HospitalInspections.org

Based on policy and procedure review, video review, medical record reviews, and staff interviews, the facility delayed notification to the legal guardian of an incident of inappropiate touching for three of four sampled patients (Pt #1, Pt #12, and Pt #20).

Findings included:

Review of the facility policy titled "Patient to Patient Sexual Contact" approved May 2021 revealed "1. Any indication of sexual activity shall be reported to the attending physician or designee, the Administrative Coordinator, and the Nurse on Call as soon as possible ..."

Review of the facility's "Adolescent Handbook" not dated revealed " ... The following rules were put in place with your safety being our number one priority at all times ... Patients are expected to either be in their rooms, or in group. During free time, patients may be in the dayroom under staff supervision ... The Progress System: We call our level system the progress system. This system is designed to make YOU responsible ...Red Zone (restricted free time): ... Failure to maintain appropriate boundaries. (Patients are not allowed to touch other patients. This includes hugging, holding hands, touching other patient's hair, and high fiving ... Using sexually inappropriate language/gesturing or behaviors ..."

Review of the video recording of the inappropriate touching involving Patient's #1, #11, #12, and #20 in the dayroom on 09/19/2021 was conducted with Administration, Accreditation #6, and Security on 12/15/2021 at 0934. Review of the video recording started at 1401:59.566 and ended at 1405:00.411. Review of video revealed Patient #1 touched Patient #12 in the abdominal area. Review of the video showed Patient #11 touched Patient #1 in her pelvic area, touched Patient #12 in the pelvic area and breast, and touched Patient #20 in the abdominal area. Review of the video revealed #20 touched Patient #12's head.

1. Closed medical record review on 12/16/2021 revealed Patient #1, a 14-year-old female admitted on 09/17/2021 at 1751 with suicidal ideation (SI) and cutting herself. Continued review revealed "Treatment Plan Summary: ... will continue with every 15 minute checks for now ..." Review of the Precautions Record dated 09/19/2021 revealed Patient #1's Location at 1400 was documented as G (G-Group), at 1415 it was documented as B (B-Dayroom - Interacting), at 1430 it was documented as R (R - Room), and at 1445, Patient #1's Location was documented as R (Room). Review of the Nurse note dated 09/19/2021 at 1446 revealed "... Then, it was observed by staff that another pt touched her (Patient #1) in between her legs, which made patient giggle more. Pt did not remove herself from the cluster of her peers, but joined in by trying to touch the others, not necessarily in a sexual way." Review of the Precautions Record dated 09/19/2021 at 1800 and 1815, revealed documentation that Patient #1 was in her room with visitors (3 hours 58 minutes after incident). Review of Nurse note dated 09/19/2021 at 2240 revealed "(Patient #1's Name) parents presented ... stating they came to pick their daughter up. They wanted her discharged immediately ... (MD #3 name) was called, and Director (Administration #13) was notified ... The parents signed an AMA (against medical advice) form ..." Review of the Discharge Summary dated 09/19/2021 at 2237 revealed " ...Later in the afternoon on 09/19, according to nursing report '... Then, it was observed by staff that another pt touched her in between her legs ...' It was later communicated to mother during the visitation by nursing staff. According to nursing staff, pt subsequently alleged that she was sexually molested her (sic) by two of the peers to her mother. Mother therefore requested immediate discharge for the patient and informed nursing staff that she will take her to (Name of Facility) ..." Review revealed Patient #1 was discharged on 09/19/2021 at 2240.

Telephone interview on 12/15/2021 at 1414 with Medical Doctor (MD) #3 revealed Patient #1 was admitted for a "very brief time." Interview revealed Patient #1 had a "long history of eating disorder and suicidal ideation." Interview revealed on the second day of Patient #1's admission, "mom expressed" upset as "there was an incident of sexual inappropriate touching." Interview revealed MD #3 was unsure of the time he was notified of the incident. Interview revealed he was at the nurses' station when he was notified. Interview revealed the incident was discussed with mom first by a nurse. Interview revealed MD #3 discussed with mom after the nurse had talked with the mother. Interview revealed Patient #1's mom requested Patient #1 be discharged.

Telephone interview on 12/16/2021 at 1206 with Registered Nurse (RN) #10 revealed she remembered the incident. Interview revealed RN #10 was unsure of the time the provider was notified of the incident. Interview revealed RN #10 could not remember if any of the involved patient's parents/guardians were notified of the incident. Interview revealed when Patient #1's mother came in for visitation (3 hours 56 minutes after the incident) she demanded to know why Patient #1 was on Red. Interview revealed RN #10 told Patient #1's mom about "a few girls touching each other." Interview revealed Patient #1's mom was not aware of the event prior to RN #10 notifying her during her visitation. Interview revealed the administrator on call spoke with Patient #1's mom. Interview revealed Patient #1's mom left the unit and about twenty (20) minutes later returned saying she wanted to Patient #1 released.

Telephone interview 12/16/2021 at 1357 with Administration revealed upon arrival to the hospital on 09/20/2021, Administration was notified closer to 1700 that the guardian of one of the patients involved in the inappropriate touching incident on 09/19/2021 wanted to talk with leadership regarding the incident and we called that guardian at that time (26 hours and 54 minutes after incident). Interview revealed Administration investigated the incident, implemented the expectation that staff be present in the dayroom, reached out and communicated the incident to the families of parties involved after they reached out to Administration.

2. Closed medical record review on 12/16/2021 revealed Patient #12, a 12-year-old female admitted on 09/16/2021 at 1816 with a "depression with suicidal ideation." Review of the Precautions Record dated 09/19/2021 revealed Patient #12's Location at 1400 was documented as G (G-Group), at 1415 it was documented as B (B-Dayroom-interacting), at 1430 it was documented as R (R-Room), and at 1445, Patient #12's Location was documented as BES (BeS - Bed-Sleeping). Review of the Nurses note dated 09/19/2021 at 1636 revealed " ... She (Patient #12) was observed with a peer's hand caressing her between her legs, and (Patient #12's name) was in turn rubbing this peer's shoulder. Staff spoke with patients, and (sic) let them know they were getting their levels dropped to red for 24 hours starting @1300 for inappropriate touching ... " Review of the Nurse note dated 09/19/2021 at 2030 revealed "(Patient #12's name) is on Red Zone tonight after being involved with inappropriate touch with peer ... (Was placed on RED day Shift [sic]. Incident of inappropriate touch occurred on day shift.)" Review revealed no documentation of guardian notification of the inappropriate touching incident. Review of the Clinical Social Work note dated 09/22/2021 at 1543 revealed "Type of Contact and Topic: Leadership Contact; CSW (clinical social worker) was contacted by pt's grandmother, (Name), with concerns about the inappropriate sexual contact that occurred on 09/19. (Grandmother's Name) expressed frustration about the lack of communication surrounding the incident, which CSW validated. CSW listened to (Grandmother's Name) concerns regarding that incident as wells as those surrounding pt's behaviors at home ... CSW expressed support for each potential intervention, verbalizing this is a difficult situation and safety must be the priority. CSW assured (Patient #12's grandmother's name) that someone from leadership will be reaching out to her regarding the incident on 09/19, to which she was agreeable and appreciative." Review of the Discharge Summary note dated 09/23/2021 at 1554 revealed " ...Hospital Course: 1. Patient was admitted to the Child and adolescent unit ... Safety: Placed in Q15 minutes observation for safety ..." Review revealed Patient #12 was discharged on 09/23/2021 at 1800 with her family.

Telephone interview on 12/16/2021 at 1206 with Registered Nurse (RN) #10 revealed she remembered the incident. Interview revealed she was the nurse assigned the Adolescent Girls Hall on 09/19/2021. Interview revealed RN #10 could not remember if any of the involved patient's parents/guardians were notified of the incident.

Telephone interview 12/16/2021 at 1357 with Administration revealed upon arrival to the hospital on 09/20/2021, Administration was notified closer to 1700 that the guardian of one of the patients involved in the inappropriate touching incident on 09/19/2021 wanted to talk with leadership regarding the incident and we called that guardian at that time (26 hours and 54 minutes after incident). Interview revealed Administration investigated the incident, implemented the expectation that staff be present in the dayroom, reached out and communicated the incident to the families of parties involved after they reached out to Administration.

3. Closed medical record review on 12/17/2021 revealed Patient #20, a 13-year-old female patient was admitted on 09/16/2021 with Involuntary Commitment (IVC) papers for Suicidal Ideation (SI) and attempted suicide via overdose. Review of the Precautions Record dated 09/19/2021 revealed Patient #20's Location at 1400 was documented as G (G-Group), at 1415 it was documented as B (B-Dayroom-interacting), at 1430 it was documented as NS (NS-Nurses Station), and at 1445, Patient #20's Location was documented as B (Dayroom). Review of the Nurse note dated 09/20/2021 at 1148 revealed "MHT turns in pt's (patient's) Daily Self Inventory Sheet. Pt reported on it that she was having thoughts of wanting to stab her eye out with her nail. This writer followed up with pt a few minutes later, and pt reports the reason for feeling this way was 'because of what happened yesterday in the dayroom.' When this writer asked her what happened. Pt states, 'There was a girl that was touching people in the dayroom, and it made me feel uncomfortable.' Pt was reassured that measures were taken to keep patients safe by having that peer separate from all the peers and that there was a staff member with that peer at all times on a 1:1 (one to one) with sitter (sic) for safety ... asked the patient to step in the office with pt's social worker and this writer at 4:15pm to discuss her feelings. At this time pt reported she fears that she will touch her again. When asked where she touched her, pt reported ... 'touched me between the legs.' When asked if pt's clothes were on at that time, pt states 'yes'. This writer and pt's SW provided emotional support to patient ... Pt's social worker, and this writer immediately after talking with pt met with the unit nurse manager and informed her of all of the above information, this writer also informed pt's NP (nurse practitioner)/provider. Unit manager and social worker plan to inform pt's mother ..." Review of the Clinical Social Work Progress note dated 09/20/2021 at 1657 (26 hours and 53 minutes after incident) revealed "Type of Contact and Topic: Incident; CSW (clinical social worker) contacted pt's mother .... To inform her of pt's report of sexually inappropriate behavior by another pt ... CSW informed (Patient #20's mothers name) of what (Patient #20's name) reported, as well as the steps taken by staff to ensure pt safety. (Patient #20's mothers name) verbalized understanding, expressed appreciation, and was given the opportunity to ask questions ..." Review of the Discharge Summary dated 09/21/2021 at 1300 revealed " ...Hospital Course: 1. Patient was admitted to the Child and adolescent unit ... Safety: Placed in Q15 (every 15) minutes observation or safety ..." Review revealed Patient #20 was discharged to her family on 09/21/2021 at 1300.

Telephone interview on 12/16/2021 at 1206 with Registered Nurse (RN) #10 revealed she remembered the incident. Interview revealed she was the nurse assigned the Adolescent Girls Hall on 09/19/2021. Interview revealed RN #10 was unsure of the time the provider was notified of the incident. Interview revealed RN #10 could not remember if any of the involved patient's parents/guardians were notified of the incident.

Telephone interview 12/16/2021 at 1357 with Administration revealed upon arrival to the hospital on 09/20/2021, Administration was notified closer to 1700 that the guardian of one of the patients involved in the inappropriate touching incident on 09/19/2021 wanted to talk with leadership regarding the incident and we called that guardian at that time (26 hours and 54 minutes after incident). Interview revealed Administration investigated the incident, implemented the expectation that staff be present in the dayroom, reached out and communicated the incident to the families of parties involved after they reached out to Administration.

Based on policy and procedure review, adverse event report, video review, medical record reviews, and staff interviews, the facility staff failed to implement a post fall protocol after a patient fall for one of two patient records reviewed (Pt #3).

Findings included:

Review of the facility policy titled "Fall Risk Assessment, Prevention, and Management," approved 08/25/2021 revealed "...5. Assessment and treatment after a fall: A. Immediately follow the post fall protocol utilized in the care area where fall occurred. In addition: ...Complete a post fall huddle to debrief ...B. Document in patient's medical record: date/time of fall; Details surrounding fall event; Patient's condition before and after the fall ...Provider notification of fall ...Post Fall Algorithm ...Assess patient Immediately ...Post Fall Actions & Documentation Requirements ...Update reason in fall risk assessment as "fall has occurred during this admission..."

Review of the adverse event report documented by the RT (Radiology Technician) #1 regarding a fall for Patient #3, with a completion date of 12/03/2021 at 0753 revealed the patient`s physician was notified, but no time; the family was not notified; and no response to what treatment was rendered.

Closed medical record review on 12/17/2021 revealed Patient #3, a 74-year-old female patient, was admitted on 12/02/2021 with complaints of weakness, confusion, head injury and multiple falls. Patient's medical history included congestive heart failure, atrial fibrillation, stroke, lung disease with oxygen use, diabetes, and a heart attack. Review revealed patient lived alone at home with hospice care. Review revealed the patient`s physician had ordered an x-ray of the thoracic spine at 1518. Review revealed the patient`s physician had ordered an additional x-ray of the right pelvis at 1551. Review revealed no post fall protocol was performed in the care area where the fall occurred or a post fall huddle. Review revealed no documentation in patient's medical record of the date/time of the fall, details surrounding the fall event, the patient's condition before and after the fall, provider notification of the fall, or an updated fall risk assessment. Review revealed vital signs were obtained at 1611 in the emergency room and the primary nurse provided pain medication at 1636. Review revealed the physician noted the fall, the right hip fracture and notification of the family at 1912.

Interview on 12/15/2021 at 0945 with the RT #1 whom cared for the patient during the fall, revealed the patient fell at approximately 1540 off the exam table, did not hit her head, and was alert and oriented after the fall. Interview revealed the patient was picked up from the floor by two radiology technicians and placed on the x-ray exam table. Interview revealed an order was obtained by the patient`s physician via phone for an additional x-ray of her hip due to increased pain. Interview revealed she was then moved to her stretcher by the two radiology technicians and returned to the emergency room. Interview revealed the primary nurse and her physician were given a report of the incident. Interview revealed she did complete an incident report. Interview confirmed no post fall protocol was performed in the care area where the fall occurred or a post fall huddle. Interview confirmed no documentation in patient's medical record of the date/time of the fall, details surrounding the fall, the patient's condition before and after the fall, provider notification of the fall, and an updated fall risk assessment.

Interview on 12/17/2021 at 0925 with the Registered Nurse #2 in the emergency department revealed she was instructed by her charge nurse that she did not need to institute the post fall protocol because the fall occurred outside of her department. Interview revealed she did go in and assess the patient and provided pain medication. Interview revealed the right hip was the only new concern. Interview revealed the patient was already a high risk for falls so she did not update the falls risk assessment in the computer.

Interview on 12/16/2021 at 1027 with the Director of Radiology revealed he had completed his investigation. Interview revealed falls in the radiology department were rare and the staff failed to implement post fall protocol. Interview revealed the staff thought the responsibility of the post fall assessment was the nurses once the patient was returned to the emergency room. Interview revealed the investigation yielded re-education of the staff of fall protocols, and the need for a new standardized fall prevention protocol for the radiology department. Interview revealed two staff members had been appointed to develop the new standardized fall prevention protocol for the radiology department. Interview revealed an outline of the new protocol had been developed.

Based on policy and procedure review, medical record review and staff interviews, Emergency Department [ED] nursing staff failed to ensure safe discharge transport by failing to communicate and provide a patient report prior to discharge for 1 of 4 ED patients discharged to a nursing home [Patient #4].

Findings included:

Review of the policy titled "Hand-Off Communication", date approved 03/29/2021, revealed "...POLICY: 'Hand-off' communication will be used when responsibilities are transferred from one care provider to another....PROCEDURE....1. Hand-off communication will occur when care of the patient is transferred from one healthcare provider to another. For example:...Transfers to providers outside of [Healthcare System Name] (another hospital, nursing home, or home health agency). ..."

ED Medical Record review on 12/14-15/2021 revealed Patient #4 arrived to the ED by ambulance on 08/07/2021 at 1544. Review of "Arrival Documentation at 1547 revealed "... Did the patient arrive from a Nursing Home or Assisted Living Facility? Yes .... Care Facility Name [Nursing Home Name]. Review of an "ED Provider Note" at 1742 revealed "... [Patient #4] is a 58 y.o. [year old] with a past medical history of ESRD [End stage Renal Disease] on dialysis....prior stroke, diabetes, anemia, hypertension presenting to ED with a chief complaint of abdominal pain....MDM [Medical Decision Making] Rules/Calculators/A&P [Assessment and Plan]....Patient is hemodynamically stable, in NAD [no acute distress], and able to ambulate in ED. Evaluation does not show pathology that would require ongoing emergent intervention or inpatient treatment. ..." "ED Disposition" review revealed "Discharge" at 1844. ED record review did not reveal any further discharge note, did not reveal any communication with family, and did not reveal a hand-off report to the Nursing Home. At 2115, "ED Care Timeline" review revealed "Pt [Patient] discharged earlier this evening. When pt got to lobby, she had someone call her a cab. Cab just returned saying the place he took pt to refused to accept her and brought her back to ED. Cab company wanted voucher.... This nurse talked with [Family member first name] who advised she did not know that pt was at hospital. This nurse explained to [family member] that pt was brought by EMS from dialysis center." At 2124, Timeline review noted "Called [name of Nursing Home] and talked with [first name], pt arrived to facility by cab, facility was unsure about accepting patient, in the meantime cab left and brought pt back to ED. Advised [first name] that pt would be returning by [transport company]. At 2223, Timeline review revealed a "Transport Certificate of Medical Necessity" that indicated "...Did the patient arrive from a Nursing Home or Assisted Living Facility? Yes....Reason for Transport: Discharge....Could the patient be transported safely by other means of transportation....No. ..."

Telephone interview on 12/15/2021 at 1500 with RN #8 revealed the RN did not recall if she was the person who originally discharged Patient #4. Interview revealed RN #8 did recall Patient #4 coming back to the ED after being discharged by cab. Interview revealed RN #8 talked with the patient's family member after the patient returned. Interview revealed the family member was upset because she was not notified about the patient being in the hospital. RN #8 stated it was very busy in August. Further interview revealed RN #8 did not think she knew the patient was from a nursing home until after the patient returned.

Telephone interview on 12/16/2021 at 1630 with RN #9 revealed RN #9 was the Charge Nurse when Patient #4 returned to the ED. Interview revealed the nursing home called RN #9 because they were "not happy" the patient came to them by taxi [cab]. Interview revealed nursing homes should be called with report before patients were discharged.

NC00180167, NC00182713, NC00182317, NC00183890