HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 8 (Pt #2) adolescent behavioral health clinical records reviewed, the Hospital failed to ensure the patient was monitored every 15 minutes as required for safety.

Findings include:

1. Hospital policy entitled, "Safety Precautions," (reviewed 02/15) required, "...Purpose: To provide a safe environment for the patient and prevent self-destructive behavior. Procedure...10. Nursing Staff: a,. Initiates safety precaution form...h. Documents patient behavior and location every 15 minutes on the Safety Precaution Form..."

2. The clinical record of Pt #2 was reviewed on 4/12/16 at approximately 10:30 AM. Pt #2 was a 15 year old male admitted on 3/10/16 with a diagnosis of mood disorder. A physician's order required Pt #2 be placed on aggression, elopement, and self harm precautions, and that Pt #2 be placed on monitoring every 15 minutes. Pt #2 was discharged 3/15/16 at 5:17 PM. Pt #2's clinical record lacked the Safety Precautions Form dated 3/15/16.

3. The Administrative Director of Quality and Regulatory Compliance stated, during an interview on 4/12/16 at approximately 1:00 PM, that the medical record department is sure the patient had his monitoring on the 15th and is still looking for the document.

Based on review of documents and staff interviews, it was determined for 1 inpatient
(Pt #1) on the Adolescent Behavioral Health Unit (ABHU), with an allegation of sexual abuse, the Hospital failed ensure that follow up after the allegation was completed in accordance with Hospital's policy. This could possibly impact all patients that present with an allegation of sexual abuse.

Findings include:

1. On 4/11/15 at approximately 10:00 AM, the Hospital's policy titled, "Alleged or Suspected Sexual Assault (revised 10/13) required for inpatients, "1... the staff will notify the patient's nurse and the Unit Director/House Administrator...the patient will be placed in a safe environment...3. A sexual assault advocate will be notified...if the patient refuses a sexual assault advocate, the RN (Registered Nurse) will document the refusal...4. The RN will notify a physician (the attending and the house physician)...5. the physician will inform the patient of the medical examination and determine if evidence needs to be collected...a. the patient/guardian must consent for the collection of evidence...7. Documentation: a. Record the history in the patient's own words...8. Treatment: counseling and /or prophylactic treatment for possible communicable disease...b. pregnancy testing...c. pregnancy prevention..."

2. On 4/11/16, beginning at approximately 2:00 PM, the medical record of Pt #1 was reviewed. Pt #1 was a 16 year old female admitted to the ABHU on 3/5/16 with a diagnosis of Major Depressive Disorder Recurrent. Upon admission, Pt #1 was placed on 1:1 precaution for suicidal ideation. The precaution orders were changed to 15 minutes observation on 3/l7/15 by MD #1. On 3/15/16 at 8:08 PM, MD #1 documented in Pt #1's medical record, "...Discussed with staff that she (Pt #1) had sex in the middle of the night with a peer..." MD #1 failed to order a physical examination, laboratory tests, or follow the Hospital's policy regarding allegation of sexual abuse for Pt #1.

3. On 4/11/16 at approximately 9:00 AM, an interview was conducted with the ABHU Manager (E #1). E#1 stated that on 3/15/16, a patient (Pt #1) on the ABHU informed a staff member of an allegation of sexual intercourse while an inpatient on the unit. During the interview on 4/15/16 at 9:00 AM, E #1 stated the Hospital was presently investigating the allegation and that Pt #1 had been discharged from the Hospital.

4. On 4/11/16 at approximately 12:35 PM, an interview was conducted with the Psychiatrist (MD #1) for Pt. #1. During the interview MD #1 stated that MD #1 had been informed by a staff member that Pt #1 had informed the staff member that Pt #1 had had sex with another patient. MD #1 stated that MD #1 did not order a gynecological examination or laboratory test for Pt #1 following the allegation of sexual intercourse. On 4/11/16 at during the same interview, MD #1 stated MD #1 did not provide any additional follow up because there were conflicting stories provided by Pt #1 and the other patient (Pt #2) [who Pt #1 alleged was involved], and because Pt #1 stated the sexual intercourse was consensual. MD #1 additionally stated when asked, that sex between adolescent patients or inpatients could not be consensual.

5. On 4/12/16 at approximately 11:00 AM, an interview was conducted with the Hospital's Vice President of Talent Management & Risk Manager (E #6). E #6 stated during the interview that the sex between the two ABHU inpatients could not have been consensual. E #6 further stated that follow up requirements for Pt #1, after the sexual allegation, were left to MD #1 to complete.

Based on document review and interview, it was determined that for 1 of 2 (Pt #9) clinical records reviewed of patients utilizing non violent restraints, the Hospital failed to ensure a complete physician's order include the type of restraint to be used.

Findings include:

1. Hospital policy entitled, "Restraints," (reviewed Jan 2014) required, "...Restraint Application for Medical/Surgical Purposes ...3. The restraint order is to include the following: Type of restraint..."

2. The clinical record of Pt #9 was reviewed on 4/12/16 at approximately 10:00 AM. Pt #9 was an 87 year old female admitted on 4/3/16 with diagnoses of syncope, hypotension and supraventricular tachycardia. Pt #9's clinical record contained a physician's order dated 4/4/16 that required "Restraint until find a sitter." The physician's order lacked the type of restraint device to be used.

3. The Administrative Director of Quality and Regulatory Compliance stated, during an interview on 4/12/16 at approximately 10:00 AM, that the physician's order for the restraints did not include the type of restraint to be used.