HospitalInspections.org

Based on interview and document review, the hospital failed to report to the State Agency (SA) in a timely manner an allegation of sexual assault for 1 of 13 patients (P1) who alleged sexual assault perpetrated by P2, another patient who was receiving treatment at the facility.

Findings include:

P1's current diagnosis lists included major depression, recurrent with psychotic features, post traumatic stress disorder, antisocial and borderline traits, rule out schizoaffective disorder.

On 11/4/19, at 9:21 a.m. P1 filed a grievance with the facility after receiving two letters from P2 expressing desire for a romantic relationship, and unwanted physical touching by P2. Following the grievance filling, P1 met with registered nurse (RN)-B to review her concerns regarding the allegation of P2 making sexual advances.

On 11/5/19, at 12:33 p.m. P1 telephoned a report to the SA stating she had been sexually assaulted by another patient, was being treated differently due to making the report, and nothing had been done to prevent recurrence of the assault.

The facility incident report dated 11/5/19, at 3:27 p.m. indicated the incident occurred on 11/4/19, at 9:21 a.m. when P1 stated received two letters from P2 over the past weekend, and P2 had expressed a desire for a romantic relationship with P1, and as a result P1 reported to staff she was feeling unsafe. P2 was then transferred to a different unit due to staff having a long term history with P1 and her treatment plan. The facility did not file a report to the SA.

On 11/9/19, at 10:30 a.m. P1 submitted a second grievance to the facility which indicated, "'I am very tired of how I am being treated by staff. I am requesting to be moved to another unit as soon as possible." When a nurse manager interviewed to assess P1's concerns, P1 stated her main concern was, "People touching me without my consent, and staff not doing anything about it."

On 11/12/19, at 3:40 p.m. nurse practioner (NP)-A documented P1 voiced a desire to transfer to another unit as she didn't feel safe, and stated, "People keep touching me." Was reassured, and 1:1 observation was continued to ensure safety.


The director of nursing (DON) was interviewed on 11/26/19, at 4:30 p.m. and indicated not being aware of the reported incidents between P1 and P2 which occurred on 11/5/19. The contact was reported as two occurrences of kissing and two occurrences of touching P1's buttocks. The DON confirmed P1 had filed a report with the SA, but the facility did not, and should have done so.

The facility policy Vulnerable Adult (VA) Maltreatment Reporting dated 10/2/18, directed all employees, agents, or persons providing services in the he program are mandated reporters and must report any suspected abuse, neglect or financial exploitation they have reason to believe has occurred. Mental Health and Substance Abuse Treatment Services affirms its commitment to comply with the reporting requirements relating to the maltreatment of vulnerable adults and observes zero tolerance for the maltreatment of any client. Persons making a report may contact their immediate supervisor or on-call supervisor to assist with staffing or environmental changes necessary to protect the VA; however, they must still contact the primary contact or the State Agency to comply with the law.

Based on interview and document review, the facility failed to ensure physician orders were completed as directed for 3 of 15 (P5, P6, P7) medical records reviewed.

Findings include:

Review of medical records on 12/2/19, at 2:45 p.m. with registered nurse (RN-A) revealed P5's medical record lacked completion of laboratory orders by the physician. P5 was admitted 7/26/19. P5 had physician orders on 7/26/19, indicated to have a urine toxicology completed. On 12/2/19, RN-A stated, "I do not see that a urine toxicology was completed on [P5], there are no lab results in [P5]'s chart.

Review of P6's medical record indicated P6 was admitted 9/26/19. P6's physician orders indicated P6 was to have a dental referral dated 9/26/19, for dental pain, broken tooth. On 12/2/19, RN-A stated P6 did not have a dental referral made. 12/2/19, at 4:50 p.m. social services (SS)-A stated there was no dental appointment set up for P6.

Review of P7's medical record indicated P7 was admitted on 11/5/19. P7's physician orders indicated a dental referral 11/20/19, for worsening pain, where ibuprofen was not helpful, and P7's gum was red. At 3:37 p.m. RN-A stated P7's dental referral was not addressed. At 3:50 p.m. SS-A stated there had been no appointment for the dentist for P7.

An interview on 12/2/19, RN-A stated the medical provider puts an order in and nursing then acknowledges the order. RN-A stated nursing then collects any ordered specimen and sends it to the laboratory. RN-A stated medical providers send orders to the clinic in the facility, and they schedule the dental appointments for the patients.

A Dental Services policy dated 9/4/19, indicated Anoka Regional Treatment Center (AMRTC): Emergent, urgent and interceptive care will be provided to clients as the clinical provider indicates.