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Based on the review of medical records, interviews with hospital staff, and the review of documentation and policies and procedures, it was determined that in one of one patient records (#2) with evidence of unwanted physical/sexual contact by another patient on the behavioral health unit (BHU), the hospital failed to provide the patient or patient's representative with a written notice of the receipt of, investigation, and results of a patient/patient representative grievance in accordance with timeframes identified in the hospital policies and procedures. Findings include:

Review of patient #2's record revealed that the patient was 32 years old and had voluntarily admitted to the BHU on 09/02/10 at 1421 hours with complaints of mood instability, insomnia, racing thoughts and passive suicidal ideations. The record also reflected that the patient was legally blind. Further review of patient #2's record and documentation that was presented during the survey revealed that the patient's hospital stay was complicated by unwanted physical and sexual contact by another patient, and that the patient had submitted a written grievance regarding those events. The patient was discharged home on 09/07/10.

The following policy was reviewed: "SUBJECT: PATIENT COMPLAINTS AND GRIEVANCES", Policy No. 205.00, revised 12/2010. A section in the policy entitled "POLICY STATEMENT" directed the following: "In the event a patient/patient's representative is dissatisfied with any aspect of their care, they will be afforded a process to express their concerns and for those concerns to be investigated and addressed." A section in the policy entitled "DEFINITIONS" directed the following: "A written complaint is always considered a grievance, whether from an inpatient, outpatient, released/discharged patient or their representative regarding the patient care provided, abuse or neglect..." A section in the policy entitled "RESPONSE TIME FRAME" directed the following: "The hospital will provide a written response to the patient/patient's representative ideally within 7 business days (excludes weekends and legal holidays). If the grievance is not resolved or if the investigation requires more time, the hospital will inform the patient/patient representative that the hospital is still working to investigate/resolve the grievance and that the hospital will follow up with a written response within 7 business days from the date of this interim contact." A section in the policy entitled "LETTER OF RESPONSE ELEMENTS" directed the following: "In the written response to the patient/patient's representative, the following elements will be included: A. Steps taken to investigate the grievance; B. Results of the grievance process; C. Date of completion-can be met by the date of the letter; and D. Name of hospital contact person-can be met by the signer of the letter and phone number."

An interview was conducted on 05/03/11 at 1600 with I1 and I2. During the interview, I2 presented a two page document entitled "PATIENT GRIEVANCE FORM" dated 09/05/10 that had been completed by patient #2. I2 further revealed that patient #2 had submitted the written grievance to a hospital manager, that the grievance had been addressed at the time it was filed, and that no written response had been provided to the patient. The top portion of the form reflected the following: "You may submit a grievance in writing, by telephone, fax, or in person. If you are unable to file the grievance yourself, a Quality Management Coordinator or Nursing Supervisor is available to assist you or your representative." Further review of the form revealed that the patient had experienced unwanted physical/sexual contact by another patient during the course of his/her hospital stay and reflected "I would like this incident & my complaint officially documented." A typed document dated 09/07/10 was attached to the front of the written grievance form and revealed that the grievance had been discussed with the patient. The attached document failed to reflect a signature or other identification of the author, an investigation, or evidence of a written response to the patient. I1 revealed that he/she had no prior knowledge of the written grievance, that he/she is normally involved in the coordination of written responses to grievances, and verified that he/she had not provided a written response to patient #2's grievance.

An interview conducted 05/04/11 at 1105 with I3 verified that he/she had received and discussed the written grievance with patient #2. I3 further revealed that he/she did not recall completing an investigation after the patient submitted the grievance form, and that the grievance had not been processed as a grievance as directed by the hospital grievance policy and procedure.

An interview and review of a document entitled "UOR Management Utility" was conducted 05/05/11 at 1300 with I1. The document reflected "Event Date 9/2/2010" and "Event Time 18:30". Review of the document revealed a report submitted by patient #2 on 09/02/10 regarding unwanted physical/sexual contact by another patient. I1 revealed that the document was an unusual occurrence report (UOR) and that it had been initiated by a charge nurse on the BHU. I1 further revealed that the report had been forwarded to a quality management coordinator on 09/20/10, and that the report lacked an investigation of the event.

An interview conducted 05/05/11 at 1430 with I2 revealed that the document entitled "PATIENT GRIEVANCE FORM" was frequently used for therapeutic purposes on the BHU, that those forms are not consistently processed as written grievances, and that the written grievance submitted by patient #2 should have been processed as a written grievance as directed by the hospital's grievance policy and procedure. No investigation of the written grievance or evidence of a written response to patient #2 was presented during the course of the survey.

These findings also reflect noncompliance with the following Oregon Administrative Rule for Hospitals: 333-505-0033 Patient Rights, A hospital shall comply with the requirements for patients rights set out in 42 CFR 482.13 (71 FR 71426, December 8, 2006).

Based on the review of medical records, hospital staff interviews, and the review of documentation and policies and procedures, it was determined that in one of nine patient records (#2) of individuals who received inpatient services in the BHU, the hospital failed to ensure the patient's right to receive care in a safe setting. Findings include:

Refer to Tag A 145 for findings.

Based on the review of medical records, hospital staff interviews, and the review of documentation and policies and procedures, it was determined that in one of nine medical records (#2) of individuals who received inpatient services in the BHU, the hospital failed to ensure the patient's right to be free of abuse. Findings include:

Review of record #2 reflected an RN progress note dated 09/02/10 at 1728 hours: "pt tearful during 1:1, described racing thoughts and inability to focus on other things...Was approached by 569, he grabbed his/her hand and walked with him/her. They sat on a bench and he rubbed his/her shoulders..." Review of RN progress note dated 09/04/10 at 2111 reflected "Pt c/o anxiety regarding fellow pt "assaulting" her soon after his/her arrival upon the unit yesterday. Described to afternoon RN that he touched her breast. He/she c/o continuing anxiety regarding that event that is distracting him/her from his/her treatment."

Review of record #11 revealed a 21 year old male with a diagnosis of schizophrenia and psychosis. The patient was admitted involuntarily to the BHU on 08/31/10 at 1639. The patient had a past history of intrusive and sexual behaviors. A document entitled "BEHAVIORAL HEALTH EMERGENT ASSESSMENT" dated 08/31/10 at 1500 reflected: "History of Violent Behavior: History of intrusive, disruptive behavior while hospitalized, including howling, paranoia, agitation, sexually inappropriate behavior...Bit a staff member in the past. During last admission, May-July pt. walked into other pt's rooms, yelled and needed frequent redirection." Further review of the record revealed that the patient was placed on 15-minute checks on 08/31/10 at 1630.

Review of record #11 reflected that the patient's behaviors began to escalate 09/02/10 at 1459. The record failed to reflect interventions to adequately address those behaviors until approximately 4-5 hours later, and after patient #2 reported that he/she had been inappropriately touched by patient #11. Review of patient #11's medication administration record reflected the following:
On 09/02/10 at 1459, the patient received an anti-anxiety medication by mouth. The patient was described as "anxious, mild agitation W inappropriate behaviors."
Review of patient #11's behavioral health notes reflected the following:
09/02/10 at 1536: "Supervisn Level (MPS): Q 15 min checks" and "raised fist to staff secondary to internal stim; exposed self to female peer; follows female peers and stares; chased charge RN" and "...gross internal stim evidenced by impulsivity and aggressive gestures" and "overt response to internal stim...sudden hostile gestures/sexual inappropriateness."
09/02/10 at 1546: "Pt followed female peer to her room and started playing with himself, "I want you..."
09/02/10 at 1845: "Pt given prn Zyprexa after he reported to the RN that voices were telling him to touch females and he had per female pt report that he had touched her inappropriately" and "Pt was placed in a TO in his room."
09/02/10 at 2047: "inappropriate touching of female pt twice tonight."
09/02/10 at 2059: "pt grabbed female patients hand and gave her a back rub, was redirected to dinner. pt approached same female patient later and grabbed her breasts and twisted her nipples (per female pt). Was given prn and rested quietly most of shift after dinner."
Review of a nursing order that was documented on a physician order dated 09/02/10 at 2000 reflected "1:1 supervision D/E/N due to allegation by female peer that (patient) touched her inappropriately..."

Review of a Washington County court document dated 09/03/10 and completed by a Certified Mental Health Investigator reflected: "On September 2, 2010, (patient #11) was sexually inappropriate with a female patient, first attempting to give her a back rub despite her protests and later grabbing her breasts..."

The following policy and procedure was reviewed: "SUBJECT: Use of Routine &
Observation for Patient Safety", Policy No. 400.38, Effective 02/2003, Revised 11/2009. The policy objective reflected: "To create a safe and therapeutic environment that matches the needs of each patient through established observation levels. Observation occurs in combination with the proper assessment, treatment and therapeutic engagement with the patient." The policy directed that all patients on the behavioral health unit are placed on
15-minute observation checks for a minimum of 48 hours. The policy further directed "A RN may immediately initiate a special observation based on behavioral or medical conditions that create potential risk to patient safety." A section of the policy entitled "Risk Assessment" directed "All patients admitted for inpatient care are subject to initial and ongoing multi-disciplinary risk assessments. The outcome of these individualized risk assessments will determine the level of observation, support, and treatment prescribed...There may be the need to increase the level of observation in an emergency." The policy further directed the following "High level of observations may be indicated, but not limited to assessment of the following factors:..Sexually impulsive or engaging in inappropriate sexual behavior and are not immediately able to reliably curtail that behavior." Review of the documentation failed to reflect effective, timely interventions to address patient #11's escalation of sexually inappropriate behaviors in accordance with the hospital policies and procedures.

Review of a document entitled "UOR Management Utility Quality/Risk Management review" reflected a section entitled "Action Taken/Conclusion." An entry in that section completed by I3 and dated 09/17/10 at 0754 reflected the following regarding patient #11: "A severely psychotic patient with no previous history of intrusive behavior toward others apparently inappropriately touched a female patient..." Review of the documentation in that report failed to identify patient #11's prior history of intrusive and sexually inappropriate behaviors.

The care plan of patient #11 was reviewed and failed to identify the patient's history of sexually inappropriate behaviors until 09/03/10, 3 days after admission.

An interview conducted 05/05/11 at 1700 with I4 revealed that staff who were providing care to patient #11 on 09/02/10 had delayed initiating 1:1 supervision of the patient because the patient had not been considered threatening based on their previous experiences with that patient. That delay failed to ensure patient #2's right to receive care that was free of all forms of abuse.

These findings also reflect noncompliance with the following Oregon Administrative Rule for Hospitals: 333-505-0033 Patient Rights, A hospital shall comply with the requirements for patients rights set out in 42 CFR 482.13 (71 FR 71426, December 8, 2006).