HospitalInspections.org

The Hospital failed to ensure patients were free from all forms of abuse by ensuring a process was in place for effectively monitoring all patients and having policies and procedures in place to prevent the sexual assault of a patient. By not having a policy or procedure for the assessment of patients for sexual safety (i.e., the identification of vulnerable patients and patients with the potential to display sexual behavior) that places other patients at risk, which resulted in the sexual assault of a patient. See deficiencies at A-143 and A-145.

Based on document review, observation, and interview, it was determined that for 24 of 24 patients, the Hospital failed to ensure that the patient's right to privacy was maintained. This failure resulted in a live video recording of Pt #1 from 4/5/2023 to 5/4/2023 during the hospital stay in the Behavioral Health Unit.

Findings include:

1. The Hospital policy entitled, "Use of Unit Video Monitoring on 5/A/G" (revised 8 2032) was reviewed on 6/7/23 at approximately 10:00 AM. The policy required "Visual cameras are located in all patient rooms and patient care areas....All patient rooms and hallways on 5A have cameras with the ability to record."

2. On 6/13/2023 a approximately 4:30 PM, the policy titled "Guidelines for the Assessment and Management of Suicide on 5 AG" (effective April 2021) was reviewed. The policy required, "5. Cameras are used throughout the unit to ensure all patients' movements can be monitored. Staff do not constantly observe the video monitors. Intermittent observation of the screens is the responsibility of staff present at the nurse's station. One staff member must remain at the nursing station at all times."

3. On 6/7/2023 between 2:30 PM and 3:30 PM, an observational tour was conducted on the Behavioral Units. There were a total census of 24 patients on the Behavioral Health Unit during the tour. All patients rooms had cameras present and cameras were present in the hallways and common areas. There were no patients on 1:1 monitoring or extra Precautions.

4. A tour of the Camera Monitoring area in the Nursing Station was conducted on 6/7/2023 at approximately 2:45 PM. There was one large monitoring screen that had live video monitoring of all patient rooms in real time. The monitor area is unaccessable and unviewable from the public and patients. Only staff members have access to the monitoring area. No specific staff member is assigned to monitor the video surveillance monitor.

5. Pt #1's record was reviewed on 6/8/2023 at approximately 10:00 AM. Pt #1 was admitted to the Behavioral Health Unit on 4/5/2023 with a diagnosis of Catatonia. General Admission orders required all patients admitted to 5AG will be rounded on every 15 minutes. . Pt #1 did not have a physician's order for restraints, seclusion, or suicide precautions. The clinical record for Pt #1 included a consent for "Acknowledgment of Expectations For An Inpatient Psychiatric Admission". the consent noted ..."you will be under video surveillance during your entire stay."

6. On 6/8/2023 at approximately 1:00 PM, the Hospital's video recording from Pt #1's room was reviewed in the presence of the the Manager of Patient Safety and Accreditation (E #1). Pt #1 had a live continuous video recording of Pt #1 being sexually assaulted by another patient. This video recording was also reviewed by two registered nurses on the Behavioral Health Nurse unit verifying this sexual assault as reported on the "Sensor" adverse event report dated 4/23/2023.

7. On 6/7/2023 at 3:30 PM, an interview was conducted the the Nurse Manager (E #5). E #5 stated, "all rooms and hallways have camera's and are under video surveillance 24/7. We have a sign posted at both nursing stations (5A/5G) and entrance door to the unit." E #5 also stated, " there is no designated staff member assigned to monitor the cameras."

Based on document review and interview, it was determined that for 1 of 1 clinical record (Pt #1) reviewed for a patient who was sexually assaulted, the Hospital failed to ensure patients were free from all forms of abuse by ensuring a process was in place for effectively monitoring all patients and having policies and procedures in place to prevent the sexual assault of a patient.

Findings include:

1. On 4/6/2023 Pt #1's "History and Physical" stated Pt #1 presented to the Emergency Room with altered mental status and symptoms of catatonia. Pt #1 was rigid and unable to communicate. Pt #1 had been in a zombie-like state for the past week. An Ativan trial was performed, and the patient responded and was able to respond to staff appropriately. Pt #1 denied SI, HI, or any history of polysubstance use, but reported heroin was her drug of choice. Pt was a direct admit to Adult Psychiatric Unit, 5G, room 583, with a diagnosis of Catatonia, MDD severe, recurrent, with psychotic features, PTSD, Stimulant use disorder (cocaine and amphetamines) and Opiate use disorder. General Admission orders required all patients admitted to 5AG will be rounded on every 15 minutes. Pt #1's rounding sheets dated 4/22/2023 to 4/23/2023 were completed and documented every 15 minutes as ordered.

2. On 6/7/2023, the Hospital's policy regarding sexual acting out and a policy for a registered sexual offender was requested of E #1 (Manager of Patient Safety and Accreditation). E #1 stated that the Hospital did not have a policy/procedure for sexual acting out or a policy for Registered Sex Offenders.

3. On 4/20/2023 at 11:25 AM, Pt #2's "History and Physical" stated Pt #2 presented to the emergency room per police with altered mental status. Pt #2 was on parole after theft of a car and is on the sex offender list from an attempted assault charge in the 80's. Pt #2 had recently been released from jail and was currently living in a halfway home. Due to Pt #2's complaints of audiovisual hallucinations, and his recent attack on a cab driver, in addition to bizarre behavior at his halfway home including running around naked and urinating on himself, Pt #2 was admitted to 5 G Adult Inpatient Psychiatric Unit, room 580 on 4/19/2023 at 6:10 PM with a diagnosis of unspecified psychosis and schizophrenia by history. The "Risks" assessment indicated "Behavior to harm others: No; Thoughts of harming others: No; Intent of harming others: No; Intent of harming others; No; Inability to protect self: Yes; and Inability to care for self: Yes." General Admission orders require all patients admitted to 5A/G will be rounded on every 15 minutes (however there is no differenation of the reason for rounds). Pt #2's rounding sheets dated 4/19/2023 at 6:30 PM thru 4/23/2023 9:30 AM (time of discharge) were completed and documented every 15 minutes as ordered until discharge. Pt #2 was not on precautions for being monitored for sexual acting out as the facility lacks a policy or procedure for patients that are sexually acting out.

4. On 6/7/2023 at approximately 4:30 PM the Hospital incident form "Sensor" dated 4/23/2023 written by Mental Health Nurse (E #6) noted. "Event Occurred 4/23/2023 at 12:25 Mental Health Unit- patient sexually assaulted another patient- On 4/23/2023 at 0025, staff were doing rounds, Charge Nurse E #6 was notified by technician, unable to locate (Pt #2). E #6 went to look for patient, still unable to find him, checking his room, looking in other rooms. E #6 asked Registered Nurse (E #7) to look at all the cameras of other patient rooms. At that time, he (Pt. #2) came out of room A583 (Pt #1 ' s room). Of note, (Pt #1) is catatonic currently. Cameras were reviewed and Pt #2 entered Pt #1 ' s room at 0025 and began rubbing her back then her buttocks, kissed/licked her face, got into bed with her (all of this over the covers) and began simulating a sexual act. He was in her room from 0025-0035 (12:25AM - 12:35 AM) while staff were looking for him.


5. On 6/7/2023 at approximately 1:00 PM, E #1 (Manager of Patient Safety and Accreditation), was interviewed. E #1 stated, "I was made aware of the event on 4/23/2023, the day of event. This was considered a Sentinel Event and the Accrediting Organization was notified. A sexual assault occurred. An RCA (root cause analysis) was completed. We were to have a meeting tomorrow (6-8-2023) with Senior Management to discuss and determine our vulnerabilities and initiate an action plan. We currently do not have a policy or procedure for the assessment of patients for sexual safety (i.e., the identification of vulnerable patients and patients with the potential to display sexual behavior that place other patients at risk)."