HospitalInspections.org

Based on record review, and interview the facility failed to keep one of one patients (P-1) on 2:1 observation status free from harm and failed to conduct an incident investigation for one of one patients (P-2) involved in an incident resulting in harm of a patient and the potential for further incidents to occur with all patients. Findings include:

1. Failure to monitor and intercept self-harming behaviors for a patient with a self-harming diagnosis. See A-0144.

2. Failure to conduct an investigation of an allegation of sexual misconduct of a patient who could not legally consent. See A-0145.

Based on record review and interview the facility failed to provide care in a safe-setting for one of one patients (P-1) reviewed for self-harm resulting in the patient self-harming and requiring hospitalization. Findings include:

On 3/27/2024 at 1520, Assistant Director of Nursing/R6 Unit Manager, staff G was queried after record review of video from 2/28/2024 and 3/25/2024 if staff were accountable for P-1. Staff G watched video documentation of RCAs not being within close proximity of P-1 and having cell phone use while on 2:1 precaution for P-1. Staff G was queried if staff were following policy of 2:1 supervision for P-1. Staff G stated, "they have all been educated on supervision and the policy of no cell phone use while on the unit...2:1 supervision is to be one arm length away at all times for P-1...No, they are not following policy." Staff G was then asked if P-1 could have opportunity to ingest or possess objects if the staff were not within one arm ' s length from P-1. Staff G responded, "they all know that they are to be close to P-1 and watching her at all times...I have reviewed the policy multiple times with staff about cell phone use and monitoring of patients."

On 3/27/2024 at 0900 a record review of P-1 video footage for 2/28/2024 and 3/25/2024, the two most recent dates of hospitalization for insertion of foreign objects / ingestion of foreign objects revealed the following (*Note video surveillance is for common areas only. Video surveillance is not permitted in patient room, bathrooms, or shower areas.):

On 2/28/2024 at 11:53:12 P-1 is observed at a doorway with RCAs (Resident Care Associates) on the opposite side of the hallway approximately 5 ft away from P-1.

On 2/28/2024 at 12:00:18 P-1 was observed at the nursing station with assigned RCAs greater than 10 ft away from P-1. RCAs did not view P-1 during that time.

On 2/28/2024 at 12:45:48 P-1 entered dining room area. RCA was observed looking at his phone and not viewing P-1.

On 2/28/2024 at 12:51:53 P-1 is observed with food tray. RCA is observed looking at cell phone behind P-1. Second RCA is observed following approximately 7 ft behind P-1.

On 2/28/2024 at 1:50:59 pm patient was approximately 10 feet away from RCAs assigned to P-1. P-1 walked into a room at 1:52 pm without RCAs assigned to P-1. Multiple staff and patients were observed in between P-1 and assigned RCAs. RCA's were not within two arms length of P-1.

On 3/25/2024 at 2:12:00 pm P-1 was observed approximately 15 feet away from RCAs and continues to walk away from assigned RCA ' s 2:1. P-1 walks into the day room RCA sits down as P-1 is approximately 6 ft away. Both RCAs are seated away from P-1. Both RCAs are observed to be distracted not viewing P-1 at 2:14:23 PM. P-1 exits day room at 2:15:30 RCA gets up once she cannot view P-1.

On 3/27/2024 review of personnel files revealed completed training on patient monitoring and recent re-education on cell phone use in January of 2024.

Further review of documentation provided for P-1 current hospitalization included a problem list in the current outside facility hospitalization records dated 3/26/2024. The following was documented for 7 previous hospitalization stays and current hospitalization stay. Under problem list the following was documented: Foreign body alimentary tract 03/08/2023, 03/30/2023, Acute cystitis with hematuria 03/30/2023, Retained foreign body of vagina 03/30/2023, Foreign body in bladder 03/30/2023, Complicated UTI (urinary tract infection) 05/26/2023, Foreign body (FB) in soft tissue 06/20/2023, Foreign body GU tract 06/28/2023, Gastric foreign body 07/07/2023, UTI (urinary tract infection) 07/07/2023, Ingestion of foreign body 08/25/2023, Foreign body in urinary tract 09/14/2023, Foreign body in bladder and urethra 03/25/2024.

P-1 was also hospitalized in 11/2023 for insertion/ingestion of foreign objects.

On 3/27/2024 at 1400 record review of P-1 medical record revealed the following, "Documentation on 3/25/2024 at 1300 by medical physician staff W stated, "Patient seen with RCA and (staff CC) psychiatrist. Patient (P-1) reports inserting ceiling tile and metal pieces from ceiling in her vagina and urethra on Friday. Notes she previously inserted waist band from brief and pieces of socks."

On 3/27/2024 at 1450 an interview was conducted with staff G the Assistant Director of Nursing / R-6 Unit Manager. Staff G was queried why P-1 had been at 3 documented different hospitals in less than 6 months. Staff G stated, "We send (P-1) to whatever hospital is willing to accept her." Staff G stated, "We make sure there is a physician at the outside facility that can handle her issues such as gastroenterology or urology...It depends on what the issue is at the time."

On 3/27/2024 at 1545 a record review occurred of policy number 221, titled, "Levels of Supervision/Precautions," dated 04/18/2022 (with a recent revision date of 3/14/2024). According to the policy under subtitle, "Assigned RCA/LPN," it states, "37. Remains with patient on 1:1 Routine supervision, within arm length at all times including showering, bathing, and toileting unless otherwise ordered by the charge nurse or physician. Maintaining direct and continuous observation of the patient including continuous visualization of the patient ' s face. 38. Remains with the patient on 1:1 2 Arm Length continuous visual observation (CVO) supervision within two to three arm's length at all times, including showering, bathing, and toileting, unless otherwise ordered by the physician. Maintaining direct and continuous observation of the patient including continuous visualization of the patient ' s face. This 1:1 2 Arm's Length (CVO) requires one staff for one patient and q15 minutes documentation. The assigned staff will remain alert to the potential for behaviors that may be injurious to the patient or others, take every precaution to ensure safety of the patient/others and to seek timely evaluation when there is a change in the patient ' s condition that warrants reassessment of the patient ' s needs."

Based on interview and record review, the facility failed to follow policy by failing to initiate a prompt and through investigation in 1 (P-2) of 1 patients reviewed for sexual abuse allegations resulting in an increased risk of harm for all patients. Findings include:

Record Review:
On 3/26/24 between the hours of 1330 and 1530 and on 3/27/24 between the hours of 0800 and 1100, P-2's clinical record, the Incident Report Log and related documents were reviewed pertaining to the allegation of patient-to-patient sexual abuse involving P-2, and revealed:
1. P- 2 was 20 years old female, with a guardian.
2. 2/29/24 at 1049, P-3 was found in bathroom with P-2 who was naked from the waist down. P-2 escorted back to unit; RN staff O notified of incident. RN staff spoke with P-2 regarding the incident and P-2 admitted that the male patient "entered her" causing her vaginal discomfort (P-2 has guardian). Medical doctor, social worker and psychiatrist were notified immediately, and an incident report initiated.

Interviews:
1. Interview on 3/26/24 at approximately 1000 with Patient Rights Officer Staff E revealed that an investigation of sexual incident involving P-2 and P-3 on 2/29/24 was NOT conducted. Staff E stated an investigation was not conducted as information on forms included statements that sexual encounter was "consensual". Staff E stated he was unaware that P-2 had a guardian.
2. Interview on 3/27/24 at approximately 1100 with Quality Staff B confirmed the Recipient Rights office is responsible to investigate all incidents of sexual abuse per facility policy.

Policy:
1. On 3/27/23 at 1000 record review of Policy titled, "Abuse and Neglect: Definitions and Reporting, dated 12/116/23 states: "All allegations of patient abuse/neglect shall be investigated..."
2. On 3/27/24 at 1015, record review of, Policy titled, "Incident Reporting" dated 10/16/23 defines "Inappropriate Sexual Act(s): 1 Between patients, if the Clinical Team has determined that one or more cannot consent...2. Between patients, if one or more has a Court-appointed guardian..."