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Based on policy review, medical record review, interview, and document review, clinical staff did not follow facility policy related to physician notification and/or assignment of care, when Patient #1 was transferred from critical care to an inpatient unit.

Findings include:

Review of policy "Transfer of Internal Patients Between Clinical Services", last revised 07/2018, indicates all transfers between different services will require a verbal provider to provider handoff. When there is a delay between transfer of service and physical transfer of a patient from critical care to an inpatient floor, the transferring team must then call the receiving team to advise them the patient is being moved to a new location.

Review of physician order dated 04/29/19 at 08:38 AM from Staff (AA), Attending Critical Care physician, requests a transfer/bed request for Patient #1. Medicine H (covers the 7th floor) is the accepting service. The Attending Physician is "To be determined" and "Notify the service upon (patient) arrival to the floor."

Review on 05/30/19 of the Critical Care History and Physical note dated 04/29/19 at 06:12 PM indicates Patient #1 was under the Medical Intensive Care Unit (MICU) service awaiting transfer to a medical surgical floor (7 zone 1). He was transferred to the floor without provider awareness. He was taken to the 7th floor where he managed to go up to the 8th floor, break the window and get down to the 6th floor ledge. Patient #1 was retrieved from the 6th floor ledge and taken to the emergency department (ED) for trauma work up and imaging.

Interview on 05/31/19 at 09:15 AM with Staff (X), Facility Medical Director, verified that no verbal handoff occurred between the critical care providers (CTU/MICU) and the medical/surgical unit (7 zone 1-Medicine H) providers. The medicine service was not notified of the transfer.

Email dated 06/03/19 at 03:31 PM from Staff (P), Patient Safety & Clinical Investigator, revealed Staff (J), 7th floor RN Unit Manager, notified Staff (Z), Physician Hospitalist on 7 zone 1, at the time of the incident (04/29/19), which is when he realized they had not received report.

Based on observation, video review, medical record review, policy review, document review and interview, the facility does not ensure patient care is provided in a safe setting. Specifically, the Comprehensive Psychiatric Emergency Program (CPEP) staff did not ensure the safety of Patient #2 who was sexually assaulted by another patient. Not providing all patients with a safe environment has the potential to result in patient injury.

Findings include:

Observation on 05/29/19 at 09:00AM of the CPEP revealed that once inside the unit, there is a long entry hallway leading to the main CPEP patient care area. Two triage rooms are in this hallway (Room #1 and 2). The triage rooms have two doors. One door allows access from the entrance hallway and the other door allows access to the triage waiting area. The triage waiting area has a locked exit door leading to the main/public waiting hallway, which staff utilize when discharging patients. The triage waiting area is visible from the triage rooms when the doors are open.

Review on 05/30/19 of CPEP Unit video surveillance dated 05/06/19 revealed at approximately 10:50 PM, Patient #3 was in the triage waiting room. At approximately 10:57 PM, Patient #2 was brought into the triage waiting room from Room #2 by Staff (S), CPEP Registered Nurse via wheelchair. Patient #2 is observed dressed in a hospital gown which is hanging off her left shoulder and she is wearing an adult incontinence brief with buttocks and legs exposed. At approximately 11:00 PM, Staff (T) and Staff (CC), Hospital Patient Safety Assistant (HSPA), are standing in the triage waiting room. Staff (Y), CPEP Psychiatrist, opens the door of Room #1 and waves to Staff (T) and Staff (CC), to come to Room #1. Both Staff (T) and (CC), HPSA, leave the triage waiting room through Room #1 and shut the door. Patient #2 and #3 are left unattended. From 11:02-11:10 PM, Patient #3 is seen exposing his penis and attempting to move Patient #2's head towards his groin area. He then takes Patient #2's hand and places it on his penis. This is followed by Patient #3 positioning himself in front of Patient #2 and moving her incontinence brief to the side. At 11:11 PM, Patient #3 stands up from Patient #2 and is seen lowering his shirt to cover his groin area and Patient #2's vaginal area is noted to be exposed as Staff (S), CPEP RN, opens the door from Room #2 and enters the triage waiting room.

Review on 05/29/19 of medical records for Patient #2 and Patient #3 dated 05/07/19 revealed Staff (Y), CPEP Psychiatrist, documented that while Patient #3 was waiting in triage waiting room, he sexually assaulted a female patient (Patient #2) when staff were busy medicating another patient and the triage room door was closed. Staff (S), CPEP RN, documented that after 11 PM, RN walked into waiting room and saw Patient #3 standing over Patient #2, who was in a wheelchair. When asked what happened, he put his arms up and stated, "I didn't do anything". RN noted Patient #2's gown was observed to be pulled up with her brief pulled down.

Interview on 05/30/19 at 11:45AM with Staff (S), CPEP RN, revealed on 05/06/19 she was assigned to the triage area, along with Staff (V), Mental Health Assistant (MHA). Patient #2 and Patient #3 were both in the triage waiting room waiting to see the social worker prior to being discharged. Staff (V), MHA, went on his break at the end of his shift, prior to the next shift arriving, leaving her alone to monitor both Patient #2 and 3. Staff (S) went to attend to Patient # 21, who arrived to CPEP extremely agitated. Staff (T) and (CC), HPSA were still in the triage waiting room, but were called by Staff (Y), CPEP Psychiatrist to assist with Patient #21 in Room #1. The doors from Room #1 and #2 to the triage waiting room were closed, leaving Patient #2 and #3 alone. Staff (S) came back into the triage waiting area, finding Patient #3 near Patient #2. Although aides are assigned to the triage area, there are times that she has been alone due to not enough staff.

Review on 05/30/19 of CPEP Assignment Sheet dated 05/06/19 for the 03:00 PM to 11:00 PM shift revealed Staff (V), MHA was assigned to the triage area at 04:00 PM. Staff (S) CPEP RN, was assigned as a second triage RN. The break schedule is not completed. HPSA assignments are not included.

Review of policy "Post Integrity", last revised 09/2018, revealed when HPSA's are assigned to CPEP, they patrol all areas of the unit, protect patients, visitors and staff, "wand" patients and visitors entering CPEP, and respond to CPEP emergencies.

Interview on 05/30/19 at 01:00PM with Staff (T), HPSA revealed on 05/06/19 he was talking to Patient #3 and Staff (Y), Psychiatrist called him and Staff (CC), HPSA to Room #1 to assist with Patient #21. HPSAs in CPEP are only utilized to wand patients in triage and respond to emergencies. HPSA's do not monitor patients and do not take any assignment from nursing.

Interview on 05/30/19 at 12:30 PM with Staff (P), RN/Patient Safety Clinical Investigation Coordinator, confirmed these findings while viewing CPEP Unit video.