HospitalInspections.org

Based on records reviewed and interviews the Hospital failed to protect the rights of one (Patient #5) patient in a total sample of ten patients reviewed when it failed to prevent Patient #5 from being abused by a Hospital staff member. The incidents were witnessed by two separate staff members, but the first staff member failed to immediately intervene.

See A 145.

Based on records reviewed and interviews, the Hospital failed to ensure that the Hospital's policies and procedures were followed; failed to ensure Hospital staff adequately documented a staff witnessed incident of patient abuse, involving one of 10 patients (Patient #5). In addition the Hospital failed to:

- Ensure staff followed the Hospital's policy related to Safety Event Reporting and for completion of a comprehensive pre-hire screening for Mental Health Worker #1, the accused staff member;

- Ensure the staff documented an accurate detail of concerns when an incident of inappropriate sexual behavior/abuse was entered into Patient #5's medical record as required;

- Ensure staff completed a review of the allegation of witnessed sexual abuse was reviewed to determine whether a criminal act had been committed and whether the Hospital was required to report to outside agencies;

- Ensure that appropriate follow-up training and education was provided to staff related to inappropriate touching, safety event reporting training following the abuse of Patient #5; and,

- Follow their policy on disclosure in Patient #5's medical record.

See A-0144

Based on records reviewed and interviews the Hospital failed to provide care in a safe setting when the Hospital failed to ensure one of 10 sampled patients (Patient #5) was free from sexual abuse. In addition, once informed of the abusive interaction between Mental Health Worker #1 and Patient #5, the Hospital failed to implement abuse prevention strategies, which included failure to:

- perform a comprehensive review of the incident to ensure that Hospital staff followed the Hospital's policy related to Safety Event Reporting;
- ensure staff documented an accurate account of the allegations/incidents in Patient #5's medical record or patient event reports, as required;
- review the incident to determine whether a criminal act had been committed and whether the requirement for reporting to outside agencies had been met;
- ensure a comprehensive pre-hire screening for Mental Health Worker #1 was completed as required;
- in response to the incident and lack of immediate intervention by Security Worker #2, the Hospital failed to conduct appropriate follow-up training and education to staff related to inappropriate sexual touching, abuse, and reporting of safety events, such as interactions between staff and patients which would constitute physical and or sexual abuse.

In addition, a facility assessment on the Hospital psychiatric unit failed to identify and take action to mitigate objects which could be used as weapons/projectiles in the unit.

1). Patient #5's medical record indicated that Patient #5 was complex both medically and psychiatrically. Patient #5 was admitted with psychosis (a mental condition with abnormal thinking and perception) and inappropriate hypersexualizing with repeated incidents of physical restraint. Patient #5's plan of care included the use of 2:1 observation (two staff assigned to be with Patient #5 at all times).

The record indicated that Patient #5's mental competence was subsequently reviewed by the court and it was determined that Patient #5 was incompetent and unable to think or act for his/herself, as to matters concerning personal health, safety and general welfare and authorized use of electro-convulsive therapy (ECT is a medical treatment most commonly used in patients with severe major depression or bipolar disorder that has not responded to other treatments. ECT involves a brief electrical stimulation of the brain while the patient is under anesthesia). The record indicated that Patient #5 was admitted to the secured Mental Health Unit but later moved to the Intensive Care Unit over the course of his/her hospitalization.

The Surveyor interviewed the Chief Nursing Officer at 11:10 A.M. on 6/18/19. The Chief Nursing Officer said that she had been quite involved with Patient #5's case. The Chief Nursing Officer said Patient #5 was moved to the Intensive Care Unit after electro-convulsive therapy and began to mentally improve. The Chief Nursing Officer said that as Patient #5's mental status improved his/her care team became concerned because of the statements related to some sexual memories from the hospitalization being voiced by Patient #5. The Chief Nursing Officer said that the care team in the Intensive Care Unit requested a consult from the Human Rights Officer.

Patient #5's medical record contained no evidence or documentation of the Human Rights consult nor any impressions rendered by the consultation visit. This was not identified prior to Survey.

The Surveyor reviewed the Human Rights Log at 3:30 P.M. on 6/18/19. The Human Rights Log did not contain an entry about Patient #5's consultation or voiced sexual concerns.

The Surveyor interviewed Security Worker #1 at 1:10 P.M. on 6/24/19. Security Worker #1 said she was assigned as one of the staff on a 2:1 observation of Patient #5 on 5/28/19. Security Worker #1 said that Patient #5 was not in restraints at any time during her 10:00 P.M. to 6:00 A.M. shift on 5/28/19. Security Worker #1 said that Mental Health Worker #1 was also assigned to the 2:1 observation of Patient #5. Security Worker #1 said that at approximately 2:05 A.M. she observed Mental Health Worker #1 with her hand on Patient #5's upper thigh. Security Worker #1 said that Patient #5 was wearing only his/her underwear and his/her thigh was bare. Also, Security Worker #1 said that Mental Health Worker #1 was also holding Patient #5's hand. Security Worker #1 recognized this behavior to be extremely inappropriate and she "dismissed" Mental Health Worker #1 from Patient #5's room and notified the Charge Nurse of her observations. Security Worker #1 said that she was asked to write a statement that night and her written statement indicated that she witnessed Mental Health Worker #1's "right hand on the Patient's left leg and very close to his/her inner thigh and towards his/her vagina".

The Surveyor interviewed Security Worker #2 at 1:25 P.M. on 6/24/19. Security Worker #2 said that she had been assigned as relief security on 5/28/19 between 1:30 A.M. and 2:00 A.M. while Security Worker #1 took her break. Security Worker #2 said that she witnessed Patient #5's hands touching Mental Health Worker #1 below the waist. Security Worker #2 said that Mental Health Worker #1 did not ask Patient #5 to do this, did not ask Patient #5 to stop touching her and did not step back from Patient #5's touch even though she had room to do so. Security Worker #2 said she told Patient #5 to stop touching Mental Health Worker #1. Security Worker #2 said after Security Worker #1 returned from her break she told the Hospital's Security Supervisor what she had witnessed. Security Worker #1 said that she was asked to write a statement that night and her written statement indicated "Mental Health Worker #1 allowed Patient #5 to touch Mental Health Worker #1 below the waistline".

The Surveyor interviewed the Executive Director of Patient Safety, Quality and Risk Management at 8:05 A.M. on 6/24/19. The Executive Director of Patient Safety, Quality and Risk Management said that she was the Administrator On-Call who was called after Mental Health Worker #1 was seen touching Patient #5 in an inappropriate manner. The Executive Director of Patient Safety, Quality and Risk Management said that she determined that Mental Health Worker #1 would be dismissed from duty as soon as possible and referred to the Human Resource Department. There was no documentation prior to Survey that any education or training was provided to the remaining Mental Health Unit Staff to ensure full understanding of appropriate versus inappropriate touching. This was not identified prior to Survey.

2) The Surveyor reviewed all of the Safety Events from the secure Psychiatric Unit from the three months prior to survey, including those specifically related to Patient #5. While there were multiple reports of behavioral issues involving Patient #5, there was no entry that reflected the witnessed inappropriate touching of/by Patient #5 that had been reported by the assigned security staff on 5/28/19.

3) The Hospital policy titled, Suspected or Perceived Violence to a Patient Within the Hospital, indicated that all reports of mental, physical, sexual, verbal abuse or neglect and exploitation were documented in the Hospital's occurrence system where they were reviewed by the Director of Quality Improvement/Patient Safety and shared with leadership as necessary or appropriate.

A review of the occurrence systems, indicated that no entry into the occurrence system was made related to the sexual occurrence involving Patient #5.

4) The Hospital's policy titled Disclosure of Adverse Patient Events, dated 7/2017, indicated that the medical record documentation should contain objective, factual details of the event.

The Surveyor reviewed the disclosure in Patient #5's medical record dated 6/4/19. The disclosure indicated an apology related to an incident that occurred with Patient #5 while he/she was restrained. This incident was not the event of inappropriate sexual abuse/touching by Mental Health Worker #1. No disclosure related to inappropriate touching was apparent in Patient #5's medical record as required by the Hospital's policy. This was not identified prior to Survey.

The Surveyor interviewed the Human Rights Officer at 9:50 A.M. on 6/20/19. The Human Rights Officer said he was asked by Patient #5's care team to provide a consultation in the Intensive Care Unit related to Patient #5's recent recollections. The Human Rights Officer said he was aware that Patient #5 had been hypersexual while in the Mental Health Unit and had required restraints at several times during which he/she would call out statements to the effect of you're raping me. The Human Rights Officer said that Patient #5 requested that his/her brother be present during the interview but Patient #5 would not share any details of his/her sexual recollections. The Human Rights Officer said that he was not required to document in the medical record and, because he could not be sure of Patient #5's mental status or his/her sexual recollections, no report was entered into the Human Rights Log. This was not identified prior to Survey.

5) The Surveyor interviewed the Senior Risk Manager at 8:00 A.M. on 6/24/19. The Senior Risk Manager said she was contacted by the Hospital's Director of Security who alerted the Senior Risk Manager that the local police had contacted the Intensive Care Unit inquiring about Patient #5. The Senior Risk Manager said that the local police had Patient #5's name and had been called anonymously regarding concerns about a sexual incident in the Hospital. The Senior Risk Manager said she contacted the Hospital's General Counsel and returned the call to the police detective. The Senior Risk Manager said that because of HIPAA (Federal privacy standards) she told the police detective that the Hospital did not have a patient by that name. The Senior Risk Manager said that Patient #5 had been discharged earlier that day.

6) The Surveyor reviewed the pre-employment file for Mental Health Worker #1 on 6/19/19. Mental Health Worker #1's file indicated she had a work history as a case manager and she indicated that she was proficient in case management, mental health support and crisis response. Mental Health Worker #1's Interview Assessment Form indicated that she had recently successfully intervened with one of her clients that was in immediate danger of self-harm. Further review of Mental Health Worker #1's list of references indicated that she named her academic advisor and professor from her current college program which is an on-line university and co-workers from an auto parts store. Mental Health Worker #1's record did not indicate a pre-hire investigation of her clinical performance. This was not identified prior to Survey.

7). During survey, the Surveyor toured the Mental Health Unit at 9:30 A.M. on 6/18/19. The Surveyor observed a water cooler in the patient's day room that had an observable 18-24 inch cord plugged into the wall. This represented a ligature risk on the secured unit. In addition, the Surveyor observed the enclosed fresh air patio where multiple plants were growing in pots. The Chief Nursing Officer said that gardening was an activity offered on the unit; however, approximately six potted plants were unsecured and could be used as a projectile.

An Environmental Risk Assessment was signed as completed on 2/22/19 that did not include either of these conditions.

Based on records reviewed and interviews the Hospital failed to provide care in a safe setting when the Hospital failed to ensure one of 10 sampled patients (Patient #5) was free from sexual abuse. On 5/28/19, from 1:30 AM to 2:00 A.M., while under a two-to-one observation, Mental Health Worker #1 was observed by Security Worker #2 to be touching Patient #5 in a sexual abusive manner and allowed Patient #5 to touch him/her in an inappropriate, sexual manner but did not intervene. At approximately 2:05 A.M., Security Worker #1, resumed care of Patient #5 and observed inappropriate sexual touching (abuse) between Mental Health Worker #1 and Patient #5. Security Worker #1 immediately intervened to protect Patient #5, dismissed Mental Health Worker #1 from Patient #5's room and notified the Charge Nurse of his/her observations. The hospital failed to ensure their staff followed Hospital policies and procedures related protecting patients, documenting, investigating, and reporting abusive incidents.

Findings include:

Patient #5's medical record indicated that Patient #5 was complex both medically and psychiatrically. Patient #5 was admitted with psychosis (a mental condition with abnormal thinking and perception) and inappropriate hypersexualizing with repeated incidents of physical restraint. Patient #5's plan of care included the use of 2:1 observation (two staff assigned to be with Patient #2 at all times).

The record indicated that Patient #5's mental competence was subsequently reviewed by the court and it was determined that Patient #5 was incompetent and unable to think or act for his/herself, as to matters concerning personal health, safety and general welfare and authorized use of electro-convulsive therapy (ECT is a medical treatment most commonly used in patients with severe major depression or bipolar disorder that has not responded to other treatments. ECT involves a brief electrical stimulation of the brain while the patient is under anesthesia). The record indicated that Patient #5 was admitted to the secured Mental Health Unit but later moved to the Intensive Care Unit over the course of his/her hospitalization.

The Surveyor interviewed the Chief Nursing Officer at 11:10 A.M. on 6/18/19. The Chief Nursing Officer said that she had been quite involved with Patient #5's case. The Chief Nursing Officer said Patient #5 was moved to the Intensive Care Unit after electro-convulsive therapy and began to mentally improve. The Chief Nursing Officer said that as Patient #5's mental status improved his/her care team became concerned because of the statements related to some sexual memories from the hospitalization being voiced by Patient #5. The Chief Nursing Officer said that the care team in the Intensive Care Unit requested a consult from the Human Rights Officer.

Patient #5's medical record contained no evidence or documentation of the Human Rights consult nor any impressions rendered by the consultation visit. This was not identified prior to Survey.

The Surveyor reviewed the Human Rights Log at 3:30 P.M. on 6/18/19. The Human Rights Log did not contain an entry about Patient #5's consultation or voiced sexual concerns.

The Surveyor interviewed Security Worker #1 at 1:10 P.M. on 6/24/19. Security Worker #1 said she was assigned as one of the staff on a 2:1 observation of Patient #5 on 5/28/19. Security Worker #1 said that Patient #5 was not in restraints at any time during her 10:00 P.M. to 6:00 A.M. shift on 5/28/19. Security Worker #1 said that Mental Health Worker #1 was also assigned to the 2:1 observation of Patient #5. Security Worker #1 said that at approximately 2:05 A.M. she observed Mental Health Worker #1 with her hand on Patient #5's upper thigh. Security Worker #1 said that Patient #5 was wearing only his/her underwear and his/her thigh was bare. Also, Security Worker #1 said that Mental Health Worker #1 was also holding Patient #5's hand. Security Worker #1 recognized this behavior to be extremely inappropriate and she "dismissed" Mental Health Worker #1 from Patient #5's room and notified the Charge Nurse of her observations. Security Worker #1 said that she was asked to write a statement that night and her written statement indicated that she witnessed Mental Health Worker #1's "right hand on the Patient's left leg and very close to his/her inner thigh and towards his/her vagina."

The Surveyor interviewed Security Worker #2 at 1:25 P.M. on 6/24/19. Security Worker #2 said that she had been assigned as relief security on 5/28/19 between 1:30 A.M. and 2:00 A.M. while Security Worker #1 took her break. Security Worker #2 said that she witnessed Patient #5's hands touching Mental Health Worker #1 below the waist. Security Worker #2 said that Mental Health Worker #1 did not ask Patient #5 to do this, did not ask Patient #5 to stop touching her and did not step back from Patient #5's touch even though she had room to do so. Security Worker #2 said she told Patient #5 to stop touching Mental Health Worker #1. Security Worker #2 said after Security Worker #1 returned from her break she told the Hospital's Security Supervisor what she had witnessed. Security Worker #1 said that she was asked to write a statement that night and her written statement indicated "Mental Health Worker #1 allowed Patient #5 to touch Mental Health Worker #1 below the waistline."

The Surveyor interviewed the Executive Director of Patient Safety, Quality and Risk Management at 8:05 A.M. on 6/24/19. The Executive Director of Patient Safety, Quality and Risk Management said that she was the Administrator On-Call who was called after Mental Health Worker #1 was seen touching Patient #5 in an inappropriate manner. The Executive Director of Patient Safety, Quality and Risk Management said that she determined that Mental Health Worker #1 would be dismissed from duty as soon as possible and referred to the Human Resource Department. There was no documentation prior to Survey that any education or training was provided to the remaining Mental Health Unit Staff to ensure full understanding of appropriate versus inappropriate touching. This was not identified prior to Survey.

The Surveyor interviewed the Senior Risk Manager at 8:00 A.M. on 6/24/19. The Senior Risk Manager said she was contacted by the Hospital's Director of Security who alerted the Senior Risk Manager that the local police had contacted the Intensive Care Unit inquiring about Patient #5. The Senior Risk Manager said that the local police had Patient #5's name and had been called anonymously regarding concerns about a sexual incident in the Hospital. The Senior Risk Manager said she contacted the Hospital's General Counsel and returned the call to the police detective. The Senior Risk Manager said that because of HIPAA (Federal privacy standards) she told the police detective that the Hospital did not have a patient by that name. The Senior Risk Manager said that Patient #5 had been discharged earlier that day.

The Surveyor reviewed all of the Safety Events from the secure Psychiatric Unit from the three months prior to survey, including those specifically related to Patient #5. While there were multiple reports of behavioral issues involving Patient #5, there was no entry that reflected the witnessed inappropriate touching of/by Patient #5 that had been reported by the assigned security staff on 5/28/19.

The Hospital policy titled, Suspected or Perceived Violence to a Patient Within the Hospital, indicated that all reports of mental, physical, sexual, verbal abuse or neglect and exploitation were documented in the Hospital's occurrence system where they were reviewed by the Director of Quality Improvement/Patient Safety and shared with leadership as necessary or appropriate.

A review of the occurrence systems, indicated that no entry into the occurrence system was made related to the sexual occurrence involving Patient #5.

The Hospital's policy titled Disclosure of Adverse Patient Events, dated 7/2017, indicated that the medical record documentation should contain objective, factual details of the event.

The Surveyor reviewed the disclosure in Patient #5's medical record dated 6/4/19. The disclosure indicated an apology related to an incident that occurred with Patient #5 while he/she was restrained. This incident was not the event of inappropriate sexual abuse/touching by Mental Health Worker #1. No disclosure related to inappropriate touching was apparent in Patient #5's medical record as required by the Hospital's policy. This was not identified prior to Survey.

The Surveyor interviewed the Human Rights Officer at 9:50 A.M. on 6/20/19. The Human Rights Officer said he was asked by Patient #5's care team to provide a consultation in the Intensive Care Unit related to Patient #5's recent recollections. The Human Rights Officer said he was aware that Patient #5 had been hypersexual while in the Mental Health Unit and had required restraints at several times during which he/she would call out statements to the effect of you're raping me. The Human Rights Officer said that Patient #5 requested that his/her brother be present during the interview but Patient #5 would not share any details of his/her sexual recollections. The Human Rights Officer said that he was not required to document in the medical record and, because he could not be sure of Patient #5's mental status or his/her sexual recollections, no report was entered into the Human Rights Log. This was not identified prior to Survey.

Based on records reviewed and interviews the Hospital failed for one of two staff to ensure that a vendor security staff person had training in first aid and current certification in cardiopulmonary resuscitation (CPR).

The Surveyor interviewed the Director of Hospital Services for the vendor security staff at 1:30 P.M. on 6/24/19. The Director of Hospital Services said that her staff were trained in de-escalation techniques and did participate in restraint application as directed by the Hospital staff.

The Surveyor reviewed the first aid and CPR certification on 7/1/19. Security Staff #2 did not have evidence of first aid training nor current CPR certification as required by regulation.

Based on records reviewed and interviews the Hospital failed to perform a comprehensive review of an adverse patient event for one (Patient #5) patient in a sample of ten patient records reviewed and failed to identify when staff failed to follow hospital policies for protecting patients, and documenting and investigating abusive incidents.

The findings included:

The Surveyor interviewed Security Worker #2 at 1:25 P.M. on 6/24/19. Security Worker #2 said that on 5/28/19, A.M., while under a two-to-one observation, Mental Health Worker #1 was observed by Security Worker #2 to be touching Patient #5 in a sexual manner and allowed Patient #5 to touch him/her in an inappropriate. Security Worker #2 did not immediately intervene to stop the interaction/abuse or to protect Patient #5.

The Surveyor interviewed Security Worker #1 at 1:10 P.M. on 6/24/19. At approximately 2:05 A.M., Security Worker #1, resumed care of Patient #5 and observed inappropriate sexual touching (abuse) between Mental Health Worker #1 and Patient #5. Security Worker #1 immediately intervened to protect Patient #5, dismissed Mental Health Worker #1 from Patient #5's room and notified the Charge Nurse of his/her observations.

The Surveyor interviewed the Executive Director of Patient Safety, Quality and Risk Management at 8:05 A.M. on 6/24/19. The Executive Director of Patient Safety, Quality and Risk Management said that she was the Administrator On-Call who was called after Mental Health Worker #1 was seen touching Patient #5 in an inappropriate manner. The Executive Director of Patient Safety, Quality and Risk Management said that she determined that Mental Health Worker #1 would be dismissed from duty as soon as possible and referred to the Human Resource Department.

The Hospital failed to identify the following concerns or opportunities for improvement related to the 5/28/19 incident involving Patient #5 and Mental Health Worker #1:

1. The staff did not follow the Hospital's Safety Event Reporting policies:

The Hospital's policy titled Safety Event Reporting and Follow-Up, dated 4/2017, indicated that a Safety Event was an accident, injury or discovery of a hazardous condition, or any occurrence that is not consistent with the routine operation of the Hospital or routine patient care.

The Surveyor reviewed all of the Safety Events from the secure Psychiatric Unit from the past three months and those specifically related to Patient #5. While there were multiple reports of behavioral issues involving Patient #5, there was no entry that reflected the witnessed inappropriate touching of/by Patient #5 that had been reported by the assigned security staff while Patient #5 was hospitalized.

2. The Hospital staff did not follow the Hospital's abuse reporting requirements or policies:

The policy titled, Suspected or Perceived Violence to a Patient Within the Hospital, indicated that all reports of mental, physical, sexual, verbal abuse or neglect and exploitation were documented in the Hospital's occurrence system where they were reviewed by the Director of Quality Improvement/Patient Safety and shared with leadership as necessary or appropriate.

No entry into the occurrence system was made related to the sexually abusive incident involving Patient #5, which was witnessed by two staff and reported to a Charge Nurse.

3. There was no documentation to indicate the Hospital staff reviewed the actions of Mental Health Worker #1 as a criminal act.

The Surveyor interviewed the Senior Risk Manager at 8:00 A.M. on 6/24/19. The Senior Risk Manager said she was contacted by the Hospital's Director of Security who alerted the Senior Risk Manager that the local police had contacted the Intensive Care Unit inquiring about Patient #5. The Senior Risk Manager said that the local police had Patient #5's name and had been called anonymously regarding concerns about a sexual incident in the Hospital. The Senior Risk Manager said she contacted the Hospital's General Counsel and returned the call to the police detective. The Senior Risk Manager said that because of HIPAA (Federal privacy standards) she told the police detective that the Hospital did not have a patient by that name. The Senior Risk Manager said that Patient #5 had been discharged earlier that day.

4. The Hospital staff did not follow their pre-employment requirements.

The Surveyor reviewed the pre-employment file for Mental Health Worker #1 on 6/19/19. Mental Health Worker #1's file indicated she had a work history as a case manager and she indicated that she was proficient in case management, mental health support and crisis response. Mental Health Worker #1's Interview Assessment Form indicated that she had recently successfully intervened with one of her clients that was in immediate danger of self-harm. Further review of Mental Health Worker #1's list of references indicated that she named her academic advisor and professor from her current college program which is an on-line university and co-workers from an auto parts store. Mental Health Worker #1's record did not indicate a pre-hire investigation of her clinical performance.

This was not identified prior to Survey.

The Surveyor reviewed the e-mail dated 6/24/19 from the Director of Human Resources. The e-mail indicated that the references checked by the vendor company used by the Hospital were appropriate.

5. There was no documentation prior to Survey that any education or training was provided to the remaining Mental Health Unit Staff to ensure full understanding of appropriate versus inappropriate touching. This was not identified prior to Survey.

6. The staff did not follow the Hospital's policy related to documenting adverse events.

The policy entitled Disclosure of Adverse Patient Events, dated 7/2017, indicated that the medical record documentation should contain objective, factual details of the event.

The Surveyor reviewed the disclosure in Patient #5's medical record dated 6/4/19. The disclosure indicated an apology related to an incident that occurred with Patient #5 while he/she was restrained. This incident was not the event of inappropriate touching by Mental Health Worker #1.

There was no disclosure related to inappropriate touching/sexual abuse was apparent in Patient #5's medical record as required by the Hospital's policy.

This was not identified prior to Survey.