HospitalInspections.org

Based on interview and document review, the facility failed to report an allegation of rape to the State Agency (SA) for 1 of 1 patient (P1) reviewed for allegations of staff to patient abuse.

Findings include:

P1's medical record indicated P1 was admitted 9/8/23, where she remained on an in-patient psychiatric unit. P1's diagnoses included schizoaffective disorder bipolar type, and post-traumatic stress disorder (PTSD).

P1's progress notes indicated the following:

-On 9/15/23 at 3:15 a.m., P1 reported to facility psychotherapist she "hurt- bruises from an incident at dawn." The note further indicated P1's report of potential abuse appeared to be a delusion.

-On 9/19/23 at 11:09 p.m., P1 reported to nursing staff she had been raped.

-On 9/20/23 at 9:53 p.m., P1 was perseverating on the idea she was "raped" last night. P1 reported her whole body was sore because of the rape.

-On 9/21/23 at 3:04 p.m., P1 had been escorted for a walk in the hallway and the used phone. P1 immediately accused a male peer of rape. P1 was re-directed back to her room after phone use. P1 was pleasant with this female nurse but was very suspicious of any male staff.

-On 9/21/23 at 10:20 p.m., P1 was withdrawn to her room for almost the entire shift, only coming out to fulfill needs and take a phone call. P1 was cooperative with staff, but not interact with peers. P1's mood was labile and anxious. P1 continued to perseverate on the belief that she and a peer had been raped. P1 became angry and irritable when out in the milieu and seeing male peers stating, "They raped me."

-On 9/22/23 1:20 p.m., P1 was irritable, angry and remained convinced she had been sexually assaulted by male staff and peers. "They came in here and took turns with me!"

-On 9/22/23 at 10:30 p.m., P1 continued to talk to staff about being "raped" by a male staff and a certain male peer.

-On 9/27/23 at 9:07 a.m., P1 stated her toes were sore from being stepped on during the rape.

-On 9/28/23 at 3:10 p.m., P1 stated she continued to be raped here and told this RN writer another patient was raped too, but they gave that patient "stuff that she doesn't remember."

-On 9/29/23 at 10:36 a.m., P1 continued to persist with the idea she has been raped by staff. "I am not crazy, I was drugged and brought in here and they just did what they wanted. I couldn't get out of bed myself for several days. That's why I am all bruised. My insides feel like they're falling out. I want a physical. Tell her [provider] that if I don't get one I will file a report for neglect!"

-On 10/4/23 at 11:10 p.m., P1 wanted her room locked while in the shower, she was paranoid about people hiding to rape her.

-On 10/5/23 at 2:49 p.m., P1 remained delusional, thinking her stomach was sore because "someone has stomped on it when they raped me." P1 again reported nausea this morning, but on further questioning P1 stated, "I am sick to my stomach because of the rape."

-On 10/9/23 at 2:29 p.m., P1 stated that she was "sore all over from being raped."

-On 10/18/23 at 12:02 p.m., P1 stated, "My gut and breasts still hurt." Nurse Practitioner (NP) was aware of "gut pain. P1 yelled frequently about being raped."

-On 10/18/23, at 8:47 p.m., P1 was interviewed by local law enforcement regarding the allegations of sexual assualt.

P1's medical record was reviewed and lacked evidence P1's allegation of sexual assualt was reported to the SA.

On 10/24/23 at 1:10 p.m., registered nurse (RN)-A stated she was the nurse manager for the adult psychiatric unit P1 was admitted to. RN-A stated she was not aware of P1's repeated allegations of rape until 10/18/23, when local law enforcement arrived to interview P1. RN-A stated this initiated an investigatory step and risk management was contacted to provide further instructions. RN-A stated all allegations of abuse including the allegations of rape which P1 had repeatedly made should have initiated an immediate internal investigation.

On 10/24/23 at 1:20 p.m., RN-B stated she was aware of P1's repeated allegations of rape. RN-B stated P1's allegations of rape were thought to be delusions, so an internal report had not been filled out by any staff who had heard or witnessed P1 making the allegations. RN-B stated all allegations of abuse including the allegations of rape which P1 had repeatedly made should have been immediately reported to the nurse manager and an internal report should have been filled out.

On 10/24/23 at 3:23 p.m., the system program manager, regulatory and accreditation (SPMRA)-A stated if there was an allegation of sexual abuse, she expected staff to follow the policy which included escalating the allegation to their leaders and also file an internal report which would initiate an internal investigation. SPMRA-A stated mental health was challenging to differentiate delusions verses reality; however, the policies and procedures were in place for patient safety and in this case, proper procedure was not followed. SPMRA-A stated an investigation was initiated on 10/19/23 related to the allegation. The allegation was determined by leadership to be unsubstantiated, and the allegation would not be reported to the SA.

The facility policy Vulnerable Adult, Identifying and Reporting Suspected or Actual Maltreatment dated 8/13/21 directed facility staff will be alert to signs of vulnerable adult abuse, maltreatment and/or neglect in our patient population. Suspected or actual maltreatment of a vulnerable adult patient while receiving services will be timely and properly evaluated, reported and documented. The policy lacked identification of "reason to believe" processes for determination of VA reporting decisions.

The facility policy Safety Event Reporting, Review and Management dated 9/23/22 directed reporting of a patient safety event is the responsibility of every individual who discovers or has knowledge of a patient safety event. An event is reported and submitted using the electronic safety event reporting system. All safety events will be reviewed, and appropriate measures will be taken to prevent reoccurrence when necessary. Fairview leadership will determine if an individual event meets requirements for external reporting to the Minnesota Patient Safety Registry or reviewable by The Joint Commission. The policy further directed the proper steps and procedure which included, when a patient safety event occurs, immediate evaluation of identified hazards and risks must be conducted, along with the identification of actions following a safety event to prevent further patient harm and reduce risks. Notify leadership and continue to manage care needs and concerns of the patient and staff. Complete safety event report in event reporting software by end of shift. This will automatically alert leadership of the occurrence.