HospitalInspections.org

Based on interview and record review, it was determined the hospital failed to promote and protect patients' rights.

Findings include:

1. The hospital failed to ensure patients' received care in a safe setting. (Refer to tag A-144)

2. The hospital failed to ensure each patient had the right to be free from all forms of abuse or harassment. (Refer to tag A-145)

4. The hospital failed to ensure patients' response to restraint intervention(s) used, including the rationale for continued use of the intervention were documented. (Refer to tag A-188)

Surveyor: Carter, Judy
Based on interview and record review, it was determined that the hospital did not ensure patients received care in a safe setting for 5 of 21 sample patients. Specifically, there were patient care and treatment concerns, which did not lend to a therapeutic and safe environment. (Patient identifiers: 10, 15, 16, 17, and 21.)

Findings include:

1. Patient 16, a juvenile, was admitted on 1/10/21 with a diagnosis of suicide ideation with suicide attempt.

A review of patient 16's medical record was completed on 4/28/21.

A review of a nursing note dated 1/11/21, at approximately 7:15 PM indicated, "Pt(patient) taking shower, 'peer that was male was in her room' pt stated he had been asking her to have oral sex with him all day, she stated Yea I guess. IR (incident report) done and witness statements".

A review of the Incident report dated 1/12/21 at 12:07 AM was completed.

The incident report indicated, "pt stated peer (patient 17) had went into her room asked her for oral sex. Pt stated she said 'Yea I guess' pt states they performed oral sex and that (patient 17) stated he wanted to go all the way. pt stated 'He put it in me & (and) came inside me'. Peer (patient 17) was talked with He states 'I couldn't get it in'. Pt stated to me she doesn't want to get pregnant. Stated she didn't tell him no."

A review of physician note revealed an order dated 1/12/21 at 4:40 PM, to increase observation to every 5 minutes for safety, related to multiple suicide attempts.

A review of a nursing note dated 1/12/21 at 2:00 AM, indicated "pt complains of vaginal pain. Reports that she has had a rough day due to issues with males on the unit and recent trauma."

A review of a psychiatry progress note dated 1/13/21, indicated patient 16 "reports sexual assault from peer triggering flashbacks/nightmares endorses thoughts of death withdrawn."

A review of group therapy notes revealed a note dated 1/13/21, indicating patient 16 was extremely anxious and has been since things happened on the unit.

A group therapy note dated 1/19/21 indicated patient 16 was depressed, anxious, quiet, withdrawn, and crying, patient 16 kept referencing rape in any topic of conversation.

On 4/27/21 at 2:47 PM, an interview was conducted with the hospital administrator (ADM). The ADM stated the therapist would provide individual counseling if a patient needed help in dealing with a difficult situation. The ADM state if individual therapy had been provided it would have been documented on a therapy note. The ADM also stated that there is only one adolescent unit in the hospital. He stated if there were issues between patients on the unit they would try to keep them separated. If necessary they would look at alternate placement for the patients. The ADM stated in this case both patients initially stated the incident was consensual. He stated if patients had changed their story then it would need to be investigated further.

On 4/29/21 at 11:35 AM, An interview was conducted with the group therapist. She stated if she noticed a patient was having a difficult time in therapy, she would try to talk to the patient and try to get the patient to talk about what is bothering them. If she felt the patient needed more help she would let the therapist know so she could look into it further. When asked about patient 16, the group therapist stated she did not remember patient 16, that was too long ago.

On 4/29/21 at 12:11 PM, an interview was conducted with the licensed marriage and family therapist (LMFT). The LMFT stated that she lead group therapy on the adolescent unit once a week. Group therapy was to help prepare kids to get out of crisis mode. She also stated she would do a psychosocial assessment on each patient. The LMFT stated that she only did individual therapy for patients if it was required by the insurance company or if she was asked to. She stated that some adolescent patients felt fearful to go to the office. She did not remember providing individual therapy for patient 16.

No documented evidence was located to indicate the hospital had provided individual therapy for patient 16 after she developed adverse behaviors related to a sexual encounter.

Note: This incident was reported and the police and division of child and family services were involved in this case.

2. Patient 17, a juvenile, was admitted to the hospital on 12/12/2020, with a diagnosis of major depressive disorder with suicide ideation.

On 4/27/21, patient 17's medical record was reviewed.

A review of the patient observation notes for patient 17 dated 12/14/2020 indicated "patient was sexually acting out. He kept getting girls to talk about things that were sexual. One of the girls lifted up her shirt. He wouldn't stop looking...He tried to walk into a girls room while she was showering."

A review of a psychiatry progress note dated 12/22/2020, indicated patient 17 had "poor boundaries and was hypersexual".

No documented evidence was located to indicate the hospital addressed his poor boundaries and hypersexual behaviors until the incident with patient 16 on 1/11/21.

A review of patient 17's physician orders revealed an order dated 1/12/21 to change observations to every 5 minutes and SAO (sexually acting out) precautions related to sexually acting out with other patients.

Further review of the observation documentation revealed staff stopped doing Q 5 observations and reverted back to doing Q 15 observations for patient 17 on 1/30/21.

No documented evidence was provided to indicate why the Q 5 observations were discontinued or that a physician or licensed practitioner had written an order to change the observation schedule.

On 4/29/21 at 12:10 PM, an interview was conducted with the quality risk manager (QRM). The QRM stated the physician or licensed practitioner must complete an order to change the observations on a patient. The QRM stated they did not have an order to change the observations for patient 17.

Surveyor: Golightly, Dacie
3. Patient 10, a juvenile, was admitted to the hospital on 4/2/21 with a diagnosis of major depressive disorder.

A review of patient 10's medical record was completed on 4/29/21.

The following nursing notes were documented in patient 10's medical record:

On 4/5/21 at 9:00 AM, "Pt was overheard talking to peer about sexual contact between he and his roommate last night, provider and nurse spoke to both pt and roommate about potential sexual activity previous night, or any other night at HRH (Highland Ridge Hospital). Both fully denied any type of sexual conduct."

On 4/5/21 at 4:30 PM, "Pt was again overheard talking to peers about sexual activity with roommate. When asked again by staff (patient 10) stated that last night pt had non intercourse sexual activity with roommate. Pt had already been moved to private room at 1000 (10:00 AM) on 4/5/21. Pt advocate was notified to meet with both involved. (Patient 10) continues to report that sexual activity occurred other pt continues to deny events took place ..."

An investigation was completed on 4/6/21 by the hospital's QRM. The documentation from the investigation was reviewed and revealed that patient 10 was placed on SAO (Sexual Acting Out) precautions.

No documented evidence of the SAO precautions could be found in patient 10's medical record aside from a box being checked next to "Sexual Acting Out" on patient 10's observation sheets from 4/5/21 to 4/8/21. Per documentation patient 10 was observed every 15 minutes.

On 4/22/21 at 2:47 PM, a telephone interview was conducted with the QRM and ADM. The QRM stated there should have been a physician's order for patient 10's SAO precautions and that order should have clarified if patient 10 was to continue on 15 minute observations or five minute observations.

4. Patient 21 was admitted to the hospital on 4/11/21 with diagnoses of mania and delusions.

A review of the hospital incident log revealed an incident involving patient 21 dated 4/15/21 at approximately 11:00 PM.

Review of the incident report revealed patient 15 had filled a pillowcase with books and hit patient 21 in the back of the head.

A focused review of patient 21's medical record was competed on 4/28/21.

No documentation was located in patient 21's medical record concerning the incident. There was no documentation that the nurse had assessed patient 21 for injuries or had contacted the family/legal representative or external agency concerning the incident.

A review of the hospital abuse policy on 4/28/21 revealed the following:

"Patient-to-Patient Abuse
a. The registered nurse will place the patient committing the offense on Q (every) 5 minute observations or 1:1 observation and notify the attending/covering physician.
b. The registered nurse will complete a nursing assessment of the patient who was abused to evaluate the patient's physical and mental condition.
c. The registered nurse will notify the designated family contact and/or legal representative of the patient who was abused."

No documented evidence was located to indicate that the nurse had contacted the patient's family/legal representative, and the physician. No documentation was provided to indicate that the nurse had assessed patient 21 for injuries related to the incident.

On 4/29/21 at 9:05 AM, an interview was conducted with the Quality/Risk Manager (QRM) and the hospital administrator (ADM).. The QRM stated that he was the one that filled out the incident report on patient 15. He stated he got the information from the nursing supervisor during report. He stated he did not know if the nurse had assessed the victim of the assault for injuries or had contacted the patient's family/legal representative and physician.

The ADM stated the RN was to assess the both patients after an incident of peer to peer abuse to ensure the each patient had no physical or mental injuries from the abuse.




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Based on interview and record review, it was determined the hospital did not ensure each patient was free from all forms of abuse, for 6 of 21 sampled patients. Specifically, the hospital did not report allegations of physical or sexual abuse to the appropriate outside agencies as per state law. (Patient identifiers: 1, 5, 7, 15, 18 and 19.)

Findings include:

After a review of 21 patient records, it was determined the hospital did report some serious allegations of abuse to the appropriate outside agencies as per state law. However, the following were not reported as required:

1. Patient 7, a juvenile, was admitted to the hospital on 4/3/21 with a diagnosis of suicidal ideation.

A review of patient 7's medical record was completed on 4/29/21.

The following nursing notes were documented in patient 7's medical record:

a. On 4/5/21 at 9:00 AM, "(Patient 7's) roommate was overheard talking to peers about non intercourse sexual activity taking place between (Patient 7) and roommate. Nurse and Provider spoke separately with both (Patient 7) and roommate. Both denied any events taking place. Both pt's (patients) moved to private rooms."

b. 4/5/21 at 4:30 PM, a nurse documented the following, "(Patient 7's) roommate was again overheard talking about sexual activity taking place previous night. Staff had private conversation with (Patient 7's) roommate who at this time stated that previous night non intercourse sexual activity took place, Pt advocate interviewed both separately (Patient 7) continues to deny any events taking place ..." It was also documented that patient 7's guardian was contacted.

An investigation was completed on 4/6/21 by the hospital's quality/risk manager (QRM). The documentation from the investigation was reviewed and revealed that on 4/5/21 a few patients approached staff and stated that patient 10, " ...had mentioned to them that he was touching his roommate (patient 7) inappropriately." The investigation revealed that patient 10 told the QRM that, "something happened," between himself and patient 7, but would not give details. Patient 7 told the QRM he knew something happened between himself and patient 10, stating that he woke up to patient 10 at the side of his bed, but did not know exactly what occurred because he was asleep.

No other documented evidence in patient 7's record or the investigation completed by the QRM could be found to indicate what "non intercourse sexual activity," occurred between patient 7 and patient 10.

No evidence could be found in patient 7's medical record to indicate division of child and family services (DCFS) or the police were notified of the sexual activity.

Patient 7 was discharged home from the hospital on 4/12/21.

The Department of Health received notification that a police report involving patient 7 had been filed on 4/13/21. It was documented that patient 7 had been "raped" by his roommate while at Highland Ridge Hospital.

On 4/22/21 at 12:29 PM, a telephone interview was conducted with patient 7's mother. Patient 7's mother stated on 4/4/21 while he was a patient at Highland Ridge her son was "molested" by his roommate. She stated when she was called to speak with her son a nurse at Highland Ridge and informed her that her son, "was involved in a sexual relationship," with his roommate and made it sound like it was consensual. Patient 7's mother stated she did not think what the nurse said was true because her son was not sexually active. She then stated the nurse did not tell her exactly what happened between her son and her roommate. She stated when she spoke with her son and asked what happened he told her he did not consent to the sexual activity but did not want to tell her exactly what happened. She then stated the nurse did ask if she was going to file a police report but that she was in shock and said no. Patient 7's mother stated her son was, "so affected," by this incident and that after he discharged she took him to be physically examined and has set up therapy appointments so he can process the incident. She stated she still did not know exactly how her son had been sexually violated since she was told by the examiners and therapists she reached out to after he discharged not to push him to talk about it. She then stated she told the police patient 7 was raped because no matter what happened he was violated and for her a violation was rape.

On 4/22/21 at 11:04 AM, a telephone interview was conducted with the QRM and administrator (ADM). The QRM stated if they were able to confirm "sexual activity," between minors that DCFS and the police would be notified. The QRM stated the incident between patient 7 and patient 10 was, "pretty vague," and they were not able to "verify" sexual activity occurred. When asked about the nursing notes stating non-intercourse sexual activity occurred, the ADM stated this case was a "gray area," and not reported because they did not have concrete information as to what occurred.

2. Patient 18, a juvenile, was admitted to the hospital on 3/29/21 with a diagnosis of bipolar affective disorder.

A review of patient 18's medical record was completed on 4/29/21.

The following was documented on a nursing note dated 4/3/21, "Pt was assaulted this evening by 2 peers. Pt sustained a nose bleed but no other major injuries. Pt continues on Q(every)15 min(minutes)check for safety. Pt contacted parents and informed them of incident. Parents did not want to speak (with) staff."

The correlating incident report for the 4/3/21 incident involving patient 18 was reviewed. It was documented that patient 18 was "punched" in the face and this caused, "a bloody nose."

No documented evidence could be found to indicate the police or DCFS was contacted after patient 18 was assaulted.

3. Patient 19, a juvenile, was admitted to the hospital on 1/3/21 with a diagnosis of bipolar affective disorder.

The local police department provided the survey team with a report of assaults which had occurred at Highland Ridge Hospital from January 2021 to April 2021, but had not been reported by the hospital as required by law, but by patients or guardians of patients. The report revealed the following:

a. On 1/8/21 the local police department received a report from patient 19's mother that on 1/7/21, patient 19 had been assaulted twice by her peers. It was also documented that patient 19 had superficial injuries from having her hair pulled, and that the hospital's QRM did not report her investigation findings to the investigating officer. Lastly, it was documented that this incident was not reported to DCFS.

An incident report involving patient 11 and 19 dated 1/7/21 was provided to the survey team. The report indicated patient 11 "rushed" into patient 19's room and "screaming and pounding" was heard from down the hall. It was documented that when staff arrived to patient 19's room patient 11 was exiting the room and patient 19 informed staff that patient 11, "hit her and pulled her hair." It was documented that patient 19 had "no apparent injuries" but was "frightened" due to the incident. The report was blank in the notification section next to family, legal guardian, and external agency notification.

A focused review of patient 19's medical record was completed on 4/29/21.

The following was documented on a "Psychiatry Progress Note" dated 1/7/21, "Phys(physically) assaulted today, coping relatively well- frustrated ...Mom concerned for safety/unpredictability ..."

No other documentation regarding patient 19 being physically assaulted on 1/7/21 could be found in her medical record. No documentation could be found to show patient 19's guardian, local police, or DCFS was notified of any physical assault patient 19 experienced on 1/7/21.

Note: Patient 19 was discharged from the hospital on 1/7/21.


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4. Patient 1, a juvenile, was admitted to the hospital on 4/13/21, with a diagnosis of major depressive disorder with suicide ideation.

On 4/20/21 at 9:15 AM, an interview was conducted with patient 1.

Patient 1 stated she did not feel safe at times. She stated patient 2 had pinched her butt and was always starring at her "butt and boobs". Patient 1 stated she told staff about the incident. She stated that patient 2 did not touch her anymore but he was still always starring at her "butt and boobs". Patient 1 stated it made her feel uncomfortable.

A review of patient 1's medical record was completed on 4/21/21.

A review of a progress note dated 4/18/21 at 5:00 PM, indicated "(patient 1) parents called in reporting that (patient 1) told that another patient 'touched her butt' and was starring at her. Spoke with (patient 1) She confirmed story. Spoke with patient allegations were made against. Placed patient on Q 5 minute observations and SAO (sexually acting out)as per provider orders. Contacted (patient 1's) mother to notify of actions taken."

A review of the incident report dated 4/18/21 was completed. No documented evidence was located to indicate that the incident had been reported to the police or DCFS.

5. Patient 5, a juvenile, was admitted to the hospital on 1/16/21 with diagnoses of disruptive mood dysregulation disorder and reactive attachment disorder.

A review of the hospital incident log revealed on 1/25/21, patient 5 punched patient 13 in the face when patient 13 turned off a video game while patient 5 was trying to save the game.

No documented evidence could be found to indicate DCFS or the police had been notified of the assault.

6. Patient 15, an adult, was admitted to the hospital on 4/14/21, with a diagnoses of psychosis and medication management.

On 4/27/21 patient 15's medical record was reviewed.

A review of the nursing reassessment form dated 4/15/21 revealed the patient was demanding, irritable and had physical aggression at 9:30 PM.

A review of the hospital incident log revealed an incident involving patient 15 dated 4/15/21 at approximately 11:00 PM.

Review of the incident report revealed patient 15 had filled a pillowcase with books and hit patient 21 in the back of the head.

No documented evidence was located to indicate the police and adult protective services (APS) had been notified of the assault.

7. The hospital's Abuse and Neglect policy last revised in April 2021 was reviewed. The following was documented in the policy, "It is the policy of the Highland Ridge Hospital to report alleged and suspected abuse and neglect to the appropriate authorities in accordance with state and federal statutes."

The following is the reporting statute for the state of Utah effective 6/29/2020:

"62A-4a-403. Reporting requirements.

(1)(a) Except as provided in Subsection (2), when any individual, including an individual licensed under Title 58, Chapter 31b, Nurse Practice Act, or Title 58, Chapter 67, Utah Medical Practice Act, has reason to believe that a child has been subjected to abuse or neglect, or observes a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, that individual shall immediately report the alleged abuse or neglect to the nearest peace officer, law enforcement agency, or office of the division.

(b)(i) Upon receipt of a report described in Subsection (1)(a), the peace officer or law enforcement agency shall immediately notify the nearest office of the division.

(ii) If an initial report of abuse or neglect is made to the division, the division shall immediately notify the appropriate local law enforcement agency.

(c) (i)The division shall, in addition to the division's own investigation in accordance with Section 62A-4a-409, coordinate with law enforcement on investigations by law enforcement undertaken to investigate a report described in Subsection (1)(a). (ii) If law enforcement undertakes an investigation of a report described in Subsection (1)(a), the law enforcement agency undertaking the investigation shall provide a final investigatory report to the division upon request."

On 4/22/21 at 11:50 AM, and 4/22/21 at 2:28 PM, telephone interviews were conducted with a Unified Police Officer (UPO). The UPO stated Highland Ridge Hospital had not been reporting assaults that were occurring to the police or to DCFS if a juvenile was involved and APS if an adult was involved. The UPO stated they were able to confirm this because reports of assault had been called in by patients or guardians after patients had discharged from Highland Ridge. The UPO stated anything criminal should be reported, which would be any physical altercation where someone was injured to include sexual acts. When asked what is considered a sexual assault he stated by law the touching of breasts, genitals, and buttocks was assault and should be reported' He confirmed the incident with patient 1 being grabbed on the buttocks by patient 2 should have been reported to the police and DCFS. The UPO stated, "We don't want any more victims, especially children."

On 4/27/21 at 2:48 PM, a telephone interview was conducted with the QRM and ADM. The ADM stated if a physical altercation occurred police and DCFS or APS was contacted "depending on the severity of the incident." When asked what was considered serious the ADM stated, "Anything that could be considered abuse." When asked if being punched in the face was abuse the ADM stated, "I guess technically yes, that would be physical abuse," and that "If we are going by the letter of the law we would need to contact at the very least CPS (DCFS)."

Based on interview and record review, it was determined that the hospital did not document the patient's response and the impact of the restraint interventions for 3 of 21 sampled patients. (Patient identifier: 5, 13, and 17.)

Findings include:

1. Patient 17, a juvenile, was admitted to the hospital on 12/12/2020, with a diagnosis of major depressive disorder with suicide ideation.

On 4/27/21, patient 17's medical record was reviewed.

A review of the record revealed patient 17 was physically restrained on 1/17/21 at 8:00 PM.

A review of the "seclusion/restraint progress note RN (Registered Nurse)/Practitioner" dated 1/17/21 at 6:00 PM, revealed patient 17 been jumping and hitting the ceiling tile. The behavioral health technicians (BHT) were telling him to stop. Patient 17 then jumped again and pulled the tile down. The RN approached patient 17 and asked what was going on. The RN was informed by another BHT that patient 17 had been going after a female peer. Patient 17 then attempted to push past the RN and the BHT grabbed onto his arm. Patient 17 continued to push and was then placed in a physical hold. He was escorted to the seclusion room and placed in seclusion. Patient 17 then punched the window in the door.

A review of the medical record revealed no documentation concerning patient 17's response to the restraint intervention. No documentation could be located in the medical record concerning the impact the restraint intervention had upon patient 17.

No documentation could be located in patient 17's medical record to indicate that any debriefing had occurred.

2. Patient 5 was admitted to the hospital on 1/16/21 with diagnoses of disruptive mood dysregulation disorder and reactive attachment disorder.

On 4/22/21, patient 5's medical record was reviewed.

A review of the record revealed patient 5 was physically restrained on 1/30/21 at 9:34 PM.

A review of the "seclusion/restraint progress note RN/Practitioner" dated 1/30/21 at 9:34 PM, revealed patient 5 became upset after a peer turned off the video game he was trying to save. Patient 5 then threw the remote control at his peer. Patient 5 then slapped another peer who was trying to calm him down. Staff then intervened and separated the patients. Patient 5 attempted to go after the peers and was placed in a hold.

A review of the medical record revealed no documentation concerning patient 5's response to the restraint intervention. No documentation could be located in the medical record concerning the impact the restraint intervention had upon patient 5.

A blank "Seclusion/Restraint Patient Debriefing" form was located in patient 5's medical record.

No documentation could be located in patient 5's medical record to indicate that any debriefing had occurred.

Further review of patient 5's medical record revealed he had an incident on 1/31/21, in which he was placed in a restraint.
Patient was placed in a restraint hold at 10:15 AM, after patient had started fighting with peers.

A blank "Seclusion/Restraint Patient Debriefing" form was located in patient 5's medical record.

No documentation could be located in patient 5's medical record to indicate that any debriefing had occurred.


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3. Patient 13 was admitted to the hospital on 1/7/21 with a diagnosis of major depressive disorder.

A review of the hospital's incident log revealed an incident between patient 13 and a peer on 1/25/21.

The incident report dated 1/25/21 revealed patient 13 was punched by a peer and a physical altercation occurred. It was also documented on the report that patient 13 was physically restrained by staff for two minutes during the incident.

A review of patient 13's medical record was completed on 4/29/21.

On 1/27/21 a physician documented patient 13 was involved in a physical altercation with a peer on 1/25/21 during which he punched a peer.

No other documentation, including the patient's response and the impact of the restraint intervention, could be found in the medical record regarding the incident between patient 13 and a peer on 1/25/21.

4. A review of the hospital restraint and seclusion policies was completed. The following was documented in both policies:

"The patient shall be debriefed by a staff person to determine the sequence of events or circumstances that precipitated the need for seclusion. Debriefing occurs in order to develop a plan that actively involves the patient to prevent future episodes from occurring. Debriefing will occur within twenty-four hours of the incident unless the patient refuses, is unavailable, or there is a documented clinical contraindication."

5. On 4/27/21 t 2:47 PM, an interview was conducted with the quality/risk manager (QRM) and the hospital administrator (ADM) The QRM stated that a debriefing with the patient was to occur after each incident, and staff were required to complete the debriefing form. The ADM stated that they have had a difficult time getting staff to complete the documentation after each incident.