HospitalInspections.org

Based on interview, record review, policy review and review of the Missouri State Statues, the facility failed to:
- Provide a safe environment when they failed to prevent sexual abuse between two adolescent patients (#8 and #9) of two adolescent patients reviewed for sexual abuse (A-0144).
- Ensure adequate measures were put into place to protect patients, after confirmed patient to patient sexual abuse by one patient (#8) of one patient reviewed at high risk for sexual abuse of others (A-0144).
- Complete contraband (harmful material) room checks for two patients (#25 and #26) of two reviewed (A-0144).
- Report in a timely manner, three allegations of abuse which involved six patients (#1, #8, #9, #27, #28 and #29), of three allegations of reportable abuse reviewed.
These failures had the potential to lead to continued abuse, injury and/or death, and could affect all patients in the facility.

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Patient's Rights. The facility census was 94.

The severity and cumulative effect of these systemic practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

As of 07/26/18, at the time of the survey exit, the facility provided an immediate action plan sufficient to remove the IJ by implementing the following:
- The facility added more detail to their Investigation of Institutional Abuse/Neglect Allegations Policy to include potential incidents to self report.
- Real time monitoring of all potential incidents every shift by a nursing supervisor or nursing educator.
- All staff reeducated on policies (to abuse, neglect, sexual abuse management) and tested on their knowledge of the policies, and if they do not score 100%, they will be taken off of the schedule until retention of education.
- The Sexual Abuse Management (SAM) Policy was revised to include more defining parameters for patients on SAM1 (risk of inappropriate sexual activity toward others) and SAM2 (increased risk of inappropriate sexual activity toward others) precautions.
- Real time monitoring will occur every shift by the nursing supervisor or nursing educator to review the SAM1 and SAM2 patients.
- Continued education of staff with real time monitoring of education with random selection of staff by presenting scenarios to 25 staff per week.
- The physician order form was revised for SAM1 and SAM2 to include patient admitted to a private or video monitored room, patient not allowed in another room with another patient unless the video monitor is on or staff present, room door kept open at all times, Line of Sight (LOS) precautions while awake, LOS precautions 24 hours, one-to-one (1:1, one staff assigned to one patient at all times) while awake and 1:1 for 24 hours.
- All staff will be tested on all new policies until 100% score is achieved and will not be put back on schedule until this is completed.

Based on interview, record review and policy review, the facility failed to provide a safe environment when they failed to:
- Prevent sexual abuse between two adolescent patients (#8 and #9) of two adolescent patients reviewed.
- Ensure adequate measures were put into place to protect patients after confirmed patient to patient sexual abuse by one patient (#8) of one patient reviewed, who was at high risk for sexual abuse of others.
- Complete contraband (harmful material) room checks for two patients (#25 and #26) of two patients reviewed. These failures had the potential to lead to continued abuse, injury and/or death, and could affect all patients at the facility. The facility census was 94.

Findings included:

1. Review of the facility's policy titled, "Precautionary Levels," dated 12/16/10, showed that Sexual Abuse Management 2 (SAM2) is ordered for any adolescent or child patient, who is a perpetrator of sexual assault, currently sexually acting out, or currently in treatment for sexual misconduct; has demonstrated major sexual acting out behaviors or is a sexual abuse victim with current sexual preoccupation.

Review of the facility's policy titled, "Sexual Abuse Management", revised 08/2014, showed there was no difference in the monitoring of patients placed on Sexual Abuse Management 1 (SAM1) or SAM2 (higher risk for sexually acting out behaviors or sexual assault on another) while on the unit, and defined major sexual acting-out behavior as, non-consensual fondling, inappropriate touching, such as touching others' breasts, buttocks, or genital area.

Review of the facility's policy titled, "Precautionary Levels," revised 08/27/13, contained no verbiage that increased the level of protective oversight between Suicide (thoughts of killing self) Precautions 1 (SP1) one and SP2 (higher risk for suicide) patients within the unit.

During an interview on 07/25/18 at 11:45 AM, Staff I, Interim Director of Nursing, after review of the policies, stated that with SP1, SP2, SAM1, and SAM2, the nursing interventions were the same, and the policies did not direct staff to appropriately increase the level of observation within the unit.

2. Review of Physician Orders for Patient #8 (15 year old male) showed that he was placed on SAM2 precautions on 06/13/18 at 9:15 AM.

Review of the facility's document titled, "Incident Report - Confidential Report of Occurrence," dated 06/19/18, showed that:
- Sexual incidents included fondling of the patient's sex organ(s) by another individual's hand.
- Patient #8 admitted to touching Patient #9 (13 year old male) sexually.
- The incident occurred on 06/17/18 at 1:00 PM.

Review of the facility's document titled, "Investigative Summary", dated 06/20/18, showed that Patient #9 reported that Patient #8 touched his legs, butt and penis in a sexual manner on 06/17/18, while in the dayroom.

Review of Patient #8's Physician Orders, showed that on 06/19/18 at 10:30 PM (after the incident between Patient #8 and Patient #9 was reported), he was to remain in Line of Sight (LOS, to be in constant visibility of staff at all times) observation while awake (W/A).

During an interview on 07/24/18 at 10:40 AM, Staff T, Licensed Clinical Social Worker (LCSW), stated that she was not aware of any changes to the unit or processes after the incident occurred between Patient #8 and Patient #9.

During an interview on 07/23/18 at 4:15 PM, Staff P, Mental Health Technician (MHT), stated that the only direction staff received after the incident between Patient #8 and Patient #9, was to be more aware and alert of peer to peer interaction.

During an interview on 07/24/18 at 9:25 AM, Staff R, Registered Nurse (RN), stated that both Patient #8 and Patient #9 remained on the unit, and the only changes made were that the dayroom and patient rooms be monitored more closely, and a staff member was to stay in the dayroom at all times.

During an interview on 07/23/18 at 3:45 PM, Staff O, RN, stated that the only process change made after the incident occurred between Patient #8 and Patient #9, was for a staff member to remain in the day room at all times. Staff O stated this was difficult, because RNs were left alone on the unit when staff responded to Code Green calls (overhead page to direct staff throughout the facility to respond to an aggressive, potentially violent situation on a particular unit), or when they left the unit to monitor patients who left the unit for activities.

During an interview on 07/23/18 at 3:20 PM, Staff N, MHT, stated that when patients went to the courtyard, two staff members went with them, and left the nurse alone on the unit with the remaining patients.

During an interview on 07/24/18 at 10:05 AM, Staff S, RN, stated that at times, two staff were scheduled for 22 patients, and if the RN provided care to a patient, only one staff member was left to supervise the other 21 patients.

During an interview on 07/24/18 at 2:45 PM, Staff V, Shift Supervisor, stated that after the incident between Patient #8 and Patient #9, there were no changes made to staffing.

During an interview on 07/25/18 at 3:20 PM, Staff I, Interim Chief Nursing Officer, stated that even though Patient #8 was on LOS W/A, it would be impossible for staff to watch him at all times, and that although nurses were responsible to provide safe oversight of the patients, it may not always be possible.

The facility had an incident involving inappropriate patient to patient sexual activity, which was initiated by a patient who was at high risk for sexual assault toward others. The facility failed to ensure that all staff who were responsible for patient care on the unit, were aware of interventions to prevent the potential for recurrent inappropriate sexual activity between patients, and failed to provide sufficient staff to ensure that the interventions put into place could be carried out to ensure a safe environment for all patients on the unit.

3. Review of the facility's policy titled, "Assessment for Contraband," dated 03/07/18, showed that room checks (for contraband) were assigned to a MHT on an assignment sheet for every shift during waking hours, and lighters/matches were on the list of contraband items that were not allowed at any time.

Review of the facility's document titled, "Rounding sheet for the MHTs," showed that on 07/24/18, on the shift between 7:15 AM and 3:15 PM, there was no signature of contraband room check completion for the Adult Unit on Hall Six.

Review of the facility's adult census form showed that Patient #25 was on Suicide Precautions (SP) and Patient #26 was on SP and Assault precautions.

Observation on 07/24/18 at approximately 10:30 AM, in Patient #25 and Patient #26's shared room, in the Adult Unit, showed a lighter inside a cigarette pack, which sat on the bedside table.

During an interview on 07/25/18 at 3:30 PM, Staff L, MHT, stated that on 07/24/18 she saw Staff M, House Supervisor, removed the lighter from Patient #26 and Patient #26's shared room, shortly after 3:00 PM (approximately 4.5 hours after it was initially found by the surveyor).

During an interview on 07/25/18 at 4:35 PM, Staff I, Interim Director of Nursing, stated that she realized that contraband was a problem and the MHTs should have completed their contraband checks.

Suicidal patients had access to a lighter, which could be used to self-harm, and/or harm others, placed all patients at the facility at risk for injury or death.






36473

Based on interview, record review and review of the Missouri State Statues, the facility failed to report in a timely manner, three allegations of abuse which involved six patients (#1, #8, #9, #27, #28 and #29), of three allegations of reportable abuse reviewed. This had the potential to allow for continued abuse of patients. The facility census was 94.

Findings included:

1. Review of the Missouri State Statute (RSMO) Chapter 210 Section 210.115, showed that when any physician, nurse, or hospital personnel that are engaged in the examination, care, treatment, with responsibility for the care of children, has reasonable cause to suspect that a child has been or may be subjected to abuse, that person shall immediately report to the division. No internal investigation shall be initiated until such a report has been made. As used in this section, the term "abuse" included abuse inflicted by any person. The reporting requirements under this section are individual, and no supervisor or administrator may impede or inhibit any reporting under this section.

2. Review of the facility's abuse/neglect self-report dated 06/25/18, made to the Missouri Department of Health and Senior Services (DHSS), showed on 06/22/18 at 3:38 PM, Patient #1 (24 year old male) reported to Staff M, Nursing Supervisor, that Staff J, Mental Health Technician (MHT), sexually abused him on a previous admission. The self-report showed the facility did not report the allegation to DHSS for more than 24 hours after the patient reported the alleged abuse.

Review of an Incident Report completed on 07/14/18, showed Patient #27 (17 year old male) exposed his penis to Patient #28 (17 year old female) and Patient #29 (15 year old female). Patient #28 and #29 reported this to a Charge Nurse, but the incident was not reported to DHSS.

Review of facility's document titled, "Investigative Summary", dated 06/20/18, showed that Patient #9 (13 year old male) reported that Patient #8 (15 year old male) touched his legs, butt and penis in a sexual manner. The facility determined that the patient to patient contact was consensual, and it was not reported to DHSS.

Review of an undated facility document titled, "Incident Report-Confidential Report of Occurrence Inpatient Services," showed that sexual incidents with oral, vaginal or anal penetration, or fondling of the patient's sex organ(s) by another individual's hand, sex organ, or object, were not reportable to DHSS

During an interview on 07/25/18 at 9:45 AM, Staff H, Quality/Risk Manager, stated that:
- She performed the investigations related to the incidents that involved Patients #1, #8, #9, #27, #28 and #29.
- The facility had time to report Patient #1's allegation to DHSS during working hours, but did not.
- She was unaware that minors (child under age of 18) could not consent to sexual activity with another minor.
- She and other members of administration made the decision not to report the incidents related to Patients #8, #9, #27, #28 and #29 to DHSS.
- The Incident Report failed to direct staff to report sexual incidents to DHSS.

During an interview on 07/26/18 at 11:30 AM, Staff E, Interim CEO, stated that the facility misinterpreted the Missouri Statues and failed to appropriately report the incidents to DHSS.


39147




36473