HospitalInspections.org

The hospital failed 4 of 16 Patients, (Patient #1, Patient #2, Patient 15, and Patient 16) by failing to keep them free from all forms of abuse. Patient's #1, Patient #2 engaged inappropriate sexual acts, Patient #15, and Patient #16 engaged in appropriate sexual acts.

Findings include

Through interview with Hospital staff #1, reported, that the patients stated that they had engaged in sexual behavior. Patient #1 initally reported that the act was consensual, but later stated she was raped.

Through observation of video footage the patients were alone in the dayroom coloring over one hour and 20 minutes. The patients were observed fondling one another, and hospital Staff #6 was observed monitoring from the doorway, but failing to enter and engage with the patients seated at the table together. Staff #1 reported "Staff may have easily noticed the sexually acting out behaviors if they entered the group room." Hospital Patient #15 was observed walking behind Patient #16 following him behind into Patient #16's room where they remained four 4 minutes. Hospital Staff #6 was desctracted by another patient and walked directly past this room failing to make an observation check.

Through record review Patient #15 started discussing the incident with staff and stated she was raped. The hospital staff #6 failed to enter into Patient #16's room and monitor for patient safety.

Through record review Patient #1 was found in Patient #2's room in his bed with her pants down. Patient #2 was found next to the bed attempting to pull his pants down.

Through record review Patient #1 was in the hallway and reported to a therapist that she had engaged in inappropriate sexual act and she was raped. She indicated she did not initally report the act due to her recall being foggy, but her memory was coming back.

Through interview hospital Staff #1 was informed that the observation rounds were not properly being done at this time when this incident occurred. Staff # 1 indicated, "there was no video footage at this time to verify rounding and observation, as the video equipment was down." The patient was found the bed of another patient with her pants down.

Policy
The hospital Policy on Patient Rights dated 04/2018, reflected, "Is the policy of Millwood Hospital and Excel Centers to ensure that all patients receive a copy of the Patient Handbook which indicates the Patient Bill of Rights as well as an oral explanation of those rights both in their primary language and in simple non-technical terms. We will strive to abide by and respect all patient rights without regard to race, religion, creed ethnicity, gender, age, sexual orientation, or handicap. Millwood Hospital and Excel Centers shall support and protect the fundamental human, civil constitutional and statutory rights of the individual patient and recognize and respect personal dignity of the patient at all times."

The hospital policy on State Reporting of Abuse/Neglect/Exploitation dated 05/2019, reflected, "It is the policy of Millwood Hospital to report all incidents of patient abuse, neglect, and exploitation within twenty-four(24) working hours of the time the incident occurred."

The hospital Policy on Patient Abuse dated 03/2018, reflected, "To establish guidelines and procedures for the reporting of child, elderly or disabled persons abuse in accordance with the Texas Penal Code. Reports are made if a person has cause to believe that the physical or mental health or welfare has been or may be adversely affected by abuse or neglect."

The hospital Policy on Patient Observation Rounds dated 062018, reflected, "To ensure patient safety, as well as, to provide a process for observing and documenting patient location and behavior ...'Perform rounds at staggered intervals and in varying pattern or sequence throughout the unit to minimized planned acting out opportunities ...While monitoring hallways and patient care areas ensure patients are: not entering rooms not assigned to them ...not left in 'Treatment Areas' without direct staff supervision ...Beware of times when your focus can be diverted, (changes of shift, codes, crisis).