HospitalInspections.org

Based on record review and interview, the hospital failed to provide an effective governing body to ensure patient care services were conducted in a safe manner.

1. While administration covered November 2022's daily nursing shifts with at least 38 contracted agency nursing personnel, none of the nurses or certified nurse aid had any hospital orientation. On at least one day, on 11/20/22, the contracted charge nurse did not have a badge or keys to leave the locked Psychiatric Intensive Care Unit (PICU) during emergencies.
2. The technician in charge of the PICUs adolescent male and female patients on 11/20/22 did not evidence the required age-based competencies of growth and developmental milestones and had never worked with a pediatric patient population prior to her assignment to the hospital.

Cross refer to A0084

Based on record review and interviews, the hospital governing body failed to ensure that the services performed by contracted agency nurses were provided in a safe and effective manner.
Administrative staff failed to provide hospital orientation to at least 38 agency nurses and nurse technicians (Agency Personnel #11, #12, #15 through #50) who covered at least 110 (one hundred ten) hospital shifts during the month of 11/2022.

On 11/20/22, Agency Personnel RN #11 worked as a charge nurse without receiving a badge or keys for emergencies. Agency Personnel Certified Nurse Assistant (CNA) #12 had not worked with a pediatric adolescent patient population prior to 11/20/22 and did not evidence age-based competencies to perform her job duties on the pediatric/adolescent Psychiatric Intensive Care Unit (PICU).


Findings included:

Record review of an untitled document received on 11/29/22 at 1950 reflected at least 110 (one hundred and ten) shifts between 11/01/22 and 11/29/22 were covered on the hospital units for pediatric/adolescent and geriatric patient population by at least 38 different agency nurses and nurse technicians (Agency Personnel #11, #12, #15 through #50).

Hospital Personnel #4 stated during an interview on 11/29/22 at 1720 that "administration was working on getting an orientation for agency nurses."

During a personal interview on 11/29/22 at approximately 1815, Hospital Personnel #14, in charge of personnel, acknowledged that "none of the agency nurses" had received a hospital orientation.

Staffing report of day shift 11/20/22 on PICU reflected Agency Personnel RN #11 and Agency Personnel CNA #12 were scheduled to work.


Agency Personnel RN #11 was phone interviewed on 11/29/22 at 1701 and denied having received a hospital orientation prior to her first shift. Instead, "another agency nurse provided the most orientation." Agency Personnel RN #11 stated she did not have keys or a badge on 11/20/22 to gain access to the locked PICU unit and was "still terrified."


During a telephone interview on 11/29/22 at 1945 Agency Personnel CNA #12 stated she had "never worked with children" before her PICU shift on 11/20/22. She confirmed she did not get oriented to the hospital.

Based on record review, observation and interview, the hospital failed to protect and promote the rights of three of ten patients (Patients #2, #3, #4) to receive care in a safe and patient-centered environment.

1. Staff failed to ensure that male adolescent Patient #4's recent sexual trauma history was communicated to nursing staff for effective care plan interventions and special staff precautionary observations for rape victimization.
2. Staff failed to adequately supervise male and female adolescent patients on 11/20/22 when female Patients #2 and #3 reported forced sexual contact after visiting Patient #4 in his room.
3. Staff failed to notify the hospital administration whose members accidentally learned of the alleged incident more than 12 hours later.

Cross refer to A0144.

Based on record review, interview, and observation, the hospital failed follow hospital policy and provide a safe environment for three of ten patients (Patients #2, #3, #4).

1. On Sunday, 11/20/22 during the evening shift change, Patients #2 and #3 were allowed to visit male Patient #4 in his room without staff intervention. Later that evening, Patient #3 notified staff that Patient #4 had forced her to perform oral sex, and Patient #2 was sent for emergency rape evaluation shortly after that. Despite Patient #3's staff notification, administrative staff remained unaware of the allegation of sexual abuse until the following day when they "overheard" unit staff talk about the event. The same day, a third female patient (Patient #1) accused Patient #4 of inappropriate touch.

2. Patient #4 had been admitted on 11/15/22 with a recent rape history while in Juvenile Detention as noted in the initial assessment. Hospital staff failed to communicate the patient's sexual trauma to clinical and nursing staff. Patient #4 was not placed on special precautions for sexual trauma victimization nor received care plan interventions targeted to his recent trauma.



Findings included:

1. A video surveillance footage dated 11/20/22 between 1913 and 1931 was surveyor reviewed on 11/29/22 at approximately 1900 with Hospital Personnel #4 present. It reflected that Patient #2 and Patient #3 were in Patient #4's room on 11/20/22 at 1920, 1923, and 1924 without staff being visible in the hallway.

Hospital Personnel #4 acknowledged during an interview on 11/27/22 at 1529 that on 11/20/22 between 1918 and 1925 staff did their shift report at the nurses' station instead of the bedside reporting as guided by hospital policy while Patients #2 and #3 were allowed to enter Patient #4's room.

During a phone interview on 11/29/22 at 1510 Hospital Personnel #9 stated she had witnessed a conversation between Patients #2, #3, and #4 about oral sex and "all three admitted it."


During a personal interview on 11/29/22 at 1530, Hospital Personnel #3 stated it "appeared" that Patient #4 forced Patient #3 to oral sex and "something happened that should not have happened."

During a personal interview on 11/29/22 at 1630, Hospital Personnel #8 stated that Patient #3 had informed her that Patient #4 was "a rapist ...were in his room ...raped us ...pried my mouth open ..." Hospital Personnel #8 stated, "something sexually happened for sure ...I assume they [the patients] were not watched."

Patient #4's Progress Note dated and signed by Hospital Personnel #3 on 11/22/22 at 1220 that a report was filed with the child protective agency "due to ... [Patient #4] reporting engaging in sexual acts with two female pts [patients] ...[Patient #4] reported he asked two female pts to engage in oral sex ...pts did what he asked them to do."

Patient #2's Night Shift Note dated 11/21/22 at 0308 reflected a nursing assessment was completed on 11/20/22 at 2000 and the patient " ...was warned today for going to a male patient's bathroom with the male patient ..."

Patient #2's Clinical Service Group Note dated 11/21/22 at 1030 reflected the patient was " ...still angry about what had happened the night before ..."

Patient #2's Shift Progress Noted dated 11/22/22 "day shift" reflected the patient stating "she wanted urine pregnancy test ...she might be pregnant ...allegations of sexual concerns ..."

Patient #2's Progress Notes dated 11/22/22 timed at 1630 reflected " ...to send patient to ER for evaluation regarding sexual concerns ..."


Patient #3's Clinical Services Group Note dated 11/21/22 at 1030 reflected Patient #3 stated "she had been assaulted by another peer the night before ..."

Patient #3's Progress Note dated and signed by Hospital Personnel #3 on 11/22/22 at 1220 reflected that a child protective agency had been notified that Patient #3 had been "sexually exploited and forced to perform oral sex ..."

During an interview on 11/27/22 at 1521 Hospital Personnel #4 stated that he was making rounds in the hospital's PICU the morning of Monday, 11/21/22 when he "overheard" a female technician and an agency nurse to discuss an allegation of sexual abuse the night before. Hospital Personnel acknowledged that he had not been notified of the incident and "the night shift nurse and technician did not report the allegation." Hospital Personnel #4 stated the unit surveillance video dated 11/20/22 between 1918 and 1925 reflected Patient #2 and Patient #3 followed Patient #4 into his room without staff interference.

During a personal interview on 11/29/22 at 1630, Hospital Personnel #8 stated that female Patient #1 informed her that male Patient #4 had touched her inappropriately while in the group room on 08/21/22.

The hospital Clinical Services Policy and Procedure titled "Patient Rights" (#1013) dated 04/07/22 reflected the policy that "Patients will be granted ...the right to a humane treatment environment that ensures protection from harm ...and promotes respect and dignity for each individual..." (p. 2).

Leadership Policy and Procedures titled "Incident Reporting" (#1002) dated 07/17/19 reflected the procedure to complete the incident form "...as soon as one becomes aware of such an occurrence..." (p.1).


2. Record review of Patient #4's Face Sheet reflected the 17-year old admission dated 11/15/22 at 1334.

Patient #4's Assessment and Referral Evaluation dated 11/15/22 at 1208 reflected the patient was brought in on an APOWW (Apprehended by a Peace Officer Without a Warrant). The patient reported he was not " ...doing so well ...claims he just got out of county due to theft ..."

Patient #4's Child and Adolescent Psychosocial Assessment dated 11/16/22 at 1330 reflected the patient was asked about his trauma history. The patient reported he was "raped in Juvie [Juvenile Detention]" by an "inmate."

Patient #4's Comprehensive Psychiatric Evaluation dated 11/16/22 at 1754 did not include sexual abuse or trauma.

Patient #4's Master Treatment Plan dated 11/16/22 at 1530 did not reflect the patient's recent sexual trauma.

Hospital Personnel #4 was interviewed on 11/29/22 at 1430. He acknowledged the above findings and stated that Patient #4's the sexual trauma had not been communicated to nursing staff.

During a personal interview on 11/29/22 at 1530, Hospital Personnel #3 stated she had not been aware of that Patient #4's report of rape and acknowledged the patient had not been on special precautions for sexual trauma.


Record review of Hospital Nursing Services Policy and Procedure (#1043) titled "Observation Level & Precaution Protocol" and dated 07/17/19 reflected "patient precautions and monitors will be ordered by the physician and initiated by the registered nurse (RN)....patient precautions for monitoring include, but are not limited to, safety...sexually acting out (SAO) ...the purpose of precaution monitoring is to provide protection to the patient and to maintain a safe and therapeutic patient care environment ...specific precautions ...shall be documented in the patient's medical record..." (p.1). The procedure called for "staff making rounds shall observe patients' activity, behavior, whereabouts, and document observations as indicated ...concerns for patient safety and/or risk shall be reported immediately to the nurse..." (p.2).