HospitalInspections.org

Based on record review and interview the facility failed to implement procedures to investigate a sentinel event for one of one (#1) sexual assault grievances reviewed.

Policies: Patient Complaint and grievance Process #1000.09 dated 02/23/2022

Definitions:
Whenever the patient or the patient's represented to request his/her complaint who is a formal complaint form grievance, when the patient requests and responses from the hospital, then the complaint is a grievance, and all the requirements apply.

Procedure:
The patient advocate will conduct an investigation of the grievance, reviewing the patient's medical record, to obtain information regarding patients' clinical condition.

G. All verbal and written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements, are to be considered a grievance that requires immediate attention. The Patient Advocate will interview the patient and/or patient's representative for additional information as needed. The Patient Advocate if we'll also query other members of the healthcare team that have been involved in the care of the patient.

H. After thorough research has been conducted, the Patient Advocate will work in tandem with staff identified as key individuals critical to problem resolution for the specific identified concern. All efforts will be made to effectively and expeditiously resolve the patient's grievance. A complaint is considered resolved when the patient and satisfied with the actions taken on his/her behalf.

I. All grievances receive immediate priority and must be investigated with efforts made toward resolution within 24 hours. If a grievance cannot be resolved within 24 hours, the grievance will be referred as described below. This organization will make every attempt to make a response within seven (7) days of receiving a grievance.

1. If a grievance is not resolved, the investigation is not complete, or the corrective action is still being investigated within the seven (7) daytime frame, the hospital shall send a response to the patient stating the hospital continues to work to resolve the complaint and the hospital will follow-up with another response within seven (7) days.

J. The patient will be provided with written notice of:
1. The name of the Patient Advocate
2. The steps taken to investigate and resolve the grievance.
3. The final result of the complaint and grievance process.
4. The date of completion of the complaint and grievance process.

Patient (#A) was admitted 7/3/22 with diagnoses including depression and autism.
On 8/5/22 patient A first reported a sexual assault grievance that morning to the technicians at the activity and later that morning to her therapist. She reported during coed recreation in the facility gym, a male patient (#D) raped her by forcing her to perform fellatio. She reported staff were in the next room and not watching.

The facility therapist documented patient A's report of abuse to her in the note for therapy 10 am to 11 am 08/5/22. There was no documentation the therapist reported patient A's complaint after hearing it.

Patient A reported a second time via a written report of the alleged sexual assault 08/07/22 and indicating she had spoken to MHT #13 about it. 08/09/22 the patient advocate signed receipt of the written grievance. Patient A discharged home to her group home 08/08/22.

After discharge, patient A reported the alleged sexual assault to her group home administrator who filed a third grievance with the facility on 09/15/22.

On 09/16/22 after the fourth grievance was received the recreation technicians (#11 and 12) and MHTs (#13 and 14) assigned to the coed gym activity 08/05/22 made late written grievance reports. The documentation 09/16/22 for MHT's 13 and 14 state the incident and allegation of sexual assault was reported to the charge nurse on Patient A's unit and the house supervisor.

There was no documentation that the charge nurse (#8) or house supervisor (#7) acted on the reported assault allegation or forwarded it.

Staff reports indicated they did not directly observe the incident due to obstructed line of sight. They did see Patient A and B in a corner and patient A was crying and immediately reported the assault to them. Both patients were escorted to their respective units without incident.

Facility internal response to the grievance 09/23/22 was Satori Alternatives to Managing Physical Aggression (SAMA) training and de-escalation technique training for all staff involved.

Facility response to the patient #A 09/25/22, by staff # 15 Patient Advocate, stated "Camera review was conducted...we were able to observe what you described as well as the immediate nursing and therapy staff intervention." "Please understand you are within your rights to press charges against the individual that assaulted you." It also stated the facility would look for opportunities to improve its safe care to psychiatric patients. It finalized with an apology "for the negative components of your experience here and not meeting your expectations."

SAMA website www.houstonsamatraining.com states "The Study Guide for participants includes the principle of the program, a breakdown of skill in the Assisting Process, a breakdown of each physical skill, exercises to increase learning, and key concepts for safety when applying protection, containment, and object retrieval skills." "The program's primary intent was to minimize full client and employee injuries as well as reduce workers' compensation claims."

No aggression other than Patient 's allegation was indicated. No physical aggress was observed. No patient mood/behavior other than Patient A's tears which had no required intervention.

Review of patient #D's chart reviled he was placed on unit restriction upon return to the unit 08/05/22. There has been no report of allegations to the State or to the police. There was no evidence of cause analysis or future mitigation action plans.

During an interview 11/08/22 at 10:30 am (#1) Director of Risk Management stated there was film of the occurrence, but it was not saved. He stated neither he the Chief Nursing Officer or the Chief Executive Officer had seen the film. He stated he was on leave and the staff on duty did not follow through with investigation in his absence.

Interview 11/08/22 at 14:30 am #15 Patient Advocate stated she was new in her position and had no guidance in how to proceed with the grievance. She stated her supervisor was absent and key staff were unavailable, so she did her best not being sure of the process.