HospitalInspections.org

During Record Review, Interview and Observation, the hospital failed 4 of 4 Patients, (Patient #1, #2, #3, #4), the right to receive care in a safe setting by allowing Patients #1 and #2 to engage in inapropriate sexual activity intercourse. As well as Patient #3 and Patient #4 to participate in inapropriate sexual activity intercourse.

Findings Include:

During Record Review the hospital Standardized Intake Assessment, on 08/05/2024 3:01PM, revealed, "Patient #1 presents reporting active SI, does not disclose his plan, CAH to kill self, visual hallucinations of brother and 'rainbow people' chasing Patient #1. Patient #1 is extremely paranoid. Delusional, sexually inappropriate by making lewd comments and exposing himself. Patient #1 reports using oxycodone he got from lady at a park last night."

During Record Review Patient #1 was placed on Q15 minute observations.

During Interview with Hospital Staff #3, the hospital had not completed all assessments and Patient #1 was moved on from Intake to PICU.

During Observation of video footage Patient #1 was observed entering Patient #2's assigned room at 5:38PM and exits Patient #2's room at 5:43PM.

During Observations of video footage Patient #2 was observed in her assigned room seated on her bed by MHT at 5:40PM but the MHT failed to observe the entire enviornment and did not enter the room. Patient #1 was in Patient #2's bathroom.

During Record Review in the hospital Daily Nursing Notes 07/22/2024 , at 11:00AM House Supervisor reported that Patient #3 claimed to have had sexual misconduct with another peer (Patient #4) on 07/19/2024.

During Interview Staff #3 was asked if this incident was reported to the department. Staff #3 responded thatt these Patients #3 and Patient #4 consented to inappropriate sexual behavior. Staff #3 indicated that corporate officals have informed them not report incidents of consensual agreement.

During Record Review Patient #3 the hospital nursing notes on 07/21/2024 at 10:00AM was observed at 11:30PM, Patient #3 was observed by MHT kissing another Patient #4. Patients #3, and #4 were immediately separated and were given expectation over boundaries.

During Record Review in the hospital Psychiatric Nursing Notes 07/20/2024 at 3:00PM, At 11:00PM Patient#3 was found to have a personal cell phone and vape device in his possession.

During Record Review of Patient #4's medical record and Psychiatric Physician Progress Note 07/21/2024, staff found Patient #4 kissing a peer (Patient #3).

During Record Review of Patient #4's medical record the hospital Psychiatric Nursing Notes 07/22/2024, "Therapist reported that Patient had sex with another patient she did not deny it and refused to press charges.

During Record Review the hospital Incident Reports were review;
1. Patient #3 engaging in Sexual Boundary Verbal/Physical non Aggressive Breach. Involving female Patient #4 on
07/21/2024.
2. On 07/19/2024, involving Patient #4 Sexual Intercourse.
3. On 07/20/2024, Contraband, found/Used other (vape, cellphone)

During Interivew with hospital Staff #4 it was reported that these two patient (3, and 4) consented to having sex and both wanted it to happen. Patient #4 indicated wanting it to happen and allowed it to. When Staff #4 interiviewed Patient #4 it was reported by Patient #4 insisted she wanted to have sex with Patient #3. Indicated not wanting to press charges against the patient. Staff #4 indicated that there were no prior incidents reported on behalf of Patient #4 or boundary violations

During Itnerview with Staff #4 it was reported that the incidents with Patient #3 and Patietn #4 actually occurred on 07/20/2024. but it was reported that the incident took place on 07/19/2024.

During Timeline video footage review on 07/20/2024 at 7:24 PM Patient #3 enters Patient #4's room, Patient #3 still in the room MHT does not see him when rounding. At 7:27 PM Patient #3 EXIT's Patient #4's room while MHT is in room across
hall rounding

Policy

The hospital Policy on Patient Rights 11/2021 reflected, "It is the policy of Millwood Hospital and Excel Centers to ensure that all patients receive a copy of the Patient handbook, which includes the Patient Bill of Rights as well as an oral explanation of those rights both in their primary language and in simple non-technical terms. We will strive to abide by and respect all patient rights without regard to race, religion, creed ethnicity, gender, age, sexual orientation or handicap. Millwood Hospital and Excel Centers shall support and protect the fundamental human, civil constitutional and statutory rights of the individual patient and recognize and respect personal dignity of the patient at all times.

The hospital Policy on Abuse, Neglect 08/2023, reflected, "It is the Policy of Millwood hospital to report all incidents of patient abuse, neglect, and exploitation as soon as possible after the time the incident is identified."

The hospital Policy on Nursing Service 12/2022, "IT is the policy of Millwood Hospital to ensure that the appropriate numbers of qualifications of nursing staff are available at all times for the care of patients. The Chief Nursing Officer is responsible for the development and ongoing review of staffing requirements based on numbers of patients, population served, acuity and measurements of patient outcomes that include patient falls, restraint/seclusion, medication errors, infection rates, patient complaints and grievances as well as other types of incident occurrences. The staffing plan for Nursing Services is designed to comply with all applicable regulatory standards and reviewed annually.'

The hospital Policy Assessment of Safety Risk Factors/Patient Precautions Preventions, 05/2023 reflected, "On admission to all levels of care, Millwood Hospital screens patients for history of sexual aggression and/or victimization history/behaviors. Patients who have a history of sexual aggression or who are exhibiting sexually aggressive behaviors will be placed on an appropriate observation level and unit precautions to provide safe, therapeutic environment. The admission clinician is responsible for completing the initial risk assessment regarding sexual aggression/victimization and documenting it on the admission assessment screen. The physician and nurse place the patient on the appropriate precaution and observation level. Patients should be educated regarding their responsibility to report verbal or physical sexual threats, abuse and the consequences of prohibited behavior on the unit. Patients at risk for sexual victimization should be evaluated for level of functioning and need for addition protection, i.e., developmentally disabled sedated, post-ECT, or medically compromised patients."

The hospital Policy Patient and Visitor Search and Contraband Policy 11/2023, reflected, "Millwood Hospital is committed to the Provisions of a safe environment for all Patients, visitors and staff by preventing the entry of dangerous items on patient care units.