HospitalInspections.org

Based on facility policy, document review, video review, medical record review, observation and interview, the facility failed to provide appropriate observations and monitoring to ensure all patients received care in a safe setting for 2 of 3 (Patient #1 and #2) sampled patients reviewed for sexual allegations.

The findings included:
1. Review of the facility's "Observations, Patient" policy revealed, "...In order to maintain safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN ...
PROCEDURE...The psychiatric practitioner will order one of three levels of observation at time of admission and as the patient's condition warrants a change...15 minute...5 minute...One-to-one...The psychiatric practitioner may also order a precaution level of observation for...Suicide...Assault...Sexually Acting Out...The RN may increase the level of observation if the patient's condition changes. The psychiatric practitioner will be contacted soon as possible for notification of the change in condition and to obtain an order for the observation level...Documentation of Observations...Documentation of the observation is to be completed once the patient has been observed...Q 15 minute Rounds...All patients are monitored at minimum once in every 15-minute block of time...During the rounds staff are to...Make direct visual contact; look for signs of danger or distress...Remain vigilant for specific risks for patients on Special Precautions ..."

2. Medical record review revealed Patient #1 was admitted to the facility on 7/13/2021 with the diagnosis of Schizoaffective Disorder.

Review of the Intake Assessment dated 7/13/2021 revealed, "...Pt [patient] reported SI [suicidal ideation] ideation [with] plan [to] cut himself ... hx of SUA [suicidal attempts] ... Pt reports mood swings & [and] anger issues ...Pt has poor insight/judgement & [and] unable to contract for safety ... Pt reported being med compliant but they are not working"

Review of the High Risk Notification Form dated 7/13/2021 at 4:35 AM revealed the patient was on every 15 minute observation precautions for suicide and assault behaviors.

Review of the History and Physical dated 7/13/2021 revealed, " Suicidal ideation to cut himself, had altercation with mother and states he shoved her, responding to internal stimuli ..."

Review of the Behavioral Health progress notes dated 7/15/2021 and 7/16/2021 revealed the following:
7/15/2021 - "... c/o [complained of] feeling unwell today. + [positive for] Stomach ache. Isolating to room. Not interacting with others. Suicidal ideations persist. Insight and judgement have not improved ..."

7/16/2021 - "... Per report, patient was sexually molested by male peer last night. Patient states 'he came into my room and put his penis in my mouth'. Police were called and patient was able to file a police report. C/o [complained of] severe 'bad nerves' related to this event happening. Vistaril 25 mg [milligrams] po [by mouth] TID [three times a day] ordered for three days for anxiety ..."

Patient #1 was discharged on 7/19/2021 to their mother's home with the discharge diagnosis of Bipolar Depression with Psychotic Features.

3. Record review revealed Patient #2 was admitted to the facility on 7/11/2021 with the diagnosis of Schizoaffective Disorder.

Review of the Intake Assessment dated 7/11/2021 revealed, "... [Patient #2] ... presents reporting suicidal ideations, hallucinations...reports a plan to cut his wrist...reports homicidal/ideations, threats of harm no one in general ... [Patient #2] vision presents with flying birds...tested positive for marijuana, patient cannot contract for safety, and needs stabilization, confused ... active homicidal/violent thoughts ... not on his meds uncooperative sometimes ... [Patient #2] presents w/ [with] severe Behavioral Disturbances ..."

Review of the High Risk Notification Form dated 7/11/2021 at 8:05 PM revealed Patient #2 was on every 15 minute observation precautions of Suicide, Assault and Sexually Acting Out (SAO) behaviors.

Review of the Behavioral Health progress notes dated 7/14/2021 and 7/15/2021 revealed the following:
7/14/2021 - "... In room talking to voices only he can hear. Mood remains labile and congruent ..."

7/15/2021 - "... Pressured rambling speech ... Insight and judgement are poor ..."

Review of the Discharge Summary dated 7/16/2021 for Patient #2 revealed, "... Per report, patient was accused of sexual assault by a male peer. [Name of City Police Department] were called and came to interview both patients. [Patient #1] decided to press charges. Patient administratively discharged into police custody ..."

4. Review of the facility's 7/15/2021 video recording (without audio) which started at approximately 4:16:59 PM, and was approximately 19 minutes long revealed the following:

Patient #2 was standing in the in the lobby area talking to Random Patient (RP) #3. Patient #2 later enters Patient
#1's room. When Patient #1 was visualized in the video, the patient was in a wheel chair.

Approximately 2 minutes and 53 seconds into the video, Patient #1 and Patient #2 are in Patient #1's room out of view.

Approximately 8 minutes and 18 seconds into the video, Patient #1 and Patient #2 are in Patient #1's room out of view.

Approximately 10 minutes and 30 seconds into the video, Patient #1 and Patient #2 are in Patient #1's room out of view.

At approximately 11 minutes and 53 seconds into the video, Tech #1 enters the lobby/activity room from one hallway, walks across the across the lobby/activity area and exits view of the video into another hallway. There was no observations of the Tech observing either Patient #1 or Patient #2.

5. Record review of the 7/15/2021 Patient Observation flowsheets for Patient #1 and Patient #2 revealed the every 15 minute observations were documented as having been conducted. Review of the video revealed there were no observations of staff conducting every 15 minute observations on Patient #1 and Patient #2.

6. Review of the facility's investigation revealed the following related to Patient #1's 7/15/2021 allegations of sexual assault by Patient #2:

On 7/15/2021 Patient #1 reported to RN #1 that Patient #2 came into his room and forced his penis into Patient #1's mouth. Patient #1 stated Patient #2 would not let him leave his room until he allowed Patient #2 to put his penis into his mouth.

RN #1's documented that Patient #1 had stated that Patient #2 had made a threat towards him that made him afraid.
Patient #2 was interviewed and Patient #2 denied the allegation and became angry. Patient #2 stated that Patient #1 asked to "suck his penis".

Patient #1 initially stated he was in the bed when the incident occurred. Patient #1 later reported to the police that he was in the bed and got up in a wheel chair when the incident occurred.

Tech #1's statement revealed that Patient #1 reported that Patient #2 came into his room and said he wanted to talk. Patient #2 then unbuttoned his pants, took his penis out and told Patient #1 to feel on it, suck it and then bend over. Tech #1 stated the other 2 techs were off the unit during the time of the allegations which left only 1 tech on the unit.
Statements obtained from Tech #2 and #3 verified they were both off the unit during the time of the allegation.

The facility's investigation revealed the staff had documented on the Patient Observation flowsheets that every 15 minute checks had been conducted on Patient #1 and Patient #2. (However, video review revealed the 15 minute observations had not been conducted).

RP #3 was interviewed by the facility and stated he witnessed Patient #2 walking in and out of Patient #1's room for 30 about minutes.

RP #4's statement revealed he witnessed Patient #2 walking into Patient #1's room about 3 times.

Patient #2 was placed from a semi-private room into a private room after the allegation. The facility determined Patient #2's treatment plan did not address SAO (sexually acting out) behaviors and the every minute checks had not been performed during the time of the alleged sexual assault incident.

The facility determined the unit's safety huddles did not always identify patient precautions; and scheduled group activities were not conducted timely which may have contributed to leisure time and potential behaviors. The facility identified the social workers and counselors had not been adequately educated on group activities.

The facility did not substantiate the sexual abuse.

After completion of the investigation, the facility had developed and had begun the implementation of action plans which included disciplinary action, education, and monitoring of identified issues. This action plan had not been fully implemented at the time of this survey. They had completed the education and had completed one week of monitoring.

8. In an interview on 8/5/2021 at 10:40 AM, the Chief Operating Officer (COO) stated Patient #1 had reported the allegations to RN #1. RN #1 asked Tech #1 to assist Patient #1 in making a written statement of the allegations, while RN #1 notified the physician.