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Based on interviews and medical record review the Hospital failed to provide care in a safe setting and provide for 1 of 11 patient's (Patient #11) care that was free from abuse.

See A-0144 and A-0145

Based on interviews and medical record review the Hospital failed to provide care in a safe setting for 1 of 11 patient's (Patient #11) when Patient #2 was sexually assaulted by a security officer.

Findings include:

Review of the Hospital's Rights and Responsibilities of Patients, Families and Patient Representatives Family Education Sheet, dated 2/26/21, indicated that Patients have the right to:
-Get safe and respectful care suited to your age, cultural and person values and needs.
-Be given care that is free from abuse or neglect, and that supports respect, dignity and comfort.

Patient #11 was a 17 y.o. patient who was admitted to the inpatient medical unit with a history of recurrent pancreatitis and complex psychiatric history including depression vs. bipolar disorder with prior suicide attempts, anxiety, attention deficit hyperactivity disorder and obsessive compulsive disorder as a psychiatric boarder while awaiting appropriate psychiatric disposition.

Record review indicated that on 4/25/21 at 3:50 A.M. Patient #11 was witnessed to be performing oral sex on Security Officer #1 while Security Officer #1 was supposed to be providing constant observation for Patient #11's Suicidal Ideation.

During an interview on 4/20/22 at 11:30 A.M., the Director of Security said that Security Officer #1 was terminated and issued a no trespass warning as well as lost all access to the Hospital. No further action was identified by the Hospital.

The Hospital failed to provide care in a safe setting, leaving vulnerable pediatric patients at risk for physical and sexual asault while being cared for in the Emergency Department and in the inpatient medical unit.

Based on interviews and medical record review the Hospital failed to provide care that is free of abuse for 1 of 11 patient's (Patient #11) when Patient #2 was sexually assaulted by a security officer.

Findings include:

Review of the Hospital's Rights and Responsibilities of Patients, Families and Patient Representatives Family Education Sheet, dated 2/26/21, indicated that Patients have the right to:
-Get safe and respectful care suited to your age, cultural and person values and needs.
-Be given care that is free from abuse or neglect, and that supports respect, dignity and comfort.

Patient #11 was a 17 y.o. patient who was admitted to the inpatient medical unit with a history of recurrent pancreatitis and complex psychiatric history including depression vs. bipolar disorder with prior suicide attempts, anxiety, attention deficit hyperactivity disorder and obsessive compulsive disorder as a psychiatric boarder while awaiting appropriate psychiatric disposition.

Record review indicated that on 4/25/21 at 3:50 A.M. Patient #11 was witnessed to be performing oral sex on Security Officer #1 while Security Officer #1 was supposed to be providing constant observation for Patient #11's Suicidal Ideation.

During an interview on 4/20/22 at 11:30 A.M., the Director of Security said that Security Officer #1 was terminated and issued a no trespass warning as well as lost all access to the Hospital. No further action was identified by the Hospital.

The Hospital failed to provide care that was free from abuse, leaving vulnerable pediatric patients at risk for physical and sexual asault while being cared for in the Emergency Department and in the inpatient medical unit.

The Hospital failed to identify opportunities for improvement, consider the incidence, prevalence and severity of problems and implement changes that will lead to improvement for 1 (Patient #11) of 11 patient records reviewed.

See A-0283

The Hospital failed to identify opportunities for improvement, consider the incidence, prevalence and severity of problems and implement changes that will lead to improvement for 1 (Patient #11) of 11 patient records reviewed.
Findings include:

Review of the Hospital's (QAPI) Quality Assurance and Performance Improvement Plan, effective calendar year 2022 indicated that the Plan Purpose was to develop, implement, and maintain an effective, ongoing, enterprise-wide, data-driven QAPI program. The QAPI plan indicates that many performance improvement activities that track clinical errors and adverse patient events, analyze their causes, and implement preventative actions and mechanism that include feedback and learning throughout the hospital are supported and facilitated by the (PPSQ) Program for Patient Safety and Quality. This program provides a coordinated system for hospital-wide assessment and improvement of inter-related safety, support and clinical care processes that affect patient outcomes including standards compliance. The purpose of the PPSQ is to support initiatives that improve the health and safety of patients and to reduce preventable patient safety events.

Review of the Hospital's Adverse Events: Response, Reporting, Disclosure policy, revised 1/29/21 indicated that following the identification of an adverse event, the first priority is the mitigation of harm to the patient and appropriate communication with the family. The responsibility for investigating and responding to events resides with the PPSQ, but may be delegated to the individual or department reporting the event for events of lower severity and that are not externally reportable. Responses to an adverse event may include, but are not limited to: Initiation of an investigation and causal analysis of events is undertaken by PPSQ staff and/or local leaders, depending on the nature and severity of the event. The approach seeks to identify system failures that contributed to the adverse event. Techniques employed may include: Root Cause Analysis (A comprehensive, systematic analysis that is performed to identify the causal and contributory factors as well as appropriate corrective actions to prevent a recurrence.


36510

Patient #11 was a 17-year-old patient who was admitted to the inpatient medical unit with a history of recurrent pancreatitis and complex psychiatric history including depression vs. bipolar disorder with prior suicide attempts, anxiety, attention deficit hyperactivity disorder and obsessive-compulsive disorder as a psychiatric boarder while awaiting appropriate psychiatric disposition.

Record review indicated that on 4/25/21 at 3:50 A.M. Patient #11 was witnessed to be performing oral sex on Security Officer #1 while Security Officer #1 was supposed to be providing constant observation for Patient #11's Suicidal Ideation.

Review of the Hospital's internal investigation, dated 5/26/21, indicated that the Hospital performed a Root Cause Analysis that identified that the root cause of the sexual assault was a failure of contracted security staff to maintain professional boundaries when alone in a room with a patient. The corrective action identified was: 1. The alleged perpetrator was immediately removed the premises and a no trespass order was issued and 2. Assign female staff only security guard with female only Hospital clinical care companion until discharged from medical floor, to ensure 2 staff in room at all times. No further corrective action was identified to prevent a like occurrence from happening in the future.

During an interview on 4/20/22 at 11:30 A.M., the Director of Security said that Security Officer #1 was terminated and issued a no trespass warning as well as lost all access to the Hospital. The Director of Security said that the Hospital provided a general retraining to all security staff members about immediate notification of reports. Further, He said that there was re-education provided to all security and observers. The Director of Security said he would provide the Surveyors with a copy of the education and signature of the re-training to all staff educated.

On 4/20/22 at 2:00 P.M., the Vice President of Patient Safety, Quality and Regulatory Affairs said the Hospital is unable to provide the Surveyors with the re-training done for the security officers and observers related to the event.

On 4/22/22, after the survey exit, the Vice President of Patient Safety, Quality and Regulatory Affairs sent additional information to The Department of Public Health. The additional documentation did not specify direct corrective action to Patient #11's assault, but signatures from security staff and care companions that they have received education on Performance Expectations and Standards of Practice. The dates do not all coincide with the assault on Patient #11. There was no documentation in the corrective action plan that identified that this was a result of the investigation to prevent a like occurrence from happening in the future.

The Hospital failed to provide system wide education and corrective actions to prevent a like occurrence from happening again after Patient #11 was assaulted by Security Guard #1.