HospitalInspections.org

482.13 Patient Rights

This CONDITION is not met as evidenced by:

Based on interview, incident report log review, medical record review, and policy review, it was determined the Acute Care Hospital failed to ensure patient rights to receive care in a safe setting after documented incidents of inappropriate sexual behavior (V-0144).

Based on medical record review, staff interview, review of incident logs, and policy review it was determined the facility failed to implement "special staff monitoring" in order to intervene promptly and effectively to ensure the safety of the patient and others. This affected four (Patient's #3, #4, #7, #8) of ten medical records reviewed. The active census was 269.


Findings include:

Review of RPH Policy: CLIN-136 effective date 02/26/12 states special precautions are utilized to address a wide range of patient conditions requiring special staff monitoring in order to to ensure safety to self and others. (e.g., assault, sexual acting out, arson, suicidality and self injurious behaviors. The facility utilizes three (3) different levels of special precautions as interventions with high risk behaviors.


1. Review of the facility incident log for February 2015 revealed incident No.154421 was reported on 02/26/15 at 8:00 PM for three individuals involved in sexually inappropriate behaviors on a mental health treatment unit. A male patient (Patient #7) flashed his genitalia at a female peer (Patient #4) on the unit, the female then fondled the male and involved another male (Patient #3) on the unit during the same incident.


Review of the medical record for Patient # 3 revealed the male patient was admitted 06/12/14 with a diagnosis of schizoaffective disorder and poor insight. Further, the patient was found to be incompetent to stand trial in relation to criminal charges. The patient's legal history included charges of gross sexual imposition and several assaults. The incident report documentation indicated the patient was involved in sexually inappropriate behaviors on 02/26/14. The medical record lacked documentation related to the incident dated 02/26/15. Further, the medical record lacked effective interventions and monitoring after sexually inappropriate behaviors were identified.


2. Review of the medical record for Patient #4 revealed the female patient was admitted to the facility on 01/24/13 after being found incompetent to stand trial for arson. Admitting diagnoses include schizoaffective disorder with a cognitive disorder. The patient's legal history included solicitation. Review of the treatment plan dated 02/07/15 indicated the patient has a history of sexually inappropriate behaviors that included being involved in the inappropriate touching of another male and on a separate incident kissed a male peer in 2013. The treatment plan was updated on 03/02/15 to include interventions related to the recent sexually inappropriate behaviors. The medical record lacked interventions from the time of the incident 02/26/15 until the treatment team updated the plan of care on 03/02/15.






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3. On 02/27/15 the facility incident log was reviewed and documented case #154379 on 02/22/15 at 01:30 PM, Unit H, category: "Major", identified as "Inappropriate Sexual Behavior", involving Patient #7 as the perpetrator and another male patient. The comment section documented, "Patient reports peer touched his penis without permission".

On 03/01/15 the medical record for Patient #7 was reviewed including an Annual Comprehensive Psychiatric Exam, a annual Nursing Assessment, a current Treatment Plan, progress notes from 02/23/15 through 03/01/15, physician orders from 01/28/15 through 03/02/15, and Special Precaution Records from 02/27/15 through 03/01/15.

The Annual Comprehensive Psychiatric Exam dated 07/07/14 documented an admission on 07/12/13 by court order after being found Not Guilty by Reason of Insanity (NGRI) on 06/24/13 on charges of Felonious Assault with a Deadly Weapon and Theft. The exam also documented Patient #7 has a history of physical and verbal abuse by his mother, stepfather, and grandfather, sexual abuse by his grandfather, and exposure to pornography by grandparents that led to symptoms of impulsivity, impaired judgment, anxiety, nightmares and intrusive thoughts.

The Nursing Assessment dated 07/24/14 documented a history of sexual abuse and exploitation as a victim.

The Treatment Plan date 02/27/15 included an objective statement where Patient #7 would not touch any peer or staff person on any part of their body except hands. Interventions added on 02/27/15 included monitoring, redirecting, investigating complaints of inappropriate sexual behavior and initiating immediate interventions of special precautions including constant observation (within eye sight) when inappropriate sexual behaviors occur.

Progress notes revealed a lack of documentation regarding Patient #7's sexual assault on 02/22/15. A treatment plan update note dated 02/24/15 documents "client is involved in another investigation where Unit H male peer reported client touched his penis on the unit this past week." No interventions were implemented on 02/22/15, the day of the incident or on 02/24/15 the day of treatment team update. A progress note dated 02/26/15 documented allegations were made by three peers that Patient #7 exposed his genitalia to them. One female peer indicated she fondled his genitalia. Patient #7 was transferred to Unit F overnight for being sexually inappropriate on his home unit.

Another progress note date 02/26/15 indicated the State Highway Patrol interviewed Patient #7 regarding the incident on 02/22/15 and Patient #7 admitted touching the male peer's penis. A progress note dated 02/27/15 documented Patient #7 was placed on Special Precautions related to his two inappropriate sexual incidents. Patient #7 was on Special Precaution Beginning 02/27/15 and remained on Special Precaution at the time of the survey exit.

Physician orders included a unit transfer on 02/26/15 and Special Precaution orders on 02/27/15, 02/28/15, 03/01/15, 03/02/15, and 03/03/15. The Special Precaution Record contained documentation every 15 minutes regarding Patient #7's behaviors from 10:00 AM on 02/17/15 through 03/03/15.

On 03/03/15 at 2:05 PM an interview was conducted with Patient #7. Patient #7 confirmed the inappropriate sexual behavior on 02/22/15 with the male peer and stated he did it because the voices told him to. Patient #7 stated he stuck his hand down the male peer's pants, touched his penis and then pulled his hand out and walked away. Patient #7 stated he was moved off the unit for an overnight sleep on 02/26/15 due to the second inappropriate sexual incident involving another patient. Patient #7 said he came back to Unit H and has been on special precautions with staff watching him since last Friday (02/27/15).

4. On 02/27/15 the facility incident log was reviewed and documented case #153863 on 01/20/15 at 5:40 PM, category: "Minor", identified as "Inappropriate Sexual Behavior", involving Patient #8 as the perpetrator and another female patient. On 03/02/15 at 10:45 AM Staff B stated the facility police substantiated the incident and no action was taken.

On 03/03/15 at 10:15 AM, Unit I Psychologist, Staff K stated in an interview there was no documentation found regarding inappropriate sexual behavior for Patient #8 on 01/20/15. Staff K stated if the incident happened off the unit, which it did, the information was never relayed back to the unit and therefore there was no documentation, no treatment team discussion, and no interventions implemented. Staff K was informed of the incident log and police investigation which substantiated the incident. Staff K could not identify how the other patient's safety was ensured when Patient #8 was identified on 01/20/15 as a sexual perpetrator in a documented incident.

On 03/02/15 at 10:45 AM Staff B stated in an interview the incident on 02/26/15 involving Patient's #3, and #4, and the second incident with Patient #7 was investigated by facility police and determined as substantiated but no further investigation was warranted as all parties involved reported the sexually inappropriate behaviors were consensual. Staff B stated the incident on 02/22/14 involving Patient #7 was substantiated yet no Special Precautions for monitoring were implemented until 02/27/15. Staff B stated the incident on 01/20/15 involving Patient #8 was investigated and substantiated but no Special Precautions were implemented.

On 03/02/15 at 4:30 PM an interview was conducted with the hospital's Medical Director. The Medical Director indicated there was no evidence or documentation that ensured the safety of other patients on the unit from the time of the sexual assault on 02/22/15 (Sunday) until Patient #7 was place on Special Precautions (being in eye sight of a designated staff at all times) after a second sexual incident on 02/26/15 (Thursday). The Medical Director stated the expectation involving an incident was documented real time discussion by the physician, nurse, and any one else involved in the situation and implementing interventions to help ensure the safety of all patients.

Based on medical record review, staff interview, policy review and the incident report log the facility failed to ensure the medical record contained updated treatment planning and documentation related to sexually inappropriate behaviors. This affected one ( Patient #3) of ten medical records reviewed. The active census was 269.


Findings include:


Review of the Treatment Planning and Documentation RPH Policy: CLIN-109 is to establish procedures governing the development and implementation of individual treatment plans. The treatment plan will be reviewed and updated by the treatment team, the patient, case manager as appropriate to evaluate the efficacy of treatment interventions and to revise goals, objectives, and interventions as indicated by the patient's clinical condition and/or progress. Changes to the plan, including discontinuation, addition or re-prioritization of problems, objectives or interventions; will be noted with the rationale in the update. New problems, objectives, or interventions, created as indicated by current assessments, will be entered into the electronic medical record comprehensive treatment plan (CTP).


Review of the medical record for Patient # 3 revealed the male patient was admitted 06/12/14 with a diagnosis of schizoaffective disorder and poor insight. Further, the patient was found to be incompetent to stand trial in relation to criminal charges. The patient's legal history included charges of gross sexual imposition and several assaults. The medical record lacked documentation related to the incident dated 02/26/15. Further, the medical record lacked effective interventions and monitoring after sexually inappropriate behaviors were identified. The February 2014 incident report documentation indicated the patient was involved in sexually inappropriate behaviors on 02/26/14.


This finding was confirmed with Staff C on 03/03/15 at 10:53 AM.