HospitalInspections.org

32820


Based on document review, observation and interview, it was determined that the Hospital failed to protect a patient (Pt. #1) from sexual abuse and failed to ensure a patient's right to privacy. This potentially placed 6 patients on the ED (Emergency Department) BMU (Behavioral Medicine Unit) at risk for serious emotional and psychological harm, as well as all other patients (unknown) who were assigned to or placed in rooms where cameras were videorecording.

As a result, it was determined that the Condition of Participation for Patient Rights, CFR 482.13, was not in compliance.

Findings include:

1. The Hospital failed to protect and promote a patient's right to be free from sexual abuse. See deficiency at A-145.

2. The Hospital failed to ensure patients' right to privacy. See deficiency at A-143.

An immediate jeopardy (IJ) began on 9/22/19, due to the Hospital's failure to protect a patient from sexual abuse, resulting in Pt #1 being sexually abused by Pt #2. The IJ was identified and announced on 12/5/19 at 11:00 AM, during a meeting with the President, Executive Vice President, Senior Vice President of Quality & Compliance and Senior Vice President of Patient Care. The IJ was not removed by the survey exit date of 12/9/19.

Another IJ began due to the Hospital's failure to ensure a psychiatric patient's right to privacy. This failure led to the invasion of Pt #1's privacy and all other assigned patients (unknown), by the use of cameras and vidotaping without consent. The IJ was identified and announced on 12/5/19 at 11:00 AM, during a meeting with the President, Executive Vice President, Senior Vice President of Quality & Compliance and Senior Vice President of Patient Care. The Immediate Jeopardy was removed by the survey exit date of 12/9/19 at 4:00 PM.

On 12/5/19, the Hospital presented their IJ Removal Plan that included:

1. "Actions taken: The camera has been removed from room (432) on 12/5/19. The only areas that will have cameras are the restraint rooms and hallways on 4 South, 4 Main and 4 East. This will ensure that the patient has ultimate privacy and will mitigate the potential for serious and psychological harm for all patients admitted to the BMU in the Hospital. The area where the cameras were has been capped over with metal plates and secured with tamper proof screws."

2. On 12/9/19 at 9:30 AM, an observational tour of the Emergency Department Behavior Medicine Unit was conducted. The two cameras were removed from the patient room.

3. On 12/9/19 at 9:35 AM, during the observational tour, an interview was cnducted with the Director of Quality (E #1). E #1 stated that the cameras were removed and metal plates were installed to cover the area where the cameras were located. E #1 stated that the cameras have been removed from the room (432) on 12/5/19. E #1 stated that the areas where the cameras were have been capped over with metal plates and secured with tamper proof screws. The only areas that will have cameras are the restraint rooms and hallways on 4 South, 4 Main and 4 East. This will ensure that the patient has privacy and will lessen the potential for psychological harm for patients admitted to the Behavioral Medicince Units (4 South, 4 Main and 4 East) in the Hospital.

Based on document review, observation and interview, it was determined that for 1 of 1 patient (Pt #1), the Hospital failed to ensure that the patient's right to privacy. This failure resulted in a live video recording of Pt #1 from 9/20/19 to 9/24/19 during the hospital stay in the ED (Emergency Department) BMU (Behavioral Medicine Unit).

Findings include:

1. On 12/4/19, the Hospital's policy titled, "Patient Rights" (reviewed 12/2017) was reviewed and required, "Jackson Park Hospital is committed to ensuring the preservation of the basic rights of all patients to maintain their independence, privacy, respect and to have access to knowledge for decision-making purposes concerning their health, and to maintain their personal dignity..."

2. On 12/4/19, the Hospital's policy titled, "Footage Review" policy (revised 10/18) indicated " ...Any reviewing of footage have to be approved by VP [Vice President] ..."

3. On 12/3/19, Pt #1's medical record was reviewed. Pt #1 was admitted on 9/20/19 for bipolar disorder ( a mental condition marked by alternating periods of elation and depression) and schizophrenia (a mental disorder involving a breakdown in relation between thought, emotion and behavior) to the Emergency Department BMU (Behavioral Medicine Unit). Pt #1's record lacked documentation regarding a consent for being recorded.

4. On 12/4/19 at 8:45 AM, the Hospital's video recording from Pt #1's room was reviewed in the presence of the Director of Public Safety. Pt #1 had a live video recording while she was a patient in 432-1 BMU ED from 9/20/19 to 9/24/19. The video recording which indicated the following:

-7:09:15 Pt. #2 entered Pt. #1's room (432-1). Pt #1 was lying in a prone position (on her stomach).
-7:10:10 Pt. #2 opened his gown and climbed on top of Pt. #1's back and put his hand around Pt. #1's mouth. Pt #2 struggled to hold Pt #1's right arm down.
-7:10:15 Pt. #1 struggled with Pt. #2 while Pt. #2 laid on top of Pt. #1.
-7:10:38 Staff ran down the hallway past Pt. #1's room while Pt. #1 and Pt. #2 continue to struggle on Pt. #1's bed.
-7:10:45 Two staff (one Registered Nurse/E #9 and one Nurse Technician/E #13) entered Pt. #1's bedroom.
-7:10:49 Pt. #2 jumped off of Pt. #1 and exited Pt. #1's room.

5. On 12/4/19 at 1:45 PM, an interview was conducted with the Director of Public Safety (E #12). E #12 stated that there are live camera recordings on each BHU - 4 East (male unit) has 4 cameras (2 restraint rooms each have 2 cameras), 4South (female unit) has 1 restraint room with 2 cameras and 4 Main-ED BHU has 2 cameras in a patient room (Pt #1) and 1 camera in the restraint room. E #12 stated that nurses at the nursing station view the live stream camera recording in patient rooms.

6. On 12/4/19 at 1:50 PM, an interview was conducted with the Vice President of Quality (E #1). E #1 stated that the live camera monitoring is used in patient rooms when the patients are in restraints. E #1 stated that she is not sure if the patients know they are being recorded. E #1 stated that the Hospital has been recording in the patient rooms since 2006. E #1 stated that the camera was left in Pt #1's room because the room used to be used as a restraint room.

Based on document review, observation, and interview it was determined that for 2 of 2 (Pt. #1 and Pt. #2) patient records reviewed for observational rounds, the Hospital failed to provide care in a safe setting by ensuring that staff performed observational rounds every 15 minutes.

Findings include:

1. On 12/3/19, the Hospital's policy titled, "Precautions" (revised by the Hospital October 2019) was reviewed and required, "precaution frequency of monitoring - close observation (CO) - every 15 minutes - assault precautions (AP)."

2. On 12/3/19, Pt. #1's clinical record was reviewed. Pt. #1 was admitted on 9/20/19 for bipolar disorder (a mental condition marked by alternating periods of elation and depression) and schizophrenia (a mental disorder involving a breakdown in relation between thought, emotion and behavior) to the Emergency Department BMU (Behavioral Medicine Unit for both male and female patients awaiting admission to gender separate BMU). Pt #1 was placed on every 15 minute checks for close observation precautions. The Physician's order dated 9/21/19 at 9:32 AM indicated, "Close Observation Precautions."

-The precaution and rounding sheet dated 9/22/19 lacked every 15 minute documentation from 8:15 AM - 8:45 AM, 11:15 AM - 11:45 AM, and 5:00 PM - 6:45 PM.

3. On 12/3/19, Pt. #2's clinical record was reviewed. Pt #2 was admitted on 9/21/19 for delusional disorder to the 4th floor Emergency Department BMU. Pt #2 was placed on close observation precautions (every 15 minute checks) on the 4th floor BMU.

-The Physician's order dated 9/22/19 at 6:13 AM included, "Close observation precautions." Another Physician order dated 9/22/19, included, "Assault precautions."

-The precaution and rounding sheet dated 9/22/19 lacked documentation of every 15 minute monitoring from 8:15 AM - 9:00 AM and 9:45 AM.

4. On 12/4/19 at approximately 10:45 AM, an interview was conducted with the Vice President of Patient Services (E#3). E #3 stated that patients on close observation should be monitored every 15 minutes and the documentation should be in the patient's clinical record.

Based on document review, observation and interview it was determined that for 1 of 2 (Pt. #1) patients, the Hospital failed to ensure the patient was free from sexual abuse. This potentially placed 6 patients on the ED (Emergency Department) BMU (Behavioral Medicine Unit at risk for serious harm.

Findings include:

1. On 12/3/19, the Hospital's incident report and investigation dated 9/22/19, was reviewed and indicated the following:

- Date of incident: 9/22/19

- Location of incident: 4M (4th floor Main/ED BMU)

- Pt. #1 stated, "I was lying in my room on my stomach when I was attacked by the only man on the unit. Why was he on the female unit? While I was laying there this guy comes in my room, covers my mouth and gets on top of me. He pulled his penis out and it was next to my butt. He did not penetrate me. I screamed and struggled until a staff person came in and then he stopped."

- "Nurse [E #9] stated, I was at the computer when Nurse Tech [technician] [E #13] and I [E#9] heard loud moaning coming from a patient's room (432-1). We ran down the hallway and witnessed [Pt. #2] on top of [Pt. #1] with his [Pt. #2] hand covering her mouth. [Pt. #1] yelled at [Pt. #2] to get off of her. [Pt. #2] then stated, 'I am sorry' and then [Pt. #2] left the room."

- "Nurse Tech [E #13] stated, I heard loud moaning coming from a patient's room (432 -1). I ran down the hallway and when I entered room 432-1, I witnessed the [Pt. #2] on top of [Pt. #1] with his [Pt. #1] over her [Pt. #2] mouth. [Pt. #2 then stated 'I am sorry' and then [Pt. #2 left [Pt. #1 room..."

-A statement written by the night Supervisor (E #11) dated 9/22/19, included, "Finally, I would like to express that beds were not denied to admitting from the 4S [Male Behavioral Medicine Unit]. The 6 psyche [Psychiatric] patient in the ER [Emergency Room] did not have orders for admission to the floor. I do not support this male patient [Pt. #2] being admitted to 4 main [ER Behavioral Medicine Unit] when there were 5 beds opened on 4S. That was a decision not supported in the interest of safety to those females on the unit."

2. On 12/3/19, Pt. #1's clinical record was reviewed. Pt. #1 was admitted on 9/20/19 for bipolar disorder (a mental condition marked by alternating periods of elation and depression) and schizophrenia (a mental disorder involving a breakdown in relation between thought, emotion and behavior) to the Emergency Department BMU (Behavioral Medicine Unit for both male and female patients awaiting admission to gender separate BMUs). Pt #1 was placed on every 15 minute checks for close observation precautions.

-The nursing progress note dated 9/22/19 at 10:52 AM, included, "Report recvd [received] from PM shift Pt [Pt. #1] involved in reportedly assault [by] male Pt [Pt. #2] on unit..."

-The Physician's progress note dated 9/22/19 at 10:27 AM [after sexual abuse incident] included "female brought down to the ER [Emergency Room] for evaluation from 4 Main..."

3. On 12/3/19, Pt. #2's clinical record was reviewed. Pt #2 was admitted on 9/21/19 for delusional disorder to the 4th floor Emergency Department BMU (mixed gender unit). Pt #2 was placed on close observation precautions (every 15 minute checks) on the 4th floor BMU.

-The Emergency Department final disposition on 9/21/19 at 7:30 AM included, "Admission: obs [observation] - Unit: Behavioral Male"

The Hospital failed to admit Pt #2 onto the BMU male unit, which would have prevented this incident.

-The nursing progress note dated 9/22/19 at 9:56 AM (after the incident), included, "report recvd [received] from PM shift Pt [Pt. #2] admitted to 4 south [Male Behavioral Medicine Unit] also Pt [Pt/ #2] found lying on top of female Pt [Pt. #1] by MA [Medical Assistant] nursing supervisor [E #11] on unit speaking with night shift. Pt [Pt. #2] has security monitoring Pt [Pt. #2] while waiting for bed assignment."

4. On 12/4/19 at 9:37 AM - 10:13 AM, videotape footage of the camera in room 432 and the hallway of 4M (Emergency Department Behavioral Medicine Unit/BMU) dated 9/22/19 was viewed with the Director of Public Safety (E #12) and indicated:

-7:09:15 Pt. #2 entered Pt. #1's room (432-1). Pt #1 was lying in prone position (on her stomach).
-7:10:10 Pt. #2 opened his gown and climbed on top of Pt. #1 and put his hand around Pt. #1's mouth.
-7:10:15 Pt. #1 struggled with Pt. #2 while Pt. #2 laid on top of Pt. #1. Pt #2 struggled to hold Pt #1's right arm down.
-7:10:38 Staff ran down the hallway past Pt. #1's room while Pt. #1 and Pt. #2 continued to struggle on Pt. #1's bed.
-7:10:45 Two staff (one Registered Nurse/E #9 and one Nurse Technician/E #13) entered Pt. #1's bedroom.
-7:10:49 Pt. #2 jumped off of Pt. #1 and exited Pt. #1's room.

5. On 12/4/19 at 10:56 AM, an interview was conducted with the Night Nursing Supervisor (E #11). E #11 stated that Pt. #2 should have been admitted to 4 south (male Behavioral Medicine Unit) after being assessed on 4 main (ED BMU), instead of to the 4th floor Emergency Department BMU (mixed gender unit).