HospitalInspections.org

Based on medical record review, documentation review, staff interview, and policy review, the facility failed to ensure that Patient #1, #2, and #3 (three [3] of 11 patients reviewed) were free from abuse at the facility's Behavioral Health Facility.


Findings include:


The State Office received a complaint involving a psychiatric technician taking pictures of three (3) young female patients while alone with them in their bedroom/bathroom during bath time. Along with the State Office the facility also notified the area police and the employee was terminated.



During the complaint investigation on 10/13/2016 the Director of Patient Safety provided the following documentation:
The facility received a call at 8:05 a.m. on 10/5/16 from the mother of recently discharged 6-year-old (Patient #1). The mother stated her daughter told her that someone came in her room at bath time. The child didn't know what day it happened on. She said it was a white man with black hair and black clothes. The man told her to turn around and he took a picture of her "fanny". The child said that he had a smartphone. The mother asked that we look into it. The facility immediately reviewed surveillance footage. On 9/26/16 video surveillance shows (Psychiatric Technician #1) entering the patient's room at approximately 5:06 p.m. A cell phone is noted in his hand. He is noted walking in and out of the patient's room/bathroom. The incident was reported to the local Police Department on 10/5/16. Police reported to the facility on the afternoon of 10/6/16 that (Psychiatric Technician #1) was in their custody. He reportedly disclosed to them he had taken photos of two additional patients. The facility identified the patients as (Patient #2 and Patient #3). The facility began the process of reviewing video surveillance. They did not know the date(s) involved. (Psychiatric Technician #1) employment was terminated on 10/7/16. (The last day Psychiatric Technician #1) had worked was 10/4/16.


Record Review for Patient #1 revealed she was a 6-year-old female admitted to the facility's Behavioral Medicine Unit on 9/25/16 and discharged on 9/30/16. Problem List/Past Medical History: Ongoing Aggression; Attention deficit hyperactivity disorder; Disruptive behavior disorder; Hyperactivity; and Tic disorder.


Record review for Patient #2 revealed that she was an 8-year-old female admitted to the facility's Behavioral Medicine Unit on 9/30/16 and discharged on 10/5/16. Her diagnoses were: Major Depressive Disorder, recurrent, severe; Attention Deficit Disorder, hyperactive type (ADHD); Oppositional Deficit Disorder; Tourette's Syndrome, and rule out Schizophrenia.


Record review for Patient #3 revealed she was an 8-year-old female admitted to the facility's Behavioral Medicine Unit on 9/28/16 and discharged on 10/5/16. He diagnoses included: Rule out ASHD, Predominantly Inattentive; Academic Problem: Rule out Explosive Disorder.


At the time of survey the facility provided three (3) disks, one for each of the three (3) patients. The videos showed Psychiatric Technician #1 going into each of the three (3) patient's bathrooms with each of the patients. There was no other employee with him at those times.


An interview conducted with the Licensed Medical Social Worker on 10/12/16 at 4:15 p.m. revealed that the children's unit has 12 beds and a bathroom in each patient's room. Bath time on the Children's Unit is 5:00 p.m. The doors to the children rooms are kept open except during bath time. The doors are closed during bath time. There is a camera in each child's room, but not in the bathrooms.


A tour of the children's unit was conducted with the Director of Behavioral Health Services on 10/12/16 at 4:10 p.m. Observation confirmed that each patient room contained a camera. There were no cameras in the bathrooms.


Video Recording Review revealed the following information:
Patient#1: The video recording showed Psychiatric Technician #1 going in and out of the patient's room and bathroom with the patient numerous times. Psychiatric Technician #1 went into the bathroom with what appeared to be a cell phone in his left hand while the patient was in the bathroom. A flash is seen in the bathroom and he leaves the room with what appears to be a cell phone in his hand. The date and time was 9/26/16 at around 5:00 p.m. The patient did not have a roommate and no other employee was observed in the patient's room.


Patient #2: The video recording showed Psychiatric Technician #1 going into the patient's room and bathroom with the patient with what appeared to be a cell phone in his hand. The tdate and me was 10/4/16 at 5:14 p.m. No other employee was observed in the patient's room. The patient had a roommate but the roommate was not in the room at that time.


Patient #3: The video recording showed Psychiatric Technician #1 going in and out of the patient's room and bathroom with the patient in the bathroom. The patient did not have a roommate and no other employee was observed in the patient's room. The time was 9/29/16 at around 5:00 p.m.


Review of Psychiatric Technician #1's personnel file revealed that he began his employment at the facility's Behavioral Health Center as a PRN (as needed) Psychiatric Technician in-training on 8/29/16. His employment was terminated for Inappropriate Conduct on 10/7/16.


An interview with the Director of Patient Safety on 10/13/16 at 11:00 a.m. revealed that the facility policy is for a female and a male employee to always enter a patient's room together. She said there was no written policy for this requirement.