HospitalInspections.org

Based on the scope and severity of deficiencies related to Patient Rights, the facility failed to substantially comply with this condition.

The findings include:

Based on interviews and document review, it was determined the facility staff failed to:

provide proper monitoring of a patient on sexual aggression precautions,

protect a patient alleging sexual assault by not preventing contact with the alleged perpetrator, and

report an allegation of sexual assault to Child Protective Services and Law Enforcement as per facility policy and mandated reporting requirements. See tag A-0145

Based on interviews and document review, it was determined physicians failed to authenticate verbal orders within twenty-four (24) hours as per facility policy for four (4) of five (5) restraint records reviewed. See tag A-0168

An Immediate jeopardy (IJ) was identified on 6/28/2023 at 2:57 p.m.

The immediate interventions implemented by the facility to remove the IJ included staff training on investigation of abuse or neglect, transfer of the affected patient to another unit, reporting of the allegation to Child Protective Services. Additionally, the Facility Risk Manager will review each patient allegation received daily to ensure policy adherence and verify timeliness of reporting abuse or neglect allegations as required. see tag A-0145

The surveyors confirmed during on-site visit that the corrective actions were implemented as documented above and the immediate jeopardy was removed on 6/29/2023 at 4:01 p.m.

Based on interviews and document review, it was determined the facility staff failed to:

provide proper monitoring of a patient on sexual aggression precautions,

protect a patient alleging sexual assault by not preventing contact with the alleged perpetrator, and

report an allegation of sexual assault to Child Protective Services and Law Enforcement as per facility policy and mandated reporting requirements.

The findings included:

On 06/26/23, the surveyor reviewed the Nursing Supervisor Report from 6/14/2023 which contained evidence that Patient #3 (P3) reported to the night shift nurse that Patient #4 (P4) "pushed" P3 into P4's room and "humped" P3. P3 attempted to push P4 off but couldn't.

A review of the statement written by Staff Member #3 (SM3) then signed by P3 from 6/15/2023 at 6:20 p.m., indicated that P3 was pushed in the room by P4 then P4 "put a sock in my mouth and I couldn't scream or anything. [P4] pushed me on the bed and humped me for a long time. [P4] was hold [sic] my hands behind my back and when I finally broke my hands free and got away from [P4] and took the sock out of my mouth. I left the room, and I did not feel comfortable telling staff and nurse because they were both new and I don't know them, so I told the nighttime nurse."

On 6/27/2023 at 11:28 a.m., the surveyor reviewed the video footage from unit 6A on 6/14/2023 capturing from 6:10 p.m. through 8:03 p.m. The surveyor observed that Patient #3 (P3) and Patient #4 (P4) were in P4's room between that time from with the door closed and both patients out of camera view for at least sixty (60) seconds on two (2) instances and for ninety-four (94) seconds during another instance in which the door was completely closed for eighty-five (85) seconds of that time. The patients were observed in the bathroom together at the same time for over four (4) minutes.

In an interview on 6/28/2023 around 11:30 a.m., SM8 stated that Patient #4 is currently on sexual aggression precautions (SAP) and sexual victimization precautions (SVP). SM8 explained that patients are usually on SVP because "something happened to them" and on SAP "if they make certain comments, touch inappropriately or have a history. Patients on SAP are heavily watched around other people and can't be in the bathroom with other people." SM8 reported that Patient #4 has been on SAP since before June 2023.

During an interview on 6/29/2023 at 12:00 p.m., SM13 stated that the patients are not allowed in the bedrooms together and did not recall seeing P3 and P4 in a room together or with the door closed. SM13 stated that SAP means that the patient remains "in the line of sight at all times, especially when another peer is around ... not touching at all on that unit ... the patient can only be in the bathroom by themselves." SM13 stated there is a flow sheet for each patient that lets staff know which patients are on any precautions like SAP or SVP.

A review of the Medical Progress Note for P4 from 6/15/2023 contained evidence of ongoing concerns about boundary issues and that P4 remained on sexual victimization (SVP) and sexual aggression precautions (SAP).

A review of the medical record for P3 contained no evidence of addressing the incident with P3 and P4 in the two (2) "therapy" notes, two "psychotherapy" notes, nursing documentation, and "treatment plan update" following the event and prior to surveyor arrival.

A review of the Medical Progress Note for P3 from 6/28/2023 contained evidence of an addendum added on 6/28/2023 "... Due to a report [the patient] provided to VDH, patient was moved to another unit on 6/28/23. CPS was notified of the allegations by the person receiving the report." This note indicated the actions taken after surveyors discovered that P3 and P4 were not separated after the P3 reported the allegations of sexual assault by P4 to facility staff.

There was no documentation or notification to the surveyor that law enforcement was notified of the sexual assault allegation by P3, as per the facility's policy. There was no documentation of the incident in the facility's incident report log from 1/1/2023 through 6/26/2023.

During an interview on 6/27/2023 at 2:19 p.m., SM1 confirmed that there was not a note in P3's medical record from the nursing staff related to the alleged incident, nor was the alleged incident addressed in any of the psychotherapy notes for P3 or P4.

During a telephone interview on 6/27/2023 at 4:08 p.m., SM6 stated that around 9:30 p.m. or 9:45 p.m. on 6/14/2023, P3 mentioned the incident to SM6 and SM6 notified the supervisor. SM6 explained that the patient's rooms did not get moved that night as they were asleep or prior to SM6 leaving in the morning, around 7:30 a.m.

During a telephone interview on 6/27/2023 at 4:15 p.m., SM7 stated that P3 came to the nurse's station and told the nurse later that night about the incident. SM7 stated that the nurse brought the patient into the room and spoke with the patient. SM7 stated that when SM7 worked the next night, P4 had been moved to a room near the front of the unit, away from P3's room on the same unit. SM7 stated that SM7 did not document anything in the medical records about the incident and assumed the nurse would document it.

On 6/28/2023 at 10:05 a.m., the surveyor contacted the county's Department of Social Services (DSS) and reported to the social worker (SW) the allegation made by P3 on 6/27/2023 as the facility failed to report the incident.

During an interview on 6/29/2023 at 2:43 p.m., SM16 stated that behavioral technicians on Unit 6A and Unit 2 report to SM16. SM16 stated that "we are all mandated reporters." SM16 recalled that after the alleged incident with P3 and P4, one of the residents was moved to a different room on the same unit.

During an interview on 6/29/2023 at 3:08 p.m., SM3 stated that anyone that has access to the facility's incident reporting system can report an incident, but it's just the nurses and nursing supervisors that have access, not the BTs. SM3 stated that SM3, the Director of Risk Management, just got access to the incident reporting system that day.

During an interview on 6/29/2023 at 4:10 p.m., SM1 confirmed that the Facility's Policy on Sexual Aggression [SAP]/Sexual Victimization Precautions [SVP] clearly states that if a Patient is on SAP, they are not to be in a bathroom with another patient for any reason.

A review of the facility's policy titled "...Policy on Sexual Aggression/Sexual Victimization Precautions" dated 05/2023 states in part:

"Purpose:
10. Patients on Sexual Aggression or Sexual Victimization Precautions may not have their bedroom doors closed.
11. Patients on Sexual Aggression or Sexual Victimization Precautions may not be in the bathroom with other patients, even when accompanied by staff ..."

A review of the facility's policy titled "...Policy on Investigating and Reporting Patient/Resident Abuse or Neglect" dated 04/2023 states in part:

" ... All [Facility] staff will be considered mandated reporters and are required to immediately report any allegation or suspicion of abuse or neglect... Protect:5. Patients will be protected during investigation of all allegations or suspicions of abuse, neglect and/or harassment... If the allegation of abuse is patient to patient or resident to resident, steps will be taken to ensure there is no contact between the two patients."

The above noted findings were disclosed to SM1, SM2 and SM18 at the time of discovery and again at the time of exit conference on 6/29/23.

Based on interviews and document review, it was determined physicians failed to authenticate verbal orders within twenty-four (24) hours as per facility policy for four (4) of five (5) restraint records reviewed.

Findings:

On 6/26/2023, the surveyor reviewed three (3) seclusion/restraint records for Patient #1 and two (2) seclusion/restraint records for Patient #3.

Restraint/seclusion records for Patient #1 contained documentation that the verbal order was received at 6:05 p.m. on 6/15/2023 and the order was signed/authenticated by the practitioner on 6/21/2023 at 11:45 (a.m./p.m. not documented), more than twenty-four (24) hours after the order was given.

Restraint/seclusion records for Patient #1 contained documentation that the verbal order was received at 9:32 p.m. on 6/15/2023 and the order was signed/authenticated by the practitioner on 6/17/2023 at 9:30 a.m., more than twenty-four (24) hours after the order was given.

Restraint/seclusion records for Patient #3 contained documentation that the verbal order was received at 7:25 p.m. on 3/24/2023 and the order was signed/authenticated by the practitioner on 3/26/2023 at 10:30 a.m., more than twenty-four (24) hours after the order was given.

Restraint/seclusion records for Patient #3 contained documentation that the verbal order was received at 6:46 p.m. on 4/21/2023 and the order was signed/authenticated by the practitioner on 5/2/2023 at 2:00 p.m., more than twenty-four (24) hours after the order was given.

During an interview on 6/27/2023 at 10:41 a.m. SM1 stated that although the "[Facility] Nursing Services Policy and Procedure on Telephone Orders" states that "Telephone orders must be dated, timed and countersigned within 72 hours by the ordering MD/LIP or their designee..." The facility follows the "[Facility] Policy on Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" policy that states that "the physician shall authenticate the telephone/verbal order within 24 hours..." SM1 stated that they would update the "[Facility] Nursing Services Policy and Procedure on Telephone Orders" policy to address telephone orders for seclusion and restraints. Later that day SM1 provided the surveyor with an updated "[Facility] Nursing Services Policy and Procedure on Telephone Orders" that included the information that "Orders for seclusion or restraint will be authenticated by the provider within 24 hours."

A review of the facility's policy titled "[Facility] Policy on Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" dated 03/2023 states in part:

"... 3.1.4 The physician shall authenticate the telephone/verbal order within [twenty-four] 24 hours..."

The above concerns were discussed with SM1, SM2, and SM18 at the exit conference on 6/29/2023 at 4:23 p.m.

Based on interviews and documentation review, it was determined the facility staff failed to document two (2) sexual assault allegations into the facility's incident reporting system.

Findings:

On 06/26/23, the surveyor reviewed the Nursing Supervisor Report from 6/14/2023 which contained evidence that Patient #3 (P3) reported to the night shift nurse that Patient #4 (P4) "pushed" P3 into P4's room and "humped" P3. P3 attempted to push P4 off but couldn't.

A surveyor review of documentation provided by SM1 on 6/26/2023 contained the following documentation. An email from 6/20/2023 at 6:10 p.m. read, "[Patient #1] on 6A just reported that a previous patient, [Patient #2] reported to [Patient #1] that [Patient #2's] therapist, [SM4], told [Patient #2] that [SM4] wanted to engage in sexual acts with [Patient #2]. [Patient #1] denied knowing when this occurred and denied knowing when [Patient #2] reported it to [Patient #1]. [Patient #1] stated [Patient #2] was depressed after sessions because of this."

A review of the facility's incident reporting system from 1/1/2023 through 6/26/2023 on 6/26/2023 found no evidence of documentation of the allegations related to Patient #2 and SM #4 and the sexual assault allegations related to Patient #3 and Patient #4.

On 6/28/2023 at 2:45 p.m., the surveyor received a one (1) page incident report of two (2) incidents that were not documented in the incident log provided to the surveyor on the first day of the survey, 6/26/2023. One incident, documented on 6/27/2023, was related to Patient #3 and noted that Patient #3 alleged that Patient #3 was "humped" by Patient #4 and both patients were clothed, with an incident date of 6/14/2023. The other incident, documented on 6/28/2023 was related to Patient #4 where Patient #3 alleged that Patient #3 was "humped" by Patient #4 and both patients were clothed. This incident report document did not include the allegation related to Patient #2 and SM #4.

On 6/29/2029, SM1 provided the surveyors with a newly printed incident report document. The surveyors were unable to locate allegation related to Patient #2 and SM4 in the new report. SM1 confirmed that they could not find this allegation in the new incident report log.

During an interview on 6/29/2023 at 3:30 p.m., SM1 confirmed that there was no evidence that the allegation from Patient #1 about SM4 was documented in the MIDAS incident reporting system.

A review of the facility's policy titled "Hospital Policy on Incident Reporting System (HPR)" dated 10/2020 states in part:

"... Purpose: ... 4. To ensure prompt reporting of serious injuries.... 5. The Healthcare Peer Review (HPR) Reporting (Incident Reporting) System is the Risk Management function of [the facility's] Peer Review Process... Definitions: ... Serious Injuries/Events constitute any of the following outcomes as a result of healthcare intervention but may not be limited to this list: ... n. Sexual involvement. o. Sexual/criminal assault ... Procedure:
18. Any facility employee or staff member who discovers, is directly involved in or is responding to an event/incident is to complete or direct the completion of a Healthcare Peer Review (HPR) incident report into MIDAS, by RDE.
a. This report is to be entered through RDE into the MIDAS system, prior to the end of the staff members scheduled shift."

Based on interviews, and document review, it was determined the facility's nursing staff failed to document an allegation of sexual assault into the medical record of one (1) of two (2) patients with sexual assault allegations (Patient #3).

Findings included:

On 06/26/23, the surveyor reviewed the Nursing Supervisor Report from 6/14/2023 which contained evidence that Patient #3 (P3) reported to the night shift nurse that Patient #4 (P4) "pushed" P3 into P4's room and "humped" P3. P3 attempted to push P4 off but couldn't.

A surveyor review of the statement written by SM3 then signed by P3 from 6/15/2023 at 6:20 p.m., contained evidence that P3 was pushed in the room by P4 then P4 "put a sock in my mouth and I couldn't scream or anything. [P4] pushed me on the bed and humped me for a long time. [P4] was hold [sic] my hands behind my back and when I finally broke my hands free and got away from [P4] and took the sock out of my mouth. I left the room, and I did not feel comfortable telling staff and nurse because they were both new and I don't know them, so I told the nighttime nurse."

A review of the medical record for Patient #3 from 6/14/2023 and 6/15/2023 contained no documented evidence of the allegation made by Patient #3 on 6/14/2023 to nursing staff.

During a telephone interview on 6/27/2023 at 4:15 p.m., SM7 stated that SM7 did not document anything in the medical records about the incident and assumed the nurse would document it.

During an interview on 6/27/2023 at 2:19 p.m., SM1 confirmed that there was not a note in Patient #3's medical record from the nursing staff related to the alleged incident.

A photocopy of nursing documentation received on 6/29/2023 for Patient #3 from 6/14/2023 contained a "Late Entry" by SM6 documented on 6/28/2023 at 10:22 p.m. that stated, "While sitting in pt's room at bed time pt told me peer pushed [Patient #3] in peer's room and "humped [Patient #3]." When asked if they had clothes on pt quickly responded "yes." I asked pt why didn't [Patient #3] push [the peer] away and pt stated "[the peer] weighs more than me." Pt was asked why [Patient #3] didn't yell out and [Patient #3] shrugged [Patient #3's] shoulders. Pt then jumped in bed and went to sleep. NSG [nursing] supervisor notified."

A photocopy of the nursing documentation received on 6/29/2023 for Patient #3 from 6/15/2023 contained a "Late Entry" by SM16 documented on 6/29/2023 at 1:34 p.m. that stated "Be advised that this late entry is to document that [Patient #3's parent] was notified of the allegation of sexual assault that [Patient #3] made on a pt. assigned to [Patient #3's] unit on 6/14/2023. I was notified the morning of 6/15/2023 and called during the middle portion of the day to notify [the parent]. [The parent] was happy we communicated with [the parent] and stated, '[Patient #3] has a history of making false accusations while in public school.' End of statement.'"

A review of the facility's policy titled "Hospital Policy on Incident Reporting System (HPR)" dated 10/2020 states in part:

"...20. Completing the HPR/Incident Report:
a. The HPR is to be completed as [sic] the time of event.

e. The event is documented in the medical record by the person most closely associated with the event and includes:
1) A concise statement of the facts of the event, statements are non-judgmental and objective.
2: Clinical condition of patient (as a result of immediate examination by physician if indicated).
3) Names, times or notification of physician, supervisory personnel, family members as necessary."