HospitalInspections.org

Based on policy review, document review, medical record review and interview, the hospital failed to ensure all patients were free from potential abuse and failed to ensure a thorough investigation of all allegations of abuse by failing to follow written protocols for incident reporting and sexually acting out precautions for 4 of 5 (Patient #1, #3, #4, and #7) sampled patients.

The findings included:

1. Review of the hospital policy "Abuse or Neglect Investigations" revealed, PURPOSE: To establish a protocol for notification of alleged neglect or abuse of residents...POLICY: It shall be the policy of The Company that all suspected incidents of current or past abuse or neglect of residents be reported to the state Division of Children Services and/or required regulatory entities in accordance with the requirements of the Division of Children Services and other applicable regulations...PROCEDURE:...The CEO [Chief Executive Officer] /designee shall determine proper action to take when abuse or neglect is suspected due to the actions of an employee...For all internal allegations and suspicions, the Vice President of Quality and Risk Management should be notified within 24 hours, and a preliminary Critical Incident Report...shall be submitted to the CEO/designee. This shall include a full description of the alleged event, the alleged perpetrators name(s), and actions taken by the reporting staff member and charge nurse on duty...For all residents disclosures/allegations given to therapists, which occurred in the past, the therapist shall complete an initial critical incident report and submit to the CEO/designee within twenty- four (24) hours..."


Review of the hospital policy "Investigation of Incident" revealed, "...PURPOSE: To provide a thorough investigation immediately after a major incident, i.e., [that is to say]...allegations of abuse..." PROCEDURE: Immediately after the incident has been reported, the nurse on duty will assure that proper documentation is completed, including Critical Incident Report. The Critical Incident Report should be forwarded to the Quality Coordinator as soon as possible after the incident, preferably within 24 hours. The CEO, Quality Coordinator and/or the Director of Nursing shall request initial written statements from all assigned staff and/or witnesses. The CEO, Quality Coordinator and/or Director of Nursing will then interview all individuals involved and compile a summary of the interviews and statements. All of these statements and forms are to be attached to the Critical Incident Report...Any immediate action necessary is taken, including safety measures and notifications. These actions shall be recorded on the Critical Incident Report. The Critical Incident Report and copies of all statements shall be forwarded to the Vice President of Quality and Risk Management as soon as possible...The Vice President of Quality and Risk Management will determine and further action..."

Review of the hospital policy "Sexually Acting Out Precautions" revised 10/21/2021 revealed, " ...Suspected incidents of a sexual nature shall be handled on an individual basis... A number of factors must be considered in determining appropriate staff response... age difference physical statue... Coercive Sexual Contact: When there is reason to suspect the sexual contact was coercive or abusive, or if one of the subjects described the behavior as unwanted. The incident will be investigated as an abuse incident and staff will follow all policy and procedure regarding such ..."

2. Review of an internal email from MSW #1 to the Director of Clinical Services dated 5/24/2022 at 11:47 AM revealed,"...I wanted to send you a quick email regarding some concerns that were brought to my attention during a family session yesterday with [named Patient #1] regarding [named Mental Health Technician #1]. I am not sure if any of the concerns were addressed prior to me writing this or if it was all just brought to my attention. [named Patient #1] ...She is claiming the following: She was not able to drink anything throughout the day while he was on duty, He spread rumors that she wet the bed and would call her 'pissy pants' in from of her peers, He would allow other kids to dump water on her while she was asleep in the group room, There was a game called slap the snitch, When the fight occurred last Friday and she was getting beat she claimed that he did not do anything that she was the one that escaped the fight to get some help, She also claimed that during the weekend he kept everyone locked in their rooms. I tried to get more specific information such as a timeframe and who it was reported to. She could not recall any of that information. I was not sure what the next step would be. So that is why I am reaching out to you. I did not say anything to [named Program Manager] about it. Please let me know your thoughts..."


Review of MHT #1's personnel file revealed date of hire 4/11/2022. Review of a Corrective Action Form dated 5/23/2022 revealed " ...written warning...observed on cell phone while on the unit...observed using profane language towards patient..." Attached to the document was a note from the nurse on duty at the time of the incident. The nurse note revealed, "Patient #3 began kicking hallway door of day room, [name MHT#1] opened door and began verbally fighting with patient (patient was also verbally yelling) [named MHT#1] states he thought patient was grabbing for his keys- at this time [name MHT #1] began cussing and yelling at patient in the hallway- nurses present and [named Physician #1] attempted to calm [MHT #1] and situation..." Review of a Corrective Action Form dated 5/27/2022 revealed, "...Termination ...On May 25, 2022 it was reported that [named MHT #1] demonstrated inappropriate unprofessional behavior towards patients...employee quit before presented..." Review of The Separation notice dated 5/27/2022 documented MHT #1 was terminated for violation of policy.


3. Medical record review for Patient #1 revealed a 11 year old female with involuntary commitment/admission date of 5/11/2022 for suicidal ideations and post traumatic stress disorder after being treated in the an emergency department. Patient #1's mother shared concerns about MHT #1 with MSW #1, during a family session, on 5/23/2022.

Medical record for Patient #3 revealed a 17 year old female admitted for suicidal ideations on 5/20/2022. Review of nursing notes dated 5/23/2022 revealed,"...patient in hallway verbally escalated and cussing at other residents, Tech [MHT #1] also involved with staff X [times] 3. MD [Physician #1] on unit and verbally engaged and attempted to deescalate patient ...


4. In an interview on 6/15/2022 at 8:35 AM, the Director of Nursing (DON) stated a new Risk Manager (RM) had started 6/14/2022, but that the DON had been serving in the role during the time there was no RM. The DON verified any incidents would be reported to her or the CEO.

In an interview on 6/15/2022 at 9:50 AM, MSW #1 brought a copy of the email she sent to Director of Clinical Services dated 5/24/2022 at 11:47 AM. MSW #1 stated she sent the email but never heard anything back about the incident. MSW #1 did not initiate a Critical Incident Report.

In an interview on 6/15/2022 at 10:50 AM, the Director of Clinical Services (DCS) verified she received the email from MSW #1 on 5/24/2022 but could not recall the date/time she opened the email. The DCS stated she shared the information with MHT #1's supervisor, the Program Manager. The DCS stated she showed the Program Manager the email. When asked what date and time she provided the information to the Program Manager, "I don't know." When asked if she documented sharing the information with the Program Manger she stated, "There is no documentation, we spoke face to face ..." When asked if MHT #1 worked after she received the email, she stated "I don't know." When asked if she reported the incident, the DCS stated that would be the responsibility of Risk Management. The DCS did not initiate a Critical Incident report

In an interview on 6/15/2022 at 11:00 AM, the DON was asked if she was aware of the allegations of abuse reported by Patient #1 to MSW #1. The DON stated, "I will have to ask [named CEO] if he got it [incident report]...I didn't get it. I really was not involved in the email or what got reported...Hard for me to believe nurse on the unit would not have reported this ..."

In a telephone interview on 6/15/2022 at 11:08 AM, MHT #1 stated his last day of employment was 5/24/2022 and he did not return to his position because he was not making enough money. MHT #1 stated he was written up for getting on his cell phone at work. MHT #1 denied any patient abuse.

In an interview on 6/15/2022 at 11:18 AM, the Program Manager (and supervisor for MHT #1 who was made aware of the allegations of Patient #1 by the DCS) verified MHT #1 worked his entire shift on 5/24/2022 and was not asked to leave pending an investigation into the allegations. The Program Manager stated she could not recall the date/time the DCS informed her of the abuse allegations.

In an interview on 6/15/2022 at 11:23 AM Nurse #2 was asked about MHT #1. Nurse #2 stated she had observed MHT #1 have a verbal altercation with Patient #3 and use profanity. Nurse #2 stated Physician #1 was present on the unit and heard the interaction and intervened with MHT #1. When asked the date if the incident, Nurse #2 pulled the medical record and reported it was on 5/23/2022 at 12:45 PM.

In an interview on 6/15/2022 at 11:42 AM, the DON stated I am not aware of an incident between MHT #1 and Patient #3. There was no Critical Incident Report for the verbal altercation between Patient #3 and MHT #1.

In an interview on 6/15/2022 at 11:44 AM, when asked about the incident of MHT #1 using profanity toward Patient #3 on 5/23/2022, the Chief Executive Officer (CEO) stated "I do remember being called by [named Physician #1] and [Physician #1] said MHT didn't cross the line and [Physician #1] tapped him [MHT #1] out [removed him from the situation] ..." The surveyor requested the CEO call the Physician for a telephone interview at 11:46 AM.

In a telephone interview on 6/15/2022 at 11:47 AM, Physician #1 verified he was present on 5/23/2022 in the conference room on the unit when he heard shouting between a patient [Patient #3] and MHT #1, he stated he heard the MHT #1 use profanity, and Physican #1 stepped out of the conference room to intervene and told MHT #1 to take a break. Physician #1 stated he later processed with MHT #1 and explained to MHT #1 he needed to be the adult and could not escalate with the patient's behavior. When asked if that was acceptable behavior, Physician #1 stated it was not acceptable, but he was not the one who hired and fired. Physician #1 further stated if this was the first incident, appropriate to counsel and document the occurrence to ensure no pattern with an employee.

In an interview with the CEO and DON on 6/15/2022 at 11:55 AM, the CEO stated he was not aware of all the allegations from Patient #1 in the email from MSW #1 to the Clinical Director. He stated, "I knew about the water part...the email wasn't enough, we kicked it down the road instead of reporting up..." The CEO further stated, "It [allegations from Patient #1] should have been an incident report and brought to Risk Management...there wasn't one for this [allegation] I would have known...we [staff] didn't follow through..." The CEO and DON verified there was no documented incident report for the allegations made by Patient #1 against the MHT #1 or for the incident when MHT #1 used profanity toward Patient #3. The CEO verified he had not investigated the allegations of abuse because the MHT #1 had not returned to work after 5/24/2022, and was terminated on 5/27/2022.

In a telephone interview on 6/16/2022 at 11:23 AM, MSW #1 stated she reported the allegations in an email to DCS because she was the supervisor of all the therapists. MSW #1 stated she had been trained how to complete a Critical Incident report in orientation but most of the time, nurses complete Critical Incident reports. MSW #1 stated she was not sure how the CEO/DON would have been informed of the allegations of abuse

In a telephone interview on 6/16/2022 at the DON stated the previous RM last day at work was 4/26/2022.

5.Medical record review for Patient #4, revealed a 16 year old female with an admission date of 5/19/2022 for command hallucinations, self-harm, and harming others. On admission, Patient #4 was on routine every15-minute checks, suicide, self-harm, and elopement precautions.

The Shift Nursing Flowsheet for Patient #4 dated 5/23/2022 at 1:00 PM revealed, " ...other residents informing nurse of possible sexual encounter 2 days ago-interviewing patient who denies anything or any contact with male resident occurred-resident also made a written statement..." The AOC, MD and the patient's mother were notified.

Review of the undated written statement revealed Patient #4 denied sexually activity with Patient #7.

The Psychiatric Progress Note for Patient #4 dated 5/25/2022 at 9:45 AM revealed, " ... recent sexual accusations with male peer ... 'A boy said I raped him but I didn't.' Patient denies sexual intercourse ..."

The Session Note dated 5/25/2022 at 2:45 PM revealed Patient #4 reported she did have sexual intercourse with the other patient last week. Patient #4 reported she was coming forward now because she was worried, she may be pregnant. The patient also reported feeling angry and uncomfortable at having to see the other patient.

Medical record for Patient #7 revealed a 13 year old male admitted on 5/14/2022, for unstable mood, suicidal ideations, and overt physical aggression. On admission, Patient #7 was on routine every15-minute checks, suicide, self-harm, and elopement precautions.

The Shift Nursing Flowsheet for Patient #7 dated 5/23/2022 at 1:00 PM revealed, " ... other residents informing nurse of possible sexual activity from 2 nights ago- interviewed resident about possible activity-patient denied any activity-reporting to nurse said he was told by tech to not be in the bathroom patient made a written statement. However patient then returned to desk and reported to nurse that a sexual encounter occurred and that he was told if he didn't participate other patient would 'tell on me'-patient reports to nurse that he was 'forced to do it'-patient then made 2nd written statement-2nd patient and other involved resident reports to nurse the sexual encounter did not occur and also made a written statement. The AOC, MD and the patient's father were notified.

Review of the undated written statement by Patient #7 revealed, " ...forced me to have sex with her ...she keeps hitting my boobs ...felt pressured and uncomfortable ..."

The Psychiatric Progress Note for Patient #7 dated 5/25/2022 at 7:55 AM revealed, " ...denied recent physical aggression ..."

The Shift Nursing Flowsheet for Patient #7 dated 5/26/2022 at 9:25 AM revealed, " ... Pt c/o of female peer over the last several days being handsy ...peers have complained of [Patient #7's] inappropriate language ...comments of sexual nature..."

In a telephone interview on 6/9/2022 at 3:15 PM, the DON revealed the team determined the sexual activity between Patient #4 and #7 was non-coercive. The facility was unable to provide any documentation of the team discussion and decision.

In a telephone interview on 6/9/2022 at 4:36 PM, MHT #2 revealed she wrote her written statement for the hospital on 6/8/2022. MHT #2 revealed she notified the unit nurses at the time she found Patient #7 in Patient #4's room.

In a telephone interview on 6/10/2022 at 4:22 PM, RN #1 revealed the incident happened at shift change and the MHT had to go unlock the door for the patients to use the bathroom. RN#1 revealed MHT #1 did not inform her she found Patient #7 in Patient #4's room.

The facility was unable to provide a written statement from RN #1.

The hospital failed to ensure critical incidents were reported and documented timely and failed to ensure allegations of abuse were investigated according to policy.