HospitalInspections.org

Based on document review and interview, facility failed to keep a patient free from abuse in one instance (patient # 6) and failed to reassess and change observation status in one instance (patient #3).

The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review and interview, facility failed to keep a patient free from abuse in one instance (Patient # 6) and failed to reassess and change observation status in one instance (patient #3).

Findings include:

1. Facility policy titled, Patient Rights and Responsibilities, PolicyStat ID 13517670, indicated on page 3, under PROCEDURE, have right to; 18. Receive care in a safe setting, free from verbal or physical abuse or harassment, Last revised 9/2021.

2. Review of Patient # 3's MR (medical record) indicated the following:
(a). Patient # 3; 21 y/o admitted to APH # 40 on 4/23/2025 to 300 unit (room # 305, then to room 308 on 4/25/2025, to room 303 on 5/10/2025), with diagnoses: Bipolar & Unspecified psychosis.
(b). Provider admission orders included, but not limited to: Activity level: up Ad lib (up as desired), Precautions: suicide, assault, elopement, Observation level: every 15 minutes.
(c). Nurse note on 5/12/2025 at 12:00 am, reflected patient was in milieu at beginning of shift. Patient was listening to music, while hanging out with other patients. Patient asked to call family. Patient took meds (medications) then went by TV (television) to watch TV. Patient was found in a resident room by staff. Patient and another female/male patient were asked what they were doing. Patient said they had sex and it was consensual. Staff took patient to his/her room. NP and supervisor were called. Patient refused and said he/she did not rape another patient.
(d) MR documentation lacked a reassessment after the event and lacked increase by provider(s) for an appropriate patient's observation status to a Level II (every 5 minutes) or Level III (1:1 Observation); related to patient # 3's inappropriate sexual behavior towards another patient (Patient # 6).

3. Review of Patient # 6's MR (Medical Record) indicated the following:
(a). Patient # 6 admitted on 5/6/2025; with diagnoses: Bipolar Disorder.
(b). Nurse note on 5/11/2025 at 11:00 pm, reflected patient was at milieu hanging out with staff and other patients at the beginning of the shift. Patient took her/his meds (medications) then went to hang out by the TV (television). Patient came to talk to nurse at nursing station, saying another patient (Patient #3) had raped her/him.

4. Review of Incident/event on 5/11/2025 on 300 unit at 10:00 pm for inappropriate behaviors for patient # 3 and patient # 6, in patient # 6's room (the bathroom).
a. BHA (Behavioral Health Associate -S # 2) found patient # 3 and patient # 6 in bathroom - Room # 306.
b. Patient # 6 was laying on floor, back in shower. BHA turned on light and took patient # 3 out of room.
c. Patient # 6 sent to hospital to get assessed for rape.

5. In interview on 5/15/2025 at approximately 4:15 pm, with S # 2 (Behavioral Health Associate), confirmed the following: When making rounds found patients (# 3 & # 6) in patient # 6's room; after started looking for patient # 3; because he/she was not in his/her room or in the milieu. Found patient in patient # 6's bathroom.

Based on document review and interview, the facility failed to ensure the patient care units were adequately staffed to provide nursing care to all patients as needed on one patient care unit. (300 unit).

Findings include:

1. Facility policy titled: Clinical Staff (Nurse) Staffing Plan, no policy number, indicated on page one (1) - Section - Purpose - This policy is to establish guidelines for providing sufficient numbers and mix of staff necessary to provide multidisciplinary patient care that is consistent with the assessed needs of the population served. Last revised 09/2024.

2. The facility Staffing Grid by shift, indicated nurses work a twelve (12) hour shift and BHA's (Behavioral Health Associate) work eight (8) hour shifts. For 2nd shift - 3:00 pm to 11:30 pm; for census of 14 or 15 patients; required staff for 2nd shift: 1 RN (Registered Nurse), 1 LPN (Licensed Practical Nurse)/RN, 2 BHA's.

3. Review of staffing plan/data for 5/11/2025, indicated the following:
On second shift staffing for 15 patients, with one patient needing a 1:1 required the following staff: 2 RNs and 3 BHAs
a. On second shift - staff that worked: 2 RN's (1 RN after 7:30 pm) and 2 BHAs; with 1 of the 2 BHAs assigned to a 1:1 observation.
b. 1 BHA left for other remaining 14 patients on unit. Unit lacked 1 BHA.

4. In interview on 5/16/2025 at approximately 1:40 pm, with A # 1 (Director Quality & Risk), confirmed/
verified staffing on 5/11/2025 for 2nd shift; with 2 BHAs. One of the BHAs was on a 1:1. Staffing grid for 2 BHAs for 15 patients, and 2 BHAs for 14 patients.

Based on document review and interview, nursing services failed to increase observation level or obtain order from provider, due to inappropriate sexual behavior in 1 instance (Patient # 3).

Findings include:

1. Facility policy titled: Patient Observation, Policy Stat ID 12931622, indicated on page 1, under POLICY: patients will continue to be assessed and monitored during their treatment to ensure observation levels are appropriate, and under PROCEDURE: 2. observation levels can be increased or decreased by a provider's order. Last revised 10/2024.

2. Review of Patient # 6's MR (Medical Record) indicated the following:
(a). Patient # 6 admitted on 5/6/2025; with diagnoses: Bipolar Disorder.
(b). Nurse note on 5/11/2025 at 11:00 pm, reflected patient was at milieu hanging out with staff and other patients at the beginning of the shift. Patient took her/his meds (medications) then went to hang out by the TV (television). Patient came to talk to nurse at nursing station, saying another patient (Patient #3) had raped her/him.

3. Review of Patient # 3's MR (medical record) indicated the following:
(a). Patient # 3; 21 y/o admitted to APH # 40 on 4/23/2025 to 300 unit (room # 305, then to room 308 on 4/25/2025, to room 303 on 5/10/2025), with diagnoses: Bipolar & Unspecified psychosis.
(b). Provider admission orders included, but not limited to: Activity level: up Ad lib (up as desired), Precautions: suicide, assault, elopement, Observation level: every 15 minutes.
(c). Nurse note on 5/12/2025 at 12:00 am, reflected patient was in milieu at beginning of shift. Patient was listening to music, while hanging out with other patients. Patient asked to call family. Patient took meds (medications) then went by TV (television) to watch TV. Patient was found in a resident room by staff. Patient and another female/male patient were asked what they were doing. Patient said they had sex and it was consensual. Staff took patient to his/her room. NP and supervisor were called. Patient refused and said he/she did not rape another patient.
(d) MR documentation lacked a reassessment after the event and lacked increase by provider(s) for an appropriate patient's observation status to a Level II (every 5 minutes) or Level III (1:1 Observation); related to patient # 3's inappropriate sexual behavior towards another patient (Patient # 6).

4. Review of Incident/event on 5/11/2025 on 300 unit at 10:00 pm for inappropriate behaviors for patient # 3 and patient # 6, in patient # 6's room (the bathroom).
a. BHA (Behavioral Health Associate -S # 2) found patient # 3 and patient # 6 in bathroom - Room # 306.
b. Patient # 6 was laying on floor, back in shower. BHA turned on light and took patient # 3 out of room.
c. Patient # 6 sent to hospital to get assessed for rape.

5. In interview on 5/15/2025 at approximately 11:50 am, with A # 1 (Director Quality & Risk), confirmed that Patient # 3 was not put on 1:1 or q (every) 5 minute checks after incident; not ordered by provider or initiated by nursing.