HospitalInspections.org

The hospital failed 2 of 2 Patients (Patient #1 and Patient #2) during there admission Intake into the hospital by failing to ensure that the medical staff was accountable to the governing body for the quality of care provided to patients. Patient #1 and Patient #2 were alleged to participate in a sexual encounter while an inpatient in the hospital. The hospital staff did not properly assess Patient #1 and Patient #2 during their Intake Assessments.

Findings Include;

During Record Review on 06/08/2022 of the hospital Summary Risk Assessment Treatment Interventions Patient #1, was not categorized as being involved in SAO Behaviors (Sexual Victimization or Sexual Aggression).

During Record Review of the hospital High Risk Notification Alert Patient #1 was not identified as having (Sexual Victimization or Sexual Aggression).

During Record Review of the hospital Psychiatric SBAR - Intake to Unit Patient Report Worksheet Patient #1 was not identified as being a High Risk For Sexually Acting Act (Victim or Perpetrator).

During Record Review of the hospital Standardized Intake Assessment dated 06/07/2022 Patient #1 was identified as a 'Readmit.' On this same form, Patient #1 was not identified as having any Sexual Behaviors. The document only reflected the current event "Mother is fearful for his safety. He was responding to internal stimuli on the way to facility. He had been banging his head screaming and yelling and talking about them dying in a car crash tonight. Patient #1 got into an argument with his sister and threatened to get a knife to cut himself. He also made additional comments about cutting himself these past few days."

During Record Review of the hospital Final Ancillary Orders (non-med) reflected Patient #1 was initially on Q 15 minute observations 06/08/2022 at 5:00 stop 06/16/2022 at 1650. On 06/08/2022 at 2100 Patient #1 was placed on 'Sexual Acting Out Precaitopms 06/08/2022 2100 Stop 06/16//2022 at 1650. Patient #1 was placed on 06/09/2022 at 900 Stop on 06/12/2022 at 13:37, reflected, "1:1 Observation while asleep." Pateint #1 was placed in a Blocked Room on 06/11/2022 at 09:00. After the incident took place and reported. Patient #1 was placed on Precautions on 06/08/2022 without any nursing documentation as to why or if the event occurred and was not properly reported prior to the incident occurring.

During Record Review Staff #9 reported after the incident occurred, Patient #2's legal guardian was notified of events. Patient #2's legal guardian responded, "Was Patient #2 the perpetrator?" Staff #9 informed the legal guardian what Patient #2 informed staff of. The legal guardian responded, "At admission I notified Intake that there was a claim that Patient #1 had been molested by his step-brother. The legal guardian reported that they did not really listen to her and when nurse came to do admission, the assessor skipped over a lot of the information and never asked about the allegations."

During Record Review Patient #'s legal guardian was notified and it was reported by the legal guardian on 06/12/2022 . Staff #9, called Patient's #1's guardian reported Patient #2 made allegations against a Patient #1. The legal guardian informed Staff #9 that there had made previous sexual allegations against family members, there was a CPS report, and nothing proven. The legal guardian stated, he lies and makes things up."

During interview with hospital Staff #5 medical record of Intake in which supervision was being overseen by them. Staff #5 indicated 'no.!' Staff #5 was asked to review the hospital's Standardized Intake Assessment for Pateint #1 first stated the person that filled this out is a tenured employee. Staff # stated that she is surprised that these areas are bypassed and documentation is not properly filled out. Staff #5 informed if these areas of the patient history on sexual victimization, abuse or SAO behavior were properly done the Patient risk factors may have been identified prior to being on unit. Staff #5 was in agreement and stated Patient #1 should have been placed on SAO behavior at Intake. The surveyor responded yes, have you seen the High Risk Notification sheet. Staff #5 responded 'No!' Staff #5 was first shown Patient #2's 'High Risk Notification Sheet' he was only identified for 'Assaultive Behavior/Homicidal behavior.' Staff #5 was the asked to review the Patient's Doctors orders. Where is documentation that reflects the patients sexually acting out or why their level of precautions changed without documentation. Staff #5 indicated she had no explanation of what, when, why, where or how the precautions were placed on the patients.


Policy
The hospital Policy on Patient Rights dated 04/2018, reflected, "Is the policy of Millwood Hospital and Excel Centers to ensure that all patients receive a copy of the Patient Handbook which indicates the Patient Bill of Rights as well as an oral explanation of those rights both in their primary language and in simple non-technical terms. We will strive to abide by and respect all patient rights without regard to race, religion, creed ethnicity, gender, age, sexual orientation, or handicap. Millwood Hospital and Excel Centers shall support and protect the fundamental human, civil constitutional and statutory rights of the individual patient and recognize and respect personal dignity of the patient at all times."

The hospital Policy on Identification and Reporting of Abuse/Neglect Exploitation dated 03/2022, reflected, "It is the policy of Millwood Hospital to report all incidents of abuse, neglect and exploitation as soon as possible. After the time the incident is identified."

The hospital Policy on Nursing Services 'Reassessment' 03/2021 reflected, "It is the policy of Millwood Hospital to assess patients at the time of admission, when transitioning to another level of care, and at the time of discharge. Additionally, reassessment occurs on an ongoing basis via daily assessment by a Registered Nurse, Psychiatrist and Treatment Team reviews."

Additional Policy
The hospital Intake Assessment Policy dated 03/2018 reflected, "It is the policy of Millwood Hospital to offer a no-cost psychological/addictive disease assessment to community members seeking these services. All patients requesting assessment will receive a thorough assessment and evaluation and will be assessed and reassessed throughout their waiting period. Potential patients will be assessed by a Masters-level Licensed Professional Counselor, Licensed Professional Counselor Intern, Licensed Masters Social Worker, Licensed Clinical Social worker, or Registered Nurse.
C. The Intake professional or trained designee will direct the individual and/or individual and/or family to the Intake area to begin the assessment proves.
b. Medical Screening/Triage
c. The Intake professional or trained designee will begin the Medical
Screening/Initial Triage. The triage includes.
" Medical Screening for brief overview of presenting problems vitals, medical history, drug allergies, and other relevant medical background
D. Intake Assessment
a. After the intake professional or designee has completed the Medical screening/Initial Triage, the intake staff will begin the full Intake assessment. The assessment will include:
e. Sexual victimization indicators/potential re-victimization risk
E. Upon completion of the assessment:
a. When an Inpatient level of care is indicated, a consultation with a physician will take place and a final disposition will be made. The recommendation will then be presented to the individual/family by the evaluating staff.

The hospital Policy on Risk Assessment of Safety Risk Factors/Patient Precautions dated 06/06/2022 reflected, "Patients assessed to be at heightened risk of suicide as determined in the conclusions of either the Intake assessment Nursing Assessment, Psychiatric Evaluation, or based upon patient statements and/or behaviors, may be placed on suicide precautions commensurate with the assessed level of risk. Staff responsible for monitoring patients on suicide precautions shall maintain the patient in a safe environment and take measures to protect the patient from self-harm ...
Sexual Aggression and Sexual Victimization Prevention Policy:
On admission to all levels of care, Millwood Hospital screens patients for history of sexual aggression and/or victimization history/behaviors. Patients who have a history of sexual aggression or who are exhibiting sexual aggressive behavior will be placed on an appropriate observation level and unit precautions to risk assessment regarding sexual aggression/victimization and documenting it on the admission assessment screen ...
1. Sexual Aggression
The admission clinician may obtain a history of sexual aggression from referral sources, emergency room reports, family members, legal system and the patient interview. The patient should be screened for history of sexual aggression, sexual perpetration, criminal history regarding inappropriate sexual behavior, hypersexual behavior verbalization, impulse control and insight. The admission clinical will document the information on the assessment form and risk hand0off sheet prior to the patient entering the unit. The admitting psychiatrist and admitting charge nurse/supervisor must be informed of the potential risk and observation requirement on the unit. The psychiatrist in consultation with the admitting nurse, will place the patient on the appropriate observation level and precaution. Patients who are risk for sexual aggression should be placed on SA (Sexual Aggression) precautions. Roommate restrictions regarding sexual history, age range between roommates of 3 years or less (for adolescents). Physical size, mental status, and cognitive abilities must be examined prior to any roommate assignments. This information should also be included in the Kardex and added to the master treatment plan.
Sexual Aggression Precautions may include:
o An increased observation levels
o Room alone (Blocked room)
o Restrict to unit
o Behavioral interventions
o Add Sexual Aggression
2. Sexual Victimization
The patient should be screened for a previous history of sexual victimization/trauma and current ability to function and care for themselves. Patients who are developmentally disabled, severely psychotic, catatonic, disoriented, sedated (including ECT) must have adequate supervision to prevent further victimization.
The admission clinician will document sexual victimization history and the initial assessment regarding risk for further trauma on the admission screening form and hand-off sheet. The psychiatrist in consultation with the nurse, will place the patient on SV (sexual victimization) precautions and determine the appropriate level. This information should also be included in the Kardex and added to the master treatment plan.
o An increased observation level, especially if medically compromised, sedated
o Restrict to unit
o Education regarding reporting of inappropriate interactions with others on the unit.
o Add Sexual Victimization to Treatment Plan
The psychiatrist and treatment team must assess all patients for changes in their behavior every shift related to sexual aggression or victimization and provide for immediate intervention/safety.

The hospital failed 2 of 2 Patients (Patient #1 and Patient #2) from the rights to recieve care in a safe setting.. Patient #1 and Patient #2 engaged in inappropriate sexual behavior while inpatients the hospital.

Findings Include:

During Record Review in written incident email from Staff #9 reflected "Patient #1, 13 year old, reported to Staff #10 that Patient #1 was forced to perform oral sex on Patient #2, Pateint #2 later stated Patient #1 also had anal sex Patient #2. Patient #2 had stated this happened twice, on 06/09/22 and 06/10/2022. This was reported to Staff #9 late Saturday evening 06/11/2022. Patient #1 and Pateint #2 were already in bed, so Staff #9 indicated they were scheduled to return to work on Sunday, 06/12/2022 to interview Patients.

During Record Reviewo on 06/12/2022 Staff #9 reflected in the email, "Patient #2, in interview with Staff #4 present. Patient #2 states in his room, got out of shower, roommate, Patient #1 walked in the bathroom, pulled his pants down and stated 'Suck my dick or I will kill you in your sleep.' Patient #2 said he sat on the toilet and sucked his dick, because 'I didn't want him to kill me in my sleep' Patient #2 states that Pateint #1 ejaculated in the toilet. Pateint #2 states that he had dinner, went to gym, and had come back and took shower. He really cannot remember time 'stated that his memory is bad and I 'don't recall memory.' Patient #2 also states later that night he went to Patient #1 bed and performed oral sex on him. Patient #1 states he was on Patient #1's bed when tech, states tech asked if anything happened and he told the tech no. Staff #9 asked Patient #2 if he screamed for help, he said no. Staff #9 asked if he told Patient #1 no, he said no. Patient #2 also states that while in the dayroom on 06/10/2022, Patient #1 was sitting beside him, leaned over and whispered, 'If you don't suck my dick, I will kill you in your sleep.' Patient #2 states that later that day, doesn't know time, but it was still light outside, they went into the bathroom in their room, 'I sucked his penis, he did not come in my mouth, then after he came, he put his penis in my anus, but did not come inside me.' 'I went to his bed and he penetrated me again.' Staff #9 reported notifying Patient #2's guardian and was advised Patient #2 made allegations against a peer. Staff #2 explained what was alleged and stated that he had made sexual allegations against family members, there was a CPS report, and nothing proven. She says he lies and makes things up.'

Diuring Record Review Staff #9 reported Patient #1 interview reported, "Based off memory, I woke up and Patient #2 was on top of me doing inappropriate stuff.' Staff #9 asked him to elaborate, Patient #1 stated, 'This is very uncomfortable to say.' Patient #1 states Patient #2 had his mouth on his penis. and that is what he woke up to. Patient #1 states he did not tell him to do this. ' I sat up, pushed him off and asked him 'What are you doing?' Patient #2 told him he was trying to do something he wanted to do. Pateint #1 states Patient #2 went to his bed and Pateint #1 pretended to go to sleep. Staff #9 asked if anything happened another day. Pateint #1 stated his memory was bad, but on Friday 06/10/2022, he states he took a shower. 'Pateint #2 came in bathroom, I had a towel around me, but took it off to put clothes on, he grabbed me, "I tired to get him off,' but then he put his penis in my butt and I just let him.' 'I never did that to him. 'Last time this happened was with my brother, I've learned my lesson and would not do that.' I asked if he yelled or called for help and he said no. Staff #9 called Pateint #1's guardian mother, Patient #1's guardian and notified her of the allegations. The guardian was understanding asking if Patient #1 was perpetrator and I told her what Pateint #1 had told me. The guardian stated that upon admission she notified intake that there was a claim that he had been molested by his step-brother. She stated that they did not really listen to her and when nurse came to do admission, she skipped over a lot of the information and never asked about the allegations.

During Record Review Patient #1 was placed on Q15 Observation Rounds/Precautions on 6/11/2022 Progress Note reflected, "Patient stated he was raped/sexually assaulted by another patient on 06/09/ and 06/10. Staff was made aware of statement submitted to nurse manager."

During Record Review 06/09/2022 Patient #1 was Identified as having SAO Precautions, but no noted action why, where, how for precautions changed and no noted documentation prior to 06/11/2022 of SAO behaviors identified in medical record."

During Interview on 06/20/2022 at 10:30AM with hospital Staff #2 reported that the hospital was "unable to prove the information that was reported, but it is believed an event took place." Staff #2 indicated video footage was reviewed, and there was no fault found in rounding by the staff. The police were notified in-regards to this incident. The police department completed a report but indicated that they would not be pursuing any charges on either of the patients.

During Interview Staff #3 indicated witnessing the interview with the House Supervisor. Staff #3 did not ask Patient #1 any questions but describeb the patient as hyperactive, but redirectable. Staff #3 stated that she had not witnessed in sexual behaviors from this patient while on the unit, but he is constantly moving about. Staff #3 reported Patient #2 was identiified as having boundary violations but redirectable. Staff #3 was asked why another nursing staff would identify Patient #2 as being a "Bully" in nursing notes. Staff #3 did not describe witnessing bully type behavior but described in the following response, "had not witnessed that but it goes with boundary violations."

Policy
The hospital Policy on Patient Rights dated 04/2018, reflected, "Is the policy of Millwood Hospital and Excel Centers to ensure that all patients receive a copy of the Patient Handbook which indicates the Patient Bill of Rights as well as an oral explanation of those rights both in their primary language and in simple non-technical terms. We will strive to abide by and respect all patient rights without regard to race, religion, creed ethnicity, gender, age, sexual orientation, or handicap. Millwood Hospital and Excel Centers shall support and protect the fundamental human, civil constitutional and statutory rights of the individual patient and recognize and respect personal dignity of the patient at all times."

The hospital Policy on Identification and Reporting of Abuse/Neglect Exploitation dated 03/2022, reflected, "It is the policy of Millwood Hospital to report all incidents of abuse, neglect and exploitation as soon as possible. After the time the incident is identified."

The hospital Policy on Risk Assessment of Safety Risk Factors/Patient Precautions dated 06/06/2022 reflected, "Patients assessed to be at heightened risk of suicide as determined in the conclusions of either the Intake assessment Nursing Assessment, Psychiatric Evaluation, or based upon patient statements and/or behaviors, may be placed on suicide precautions commensurate with the assessed level of risk. Staff responsible for monitoring patients on suicide precautions shall maintain the patient in a safe environment and take measures to protect the patient from self-harm ...
Sexual Aggression and Sexual Victimization Prevention Policy:
On admission to all levels of care, Millwood Hospital screens patients for history of sexual aggression and/or victimization history/behaviors. Patients who have a history of sexual aggression or who are exhibiting sexual aggressive behavior will be placed on an appropriate observation level and unit precautions to risk assessment regarding sexual aggression/victimization and documenting it on the admission assessment screen ...
1. Sexual Aggression
The admission clinician may obtain a history of sexual aggression from referral sources, emergency room reports, family members, legal system and the patient interview. The patient should be screened for history of sexual aggression, sexual perpetration, criminal history regarding inappropriate sexual behavior, hypersexual behavior verbalization, impulse control and insight. The admission clinical will document the information on the assessment form and risk hand0off sheet prior to the patient entering the unit. The admitting psychiatrist and admitting charge nurse/supervisor must be informed of the potential risk and observation requirement on the unit. The psychiatrist in consultation with the admitting nurse, will place the patient on the appropriate observation level and precaution. Patients who are risk for sexual aggression should be placed on SA (Sexual Aggression) precautions. Roommate restrictions regarding sexual history, age range between roommates of 3 years or less (for adolescents). Physical size, mental status, and cognitive abilities must be examined prior to any roommate assignments. This information should also be included in the Kardex and added to the master treatment plan.
Sexual Aggression Precautions may include:
o An increased observation levels
o Room alone (Blocked room)
o Restrict to unit
o Behavioral interventions
o Add Sexual Aggression
2. Sexual Victimization
The patient should be screened for a previous history of sexual victimization/trauma and current ability to function and care for themselves. Patients who are developmentally disabled, severely psychotic, catatonic, disoriented, sedated (including ECT) must have adequate supervision to prevent further victimization.
The admission clinician will document sexual victimization history and the initial assessment regarding risk for further trauma on the admission screening form and hand-off sheet. The psychiatrist in consultation with the nurse, will place the patient on SV (sexual victimization) precautions and determine the appropriate level. This information should also be included in the Kardex and added to the master treatment plan.
o An increased observation level, especially if medically compromised, sedated
o Restrict to unit
o Education regarding reporting of inappropriate interactions with others on the unit.
o Add Sexual Victimization to Treatment Plan
The psychiatrist and treatment team must assess all patients for changes in their behavior every shift related to sexual aggression or victimization and provide for immediate intervention/safety.