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Based on document review and staff interview, the hospital's administrative staff failed to follow their policy and ensure an allegation of child abuse was reported to the Department of Human Services (DHS) after 1 of 7 patients reviewed (Patient #2) told multiple clinicians that they had been sexually assaulted during a previous admission at another hospital. Failure to report an allegation of suspected child abuse put all patients at risk of potentially being exposed to a child abuser because the hospital did not report the allegation. The hospital's administrative staff identified a census of 51 patients on entrance.

Findings include:

1. Review of policy "Reporting Suspicions of Abuse and/or Neglect", last revised 2/2021, revealed in part: "...[A]ll employees of our facility who...has reason to suspect that a child has been a victim of abuse or neglect, is to notify ...the Iowa Department of Human Services [DHS]... immediately...also a written report of the suspected abuse/neglect must be completed within 24 hours."

2. Review of Patient #2's medical record revealed:

a. On 1/17/23 at 5:30 PM, Patient #2 was admitted for depression and family's concern for suicidal thoughts and cutting (harming your own body on purpose as a way of coping with negative emotions).

b. On 1/17/23 at 8:45 PM, RN B signed the "High Risk Notification Alert" that identified that Patient #2 had been sexually victimized at another hospital in August of 2022.

c. On 1/18/23 Psychiatry Resident Physician R examined Patient #2 and documented that Patient #2 had reported they had been sexually assaulted at another hospital in August 2022. Advanced Registered Nurse Practitioner (ARNP) S and Psychiatrist T also signed the document.

d. On 1/18/23 at 1:15 PM, Licensed Independent Social Worker (LISW) U documented that Patient #2 had reported that they had been raped by a 14-year-old patient 5 months ago.

e. Discharge Summary dated 1/24/23 again noted that Patient #2 had reported being sexually assaulted at another hospital. Psychiatry Resident Physician R and Psychiatrist T both signed the document.

f. Medical record lacked documentation that hospital had reported an allegation of potential child abuse to the DHS.

3. During an interview on 2/8/23 at 3:50 PM, RN B stated that Patient #2 had never directly told them that they had been sexually assaulted. RN B just knew it upset Patient #2, did not know where this was alleged to have happened, and believed it had been several months ago. RN B knew that RN Q had talked to Patient #2's father, had heard that it had been another patient in the previous hospital who had assaulted Patient #2.

RN B did not report this as potential child abuse. RN B explained that it did not occur to them that they should report it because it happened so long ago, and RN B had guessed Patient # 2's father had already reported it. RN B did not know if administrative staff or anyone else had reported the allegation.

4. During an interview on 2/9/23 at 8:00 AM, RN Q explained that they had had a phone call with Patient #2's father and he had explained that Patient #2 had been assaulted by a staff member when Patient #2 was at a previous hospital about five months ago. RN Q assumed that Patient #2's father had reported this to the DHS but was not positive.

5. During an interview on 2/8/23 at 10:45 AM, Psychiatry Resident Physician R recalled that Patient #2 had mentioned that they had been sexually victimized by a male patient. Psychiatry Resident Physician R did not ask Patient #2 where that had occurred but recalled hearing those details later.

Psychiatry Resident Physician R did not report this to the DHS as possible child abuse because they assumed it had been reported if it had happened at an outside hospital.

6. During an interview on 2/8/23 @ 11:20 AM, ARNP S recalled that initially Patient #2 was very guarded and did not want to talk about the allegation, but then said they were assaulted. Patient #2 did not give any names, did not want the person to get into trouble. Patient #2 told ARNP S that they had told their parents so they could call the hospital where it happened. Patient #2 said the person had apologized to them and they did not want to ruin this person's life.

ARNP S did not report the allegation to DHS. Patient #2 had reported it to their parents and the parents had contacted the hospital so ARNP S assumed the hospital had done an investigation. Patient #2's father had said he had contacted the police. Apparently neither the hospital or police could do anything about it because Patient #2 would not divulge a name.

7. During an interview on 2/9/23 at 7:30 AM, Psychiatrist T confirmed they were aware of alleged sexual assault at a different facility. Psychiatrist T did not report the allegation to DHS because they had talked to Patient #2's legal guardian and they were very aware of the alleged sexual assault, and they had mentioned that staff at the prior hospital were also aware and had told Patient #2's father that they were doing an internal investigation. Police were also involved but Patient #2 had chosen not to press charges. Psychiatrist T felt that everything had been handled appropriately and they did not want to re-expose Patient #2 to that traumatic event.

8. During an interview on 2/8/23 at 10:40 AM, LISW U recalled that Patient #2 had only shared that they had been sexually assaulted but would not divulge any other information so LISW U did not know how to report that allegation. LISW U did acknowledge that clinical staff were aware and they did discuss it, but LISW U had never heard where it had allegedly occurred.

9. During an interview on 2/8/23 at 9:00 AM, Director of Performance Improvement and Risk Management confirmed they had no knowledge of this allegation, and there was no documentation that it had been reported to the DHS as potential child abuse.

Based on document review and staff interview, the acute care hospital's administrative staff failed to immediately address and remediate risk for all patients after 1 of 1 patients (Patient #1) was able to enter the hospital with a razor that they then used to cut their arm which then required transfer to an Emergency Department for treatment of lacerations (cuts). Failure to thoroughly address and remediate risk put all patients at risk for harm from contraband (item/s that could be used to cause harm) that was not identified and removed upon admission to the acute care hospital. The hospital identified a census of 51 on entrance.

1. Immediately address and remediate any further risk of injury to patients from contraband. (Please see A-395).

The cumulative effect of this failure and deficient practices resulted in the hospital's inability to ensure all patients received safe and appropriate nursing care.

2. The survey team identified an Immediate Jeopardy (IJ) situation (a crisis situation that placed the health and safety of patients at risk) related to the Condition of Participation for Nursing Services (42 CFR 482.23). The State Agency (SA) notified the hospital administrative staff on 2/10/23 that failure to immediately address and remediate risk put all patients at risk for sustaining an injury from contraband. The hospital's administrative staff removed the immediacy prior to the survey team exiting on 2/15/23 when the administrative staff took the following actions:

On 2/10/2023, gathered members of leadership, nursing, and intake to discuss actions to ensure that team members know the Contraband and Patient search policy and procedure. The Contraband and Search policy was revised on 2/6/2023 to include visual inspection of the mouth.

All patients currently admitted will have a contraband and patient search conducted on 2/10/2023.

Immediate retraining will be conducted 2/10/2023-2/12/2023 for all leadership, Nurses, and Mental Health Technicians (MHT) on Contraband and Patient Search policy. Any staff members who do not receive the retraining within the next 72 hours will receive retraining prior to start of their next scheduled shift. Re-education and re-training outlined the addition to the Contraband and Patient Safety policy to include a visual inspection of the mouth will be completed by having the patient open their mouth, remove any dentures, move tongue up and down and from side to side. Components of this check will include that all patients remove all clothing including undergarments and binders. Patients will be provided with scrubs for privacy. Per policy, two staff members are present during contraband/personal search. The RN conducts the personal and skin search and the nurse or the other team member can perform the belongings search to check for contraband. Either one of the two staff members will have the patient change into scrubs. The nurse will conduct the skin assessment by visually observing the patient and noting any marks, injuries, scars, etc. Findings are documented in the nursing assessment. The nurse will also ask the patient to open their mouth for the oral cavity check. A nurse supervisor will be present to monitor the process. All belongings including what the patient is wearing are checked for contraband/safety/ligature risks this includes checking pockets, looking for and removing strings, observing for any contraband in clothing. A checklist was added to ensure that the following were conducted: Patient electronically searched (wanded) at intake. Patient switched to scrubs. Patient was asked to remove clothing items including bras, binders, underwear, socks). Oral cavity check was performed. Patient's clothing was checked thoroughly for contraband. The checklist is signed by both parties present conducting the contraband search and a nursing supervisor will be present to ensure that all steps are followed. Chief Nursing Officer will send a facility-wide email on 2/14/2023 on expectation of the immediate need to report any safety related issues including non-adherence to policies and procedures relating to contraband and patient search. Emailed also informed on how and who to report to. Nursing managers will discuss expectations during team meetings and huddles. Reporting expectation will also be reviewed in daily shift meetings everyday until all staff receives communication. Staff were educated that any staff members who witnessed any deviation from this policy and procedure is obligated to report and notify charge nurse, any member of leadership, their direct supervisor or administrator on call immediately. Signed attestation will be completed.

All staff who conduct contraband and patient search (all Intake Nurses, floor Nurses and MHTs), starting 2/10/2023 will be re-educated and re-trained. Only trained staff will complete contraband checks. At time of contraband and patient search, nursing will document that patient changed into scrubs to check existing clothing for contraband.

Nurse managers or designee will review documentation on each admission that all clothing items were removed and checked. This process will be temporary until established and conducted as expected with continued monitoring from Chief Nursing Officer or designee. Effective 2/10/2023, Nursing leadership on every shift will report to Administrator on call that contraband and patient search were completed per policy by changing into scrubs and checking clothing for contraband. This process will be temporary until established and conducted as expected with continued monitoring from Chief Nursing Officer or designee.

Based on document review and staff interview, the acute care hospital's administrative staff failed to thoroughly address and remediate risk for all patients after 1 of 1 patients (Patient #1) was able to enter the hospital with a razor that they then used to cut their arm which required transfer to an Emergency Department for treatment. Failure to thoroughly address and remediate risk put all patients at risk for harm from contraband (item/s that could be used to cause harm) that was not identified and removed upon admission to the acute care hospital. The hospital identified a census of 51 patients on entrance.

Findings include:

1. Review of the policy "Contraband [items that could be dangerous to patients] and Patient Search", last reviewed 05/2022, revealed in part: "...All patients will have a personal search conducted by nursing staff...Ask the patient to remove the clothing from sections of their upper body and then lower body. This will include but is not limited to, torso, arms, hands, neck, face, ears, head, legs, feet, (top and bottom), back etc..."

2. Review of Patient #1's medical record revealed on 1/29/23 at approximately 8:15 PM, Patient #1 presented to the hospital for suicidal thoughts after having an argument with their foster parent. RN P documented that Patient #1 had a known history of cutting (harming your own body on purpose as a way of coping with negative emotions), and had just been an inpatient in January of 2023 at another hospital where they had cut their wrists. On 1/29/23 at approximately 11:10 PM, RN B documented multiple scars from prior cutting. RN Supervisor A searched Patient #1 for contraband, and at 11:20 PM Patient #1 was taken to their room. At 11:40 PM, Patient #1 came out to the nurse's station with bloody paper towels and it was noted that they had cuts to their right arm. Patient #1 produced a small razor, bra and binder were removed, and it was noted that bra had two zipper pockets. On 1/30/23 at approximately 12:00 AM, Patient #1 was transferred to Hospital A Emergency Department where they received 16 sutures to repair the laceration (cut).

3. During an interview on 2/9/23 at 9:00 AM, RN P recalled Patient #1's foster mother had brought them to the hospital because Patient #1 had voiced they were having suicidal thoughts, and on arrival had endorsed a plan to commit suicide by cutting themselves or overdosing. RN P knew Patient #1 because they had been at the hospital before, learned that they had been in another hospital about a month ago where they had cut themselves and needed stitches. Patient #1 had visible scars from cutting.

RN P did not perform the contraband check but was present for at least part of it. RN P did see RN Supervisor A run their fingers around the bra but did not ask Patient #1 to take off their bra or binder. RN P stated hospital policy required the patient to remove every item of clothing during the check for contraband. RN P was relatively new to their role and did not intervene with RN Supervisor A. RN P could not recall any follow up from the hospital related to this issue.

4. During an interview on 2/6/23 at 4:00 PM, RN Supervisor A recalled Patient #1 had a history of cutting and remembered thinking that the scars on their arms were far worse than what they'd seen previously when caring for Patient #1. RN Supervisor A and RN B did the contraband check together, Patient #1 was wearing a bra (and a binder over the bra) and to check for contraband RN Supervisor A put their hands around the edges of the bra, pulled it away from the skin, and shook it. They also slid their hands up underneath the binder everywhere except the breast area, and then pulled open the straps and looked down through the cleavage. RN Supervisor A did not find any type of contraband. RN Supervisor A did not have Patient #1 remove their bra and binder. RN Supervisor A then left the unit but was quickly called back because Patient #1 had used a small razor to cut themselves. Patient #1 was sent to the ED for sutures (stitches).

RN Supervisor A said Patient #1 said they had hidden the razor in their bra, and had also said they had it in their mouth. RN Supervisor A found it believable that the razor had been in Patient #1's mouth because Patient #1 had not spoken very much during the assessments.

RN Supervisor A said as far as they knew it had never been the policy to have a patient remove their bra, it's done on a case by case basis, and at RN Supervisor A's discretion they did not have Patient #1 remove their bra and binder during the check for contraband because they were being sensitive to the fact that Patient #1 was transgender. RN Supervisor A was not aware of any requirement to check a patient's mouth and did not routinely do that.

RN Supervisor A believed there had been some follow up from the Director of Risk Management and Performance Improvement or someone else in management or HR but could not recall specifics.

5. During an interview on 2/6/23 at 10:00 AM, RN B explained that RN Supervisor A had done the check for contraband and then they had taken Patient #1 to their room. Approximately 10 minutes later, Patient #1 came back to the nurse's station carrying bloody paper towels and RN B saw the cuts on their arm from a small razor that Patient #1 had in their possession.

RN B recalled that Patient #1 had on a sports bra and a binder and RN Supervisor A had conveyed to RN B that their policy says you should leave the bra and binder on and just pull them out from the skin and shake the fabric. RN B was not aware of hospital policy but offered that they would have taken off the bra and the binder to search for contraband. After Patient #1 had cut themselves, they removed the bra and binder and found there were hidden zippers on the left and right side of the bra. Patient #1 told RN B that they had hidden the razor in their mouth, but then had also told RN Supervisor A that they had hidden the razor in their bra. RN B was unsure whether or not they were required to look in a patient's mouth when checking for contraband.

RN B could not recall any follow up from hospital administration related to contraband checks.

6. During an interview on 2/6/23 at 2:05 PM, Mental Health Tech (MHT) C confirmed they were present after Patient #1 cut themselves. MHT C recalled Patient #1 had said they had the razor in their mouth, but later on they had said it was in their bra.

7. During an interview on 2/6/23 at 9:30 AM (approximately one week after the incident where Patient #1 had cut themselves with retained contraband and required sutures), CNO confirmed that staff members had not fully removed the bra so that was the re-education with those employees. CNO explained that the Nurse Managers were to discuss this with staff in their daily Huddles, and an email had been sent out to Nurse Managers regarding the importance of safety checks during admission. CNO acknowledged that the email that had been sent out did not go to all staff, and did not address this specific incident, but rather to call attention to safety checks in general.

CNO explained that they were unsure whether or not the razor had been hidden in Patient 1's bra or their mouth. Staff have not been required to do a mouth search but now some staff were saying they needed to open a patient's mouth and do an oral check. CNO confirmed there had been no policy change, they would need to follow up with Director of Performance Improvement and Risk Management.

8. During an interview on 2/6/23 at 9:30 AM (approximately one week after the incident where Patient #1 had cut themselves with retained contraband and required sutures), Nurse Manager D explained that the razor had probably been hidden in Patient #1's bra or mouth, understood that RN Supervisor A had Patient #1 pull out their bra and shake it but did not have Patient #1 take it all the way off as required. Nurse Manager D stated they have not checked patient's mouths prior to this incident, but now they should have patients open their mouth so staff can check inside for contraband.

Nurse Manager D had spoken with RN B but had not had a chance to speak directly to RN Supervisor A and was unsure if anyone else talked to RN Supervisor A about this incident. Nurse Manager D believed the email that had been sent by the CNO was in reference to another issue, did confirm that they had shared this incident with staff in their daily huddles. Nurse Manager D had also talked to Nurse Educator F to discuss how they could be sure to get the information to all staff but did not think anything had been done.

9. During an interview on 2/6/23 at 8:30 AM (approximately one week after the incident where Patient #1 had cut themselves with retained contraband and required sutures), Nurse Manager E revealed they had not been involved in this incident but did confirm that staff should be removing all clothing, including a bra, during a check for contraband. Nurse Manager D became aware of this incident the next day when it was discussed during morning report. Nurse Manager D said they have a daily huddle with all staff where they share this information, or they send out an email. Nurse Manager D could not recall staff receiving an email about this specific incident.

10. During an interview on 2/6/23 at 1:30 PM, RN G explained that during a contraband check they would not necessarily have a patient take off their bra to look for contraband as long as they can lift it up and see under all areas. RN G was not aware of any recent incident involving a patient cutting themselves.

11. On 2/6/23 at 1:35 PM, RN H explained that during a contraband check they would have a patient raise up their bra and RN H would look underneath it, and then check any padding and the arm straps for any contraband. RN H does not have patients take off their whole bra. RN H said a co-worker had told them about an incident where a patient had brought in contraband in their bra and cut themselves, but did not recall any other communication from the hospital about this incident.

12. During an interview on 2/6/23 at 1:40 PM, RN I confirmed that they do not always have patients remove their bra to check for contraband, but they do check the bra to see if there is anything they can feel or if there is a hidden area/compartment where a patient could hide something. RN I could not recall hearing about any incident related to a patient hiding contraband in their bra.

13. During an interview on 2/6/23 2:10 PM, RN J recalled hearing about this incident during one of their huddles. RN J confirmed that they do not have a patient remove their bra, nor do they feel the bra anywhere to detect any item. RN J has the patient pull the bra forward and lift the straps so RN J can see if there is anything underneath. RN J had also heard the razor could have been in Patient #1's mouth. RN J had never been told to look inside a patient's mouth but this had made RN J think twice about that. RN J recalled they had been told to be more cautious when doing contraband checks.

14. During an interview on 2/7/23 at 11:00 AM (over one week after the incident where Patient #1 had cut themselves with retained contraband and required sutures), Nurse Educator F confirmed that they knew about the incident but had not yet looked at the video or done any further follow up. Nurse Educator F confirmed that staff were supposed to remove the bra when doing a check for contraband.

15. During an interview on 2/7/23 at 10:30 AM (over one week after the incident where Patient #1 had cut themselves with retained contraband and required sutures), Director of Risk Management and Performance Improvement confirmed that the policy required staff to remove all clothing, including a bra, during a check for contraband. Shared an updated policy requiring staff to now also do oral checks, stated the policy was to be approved and then would be distributed to all staff.

Based on document review, medical record review, and staff interviews, the acute care hospital's administrative staff failed to ensure a nursing care plan was developed for 1 of 7 patients reviewed (Patient #1). Failure to ensure a nursing care plan was developed could potentially result in nursing care that is not individualized and focused on each patient's specific medical and psychiatric problems which could result in substandard nursing care. The hospital's administrative staff reported a census of 51 patients on entrance.

Findings include:

1. Review of the policy "Nursing Standards of Practice", last revised 02/2021, revealed in part, "On admission, the nurse initiates the collection of data concerning the health status and emotional state of the person...Problem lists are derived from admission data and are formulated in the nursing care plan...Nursing actions are consistent with the care plans..."

2. Review of Patient #1's medical record revealed that on 1/29/23 at 9:00 PM, Patient #1 presented to the acute care hospital for suicidal thoughts. Patient #1 had a known history of cutting (harming your own body on purpose as a way of coping with negative emotions) and had visible cuts on their arm.

3. Review of Patient #1's medical record on 2/2/23 (over two days after admission) revealed nursing staff had failed to establish a nursing care plan.

4. During an interview on 2/2/23 at 2:30 PM, Nurse Educator F confirmed that Patient #1's medical record lacked a nursing care plan.