HospitalInspections.org

The facility failed to promote each patient's rights when the facility failed to:

A. ensure care in a safe setting. Cross refer to A0144
B. ensure each patient had the right to be free from all forms of abuse or harassment as the facility did not follow their policy related to the investigation of actual events of sexual allegations; placing all patients at risk of incomplete investigations. Cross refer A0145

Based on review of patient records, facility incident reports, review of the facility internal investigation and confirmed in interview, the facility failed to protect each patient's right to care in a safe setting by failing to

A) assess and implement interventions to reduce risk to patient for one of ten patients (Patient #1)
B) monitor the patient's hallway resulting in a female and male adolescent patients engaging in sexual intercourse for one of six incidents reviewed (Patients #1 and #2)


Findings included:

A) assess and implement interventions to reduce risk to patient for one of ten patients (Patient #1)

Patient #1 (female 17 yo): admitted 01/03/2023 with the following diagnoses: major depressive disorder, recurrent, moderate to severe without psychosis, disruptive mood, dysregulation disorder, anxiety disorder, unspecified

Review of Patient #1 Direct Admission Assessment Tool documented on 01/03/2023 at 8:03 PM described her Presenting Problems and Significant History as "suicidal thoughts." Further review of the Admission Assessment Tool under Sexually Aggressive Behavior and Potential for Sexual Victimization Behavior, the nurse (Personnel #F) selected "no" for both indicators for history of sexual aggression and sexual victimization (over lifetime)

Review of the initial nursing assessment documented on 01/03/2023 at 9:40 PM , the nurse (Personnel #G) selected "no" for both history of sexual victimization (over lifetime) and history of sexual aggression (over lifetime)

Review of the Initial Nursing Treatment Plan on 1/03/2023 at 10:00 PM revealed no documentation of any Problems/Short-term Goals for Sexual Acting Out as documented by Personnel #G.

Review of the initial examination by the Physician Assistant (Personnel #H) on 01/04/2023 at 12:06 PM indicated a history of sexual abuse as indicated by the History of Present Illness which described "[Patient #1] states that she has been in CPS [child protective services] since 3 years old due to physical and sexual abuse by her biological parents."

Review of the facility policy Sexual Aggression and Sexual Victimization: Prevention and Response Notification Plan 872015 (date reviewed 05/17/20) under Purpose states "provision of a safe and therapeutic environment of care includes the prevention of patient-to-patient sexual incidents, as well as any verbal/physical threats of sexual incidents. To provide a plan for the Prevention of Sexual Behavior including Aggression and Potential for Victimization by identifying early warning signs of sexual behavior, monitoring the patient with a suspected potential for sexual aggression/victimization, and implementing intervention steps to minimize the risk of sexual behavior."

Further review of the policy provided the following procedure:
"Early identification: intake/admission staff assesses patients for potential for sexual aggression
-History of sexually aggressive behavior including criminal sexual history,
sexual abuse/assault, psychosis with sexual preoccupation or promiscuity
- Current risks for sexual behavior/aggression such as sexually inappropriate
verbalization, provocative behavior or gestures
- Intended victims are identified from patient report and/or historical
information
- Potential for Sexual Victimization:
- History of being sexually abused/assaulted, being developmentally disabled,
or physical status/medical conditions that may compromise the patient's
selfdefense, and/or having sexually provocative/ hypersexual behaviors

Historical data is gathered from the patient, family/guardian, previous hospitalizations/
placements, referral/custodial agencies, and available medical, social, and legal history.

Intake/Admission staff/Unit Nurse:
- Completes the High Risk Visual Notification Alert and identifies
either Sexual Aggression and/or Sexual Victimization, as appropriate"

Review of the Patient #1 initial Precautions ordered on 01/03/2023 at 10:00 PM included only Suicide precautions and Unit Restrictions Precautions. The High Risk Notification Alert documented by both Personnel #F and Personnel #G only included Elopement; Self Harm; Suicide; and Unit Restrictions. No Sexual Acting Out (Aggressor or Victim) indicated.

Review of the Diagnosis Code and Description coded on 01/07/2023 included "Z62.810 Personal History of physical and sexual abuse in childhood"

Increased precautions for Sexual Aggression Risk were not ordered until AFTER the sexual incident on 01/07/2023.

An interview with Personnel #A on 03/07/2023 at 1:10 PM confirmed the above findings. He reviewed the patient chart and found no indication of increased precaution for the sexual history.


B) monitor the patient's hallway resulting in a female and male adolescent patients engaging in sexual intercourse for one of six incidents reviewed (Patients #1 and #2)


Review of the self-reported incident report dated 01/11/2023 described a sexual incident on 01/06/2023 at 10:20 PM between Patient #1 and Patient #2 in Unit F.

Patient #1 (female 17 yo): admitted 01/03/2023 with the following diagnoses: major depressive disorder, recurrent, moderate to severe without psychosis, disruptive mood, dysregulation disorder, anxiety disorder, unspecified

Patient #2 (male 14 yo): admitted 01/04/2023 with the following diagnoses: major depressive disorder, recurrent, severe without psychosis; cannabis, alcohol use disorder, unspecified

"The incident occurred at 10:20 pm when the MHT (mental health technician, Personnel #C) entered Patient #2's room and found Patient #1 in the bathroom undressed with Patient #2 in his bathroom. An interview of both adolescent patients stated they had engaged in sexual intercourse."

Review of the facility policy Patient Observation Rounds (date reviewed 05/17/2022) stated "Perform rounds at staggered intervals and in a varying pattern or sequence throughout the unit to minimize planned acting out opportunities...While monitoring hallways and patient care areas ensure patients are not entering rooms not assigned to them; not in rooms or areas that are designated 'off limits' areas to patients; not left in 'treatment areas' without direct staff supervision ...Visually observe patients when behind closed doors by knocking on bedroom and bathroom doors, announce that they are stepping into the room for rounds, open the door and visually observe the safety of the patient."

The investigation summary of the above incident report by the Director of Risk Management (Personnel #B) indicated she reviewed the video of the incident on 01/07/2023. Camera review details indicated that "at 10:02 pm one MHT (Personnel #C) is in the nurse's station and the other MHT exits the unit for approximately 1 minute. There is no hallway presence. It is during this minute that four female patients [Patient #1, Patient #10, Patient #22, and Patient #23] from two different rooms and run into a male patient room (Patient #2). At 10:11pm, MHT appears to hear noise down the hall and walks down to male patient room (Patient #2) where the four female patients were. A few seconds later, 3 female patients (Patient #10, #22, #23) and the MHT [Personnel C] exit the male patient room ...Patients (Patient #1, #2) were discovered together in male patient's bathroom on 01/06/2023 at approximately 10:20pm."

An interview with the Director of Quality (Personnel #A) on 01/31/2023 at 3:40 PM in the exercise room confirmed the above findings. He agreed that there were no 'hallway presence' that allowed the adolescents to be unsupervised and provided the opportunity to engage in sexual intercourse.

The lack of appropriate monitoring and/or intervention is a risk to health and safety as it places all patients at risk for adverse events including inappropriate sexual contact, injuries by self or other patients, and possible death.

Based on review of the incident report, review of the facility internal investigation, review of patient records, facility policies and confirmed in interview, the facility failed to ensure patients are free from all forms of abuse or neglect by failure to implement action plans identified when sexual actions between patients occurred (Patients #1 and #2) for one of six incidents reviewed.

Findings included:

Review of the self-reported incident report dated 01/11/2023 described a sexual incident on 01/06/2023 at 10:20 PM between Patient #1 and Patient #2 in Unit F.

Patient #1 (female 17 yo): admitted 01/03/2023 with the following diagnoses: major depressive disorder, recurrent, moderate to severe without psychosis, disruptive mood, dysregulation disorder, anxiety disorder, unspecified

Patient #2 (male 14 yo): admitted 01/04/2023 with the following diagnoses: major depressive disorder, recurrent, severe without psychosis; cannabis, alcohol use disorder, unspecified

"The incident occurred at 10:20 pm when the MHT (mental health technician, Personnel #C) entered Patient #2's room and found Patient #1 in the bathroom undressed with Patient #2 in his bathroom. An interview of both adolescent patients stated they had engaged in sexual intercourse."

Review of the facility policy Response to Sexual Allegations/Actual Events (date reviewed 05/17/2022) stated in part "Staff will immediately separate the patients, moving one to a different unit if possible and if not possible moving patients to opposite ends of the hallway and placing one of the patients on a 1:1 and placing both patients on Sexual Aggression/Sexual Victimization Precautions.
Staff will immediately interview both patients to determine if there are any allegations of rape or if incident was mutually consensual.
Staff will notify all appropriate persons:
charge nurse on unit will notify:
nursing supervisor
Administrator on call
Risk Manager
CEO
DON and Director of Clinical Services
Physician
Nursing Supervisor will notify (after speaking with RM and AOC)
family/guardian (if patient is an adolescent or child)
police and/or court officer (if allegation of rape)
Social Services agencies of the state if patient under their custody
probation officer, if applicable
If both patients confirm mutual consent
Both patients will be tested for STD/HIV, Hepatitis C
Female patient will receive pregnancy testing and be offered Plan B as appropriate and as ordered by physician
Both patients will receive appropriate STD and Infection Control counseling
Following patient sexual allegations/actual sexual event clinical and nursing staff will complete an initial review and debriefing including
A Healthcare Peer Report (HPR)
Contributing factors and circumstances precipitating and leading to the sexual event
Patient change(s) in condition
High Risk Notification, precautions, and MHT round monitoring
Remedial measures regarding unit of occurrence (e.g. blocking of room(s), room reassignment, line of sight or 1:1 supervision)"

Review of the facility policy Sexual Aggression and Sexual Victimization: Prevention and Response Notification Plan 8272015 (date reviewed 05/17/22) stated in part under Response "Discovery of a Sexual Allegation can occur either as witnessed by staff, and/or as reported to staff by a third party witness or one of the patient allegedly involved.
Upon report or discovery of an allegation of sexual behavior between patient/patient,
staff/patient or stranger/patient the Charge Nurse and facility leadership
-Immediately separate patients upon discovery of sexual behavior or who are
alleged to have engaged in sexual behavior
- Secure the area/room where the incident occurred/is suspected of occurring
- Preserve/save any evidence, hospital or patient property such as sheets and
clothing as evidence for the investigation process
- Secures the Medical Record
- Initiate investigation including interviews of the patients involved (maintaining
separation), any witness (es), and staff directly responsible for the observation
rounds at the time of the event. Clarify the type of sexual incident/contact as oral,
anal, vaginal penetration, or fondling, for example.
- Prepare patient(s) for transport to the ER for rape/trauma evaluation for cases
involving non-consent, allegation of force, assault/rape.
- Complete a HPR/Incident Report during the shift the incident occurred and
forward the report to Risk Management within 24 hours.
Notification:
Person discovering the incident/event:
- Notify the Charge Nurse and Nursing Supervisor.
Charge Nurse:
- Notify the Director of Nursing, Risk Manager and the Attending Psychiatrist
-Obtain orders for: Evaluation/ER visit/rape kit, STD/HIV testing (Chlamydia, Gonorrhea, HIV,
Hepatitis B, C and Pregnancy testing) or Plan B reviewed/offered by the ER, as appropriate
- Implementation of Sexual Aggression and/or Sexual Victim Precautions
- Implementation of increased level of monitoring, as required
Attending Psychiatrist:
- Reviews all relevant findings with the patient(s) involved and documents the
discussion and patient response in the medical record
- Assesses the need for birth control and Plan B
Unit/Clinical Team:
- Update the patients' treatment plans as applicable"

Per the facility policy corrective actions after sexual incidents included:
a) clarify the type of sexual incident/contact as oral, anal, vaginal penetration or fondling for example
b) doors to remain closed between the male and female rooms
c) increased precautions
D) STD and Infection control counseling and STD/HIV testing (Chlamydia, Gonorrhea, HIV, Hepatitis B, C
e) updated treatment plans


a) clarify the type of sexual incident/contact as oral, anal, vaginal penetration or fondling for example

Review of the self-reported incident report dated 01/11/2023 described a sexual incident on 01/06/2023 at 10:20 PM between Patient #1 and Patient #2 where they engaged in sexual intercourse.

"The incident occurred at 10:20 pm when the MHT (mental health technician, Personnel #C) entered Patient #2's room and found Patient #1 in the bathroom undressed with Patient #2 in his bathroom. An interview of both adolescent patients stated they had engaged in sexual intercourse."

Review of the medical consult by Personnel #J on 01/07/2023 at 10:05 AM indicated "staff reported that [Patient #1] was found in [Patient #2] bathroom without her clothes on. [Patient #2] was clothed. [Patient #2] reports that they had sex. [Patient #1] denies penetration. Both deny injuries. Patient has been tested today for STIs and labs pending. Family informed. Nurse to contact supervisor to determine if a legal report is needed."

No other documentation was provided to indicate any further investigation as to the type of sexual incident was provided for review.

b) doors to remain closed between the male and female rooms

Review of the facility corrective actions of the above incident did NOT include documentation of remedial measures to include blocking of rooms. Re-education of staff only included the MHT (Personnel #C) involved in incident, not all staff.

An interview with the Director of Quality (Personnel #A) on surveyor tour of unit on 01/31/2023 at 1:40 PM indicated that part of the corrective actions was to close the door in between the male and female rooms at night. Surveyor observed that the unit door between the male and female hallways were closed.
However, an interview with the lead MHT (Personnel #D) on 02/01/2023 at 11:00 AM confirmed that the doors are closed only on certain time frames (during quiet times or shower times). She was unaware of any facility implementation of the unit door closure at night.

Surveyor made a request for documentation of a policy for blocking of doors between male and female units at night and none were available for review.

c) increased precautions

Facility corrective actions included increased precautions as ordered by the provider. However, High Risk Notification Form for both Patient #1, #2 did not include Sexual Aggression Risk precautions. Furthermore, the Q15 observations log did NOT include documentation of the increased precautions for two of two patients (patient #1, #2).

Review of Patient #1 medical ancillary orders confirmed a Sexual Aggression Risk Precaution was ordered by the Personnel #C after the incident on 01/07/2023 at 09:00 AM.
Review of Patient #1 Q15 observations logs for 1/8/2023 revealed no documentation of the required Sexual Aggression Risk Precaution

Review of Patient #2 medical ancillary orders confirmed a Sexual Aggression Risk Precaution was ordered by the Personnel #C after the incident on 01/07/2023 at 09:00 AM.
Review of Patient #2 Q15 observations logs for 1/8/2023 revealed no documentation of the required Sexual Aggression Risk Precaution.

d) Review of the facility corrective actions of the above incident did NOT include any STD and Infection Control counseling per the facility protocol nor any lab results for Hepatitis B and C.

Review of the facility policy Sexual Aggression and Sexual Victimization: Prevention and Response Notification Plan 872015 (date reviewed 05/17/2022) stated "Purpose Provision of a safe, therapeutic environment of care includes the prevention of patient-to-patient sexual incidents, as well as any verbal/physical threats of sexual incidents ...
Attending Psychiatrist:
Reviews all relevant findings with the patient(s) involved and documents the discussion and patient response in the medical record"

Review of Patient #2 Psychiatric progress notes from 01/07/2023 to the date of discharge 01/10/2023 revealed no documentation of the patient's sexual incident or patient response.

Social Services progress notes for Patient #2 on 01/09/2023 at 02:00pm indicated "PT presents with depressed mood. PT was caught participating in inappropriate sexual behaviors. PT insight appears limited. However, he is able to identify some triggers but not able to ID changes needed moving forward. PT denies SI [suicidal ideation] since admission. PT does not have after care plans established at this time."

Review of the laboratory reports provided on 03/07/2023 for both Patient #1 and Patient #2 included only Chlamydia, Gonorrhea and HIV testing. No Hepatitis B or C and testing were available for review per facility policy.

Review of available records revealed no further information documented on how the staff was going to protect the adolescents, how the patients were coping from the incident, or if any follow-up were required with their STI testing.

e) updated treatment plans
Review of the facility policy Sexual Aggression and Sexual Victimization: Prevention and Response Notification Plan 872015 (date reviewed 05/17/2022) stated in part "Unit/Clinical Team: Update the patient's treatment plans as applicable."

Review of the treatment plans for both Patient #1 and Patient #2 revealed no documentation of any update after the incident.

Treatment plans were not updated, per facility policy. Without an update to the treatment plan, staff cannot appropriately monitor/implement interventions.

An interview with the CEO (Personnel #E) via phone call on 02/13/2023 at 10:30 AM confirmed the above findings. He agreed that the facility has room for improvement in how they handled the incident.

The facility did not follow their policy related to the investigation of actual events of sexual allegations, placing all patients at risk of incomplete investigations.