HospitalInspections.org

Based on medical record review, document review and interview it was determined the facility failed to follow policies and procedures in reporting incidents in two (2) out of thirty (30) patients, patient #2 and #3. This failure has the potential to negatively impact all patients at the facility.

Findings include:

1. A review was conducted of patient #2's medical record. The patient was admitted on 08/24/20 with a diagnosis of major depressive disorder. On 02/16/21 it was documented by Registered Nurse (RN) #1, "(Patient #2) displayed escalating and oppositional behavior most of this shift; it was reported and witnessed, that male peer, (Patient #3) had touched/groped her chest in the hallway ..."

2. A review was conducted of patient #3's medical record. The patient was admitted on 07/17/20 with a diagnosis of post-traumatic stress disorder. On 02/16/21 it was documented by the physician, "It was reported and witnessed that this patient touched/groped a female peer, (patient #2) over the chest/breast area ..."

3. The incident report log was reviewed for the past two (2) months. No incident reports were reported for 02/16/21.

4. A review was conducted of policy titled "Incident Reporting and Severity Classification-Acute" dated 02/2020. The policy states in part: "Procedure: 1.0 Any facility staff member who witnesses, discovers or has direct knowledge of an incident should complete an incident report as soon as practical after the incident is witnessed or discovered and/or before the end of the shift/workday. 2.0 An incident Report should be filed for any incident including, but not limited to: An undesirable event occurs which appears inconsistent with normal patient care. 7.0 Definitions- Boundary Transgressions- Sexual Familiarity- inappropriate acts of sexual intimacy by patient to another patient..."

5. An interview was conducted with the Director of Quality on 02/22/21 at 1:00 p.m. He confirmed there were no incident reports filed on 02/16/21 involving sexual misconduct by patient #2 or patient #3.

6. A telephone interview was conducted with BHT #1 on 02/22/21 at 2:01 p.m. He stated regarding the incident involving patient #2 and patient #3, "They were both on social separation. I was in the nursing station. When I walked back over to the hallway they were in, (patient #3) was groping (patient #2). It was definitely mutual. I immediately told the RN and two (2) therapists who were in their office. I did not fill out an incident report, I didn't know I had to."

7. A telephone interview was conducted with the Program Manager of Unit Two (2) West on 02/23/21 at 1:07 p.m. Regarding the sexual misconduct incident involving patient #2 and patient #3 she stated, "The way I would interpret it is 'sexually inappropriate behavior' and we would normally do an incident report. I don't know if it was just missed, or they didn't think to do one."