HospitalInspections.org

Based on record review and staff interview, it has been determined that the hospital failed to meet the Condition of Participation §482.13 related to Patient Rights, due to the hospital's failure to ensure patient safety and provide care in a safe setting for 1 of 9 sample patients, Patient ID #1.

Findings are as follows:

The hospital failed to protect all patients and provide a safe environment relative to a patient-to-patient assault resulting in impaired emotional well-being for Patient ID #1. (Refer to A-144)

Based on policy review, record review, and staff interview, it has been determined that the hospital failed to ensure patients are provided with an environment a reasonable person would consider safe relative to an allegation of sexual assault where it was determined that Patient ID #2 touched Patient ID #1's thigh intentionally resulting in emotional upset and nightmares for Patient ID #1.

Findings are as follows:

The hospital 's policy titled, "Institutional Abuse, Neglect or Exploitation; Alleged or Confirmed, Patient care" last revised in 4/2021 states in part,

"... Definitions:

Abuse/ Neglect/ Exploitation

...Any intentional behavior which would reasonably be expected to impair emotional well-being. This may include physical, verbal, sexual and emotional abuse..."

A report submitted to the Rhode Island Department of Health on 3/17/2023 stated that on 3/16/2023 at approximately 7:00 PM, Patient ID #1, alleged that Patient ID #2 touched their groin area over the pants while sitting next Patient ID #2 in the activity room. The report further states that Patient ID #1 also reported to staff that Patient ID #2 took their hand and placed it over the Patent ID #2's private area and that Patient ID #2 also touched them under the pants.

Record review for Patient ID #1 revealed she/he presented to the hospital in February of 2023 after expressing suicidal ideation with a plan to overdose on medications in the home. Patient ID #1's diagnoses include, but are not limited to major depressive disorder, and cannabis related disorder.

Record review for Patient ID #2 revealed that she/he presented to the hospital in November of 2022 after assessed as being an acute risk to harm himself/herself. Patient ID #2's diagnoses include, but are not limited to, attention deficit hyperactivity disorder, anxiety, substance abuse, aggressive behavior, and post-traumatic stress disorder.

Review of Patient ID #1's "Plan of Care" note completed by nursing on 3/16/23 at 10:36 PM states in part:

"...Pt [patient] was observed to become tearful around 1900 [7:00 PM] and was able to check in with nurse and tell nurse...[Patient ID #2]...was in the activity room sitting next to pt. When staff were sitting in the hallway, pt reported [Patient ID #2] began touching pt in the private area over the pants. Pt reported they froze for a second and when staff stepped into activity room, [Patient ID #2] took hand away and pt got up and left activity room tearful. Per...report, pt reported to them [Patient ID #2] also took pt's hand and put it over [his/her] private area..."

A physician's "Progress Notes" dated 3/17/2023 at 10:30 AM stated that Patient ID #1 alleged that "last night that a...peer touched them under their pants while playing a board game." The physician further states in their note, "...discharge had been planned later today and had to be rescheduled because pt reported active SI [Suicidal Ideation]...and urges to self harm...They reported feeling upset with staff for not preventing the incident above. Claimed that the checks person was in the hallway and was not paying attention..."

Additional record review for Patient ID #1 revealed a "Plan of Care" note completed by nursing dated 3/17/2023 at 10:18 AM which stated,

"...Pt presented with a stable to anxious affect this shift...Pt endorsed having nightmares r/t [related to] the sexual assault..."

Patient ID #1 was examined at a Child Protection Center following his/her discharge in March of 2023 for concerns of sexual abuse.

The following statement was obtained from Patient ID #1 by a physician who interviewed him/her.

"...this kid in Bradley hospital had grown a so called "liking" to me and one day me and [Patient ID #2] and another kid were playing the board game and all of a sudden [Patient ID #2] starts touching my thigh. I was confused at first then [Patient ID #2] grabbed my hand and made me touch [him/her] inappropriately and my body froze, my mind froze, I couldn't feel or think about anything, I was just blank..."

Review of a "Significant Event" note for Patient ID #2 completed by nursing dated 3/17/2023 at 12:29 PM states in part,

"...[Patient ID #2] endorsed that [she/he] was playing [a] game with two peers in the activity room using the back of a chair as a table. [She/He] stated peer had their leg on [his/her] under the chair, out of sight of staff. [She/He] stated [she/he] quickly touched the peer's thigh over their clothes while staff was monitoring the room from the hallway. [She/He] denied touching the peer under their clothes..."

During a surveyor interview on 3/27/23 at 11:18 AM with Employee A, Behavioral Health Specialist, she revealed that on the day of the allegation, she was responsible for observing four patients, two of which were Patients ID #1 and ID #2. She revealed that Patient ID #1, Patient ID #2, and another patient were sitting in chairs in the activity room playing a board game that they had placed on top of chair they flipped over. She stated that the hospital's policy is for the "checks person" to stay in the hallway, not inside the activity room as there are other patients in the hallway to be observed. She revealed that Patient ID #1 and Patient ID #2 were redirected multiple times because they were "close to each other." When asked to elaborate on what she meant when she said that the patients had to be redirected multiple times because they were "close to each other," she explained that they were leaning towards each other, but their arms never touched. She stated that on that day, she told Patient ID #2 to get up and walk away from Patient ID #1 and indicated that Patient ID #1's face changed as if she/he were angry but was unable to see any touching between the patients.