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Based on observation, interview, and record review, the facility failed to ensure that patients received care in a safe setting in 5 out of 30 sampled patients (Patient #31, #28, #20, #2, and #3).

1) Patient #31, who was on suicide precautions, was not monitored for 36 minutes, while in his room. Patient #28, who was on transitional observation, was not monitored for 36 minutes, while in his room. Patient #20, who was on sexually acting out precautions, was not monitored for 30 minutes, while in her room.

2) Patient #2 was found to be sexually traumatized after claiming to be raped by Patient #3 the previous evening.

3) Patient #3 received a removal of his privileges to go off unit (green band removal), and was given back his privilege to smoke by nursing staff, without obtaining a physician's order for removal or return of privileges.

4) The facility's Root Cause Analysis of the alleged sexual assault incident identified the need for increased memory of the video camera equipment, which was not completed. There was no hospital policy available during the investigation regarding the use of video camera monitoring equipment.

The facility's failure impacted 5 patients and could have impacted all patients, who resided on the third floor short hallway, by increasing their risk of unsafe care related to staff not performing rounds appropriately and the lack of hospital policy/Governing Body direction related to preventing and identifying abuse through videotaped recordings and clarification of nursing roles in removing and restoring privileges.

Findings:

1) Patients #31, #28, and #20

Observation of video surveillance, on 4/17/13 at from 8pm to 10pm in the 3rd floor short hall, revealed at 8:22 pm, a psychiatric technician making rounds on each patient room before going to sit in the day room. At 8:45 pm, the same psychiatric technician was observed going back to the nursing station and taking out some patients to smoke. At 9:01 pm, the same psychiatric technician returns with the patients and begins handing out snacks and calling patients for medications. At 9:28 pm she is seen doing vital signs at the nursing station. At 9:30 pm, she is seen going to rooms 354 and then 353. At 9:36 pm she is seen going into room 357 with the vital signs machine. At 9:59 pm she is seen holding a clipboard and standing in the day area. Throughout the video, patients can be seen going in and out of rooms.

Observation of Patient Rounds, on 4/19/13 at from 10:25 am to 11:59 am in the facility 3rd floor short hallway, revealed numerous patients going into and out of their rooms. Rounds were being done by 3 psychiatric technicians; however they did not enter all of the rooms. From 11:15 pm to 11:40 pm psychiatric technicians were not observed in the hallways making rounds.

Review of Patient #31's Observational record, dated 4/17/13, revealed that he was on suicide precautions and in room 357. The record also indicated that he was in his room lying down from 9 pm through 10 pm. (Surveyor's note: The psychiatric technician did not enter room 357 until 9:36 pm.)

Review of Patient #28's Observational record, dated 4/17/13, revealed that he was on transitional observation and in room 357. The record also indicated that he was in his room laying down from 9 pm through 9:15 pm, and sleeping from 9:30 pm to 10 pm. (Surveyor's note: The psychiatric technician did not enter room 357 until 9:36 pm.)

Review of Patient #20's Observational record, dated 4/17/13, revealed that she was on sexually acting out precautions and in room 350. The record also indicated that she was in her room lying down from 9:30 pm through 10:00 pm. (Surveyor's note: The psychiatric technician did not enter room 350 after the initial rounds at 8:22 pm were observed.)

An interview with Psychiatric Technician #15, on 4/19/13 at 12:00 pm, revealed, that rooms were only checked twice a shift. He indicated that knowledge of where a patient was located was adequate for rounds. He stated that staff did not need to go into the patient's room if they knew that the patient was in there. He stated that this was how he was trained in orientation.

An interview with Psychiatric Technician #16, on 4/19/13 at 12:02 pm, revealed, that rooms were only checked twice a shift. She indicated that knowledge of where a patient was located was adequate for rounds. She stated that staff did not need to go into the patient's room if they knew that the patient was in there. She stated that this was how she was trained in orientation.

An interview with Psychiatric Technician #23, on 4/19/13 at 12:04 pm, revealed, that rooms were only checked twice a shift. She indicated that knowledge of where a patient was located was adequate for rounds. She stated that staff did not need to go into the patient's room if they knew that the patient was in there. She stated that this was how she was trained in orientation.

An interview with the facility DON, on 4/18/13 at 4:20 pm, revealed, that psychiatric technicians were not trained to perform rounds from either the nursing station or the day room. She stated there were supposed to be at least two psychiatric technicians on the floor to manage the unit. She agreed that staff did not have x-ray vision to know what was going on in rooms during rounds and that if a patient was in the room, observation meant going into the room to check on the patient.

Review of the facility ' s policy on Patient Rounds, revised 2/11, revealed that nursing staff shall document patient whereabouts by observation or established knowledge that patients are in direct care of another staff member. The policy also indicated that nursing staff shall observe or safety hazards, e.g. unlocked exits, unlocked contraband cabinet, contraband in rooms, tempered windows, etc.

2) Patient #2's alleged sexual abuse

Review of Patient #2's nursing note, dated 2/8/13 at 16:35, revealed that a nursing report was given regarding Patient #2's examination of sexual assault from a nurse at the facility which examined Patient #2 for sexual assault. The note stated that there was "a lot of evidence of assault" and "bruising and bleeding of the cervix" The nursing note indicated that according to the nurse at the facility evaluating for sexual assault, there was no question that Patient #2 had been sexually assaulted.

Review of Patient #2's Initial Psychosocial Assessment, dated 2/5/13, revealed that Patient #2 denied any history of sexual abuse on admission to the facility.

Review of Patient #2's Initial Nursing Assessment, dated 2/5/13, revealed that she was a low risk for Sexually Inappropriate Behavior. She denied being sexually active. She was not recommended for Sexually Acting Out (SAO) precautions.

Review of Patient #2's Clinical Record, dated from 2/5/13 to 2/14/13, revealed that she was admitted with the diagnoses of Major Depressive Disorder with psychotic features. The record did not contain any clinical assessments or history of Patient #2 making false allegations. On 2/6/13, there was an order indicating Patient #2 was to be placed on transitional observations, indicating she was cooperative and cognizant enough to participate in off unit activities, including smoking.

Review of Patient #2's written statement regarding the alleged sexual assault on 2/7/13, dated 2/8/13, revealed Patient #3 put her hands behind her back and told her that if she screamed or told anyone, he would find her family. The statement indicated that she told [A nurse on the unit] what happened the next day.

Review of Patient #5's (Patient #2's Room mate) statement regarding the alleged sexual assault on 2/7/13, which was undated, revealed that she and one of the nurses, witnessed Patient #3 trying to get Patient #2 into his room " last night " . Patient #2 told her that Patient #3 wanted to talk. The statement stated, "I'm very upset and I'm very nervous that he raped her."

Review of Patient #3's statement regarding the alleged sexual assault on 2/7/13, dated 2/11/13 revealed that he wanted to go to court "on this woman for lying on me." Also, the statement stated "I did not have sex [sic] No one in the hospital."

Review of Observation Records for Patient #2, Patient #3, and Patient #5, dated 2/7/13, revealed that at 10:15pm, Patient #2 and Patient #3 were in their room (not visible from the nursing station), while Patient #5 was getting medication.

Review of Safety Rights Officer Notes, which were undated, revealed that the Rights Officer met with Patient #5, who told her that she did not witness the incident, but was in the dayroom and heard her door room close and saw Patient #3 standing on the outside of her door. Patient #5 indicated that she believed Patient #3 was in her room because of this. (Surveyor's note: Patient #5 and Patient #2 ' s room was adjacent to where patients wait for their medications to be dispensed by staff.)

Review of the Facility's Root Cause Analysis (RCA) regarding the alleged sexual assault on 2/7/13, dated 3/8/13 revealed that Patient #2's insight was good. Her judgment was fair. Her impulse control was fair. Her diagnoses were bipolar I NOS, positive rape kit, HIV negative, and Obese. Patient #3's insight was poor. His judgment was poor. His impulse control was poor. His diagnoses were Bipolar I, borderline personality traits, and possible borderline intellectual functioning.

Review of the Facility's Risk Management Committee Meeting, dated 3/19/13, revealed that a RCA was completed on the alleged sexual assault, and that recommendations were considered regarding training the psychiatric technicians with regards to the 15 minute rounds.

Review of Psychiatric Technician #26's Personnel File, dated 3/14/13, revealed that he was terminated on 3/14/13 for "incomplete rounds". Psychiatric Technician #26 was assigned to monitor Patient #2 and Patient #3 at the time that the alleged incident occurred.

Record review of the facility policy on abuse, neglect, and exploitation, dated 2/13 revealed the following: Abuse was defined as rape, sexual assault, or sexual exploitation of a patient. Neglect was defined as failure to provide a safe environment. Review of the record did not reveal any evidence to support facility non-compliance in Resident/Patient/Client Neglect, Resident/Patient/Client Rights, Quality of Care/Treatment, or Nursing Services.

3) Patient #3's privileges

Review of Psychiatric Technician #24's written statement regarding the alleged sexual assault on 2/7/13, dated 2/15/13, revealed that on 2/7/13 Patient #3 cursed out a staff member and attempted to jump over the nursing station wall to fight with a staff member but was stopped. The statement indicated that Patient #3 was placed on Unit Restriction. The statement indicated that later Patient #3 demanded to go for a smoke break and the nurse allowed him in order to make the unit peaceful. (Surveyor's note: There was no order for Unit Restriction in Patient #3's record for 2/7/13.)

Review of Psychiatric Technician #25's written statement regarding the alleged sexual assault on 2/7/13, dated 2/15/13, revealed that on 2/7/13 she was mostly at the nursing station, except when she was attending to patient requests and also bathroom breaks. Her statement indicated that Patient #3 had been aggressive, which caused him to be placed on unit restriction. The statement indicated that Patient #3 kept coming back and forth stating he would behave better. After Patient #3 was quiet and appropriate, the nurse allowed him to go downstairs for a smoke break. (Surveyor's note: There was no order for Unit Restriction in Patient #3's record for 2/7/13.)

Review of RN #27's written statement regarding the alleged sexual assault on 2/7/13, which was undated, revealed that she was on duty that night from 7pm to 7am and was assigned to the long hallway. The statement indicated that Patient #3 was agitated due to the fact he had not received his green band. Patient #3 was observed at the nursing station repeatedly asking his nurse for his green band. He was also observed standing in the middle of the short hall inquiring about not having the band in a loud, agitated manner on several occasions throughout the night.

Review of Psychiatric Technician #26's written statement regarding the alleged sexual assault on 2/7/13, dated 2/15/13, revealed that he was assigned to the short hallway on 2/7/13. The statement indicated the unit was peaceful and quiet except for Patient #3, who kept asking for a smoke privilege. He kept asking every staff why he couldn't go downstairs to smoke, and that finally a nurse said that he could be taken downstairs to smoke if he promised to be good for the rest of the day. The statement indicated that he took 6 patients to smoke, including Patient #2 and Patient #3, at 8:45 pm.

Review of Patient #3's Physician Orders, dated 2/7/13, revealed That there were no orders to either discontinue Patient #3's current level of observation (transitional observation), or to give Patient #3 a yellow band privilege of smoking downstairs for that evening.

Review of Patient #3's nursing notes, dated 2/7/13, revealed that he was labile, displaying verbal aggression, and disruptive behavior. The notes did not indicate that the physician had been notified about Patient #3's unit restriction, or removal of privileges. The notes also did not mention Patient #3's behavior of asking for his privileges back from the nursing staff.

An interview with the facility DON, on 4/19/13 at 9:35 am, revealed, that there was no specific policy involving green or yellow bands. They are reflections of a patient's privileges. A nurse can remove the privileges, which is the same as placing a patient on special observations, with subsequent authorization from the physician. When asked about Patient #3's situation, she stated the nurse was justified in removing his privileges and then giving them back without notifying the physician, because he had been a patient at the facility 8 times, was mentally retarded, and the nurse was familiar with his behaviors.

An interview with RN #10, on 4/19/13 at 10:25 am revealed that it was up to the discretion of the nurse to either take away or return either a green or yellow band to a patient. She stated that the physician could be informed the next day through a nursing report if the band was taken away after the physician had visited.

An interview with RN #11, on 4/19/13 at 10:35 am revealed that it was up to the discretion of the nurse to either take away or give back either a green or yellow band. The nurse stated a doctor could be notified the next day if the band was taken away after the physician had left the building.

An interview with Unit Secretary #28, on 4/19/13 at 11:33 am, revealed, that it was up to the nurses to decide if a patient lost his or her green or yellow band. When asked if the physician should be notified about that, she stated "I don't know about that."

Review of the facility policy on Special Observation Record, dated 2/2011, revealed that a patient can be placed on special precautions for numerous reasons, including assaultive behavior, and sexually acting out behavior. The policy indicated that a patient can be placed on special precautions "per a physician's order or under the direction of a registered nurse with subsequent authorization from the physician." The policy did not define the term " subsequent "

4) Facility recording capability

An interview with the facility CIO, on 4/18/13 at 1:30 pm, revealed, that there was no facility policy on using video cameras to monitor either activity on the units, or staff job duties. He stated that the cameras were originally for the outside only, but that they were placed on the units some time back. He stated that the only time anyone had ever asked for a recording was with the alleged sexual assault that occurred on 2/7/13. He stated that there was not enough memory in the system to maintain recordings for more than 3 days.

An interview with the facility CEO, on 4/19/13 at 9:30 am, revealed, that there was no current policy in place to determine how long the facility should record the units. He stated it was determined in the RCA to increase the storage capability, but there was no mention of who was responsible or a timeline for the upgrade.

Observation of the facility video monitoring equipment, on 4/18/13 at 11:00 am in the facility Information Technology equipment room, revealed two Digital Video Recorders stacked on top of each other on a shelf with a monitor on top displaying several channels.

Review of the Facility's Root Cause Analysis (RCA) regarding the alleged sexual assault on 2/7/13, dated 3/8/13 revealed that the action plan of the RCA " identifies strategies that the organization intends to implement to reduce the risk of similar events occurring in the future. It should address responsibility for implementation and include time lines and strategies for measuring the effectiveness of the actions. " Action Item #1 stated that the video surveillance DVR only had the capacity to store approximately 3 days of data before it was replaced by new recordings. Action Item #1 stated "We need to expand the memory to get more of a window for reviewing the recorded data. This data would have clarified if [Patient #3] entered the female patient's room." Action Item #1 did not include either responsibility for implementing the item, or a time frame for implementing the item. (Surveyor's note: Action Item #1 had not been implemented at the time of the investigation, which was approximately 69 days after the facility learned of the incident.)

Review of the Facility's Risk Management Committee Meeting, dated 3/19/13, revealed that a RCA was completed on the alleged sexual assault. The facility Chief Information Officer (CIO) was to look into adding more recording time. (Surveyor's note: There had been no addition of recording time to the facility's DVR as of the current investigation.)