HospitalInspections.org

Based on observation, review of medical records, review of the facility's e-mail to employees regarding the change in practice to the facility's "Patient Monitor" policy, review of the facility's policies and procedures, review of the meeting minutes of the facility's investigation, and staff interviews, the facility failed to ensure supervision dictated by the psychiatric units and hall monitoring plan instituted on 12/01/10, were implemented to ensure Patient #2 was free from sexual assault by Patient #1. The sample size was ten patients and involved one of three psychiatric units, 8 West, with a census of 24 patients. The facility had a total census of 48 psychiatric patients at the time of the survey.

Findings include:

The facility failed to ensure supervision of the psychiatric unit's plan to prevent sexual assault, resulting in one patient (#2) being sexually assaulted by another patient (#1) on the psychiatric unit.

Please refer to 42 CFR 482.23 (b)(3); Tag A395, RN Supervision of Nursing Care for more detail.

Based on observations, review of medical records, review of the meeting minutes of the facility's investigation, review of the facility's e-mail to employees regarding the change in practice to the facility's "Patient Monitor" policy, review of facility policies and procedures and staff interviews, the facility failed provide supervision to prevent a sexual assault. The facility failed to follow the psychiatric units' "change in practice" e-mail regarding the monitoring of the hallway and environment, instituted on 12/01/10, after another sexual assault to a patient that occurred on 11/30/10, failed to provide adequate supervision which resulted in the sexual assault of Patient #2 by Patient #1 and failed to ensure the hospital clinical manager conducted a safety evaluation to ensure the patient who experienced the abuse was safe from further risk of abuse during the investigation.

The sample size was ten patients and involved one of the facility's three psychiatric units; 8 West. The 8 West psychiatric unit's census was 24 patients and the facility had a total census of 48 psychiatric patients at the time of the survey.

Findings include:

Review of the medical record for Patient #2 on 01/03/11, revealed a nursing progress note entry, dated 12/23/10 at 7:03 AM that documented Patient #2 had reported that Patient #1 sexually assaulted her. This entry noted that the following persons or entities were notified of the sexual assault: medical doctor, supervisor, unit manager and the local police. The entry indicated Patient #2 was verbally assured of her safety. No other interventions taken by the nursing staff were noted.

Review of the facility's policy titled "Abuse, Neglect & Exploitation" last revised July 2009, revealed that it is the facility's procedure to "Conduct a safety evaluation to ensure the patient is currently safe from any further risk of abuse...and/or providing the patient with an option to move to another location. There was no documentation in the medical record the hospital had conducted a "safety evaluation" to ensure Patient #2 was safe from any further risk of abuse, including taking measures to protect the patient during the investigation of the alleged sexual abuse by Patient #1 as directed by the hospital's policy.

The next nursing progress note entry, dated 12/23/10 at 7:30 AM, documented the local police had been notified and was up to speak with the patient (#2), Patient #1 had been placed under the observation of a Security Officer, both patients' doctors were notified, an order was obtained to transfer the patient to another unit, Patient #2 was made aware of the transfer of the male patient and Patient #2 was given reassurance the incident was being taken care of and she was safe. This same entry indicated the male patient was transferred to another unit. However, documentation reviewed from the medical record of Patient #1 indicated the patient was not transferred to the other unit until 8:45 AM.

Review of the documentation of the facility's investigation on 01/03/11, revealed this incident occurred on 12/23/10 at 7:00 A.M. and was classified as a sexual assault. According to the documentation in the investigation the perpetrator (Patient #1) had not been separated from the victim (Patient #2) immediately after the allegation was made per the facility's policy. The facility's investigation reported that when the facility's Security Officer Supervisor (Staff E) arrived on the unit (no time specified in the report), he was informed by a nurse at the nurses' station (Staff G) the two patients involved in the sexual assault (Patient #1 and #2) were both eating breakfast in a common area. When the Security Officer requested the two be separated, Staff G replied "Why?, it's not like they are having sex". According to documentation at that point in time, the Director of Security (Staff J) arrived on the unit and Staff E relayed the content of the conversation between himself and the nurse (Staff G).

Staff J then informed this same nurse (Staff G) he would be conducting the interview with the victim, wanted the two patients separated and the perpetrator immediately moved to a different wing. The facility's report of the investigation did not indicate a time this conversation occurred. Further review of the facility's investigative report noted that Staff J asked the victim, Patient #2, to recount what happened. She reported the assault had occurred around 7:00 A.M. She was sleeping and as she awoke, the perpetrator, Patient #1, was "repeatedly grabbing and massaging my butt." Patient #2 told Staff J she did not "feel safe in this hospital." A local police officer was present during this interview and informed Patient #2 and Staff J that staff members (the report did not specify the staff members names or titles) had told the officer "(Patient #1)...was probably confused and was trying to remove the covers of what he thought was his bed and touched her by mistake". The victim, Patient #2, became agitated when she heard this statement and said that is what they (staff names and titles not identified) tried to tell her, but Patient #2 was adamant that was not the case. Patient #2 said "she was there and knows what he was doing." The investigative report indicated Patient #2 demonstrated to Staff J and the police officer with her hands how Patient #1 was grabbing and groping her buttocks. Patient #2 was upset that the staff (not specifically identified) didn't take her seriously.

Review of the medical record for Patient #1 on 01/03/11, revealed Patient #1 was admitted to the emergency room for being loud, agitated and threatening to his peers and staff at another facility. A physician's progress note dated 12/23/10 at 0400 AM revealed that the patient was assessed as threatening to others. The patient was admitted on 8 West on 12/23/10, at 0615 AM.

Review of the facility's policy titled "Observation Levels" last revised on 10/21/10, revealed that it is the facility's policy to "Provide each patient with the level of observation necessary to promote privacy and independence while ensuring a safe and therapeutic milieu for patients and associates." The policy further instructed that the evaluating physician will order a frequency of observation. The physician, based upon his/her assessment and clinical judgement will determine the level of observation for the patient based upon the following three options:

Constant - the highest level of precaution used for patients who are actively violent or harming self or others.

Heightened - requires 15 minute checks and is for patients with behaviors such as violence suicide, wandering, etc...

Standard - Requires a risk assessment each shift and monitor hourly.

Staff A said Patient #1 was not started on fifteen minute checks upon admission, just standard observation and he/she was able to ambulate about the unit. Staff A told the surveyor Patient #1 had just wandered into the wrong room.

Review of the e-mail sent to Psychiatric Services staff on Wednesday, 12/01/10, to inform the staff of a "Change in Practice" related to the the facility's "Patient Monitor" policy, revealed the memo included the following; "It is required that staff be in the hallway in an area where patient rooms and the entrances to the common areas can be visualized at all times. The staff monitoring the environment shall not leave the area unattended for any reason without being relieved by the RN or the RN designated replacement......At no time are patients or visitors to enter another patient's room. However, if a patient enters another's room we must assess the safety of all involved patients." This e-mail was initiated after another incident was reported on 11/30/10, that a patient wandered into another patient's room and sexually assaulted the patient.

During an interview with Staff A on 12/30/10 at 3:12 P.M. Staff A said the psychiatric units had a plan in place since 12/01/10, to have one staff member posted in the hallway at all times to monitor the patients. Staff A said staff had been educated to intervene and re-direct any patient who attempted to wander into others' rooms.

Tour of the 8 West unit, on 01/03/11 and a review of the 8 West floor plan demonstrated Patient #2 had been assigned to a room near the entrance to a day room located at the far end of the hall and Patient #1 had been assigned to a room located at the opposite end of the hall. Patient #1 would have had to walk past the nursing station to gain access to Patient #2's room.

During an interview, on 1/3/11 at 4:31 P.M., Staff C admitted there had not been a staff member in the hall to intervene when Patient #1 entered Patient #2's room. Staff C acknowledged a plan had been in place for a staff member to be in the hallway of the psychiatric unit at all times to monitor patients' activities and that the facility had not followed the psychiatric unit's policy regarding hallway monitoring (supervision) of the patients' activities.

During an interview on 12/30/10 at 2:55 P.M., Staff D informed the surveyor the staff members were to take turns, always having someone posted in the hall to observe the patients' activities, but said, in the event of an emergency on the unit, staff may be absent from those (hall monitoring) duties.