HospitalInspections.org

Based on review of clinical records, policy and procedure review, review of facility incident reports and staff interviews, it was determined that in 11 of 11 patients (Patient #2, 7, 9, 10, 11, 12, 13, 14, 15, 16, and 17) out of a total universe of 17, the hospital failed to maintain patient safety.

Findings include:

The facility's failure to promote and protect all patients safety resulted in actual harm. See tag A-144.

The result of this systemic failure resulted in actual and potential patient harm.

Based on clinical record review, policy and procedure review, incident report review, and staff interview the hospital failed to ensure that 11 of 11 patients (Patient #2, 7, 9, 10, 11, 12, 13, 14, 15, 16, and 17), out of a total universe of 17 records reviewed, were safe from inappropriate sexual contact in their environment.

Findings include:

Current hospital policy MHC#206 titled, "Patient Rights Policy and Procedure" dated 3/14/97 states on page 8, "HUMANE PSYCHOLOGICAL AND PHYSICAL ENVIRONMENT: The MHD [Milwaukee County Mental Health Division] will provide a clean, safe and humane environment in all treatment facilities."

A patient pamphlet titled, "Client Rights and the Grievance Procedure for Inpatient Services" is provided for all inpatients. Under the heading of Personal Rights the first bullet point states, "You must be treated with dignity and respect, free from any verbal, physical, emotional, sexual abuse or harassment." The 7th bullet point under the same headings states, "Your surroundings must be kept safe and clean." The 9th bullet point under the same heading states, "You have the right to receive treatment in a safe, psychologically and physically humane environment."

Current hospital policy MS:#6.4.6, NS: #208 "S" titled, "Sexual Contact Between Patients" with dated of 4/27/2000 states, in the Policy statement, "Sexual contact with others is considered inappropriate and therapeutically contraindicated during hospitalization." In section II, Standard of Care, the policy states that patient's can expect, "A. The staff will provide a safe living environment during his/her inpatient stay...C. To be informed of the MHD Sexual Contact Policy...D. Staff is knowledgeable regarding procedure to follow in cases of sexual contact."

In this same policy, Section B. Patient Care, 4. states, "...In addition, a female patient should have a follow-up pregnancy test in six weeks." In #6 of this same section the policy states, "Patients under 18 or declared incompetent: a. Social Workers at CATC, Acute & RCC, and QMRP's in FDD [areas within the hospital complex] will contact parents/legal guardians to inform them of the situation and obtain permission for examination and tests as soon as possible. If they cannot be reached within the first 72 hours of the sexual contact episode patient will be treated per policy and procedure for best interest in his/her health and safety...b. Three attempts to contact parents/legal guardians must be attempted within the first 72 hours and clearly documented in the progress notes."

Also, in the same policy, in another section indicated as "Section B. Documentation, 1. RN [Registered Nurse] documentation in the progress record will include an objective description of the incident as witnessed or reported..."

Current hospital policy MS 3.1.6.12/ NS#207 "B" titled, "Behavior Observation Status" dated 3/10/04 states in the policy statement, "Patients at risk for engaging in behaviors that may jeopardize their safety or the safety of other patients and/or staff will be observed on a regular basis."

Section II. Intervention of this same policy states, "B. Medical staff will write an order or give a verbal telephone order for either 1:1 or 15 minute behavior observation monitoring, specific behavior to be monitored and special precautions...H. The RN will document the behavior to be observed and corresponding precautions on the Behavior Observation Flow Sheet...I. The RN is accountable to ensure completion of observation monitoring and documentation by delegated staff...K. The RN will review and sign the Behavioral Observation Flow Sheet each shift...M. RN will initiate the Recovery Plan and the treatment team will address at the Recovery Planning Conference and initiate an IPP or BTP as clinically indicated [abbreviations are not identified in policy, BTP=Behavior Treatment Plan but IPP is not known]..."

Section IV. of the same policy, "Discontinuation of Behavioral Observation Checks" indicates that a written order by the Medical Staff is needed and that collaboration with the RN and Medical Staff should occur about the decision to discontinue the checks. Also, "Behavioral Observation checks must be discontinued prior to off-ward privileges, home visits, or discharge."

Current hospital policy number ADM #002 titled, "Passes and Off Ward Privileges for Acute Adult Inpatient Units" dated 9/22/08 states on page 3 of 4, "C. Off Ward Privileges (OWPs) 2. Patients who meet the following criteria will not be granted OWP: ...behavioral management problems, ...dangerousness to self or others...behavioral checks or suicide precautions status...high risk for contraband...nonadherence with treatment plan."

In section "D. Off Ward Privileges Procedure " of this same policy, # 2. states, "Attending medical staff will write an order for OWP, indicating the amount of time for OWP (generally 30 minutes) and the daily frequency of OWP (up to 3 per day)...4. Immediately upon return to the unit, the patient will be wanded for metal objects and all items searched per BHD [Behavioral Health Division] Search and Contraband Policy."

Current hospital policy Medical Staff/Nursing/Treatment Team (Acute Inpatient) policy #MS1.1.9 NS #232 " R " ADM #008 titled "Recovery Planning and recovery Conference Guidelines: Treatment Team Assessment and Procedures (Acute Inpatient)" Dated 05/04/09 indicates the following: Procedure: I. " Admission, Assessment, and Additional Pertinent Information "
A. " Nursing Initial Assessment and Additional Recovery Plan "
Notes that " Information will be gathered from the patient, from observation, and from review of collateral information, as available. "
B. " Assessment by Disciplines "
2. " History and Physical - The H & P must be completed within 24 hours of admission by a physician or nurse practitioner. Attempts will be made and documented daily to complete the H & P. "
C. " Other Information Sources "
3. " Previous Treatment Records - The patient ' s treatment records from
prior admission to the Behavioral Health Division (BHD) shall be
obtain per BHD Medical records Policies and reviewed. "
5. " Coordination with other Providers and/or Clinician - In those instances where it is known that the patient is active with other BHD programs or service, or a private provider, every effort will be made to involve the provider(s) in the recovery planning process, particularly if they will be involved in continuing care. "
IV. " Change in Condition-Revisions to the Recovery Plan "
" The Recovery Plan will also be reviewed and updated, as needed, after the occurrence of any event that would be reportable per Incident/Risk Management Reporting Policy, or if there is a noteworthy change in the condition in the condition of the patient. The Recovery Plan will be updated during the shift in which the event occurred by adding a problem to the appropriate domain and a corresponding objective and method, with their signature, to address the issue.

A clinical record review was conducted on 1/19/2010 in the afternoon on Patient #2's closed acute psychiatric record. Patient #2 was admitted to the acute psychiatric unit of the hospital on 7/1/09 after becoming agitated, aggressive and exhibiting threatening behavior in the group home where Patient #2 had been residing. Patient #2 also has a history of a Seizure Disorder, Mood Disorder, Iron Deficiency Anemia (not enough iron in the blood), and mild Mental Retardation. Patient #2 has a legal guardian as Patient #2 was found incapable of making decisions independently prior to this hospitalization.

A clinical record review was conducted on 1/19/2010 in the afternoon on Patient #7's closed acute psychiatric record. Patient #7 was admitted to the acute psychiatric unit of the hospital on 12/4/08 with diagnoses of: Conduct Disorder, Disruptive Behavior Disorder, Impulse Control Disorder, Post Traumatic Stress Disorder, Learning Disability, and mild to moderate mental retardation. A Behavior Treatment Plan, dated 10/24/08, also indicates Patient #7 had exhibited sexually inappropriate behavior with hospitalized peers since June of 2004 when Patient #7 had entered the hospital system, with transfers to different levels of care until the transfer to the Adult Acute Psychiatric unit. Patient #7 was transferred to the acute unit after Patient #7 and a peer, "Chased down and brutally physically assaulted another peer on the unit" on October 11, 2008. Patient #7 has a legal guardian as Patient #7 was found incapable of making decisions independently prior to this hospitalization.

A tour of the acute adult psychiatric unit was conducted by Surveyor #26711 and #22198 on 1/19/2010 at 10:30 a.m., accompanied by Director of Nursing 'D' and Manager 'K'. Director 'D' stated that supervision levels vary depending on the needs of the patient and that staff try to assess patient vulnerability to determine room assignments. Manager 'K' stated they try to maintain a separate male and female hallway if possible.

On 01/19/10 at 10:50 a.m. Registered Nurse (RN) 'J' told Surveyor #22198, that the hospital had no special restrictions or requirements for room placement for Developmentally Disabled (DD) patients.

An interview conducted on 01/21/10 at 11:30 a.m. by Surveyor #22198 with RN Staff 'O' confirmed that each unit has 2 wings one is supposed to be female the other male, however based on the high female population, one of the wings is co-mingled (male and female).

On 7/1/09 at 7:45 p.m. an incident report was filed in which a Certified Nursing Assistant (CNA) observed Patient #2 leaving the bedroom of Patient #7. Patient #2 was fully clothed, Patient #7 was in the bathroom with pants dropped down. At the time of the encounter both patients denied intimate/physical contact to CNA 'U'. Patient #2 was placed on every 15 minute behavioral checks for inappropriate sexual behavior. Patient #7 was not put on behavioral checks and both patients were directed to stay away from each other. Patient #2 and #7 remained on the same unit but on different care teams within the unit.

The nursing staff failed to update Patient #2's "Recovery Plan" (a care plan to direct staff to the needs of the patient). There is no documentation regarding this incident in Patient #2's progress notes. The physician did order Behavioral Checks for inappropriate sexual behavior to be done every 15 minutes on 7/1/09 at 7:55 p.m. There is no documentation from nursing staff on the "BHD Acute Adult Nursing Note" (Behavioral Health department nursing note, BHDNN) regarding the incident on 7/1/09. On 7/2/09 the nursing note mentions Patient #2 was on behavior checks for assaultive and sexually inappropriate behavior. There is no documentation that Patient #2's legal guardian was contacted.

The Recovery Plan was not adjusted to reflect Patient #7's sexual contact on 7/1/09. On 7/1/09, on the BHDNN, nursing documentation indicates Patient #7 was "found with pants down and a female patient in the room. Both deny sexual contact." On a progress note dated 7/2/09, documentation states, "Admits [Patient #2] performed oral sex on him, [Patient #2] was waiting in his room for him." On a progress note dated 7/3/09, the documentation states that Patient #7 verbalized engaging in oral sex was inappropriate. There is no indication that Patient #7's legal guardian was contacted. The sexual history section in Patient #7's history and physical is not complete and does not reflect his history of sexually inappropriate behavior.

Patient #2's Behavioral Observation flow sheet for the 15 minute checks does not include a signature for RN review, as per hospital policy titled, "Behavior Observation Status", on 7/1/09 p.m. shift, 7/6/09 p.m. shift, 7/10/09 a.m. shift, 7/18/09 p.m. shift, 7/21/09 a.m. shift, and 7/23/09 p.m. shift (Patient #2 was transferred to a different unit during this shift). The RNs are completing the behavior check form at the beginning of each shift and would be unable to account for behavior during times that show documentation as incomplete.

There are no behavior checks documented as being completed on 7/4/09 from 2:00 p.m. through 2:45 p.m., on 7/13/09 from 11:45 a.m. through 12:15 p.m. and 3:15 p.m. through 3:45 p.m., and on 7/16/09 from 7:15 a.m. through 7:45 a.m.

On 7/23/09 at 9:45 a.m. another incident report was completed stating that during a recovery plan meeting (care planning) on 7/23/09 Patient #2 announced she had been having sex with Patient #7 for at least 3 weeks, and that the latest contact took place on 7/20/09 at 8:00 p.m. in the community bathroom (a bathroom accessible from the hallway for patients to use when they are not in their own rooms) where she claimed she was forced by Patient #7 to have sex. After being escorted to the Sexual Assault Treatment Center (SATC) Patient #2 was transferred to another unit.

On 7/23/09 Patient #2's Recovery Plan was updated to include inappropriate sexual behavior (22 days after the initial incident on 7/1/09). According to documented interviews conducted by Director 'A' on 9/14/09 with Patient #2, Patient #2's claim to being forced to have sex with Patient #7 changes between being consensual and non-consensual.

On 7/23/09 Patient #7's Recovery Plan was updated to include inappropriate sexual behavior (22 days after the initial incident on 7/1/09). Patient #7 was placed on behavioral checks every 15 minutes for sexually inappropriate behavior on 7/23/09 by MD 'R'. In the progress notes Patient #7 admits to having sexual contact with Patient #2.

Patient #7 remained on the same unit and his off ward privileges (OWP) were discontinued with a physician order from MD 'R'.

Nursing Administrator 'D' acknowledged on 1/20/09 at 9:30 a.m. that the hospital had identified the lack of communication on the units and between the different teams. The teams on the same unit failed to protect Patient #2 and develop safeguards to prevent Patient #7 from continuing sexually inappropriate behavior for 22 days (7/1/09-7/23/09).

On 7/27/09 Psychiatric Social Worker (PSW) 'Q' documented in Patient #7's clinical record that PSW 'Q' was approached by MD 'S' who reported that while on an OWP, Patient #7 was accused of approaching three 8 year old girls and was asking personal questions and blocked their escape.

Per interview with PSW 'Q' on 1/21/2010 at 10:50 a.m., PSW 'Q' told Surveyor that on 7/26/09 in the p.m. when MD 'S' approached PSW 'Q', he was quite upset about the OWP incident of Patient #7. According to PSW 'Q', MD 'S' was notified by an unknown nurse or security person that they had witnessed inappropriate behavior while Patient #7 was off the ward and on the 4th floor. According to PSW 'Q', Patient #7 "Was not in the right place."

PSW 'Q' stated when Patient #7 was on OWP, "He generally listened to his iPod, or whatever it was, and wandered all over the building with it. Because of his strong history of sociopathic behavior, he was probably up to no good when he ran into these girls."

Also present during this interview was Director 'H' who told Surveyor #26711, "The girls were most likely visitors as the nursing home is also on the 4th floor."

There is no indication in the clinical record that Patient #7's OWPs were re-ordered after being discontinued for inappropriate sexual behavior on 7/23/09 by MD 'R'. Patient #7 remained on every 15 minute behavior checks during the time period of this reported incident (7/26/09).

Leaving the unit on every 15 minute behavior checks is in opposition to the hospital policies of Behavior Observation Status and Passes and Off Ward Privileges.

Review of Patient #7's Behavior Observation Flow Sheet reveals that the 15 minute behavior checks initiated on 7/23/09 through 8/7/09 showed that all checks were completed every 15 minutes. The 15 minute behavior checks do not indicate that Patient #7 was off ward on 7/26/09 when he approached the three 8 year old girls.

Per Surveyor #22198, on 01/21/10 at 10:45 a.m. during an interview CNA staff 'M' explained what was expected of the CNAs regarding 15 minute behavior checks as: behavior checks are done every 15 minutes and the patient must be observed along with the patients activity because sometimes "you see their face, however their hands may be in an inappropriate place." This was confirmed by 3 additional interviews on 01/21/10 by CNAs 'N' and 'P' and RN 'O'.

During the period of 7/23/09-8/10/09 Patient #7 remained on behavioral checks for inappropriate sexual behavior. Patient #7's Behavioral Observation flow sheet for the 15 minute checks does not include a signature for RN review, as per hospital policy titled, "Behavior Observation Status", on the following dates within this time period: 8/1/09 a.m., 8/2/09 p.m., 8/6//09 a.m., and 8/7/09 a.m.

Patient #7's recovery plan was not updated to reflect newly reported inappropriate behavior from 7/26/09.

Patient #7 was given an overnight pass from 8/21/09-8/23/09 to an unnamed group home. This form is incomplete as the RN section of the form only contains an RN signature and is not signed by either Patient #7 or his escort.

Allowing Patient #7 off the unit for this group home pass failed to follow the hospitals policy on Behavioral Observation (MS 3.1.6.12) or the Passes and Off Ward Privileges policy (ADM #002).

On 8/21/09 at 3:00 p.m., an incident report was filed by RN 'T' stating that Patient #9 reported to RN 'T' that she had consensual sexual contact with Patient #7 "a couple days ago" for cigarettes. Patient #9 refused to speak with police or file a complaint.

There is no indication of this incident in Patient #7's progress notes. Patient #7 remained out on pass.

On 8/24/09 at 1:00 p.m. an incident report was filed by RN 'O' stating she redirected Patient #11 from going in the male hallway at 12:55 p.m. and at 1:00 p.m. found Patient #11 in the community bathroom with Patient #7. Patient #7 was fully clothed, while Patient #11 had her pants down. Patient #11 was unable to comprehend questioning by hospital staff regarding pressing charges due to her current psychotic state.

At 1:47 p.m. on 8/24/09 there is an entry into Patient #7's progress notes from PSW 'Q' that Patient #7 "had a good pass," referring to the pass from 8/21-8/23. There is no mention in this entry of another inappropriate sexual contact.

On 8/26/09 there is a physician's order to discontinue OWPs for a 24 hour period for Patient #7 in lieu of the 8/24 incident, and Patient #7 must follow strict guidelines to regain OWPs.

On 8/27/09, 3 days after the sexual incident, PSW 'Q' reported the misconduct to the group home Patient #7 had been visiting on pass, Patient #7's legal guardian, and his disability case manager. There is no indication that attempts were made prior to 8/27/09 to notify these parties of Patient #7's behavior of 8/24/09.

On 8/28/09 Patient #7 received a 2 day pass to the group home accompanied by an escort. Patient #7 returned to the hospital on 8/30/09.

On 8/30/09 at 8:15 p.m. an incident report was filed which states that Patient #10 reported to 3 separate staff in 3 separate interviews that she and Patient #7 had sexual intercourse on the floor in Patient #7's room.

After this incident Patient #7 was placed on 1:1 observation until his incarceration on 9/22/09.

The findings in these records were discussed and confirmed by Director 'A' and Director 'B' throughout the day on 1/19/2010 and 1/20/2010 as they were discovered.

On 9/14/09, Director 'A' was notified of a positive pregnancy test on Patient #2 after Patient #2 was transferred from the acute adult unit to a different unit in the complex.

Patient #2's clinical record did not reflect that a pregnancy test was conducted 6 weeks after the 7/23/09 incident report was filed, as per hospital policy MS:#6.4.6, "Sexual Contact Between Patients." This was further confirmed by Director 'A' in an interview on 1/19/2010 at 11:55 a.m.

In an interview with Director 'A' on 1/19/2010 at 11:55 p.m., the hospital completed an internal investigation and education was completed to the medical and management staff, and some social workers, between 9/14/09 and 9/24/09 regarding the duty of the staff to protect its patients. Director 'A' stated it was an expectation that the management staff relay the education they received to their staff.

Director 'A' stated that it became clear to them that the front line staff was not aware the hospital had a "no sexual contact policy during the time the two patients (Patient #2 and #7) were on the unit."

On 01/21/10 at 10:45 a.m. during an interview CNA 'M' told Surveyor #22198 that she received patient rights education upon hire and annually. CNA 'M' confirmed she had not received additional education or updates.

On 01/21/10 at 11:30 a.m. during an interview RN 'O' told Surveyor #22198, that she was not aware of a policy related to sexual contact between patients.

RN 'O' told Surveyor #22198, she had not received any recent updates or changes to their patient rights education related to sexual contact.

Further review of incident reports after the 9/24/09 education with medical and management staff was completed revealed:

On 01/20/10 at 4:30 p.m. Surveyor #22198 along with Director 'A', Director 'B' and Medical Director 'C' and Nursing Administrator 'D' reviewed the findings for Patients #14 and #15.

On 09/24/09 the hospital started an investigation of an allegation that Patient #15 had sexually assaulted Patient #14, noting the alleged sexual assault happened on the night of 09/24/09.

Review of Patient #15s clinical record indicated Patient #15 was discharged 09/24/09 at 1430 (2:30 p.m.). No documentation of an assessment related to the sexual assault allegations or the behaviors related to the allegations were mentioned in Patient #15s medical record.

Director 'A' acknowledged that the alleged assault date was incorrect since Patient #15 would have been discharged from the hospital the night of 09/24/09.

Director 'A' stated the hospital ' s investigation started the day after the allegation.

Review of Patient #14s clinical record indicated Patient #14 has a history of having moderate mental retardation and impulse control disorder.

Patient #14s clinical record noted that on 09/23/09 at 10:15 a.m. Patient #14 was seen urgently by the psychiatrist after informing a unit nurse that " his roommate had f****d him up last night " , indicating that his roommate (Patient #15) had penetrated his rectum.

The psychiatrist asked Patient #14 " if he could have had a nightmare dream? " to which Patient #14 answered "yes." Patient #14s description of the allegations of sexual assault were noted in the clinical record as a "delusional episode and/or a dream", therefore considered to have no basis for the allegations.

No physical assessment for Patient #14 was completed at the hospital at the time of the allegation, nor was Patient #14 offered treatment at the Sexual Assault Treatment Center.

Review of findings noted 3 CNAs were questioned about the night of 09/24/09 indicating both patients slept all night without incident, however noting the above allegation by Patient #14 was made on the morning of 09/23/09. This would make the occurrence of the allegation of sexual assault on the night shift between 09/22/09 and 09/23/09.

When Surveyor #22198, asked Medical Director Staff 'C', if it was normal during a sexual assault interview for the interviewer to ask an alleged victim if it were a dream? Medical Director Staff 'C' acknowledged, that it was not.

Medical Staff 'C' acknowledged that in an allegation of sexual assault a physical exam should be done.

In a review of Patient #14s medical record noted Patient #14 to have volatile behavior.

Events noted within Patient #14's clinical record revealed that:
09/17/09 at 18:45 (6:45 p.m.) Patient #14 was noted as dancing in his room with another patient.
09/17/09 at 2100 (9:00 p.m.) Scared a female patient by " touching her inappropriately - hugging and telling her he would come to her room during the night and take care of her. "
09/19/09 at 2100 (9:00 p.m.) Patient #14 asked the Registered Nurse (RN) on the unit " do you love me " brushing his hand up against the RNs hand twice. The RN noted that Patient #14 continued to be intrusive, needing constant redirection.
09/20/09 at 2100 (9:00 p.m.) Patient (14) remains at desk constantly. Patient (14) is intrusive and often breaks personal space of staff. Can be overly friendly, touching and feeling others, then becomes angered by very minor problems.
09/23/09 at 9:45 a.m. Psychiatric Social Workers (PSW) note stated Patient #14 had a long history with Behavior Health dating back to 2001 with the last inpatient being 06/09 having a history of ' intermittent explosive disorder " .
09/23/09 at 10:15 a.m. note indicated Patient #14 alleged his roommate had sexually assaulted him. Patient #14 was interview by a Psychiatrist; however no physical exam was done.
09/23/09 at 1420 (2:20 p.m.) Patient #14 while at the nurses station said he had marks on him and wanted to jump over the nurses station and beat the s**t out of a nurse. Noting Patient #14s hostile agitated mood and threatening gestures and posturing required medication intervention.

Patient #14s treatment plans did not include Patient #14s sexually inappropriate behaviors.

Behavioral monitoring did not include Patient #14s sexually inappropriate behavior.

Psychiatry notes did not reflect the medical team had been informed of Patient #14s sexually inappropriate behaviors.

On 10/02/09 Patient #14 was discharged back to a group home however documentation did not indicate that the group home was informed of the alleged sexual assault, or of Patient #14s inappropriate sexual behaviors towards staff or peers.

On 10/5/09 an incident report was filed regarding a possible sexual contact between Patient #16 and Patient #17 when a CNA doing unit checks discovered the patients in the bathroom. One patient with an evident erection in his pants and a packet of Vaseline in his hand, and one patient who refused to come out of the bathroom for several minutes, but was clothed.

In a review of their clinical records, completed on 1/20/2010 between 3:40 p.m. and 4:00 p.m. Patient #17 denied any sexual contact but Patient #16 stated he did have sexual contact with Patient #17 but refused to elaborate.

On 12/11/09 an incident report was filed regarding an oral sex act between Patient #12 and Patient #13. Both patients admit to the act being consensual however this in conflict with the hospitals policy on sexual contact between patients.

The findings in these records were discussed and confirmed by Director 'A' and Director 'B' throughout the day on 1/19/2010 and 1/20/2010 as they were discovered.