HospitalInspections.org

Based on document review, observation, and interview, it was determined that the Hospital failed to protect and promote each patient's rights by ensuring precautions were implemented for a patient exhibiting sexually acting out/victimization behaviors. As a result, the Condition of Participation, 42 CFR 482.13 Patient Rights was not in compliance.

Findings include:

1. The Hospital failed to ensure care in a safe setting by implementing precautions for a patient exhibiting sexual behaviors. (A-144)

Based on document review and interview, it was determined that for 2 of 4 patient (Pt. #2 and Pt. #7) records reviewed for psychotropic medication consents, the Hospital failed to ensure the patient acknowledge and consented to received psychotropic medication prior to administration.

Findings include:

1. The Hospital's policy titled, "Patient Informed Consent for Psychotropic Medication" (revised 5/2018), was reviewed on 1/18/2023 and required, "Patients/guardians are to provide informed consent for psychotropic medications... RN/LPN [Nurse] will obtain written signature from the patient or legal guardian to medications after they have provided medication education regarding reason, side effects and importance of compliance... If the adult is unable to sign or refuses to sign but provides verbal approval for medication administration, documents such in the Patient consent form for psychotropic medications... Ensure consent is obtained prior to administration of Psychotropic medications..."

2. The clinical record of Pt. #2 was reviewed on 01/17/2023. Pt. #2 was admitted to the Psychiatric Hospital on 12/9/2022, with diagnoses of major depressive disorder and psychosis. The Medication Administration Record (MAR) indicated that Pt. #2 received the following psychotropic medications between 12/10/2022-12/29/2022: lorazepam (for anxiety), amitriptyline (for psychosis), olanzapine (for psychosis), clonazepam (mood stabilizer), lurasidone (for mood regulation), lithium (mood stabilizer); and haldol (for agitation/aggression). However, the patient's written signature for consent was not obtained for these medications until Pt. #2's discharge on 12/30/2022 (after administration).

3. The clinical record of Pt. #7 was reviewed on 01/18/2023. Pt. #7 was admitted to the Hospital on 12/4/2022 with a diagnosis of bipolar disorder. The MAR indicated that Pt. #7 received the following psychotropic medications between 12/5/2022-12/28/2022: olanzapine, clonazepam (for anxiety), paliperidone (for bipolar disorder), lorazepam, and haldol. The record lacked Pt. #7's written signature for consent for administration of these medications. The consent form required, "Verbal consent requires witness by second Nurse if obtained by Nurse..." The forms lacked a signature of a second nurse to indicate that verbal consent was obtained and verified.

4.. A telephone interview with the Charge Nurse (E#12) was conducted on 01/18/2023, at approximately 9:46 AM. E#12 stated that the patient's signature should be obtained on admission for psychotropic medications. E#12 stated that the consent should be obtained prior to administration.

Based on document review and interview, it was determined that for 1 of 2 clinical records (Pt. #2) reviewed for patient-to-patient interaction, the Hospital failed to ensure care in a safe setting by implementing precautions for a patient exhibiting sexual behaviors.

Findings include:

1. The Hospital's policy titled, "Sexual Allegation, Aggression and Sexual Victimization: Prevention, Response & Notification Plan" (revised 2/2022), was reviewed on 1/18/2023 and required, "Provision of a safe, therapeutic environment of care includes the prevention of patient to patient or staff to patient sexual incidents... To provide a plan for the prevention of sexual behavior including aggression and the potential for victimization by identifying early warnings of sexual behavior... Boundary Violations [includes]: Exposing/flashing self... inappropriate touching... Action steps: Early identification: Current risks for sexual behavior/aggression such as sexually inappropriate verbalization, provocative behavior or gestures... Nursing Staff: Assesses patient risk factors for Sexual Aggression/Victimization and places patient on SAO [sexually acting out]-Aggression or Risk of Victimization (RV) Precautions. Contacts the attending to communicate risk and obtains orders for: Precautions for SAO or RV... Unit Staff: Observe patients for specific behaviors/precursors to sexual acting out behaviors:... Sexual Aggression: Sexually inappropriate interactions, ..lingering near patient bedrooms or bathrooms... Sexual Victim: Poor social boundaries, confusion and poor orientation to surroundings, inappropriate touching or attempts at inappropriate touching..."

2. The clinical record of Pt. #2 was reviewed on 01/17/2023. Pt. #2 was admitted to the Psychiatric Hospital on 12/9/2022, with diagnoses of major depressive disorder and psychosis.

Nurses' Notes from 12/10/2022-12/30/2022 were reviewed and included the following:
- 12/16/2022 2:26 PM: "Sexually Inappropriate: Exposing self ... The patient was seen running naked in hallway during shift change ..."
- 12/17/2022 3:29 PM: "Crying, stating husband is planning to leave her; keeps taking off clothing ..."
- 12/18/2022 3:17 PM: "Patient is confused and illogical not ready to grow within milieu; Poor insight..."
- 12/22/2022 10:32 PM: "PT [Pt. #2] tried to touch staff inappropriately. PT walked in other pt room. PT also got naked in room and laid in someone else bed ..."
- 12/23/2022 5:31 AM: "Patient attempted to go to other patient's room multiple times."
- 12/24/2022 7:03 PM: "Pt walked into another male peer's room and took shower and then went and laid in bed, the bed in that room. Patient was informed by staff to go back to room during nap time. Patient stated 'D***** told me to bond with him.'... Staff asked patient what happened? Patient responded 'I needed to take a shower, so I went in the room to take a shower {referring to peers room}. I took a shower then I thought he was D***** and I wanted to bond.' Staff asked patient did he {peer} [identified as Pt. #7] insert his penis in your vagina? Patient stated, 'yes.'"
- 12/24/2022: "This writer interviewed patient after it was reported that the patient had sexual intercourse with a male patient.... She displayed detachment from reality. She believed that she had intercourse with someone she knew from the past and stated that she was tricked. MD and risk management notified."

Physician's Orders, Nursing Notes, and Observation/Precaution Sheets from 12/10/2022-12/30/2022 were reviewed and indicated that Pt. #2 was not placed on SAO [sexually acting out] and/or RV [Risk of Victimization] precautions until 12/24/2022 (following the incident on 12/24/2022 at approximately 2:00 PM.

3. A telephone interview with the Charge Nurse (E#12) was conducted on 1/18/2023, at approximately 9:46 AM. E#12 described Pt. #2 as impulsive and confused. E#12 stated that on 12/24/2022, around 2:00 PM, Pt. #2 went into the room of a male patient. Some minutes later, another staff member was rounding and found Pt. #2 and the male patient [identified as Pt. #7] having sex. E#12 stated that after the incident, Pt. #2 was moved to another unit so she would not have contact with Pt. #7. E#12 stated that prior to this incident, Pt. #2 was not on SAO or RV precautions. E#12 stated that some initial behaviors that a patient may need to be on SAO and/or RV include taking off clothes, flashing others/exposing self, and inappropriately touching others such as trying to hold their hand or touching their leg. E#12 stated that he was not aware that Pt. #2 displayed any of these behaviors. E#12 stated, "If we observed those behaviors, we would put the patient on SAO/RV precautions and then notify the MD [doctor]." E#12 stated that SAO/RV precautions may include separating the patient from particular patients/staff they may be focused on, moving them closer to the nurse's station, and/or blocking their room (i.e. no roommate). E#12 stated that if the patient continues to try and go into other patient's rooms, they made need a 1:1 to sit/follow them. E#12 stated that the purpose of SAO precautions is to keep the patients safe by preventing sexual interactions (patient-to-patient and/or patient-to-staff) such as what happened between Pt. #2 and Pt. #7. E#12 stated, "I'm not sure from her [Pt. #2's] state of mind that she knew it [having sexual interactions with another patient] was not right. Her judgement was not perfect."

4. An interview with the Attending Psychiatrist (MD#1) was conducted on 1/18/2023, at approximately 10:32 AM. MD#1 stated that Pt. #2 exhibited bizarre behavior such as wandering into other's rooms and described Pt. #2 as confused most of the time. MD#1 stated Pt. #2 was having auditory-visual hallucinations and would think her husband was coming here to get her. MD#1 stated that it was reported to him that Pt. #2 had sexual intercourse with a male patient. MD#1 stated that Pt. #2 was then moved to the other side [another unit] to separate them and keep everyone safe. MD#1 stated that Pt. #2 was put on 1:1 monitoring following the incident. MD#1 stated that he was aware that Pt. #2 had been getting naked and going into other patient's rooms prior to the incident. MD#1 stated, "I believe she was on SAO precautions prior to the incident but I'm not sure." MD#1 stated that behaviors such as exposing herself, touching others, and going into other patient rooms naked would have prompted the need for SAO and/or RV precautions. MD#1 stated that the purpose of SAO/RV precautions is to prevent patient-to-patient sex or other boundary violations between patients and/or staff.

5. An interview was conducted with the Social Worker (E#19) on 1/18/2023, at approximately 1:33 PM. E#19 stated that she spoke with Pt. #2 about the incident that occurred over the weekend. E#19 stated that according to the notes Pt. #2 did have intercourse with the other patient. E#19 stated that Pt. #2 stated that she [Pt. #2] was not herself when she went into the peer's room, she was her "inner child" at the time and had believed the peer was her husband because the peer had told her he was her husband. E#19 stated that Pt. #2 never used the term "rape"; however, E#19 stated that Pt. #2 was still exhibiting psychosis at the time and was not in a state to consent.

6. An interview was conducted with MHS (E#17) on 1/18/2023, at approximately 2:45 PM. E#17 stated that he rarely worked on 2 South (unit where incident occurred) however, did remember Pt. #2. E#17 stated that Pt. #2 was psychotic, talked to herself and would try to go into other patient's rooms and get naked. E#17 stated that Pt. #2 tried to inappropriately touch E#17 by grabbing his hand. E#17 was uncertain if Pt. #2 had orders for SAO precautions prior to the incident; however, stated, "She definitely was sexually acting out and should have been on SAO precautions."