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A. Based on Hospital policy review, clinical record review, and staff interview, it was determined that, for 2 of 4 (Pt. #s 1 and 2) clinical records reviewed for patients involved in sexual activity during the hospitalization, the Hospital failed to ensure the patients were monitored for safety, as required by physicians' orders.

Findings include:

1. Hospital policy #MSH-PSY-D-059 entitled, "Behavioral and Health Precautions on the Inpatient Psychiatric Unit," reviewed on 9/1/10 at approximately 10:20 A.M. requires, "There are eight types of precautions that may be ordered; all ensure the patient is checked every 15 minutes:.. Admission Precautions... Suicide Precautions... Assault Precautions... Sexually Acting Out... Close Observations... One-to-Ones... may be ordered to prevent a patient from harming self or others... and requires staff at arm's length from the patient at all times."

2. The clinical record for Pt. #1 also included a physician's order dated 7/26/10 for suicide, close observation, and assault precautions. The record also included an order dated 7/28/10 for sexual acting out precautions. All of the above required the patient to be checked every 15 minutes. The record lacked documentation that Pt. #1 was monitored/checked every 15 minutes as required by physicians' orders. Examples are:
* 7/26/10 -no documented check at 4:45 A.M.
* 7/28/10- no documented checks at 11:00 and 11:15 P.M.
* 7/29/10- no documented checks at 4:00 and 4:15 A.M.
* 8/3/10- no documented checks from 4:15-4:45 A.M.
* 8/5/10- no documented checks at 8:30 P.M.

3. The clinical record for Pt. #2 reviewed on 9/1/10 at approximately 3:10 P.M., included that this was a 46-year-old male admitted 7/22/10 with a diagnosis of Mood Disorder, Not Otherwise Specified. The record included documentation of physician's orders dated 7/22/10 for suicide precautions. The record lacked documentation the the checks were completed every 15 minutes on 7/2410, 7/26/10, 7/28/10, and 7/29/10.

4. The above findings were confirmed during an interview with the 6 East Unit Director, on 9/2/10 at approximately 8:30 A.M.


Surveyor: 07105

B. Based on policy review, clinical record review and staff interview, it was determined that for 1 of 2 clinical record (Pt. #5) of an alleged perpetrator of sexual inappropriateness, the Hospital failed to ensure the alleged perpetrator was placed on 1:1 monitoring in accordance with policy.

Findings include:

1. Hospital policy #MSH-PSY-D-072 entitled, "Protection from Actual or Perceived Sexual Harm," reviewed on 9/1/10 at approximately 10:20 A.M. requires, "For reported/suspected sexual contact or abuse the following steps will be followed... provides 1:1 continuous observation until the validity of the accusation can be determined."

2. The clinical record for Pt. #5 was reviewed on 9/2/10 at approximately 9:00AM. Pt. #5, a 26 year old male was admitted to the 6th floor psychiatric unit on 8/3/09 from the emergency department with a diagnosis of Bipolar Disorder Manic. The patient arrived to the ED escorted by the Chicago police after because he was standing in the middle of the street throwing things at cars and taking off his clothes. Initial orders, dated 8/3/10 included CO with every 15 minute safety checks. The psychiatric exam dated 8/3/09 included information that Pt. admitted with auditory hallucinations and denied any suicidal or homicidal ideation. A nurse's note dated 8/6/09 at 9:23AM, included information that Pt. #5 was sexually inappropriate in the hallway. Medication was administered and the Pt. was redirected. On 8/6/09 at 10:32PM an RN documented that Pt. #5 admitted to inappropriate consensual activity yesterday (8/5/09). Pt. #5 was not placed on 1:1 observation pending completion of an investigation in accordance with policy.

3. The above finding was confirmed by the Director of the Psychiatric Unit during an interview on 9/2/10 at approximately 11:00AM.

A. Based on Hospital policy review, clinical record review, staff interview, and review of the Hospital's Action Plans, it was determined that, for 4 of 4 (Pt. #1, 2, 3, and 5) clinical records reviewed for patients involved in sexual activity during the hospitalization, the Hospital failed to ensure actions were implemented timely and failed to ensure all problems were identified.

Findings include:

1. Hospital policy #MSH-ER-C-007 entitled, "Care of the Sexual Assault Survivor," reviewed on 9/1/10 at approximately 10:55 A.M., required, "the physician or nurse must notify the local law enforcement agency of that jurisdiction. It is the patient's choice as to whether to file a police report.

2. The clinical record for Pt. #1, reviewed on 9/1/10 at approximately 12:00 P.M., included that this was a 48-year-old female admitted 7/26/10 with a diagnosis of Bipolar Disorder, Not Otherwise Specified. The record included documentation that Pt. #1 was admitted from a nursing home, and had exhibited behaviors of running in the halls half dressed, and making suicidal statements. The record included documentation in the nursing note dated 7/30/10 at 9:43 P.M., that at 5:00 P.M. Pt. #1 approached the mental health technician(MHT), E#1 informing her that Pt. #1 had sex in the male restroom with male peer (Pt. #2). The record included documentation that an OB/GYN consult was not ordered until 8/2/10 at 12:51 P.M.(3 days after the sexual activity incident occurred).

3. The OB/GYN physician's orders dated 8/2/10 at 3:20 P.M. included: Urine pregnancy tests, urine Chlamydia, GC (gonorrhea). The record lacked documentation to indicate that a urine pregnancy was completed following the incident, or documentation describing why it was not completed. In addition, the gonorrhea and chlamydia tests were not completed until 8/4/10 (5 days following the incident).

4. An OB/GYN consult was completed for Pt. #1 on 8/2/10 at 3:20 P.M. for a chief complaint of "Sexual Abuse by another patient ... few days back, she states he forcefully had anal and vaginal intercourse with her ... pt. expressed concern about being pregnant and rape charges (claims she is scared about harm from the assailant on doing so)..." There was also no documentation to indicate that a law enforcement agency was notified.

5. In an interview with the Chief Safety Officer (CSO) on 9/1/10 at approximately 10:45 A.M., when inquiring if the police had been notified, the CSO stated that the Hospital did not notify the police department because Hospital determined through investigation that the sexual contact between Pt. #1 and Pt. #2 was consensual, and Pt. #1 did not want to file a report.

6. In addition, the clinical record for Pt. #1 also included a physician's order dated 7/26/10 for suicide, close observation, and assault precautions. The record also included an order dated 7/28/10 for sexual acting out precautions. All of the above required the patient to be checked every 15 minutes. The record lacked documentation that Pt. #1 was monitored/checked every 15 minutes as required by physicians' orders. Examples are:
* 7/26/10 -no documented check at 4:45 A.M.
* 7/28/10- no documented checks at 11:00 and 11:15 P.M.
* 7/29/10- no documented checks at 4:00 and 4:15 A.M.
* 8/3/10- no documented checks from 4:15-4:45 A.M.
* 8/5/10- no documented checks at 8:30 P.M.

7. The clinical record for Pt. #2 reviewed on 9/1/10 at approximately 3:10 P.M., included that this was a 46-year-old male admitted 7/22/10 with a diagnosis of Mood Disorder, Not Otherwise Specified. The record included documentation of physician's orders dated 7/22/10 for suicide precautions. The record lacked documentation the the checks were completed every 15 minutes on 7/2410, 7/26/10, 7/28/10, and 7/29/10.

8. The above findings were confirmed during an interview with the 6 East Unit Director, on 9/2/10 at approximately 8:30 A.M.

9. The Hospital's Action Plan for the root cause analysis summary dated 8/5/10 failed to identify incomplete documentation to evidence that safety checks for were completed every 15 minutes as required by physicians' orders for Pt #1 and Pt. #2.


Surveyor: 07105

10. The Hospital 's Action Plan, in response to a sentinel event on 8/5/09, was reviewed on 9/1/10 at approximately 1:00PM. On 8/6/09 a 24 year old female patient (Pt.#3) reported to a 6 East RN that Pt. #3 had consensual intercourse with a 27 year old male peer (Pt. #5) in her room on August 5th around 3:30PM. The report (video surveillance time line) documented by the Hospital and reviewed by the surveyor on 9/1/10 at approximately 1:30PM included information that a male peer (E#5) snuck into the female patient's room (E#3) three times (once at 3:30PM for a few seconds, and at 3:32PM for 12 minutes and again at 4:40PM for 9 minutes). According to the report, the guardian of the Pt.(Pt. #3) was contacted. The Hospital's Action Plan included:

*Re-analysis of Action Plan will be submitted February 2010 to Quality Department. This was not implemented according to the Director of the Psychiatric Unit. In addition, the Action Plan failed identify that Pt. #3's physician ordered a gyne exam on 8/7/09 which was not obtained.

11. The above finding was confirmed by the Director of the Psychiatric Unit during an interview on 9/2/10 at approximately 10:00AM.