denied pain, nor injury of any part of his body, no bleeding noted. Pt #1 said he was fine, his vital signs were checked and were stable. E #6 instructed E #4 to put both the patients on 1:1 for safety and they were put on 1:1 sitter, close observation ..." Pt #1's medical record dated 11/13/18 at 2:07 PM noted " ...Received report that Pt #1 had been found in room with another patient inappropriately during patient rounds yesterday on afternoon shift. This was investigated on pm shift yesterday by evening supervisor (E #6) with the Nurse Manager (E #5) present for part of the interview. Pt #1 at that time, admitted to this being a sexual encounter and stated it was consensual. When questioned, he repeatedly stated it was consensual. At that time, Pt #1 stated that there was oral sex but that they were interrupted before any other sexual activity occurred. This am, spoke with Pt #1 and Pt #1 again stated that it was completely consensual and there was no need to discuss it further as he was finished with it. However, after he found out that the other patient was being discharged and he was not, Pt #1 became very angry and then stated that he was sexually assaulted and he wanted the other patient arrested. The Psychiatrist (MD #1) was notified. Pt #1 taken to ER (Emergency Room) with sitter and security.

3. On 12/26/18 at approximately 10:50 AM, Pt #2's medical record was reviewed. Pt #2 was a 35 year old male admitted to the Hospital's Psychiatric Unit on 11/12/18 with the diagnosis of major depressive disorder. Pt #2's medical record noted "Pt #2 was having auditory hallucinations (a perception of having heard something that is actually not there). Pt #2 stated that the voices seem to have gotten louder and they were telling him to go ahead and kill himself and kill friends. Pt #2 stated that he began to be preoccupied with killing himself and became increasingly more agitated and restless ...On admission, Pt #2 hearing voices that were extremely loud telling him to go ahead and hurt himself and do things to other people ...Pt #2 reports the voice telling him to do things. Pt #2 endorsed suicidal ideation with a plan to cut himself or set himself on fire (note dated 11/12/18 at 12:31 PM). Pt #2 physician orders dated 11/12/18 note that Pt #2 was on close observation.

4. On 12/26/18 at approximately 12:45 PM, the Hospital's Risk Management Investigation Report dated 11/15/18 was reviewed. The report noted "Incident Type - Sexual Assault Allegation - Pt #1 & Pt #2, location 4 South on 11/12/18 at approximately 6:08 PM and 7:07 PM.
Findings:
-On 11/12/18 at approximately 7:15 PM, the Nurse Technician (E #3) reported to
the Unit Charge Nurse (E #7) that she found 2 male patients (Pt #1 & Pt #2) engaging in sexual activities in room 447 while she was making her every 15 minute rounds.
-Pt #1 is a 20 year old male with a long standing history of bipolar disorder.
-Pt #2 is a 35 year old male with a long history of bipolar disorder.
-Risk Management interviewed the nursing staff with statements attached. Earlier on the day of the incident, both patients admitted to consensual sexual activities but later the next day Pt #1 alleged sexual assault.
-Risk Management reviewed the unit video camera and noted the following:
-Camera #9 - Pt #2 is seen coming out of his room at 6:07 PM and walking about in the hallway.
-Camera #13 - Pt #1 is seen coming out of his room at 6:07 PM and walking about in the hallway.
-Camera #12 - Both Pt #1 & Pt #2 are seen at 6:08 PM walking together next to each other towards the hallway leading to the community bathroom but goes out of camera view.
-In an interview, Pt #1 stated that he went to take a shower by himself in the community bathroom and the next thing he realized was Pt #2 forcing himself on him. Furthermore, he stated that after the initial sexual assault, he was instructed by Pt #2 to meet him in room 447 and Pt #1 complied because he was afraid of Pt #2.
-Pt #2 was interviewed by the Ombudsman and he denied any sexual activities with Pt #1. However, in an interview with the PSO (Public Safety Officer) E #8), Pt #2 stated "I f***** him, Pt #1 kept asking me to f*** him in the a** so I did. Pt #1 also s***** my d*** too."
-Camera #12/#13 - Both Pt #1 and Pt #2 are seen again about 6:13 PM walking next to each and they both keep going in and out of their individual rooms from 6:14 PM thru 6:17 PM.
-Camera #9 - Pt #2 is seen entering room 447 at 7:06 PM and subsequently followed by Pt #1 at 7:07 PM
-Camera #9 - E #3 is seen making her every 15 rounds and enters room 447 at about 7:12:21 PM and is subsequently seen coming out with both patients at 7:12:52

-Conclusion: (from the Risk Management Investigation Report)

-All indications are that both Pt #1 and Pt #2 were involved in a consensual sexual activities that was later witnessed and stopped by E #6.

-Recommendation: (from the Risk Management Investigation Report)

-Consider hallway monitors - strategically stationed on the unit to interrupt and/or stop unaccepted behavior.

5. On 12/26/18 at approximately 9:00 AM, an interview was conducted with the Psychiatrist (MD #1). MD #1 stated that staff members called him the evening that Pt #1 was found having sex with another male patient. MD #1 stated that he interviewed Pt #1 the day after the incident and Pt #1 told him that he had been sexually assaulted in the shower. MD #1 stated that only one patient at a time should be allowed to go into the shower. MD #1 stated that he is not sure how no one saw 2 patients (Pt #1 & Pt #2) go into the community shower room. MD #1 stated that the hallway monitor staff member should prevent 2 people from going into shower room. MD #1 stated that the protocol when a patient alleges a sexual assault, is to send the patient to the ER for a rape kit. MD #1 stated that Pt #1 was sent to the ER for a sexual assault evaluation.

6. On 12/26/18 at approximately 11:00 AM, an interview was conducted with the Emergency Room Nurse (E #2). E #2 stated that she cared for Pt #1 on 11/13/18 when he was transferred to the ER from the Psychiatric Unit for a rape kit. E #2 stated that Pt #1 appeared "shaken up." E #2 stated that Pt #1 told her that another patient approached Pt #1 while Pt #1 was in the shower and forced Pt #1 to have oral sex. E #2 stated that Pt #1 stated that after the shower, Pt #1 was then forced to the same patient's room and forced to have anal sex. E #2 stated that Pt #1 reported the incident to the staff on 11/13/18.


7. On 12/26/18 at approximately 12:00 PM, an interview was conducted with the Senior Vice President of Quality (E #10). E #10 stated that video footage of the hallway in the Psychiatric Unit cannot be viewed due to the fact that the video is only available for 15 days. E #10 stated that in November 2018, there were no hall monitor Mental Health Technicians on the Behavioral Health Unit. E #10 stated that the Hospital has implemented hall monitor Mental Health Technicians.

B. Based on document review and interview, it was determined that for 4 of 4 Registered Nurses (E #1, E #2, E # 4, E #7) and 2 of 2 Mental Health Technicians (E #3 and E # 9), the Hospital failed to ensure abuse training was conducted for the employees.

Findings include:

1. On 12/27/18 at 10:00 AM, the Hospital's "Abuse Policy" (2007) was reviewed and did not include abuse training requirements for employees.

2. On 12/27/18 at approximately 10:30 AM, the Registered Nurses' (E #1, E #2, E #4, E #7) and the Mental Health Technicians (E #3 and E #9) employee files were reviewed and lacked documentation of abuse training.

3. On 12/27/18 at approximately 10:45 AM, an interview was conducted with the Senior Vice President of Quality (E #10). E #10 stated that employees did not receive abuse training. E #10 stated that abuse training will be incorporated into the annual training.