HospitalInspections.org

The facility failed to meet the Condition of Participation when it failed to ensure the safety of patients and staff; the facility failed to develop, train staff, and implement a policy for the safe management of patients demonstrating sexually acting behaviors and did not include a patient's cognitive capacity to be safely treated in the facility; these failures placed patients at risk of unwanted sexual harassment and possible assault and murder.

Cross Refer: A0145, A1640

Based on observation, interview, and record review the facility failed to protect the safety of a female patient (Patient #1) admitted with diagnoses of Autistic and Intellectual Developmental Disability (IDD), who was not identified as having a potential for victimization and interventions were not put in place to protect her; she was, allegedly, raped by a male patient, who was admitted with a risk of harming others.

Findings include:

Review of Patient #1's Preadmission Evaluation and Medical Clearance Screening reflected a 24-year-old-female admitted on 11/12/22 with a chief complaint of Homicidal Ideation, she was threatening to kill her sister, and had made a previous attempt. Patient #1 has a past medical history of Seizure, Autism, IDD, and Post traumatic stress disorder (PTSD).

During a telephone interview, on the morning of 11/17/22, Patient #1's mother stated, "The doctor told me Patient #1 has the mentality of a 5-year-old. She went to special education and graduated through them; she can't read. She has PTSD from being raped three years ago. She went there to get help; I don't think she is going to get over this. She asked me, 'Why do people do this to me?'"

Review of Patient #1's medical records revealed, in the first 72 hours, the facility did not inquire why Patient #1 had PTSD; she had been raped 3-years prior. Patient #1 was vulnerable and required the facility to keep her safe from others.

Review of Patient #1's treatment plan reflected a risk for violence. The treatment plan's liabilities and special needs did not reflect the patient's Autism and IDD.

Review of the Patient #1's Multidisciplinary note dated 11/13/22 at 11:20 pm reflected, "Patient reports having been assaulted by another patient. Attempting to notify administration."

During an interview on the morning of 11/16/22, in the admission office, Staff #1, Vice President of Operations stated in part, "Patient #1 said she was assaulted. We reviewed the video; Patient #2 can be seen looking down the hall before entering Patient #1's room ...the police arrested Patient #2."

Review of Patient #2's physician initial assessment, dated 11/12/22, electronically signed at 12:52 pm reflected, "This patient is a 61 y/o (year old) male that presents to Oceans voluntarily from [an Acute Care Hospital] with psychosis and homicidal ideations. He is delusional and paranoid and believes that the Mexican mafia is after him. He is guarded and suspicious. Very anxious and restless. Fidgety. His affect is worrisome ... He is volatile and labile. Impulsive and unpredictable. He is irrational and on the edge. His thoughts are bizarre and disorganized ...He lacks insight and judgment is poor ...He is unstable and at risk of harm to self and others ..."

Patient #2's Treatment Plan Included Prevention of injury to others, Prevention of injury to self.

Review of Patient #2's Multidisciplinary Treatment plan dated 11/11/22, included Problem #3 Risk of Violence. The interventions included: Increase security throughout duration of stay, assess potential for violence and past history as needed, maintain person space during patient encounters daily.

Review of Patient #2's ADMIT NURSING ASSESSMENT, dated 11/11/22 at 4:05 pm, reflected,
"Are there any medical conditions, history of abuse, psychological/sexual trauma or disabilities that would increase the risk of injury if S&R (seclusion & restraint) is used? Yes
If yes, explain: Sexual.
HOMICIDE/VIOLENCE RISK SCREEN
A. Risk factors:
"Male, History of incarceration, has 2 symptoms of loss of reality, delusional beliefs, command hallucinations, feeling of being out of control, paranoia, poor impulse control, mania"
Moderate Risk had been circled; interventions included: implement q (every) 15-minute observation, assign patient to room closest to Nurses station and with roommate; Implement Risk of Violence treatment plan; monitor for changes in status.

Review of Patient #2's Multi-Disciplinary Notes reflected the following:
*11/11/22 at 4:55 pm reflected, " ...Pt is making sexual comments to intake staff, when redirected pt. told himself to 'shut up' and slapped his own face then stated 'see, I stopped ..."
*11/13/22 at 12:05 am, "Was adjusting covers of a female patient who was asleep in lobby and was asked not to touch her became irate at staff. Yelling cussing and threatening staff also slapping himself, unable to calm patient or redirect."
Patient #2's treatment plan was not updated to reflect these incidents and additional interventions were not put into place to ensure the safety of other patients.

This investigator asked multiple times to review the video footage for the incidents on 11/12/22 and 11/13/22, the facility did not provide the videos as requested.

The facility failed to provide individualized, comprehensive treatment plans based on an inventory of each patient's strengths and disabilities. This placed Patients #1, 8, and 10 at risk of unsafe or ineffective treatment and care.

Findings include:

Review of Patient #1's Preadmission Evaluation and Medical Clearance Screening reflected a 24-year-old-female admitted on 11/12/22 with a chief complaint of Homicidal Ideation, she was threatening to kill her sister, and had made a previous attempt. Patient #1 has a past medical history of Seizure, Autism, IDD, and Post traumatic stress disorder (PTSD).

During a telephone interview, on the morning of 11/17/22, Patient #1's mother stated, "The doctor told me Patient #1 has the mentality of a 5-year-old. She went to special education and graduated through them; she can't read. She has PTSD from being raped three years ago. She went there to get help; I don't think she is going to get over this. She asked me, 'Why do people do this to me?'"

Review of Patient #1's medical records revealed, in the first 72 hours, the facility did not inquire why Patient #1 had PTSD; she had been raped 3-years prior. Patient #1 was vulnerable and required the facility to keep her safe from others.

Review of the facility provided policy (number CS-02, Treatment Planning), last revised 4/01/21, reflected in part, "Policy:
The multi-disciplinary treatment team, under the direction and supervision of the attending physician, shall develop an integrated written, comprehensive Treatment Plan with specific goals and objectives necessary to address deficits and cultivate strengths identified in the assessment process. The Treatment Plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient's involvement, throughout the course of treatment. The treatment plan includes defined problems and needs, measurable goals and objectives based on assessed needs and identified by the patient, strengths and limits, frequency of care, treatment and services, facilitating factors and barriers, and transition criteria to lower levels of care."

Review of Patient #1's treatment plan did not include Patient #1's cognitive limitations, due to her diagnosis of Autism and IDD diagnoses.

Review of Patient # 8's medical record revealed he was admitted on 11/9/22 for Homicidal Ideation; Patient #8's treatment plan reflected Self-Harm, but did not include risk to others.

Review of Patient #10's medical record revealed she was admitted on 11/8/22 with a history and physical that stated in part, "...poses a risk of danger to herself and others. She is not stable." Patient #10's treatment plan reflected Self-Harm, but did not include risk to others.