HospitalInspections.org

Based on document review and interview, the facility failed to ensure all patients were free of all forms of abuse from other patients at the facility and ensure all allegations of patient abuse and neglect were thoroughly and objectively investigated for one occurrence (patient #1).

Findings include:

1. Review of the policy/procedure reporting of Adverse and Unanticipated Patient Safety Events (approved 5-13) indicated the following: "At the time of completion of the report, complete information concerning the event and/or outcome may not be available. The purpose of the report is not to determine error or arrive at judgement concerning the facts but to trigger an investigation, which will produce whatever conclusion / outcomes are appropriate after a complete review of the facts."

2. Review of the policy/procedure Handling of Sexual Complaints Involving Patients (approved 10-16) indicated the following: "All allegations of a sexual nature will be taken seriously and will be reported by unit staff or manager to the proper authorities... as soon as staff become aware of the allegations... Document the facts in the electronic medical record. For incidents involving adults: (a) Security must be notified ASAP (as soon as possible) at all times for directions. The Security Investigator will direct the investigation and determine when / if the police are to be notified..."

3. At 1615 hours on 11-2-16, the director of quality, staff A3 indicated the security staff A7 and A10 were the network security staff responsible for investigating all patient allegations of a sexual nature.

4. Review of the MR entry for patient #1 on 9-13-16 at 0930 hours by charge nurse, staff N10 indicated the following: "Pt (patient #1) reported to staff member that a... pt (patient #3), that is now discharged, made... (patient #1) make out with... (patient #3) in the group room Sunday evening. Security notified."

5. Review of the MR entry for patient #1 on 9-13-16 at 1027 hours by social worker, staff A8 indicated the following: "CM (case manager) met with pt (patient #1) on unit. It was reported to CM when he/she arrived on unit by mental health specialist, staff N19 that pt (patient #1) was making claims of inappropriate sexual contact with another pt (patient #3)... CM and pt (patient #1) discussed the accusations and staff N10 made report to officer (staff A9) and officer will be making a report...CM spoke with pt's [family member] FM11 on the phone... CM also informed FM11 of the accusations pt (patient #1) made. FM11 id (indicated) that it sounded "strange" and pt (patient #1) probably felt comfortable to tell now that the other patient (patient #3) is gone... "

6. Review of the 9-11-16 Every 15 Minutes Safety Checks for patient #s 1, 2 & 3 indicated all three individuals were present in the group room at 2030 and 2045 hours and indicated patient #1 and #3 were present in the group room at 2115, 2130, and 2145 hours.

7. Review of administrative documentation on 9-13-16 at 1005 hours by security officer, staff A9 failed to indicate the security staff conducted an interview with patient #1 or #2 at the time of the report. The report by officer A9 (dated 9-14-16 at 0734 hours) failed to indicate that patient #1 reported allegations of inappropriate sexual misconduct by patient #3 including a description of the sexual behavior experienced by patient #1 or indicate a network security investigator (staff A7 or staff A10) with the responsibility for investigating all allegations of sexual misconduct was notified of the report.

8. At 1115 hours on 11-3-16, the social worker and case manager for patient #1, staff A8 confirmed the security staff A9 conducted an interview with patient #1 on 9-13-16 at 0930 hours and confirmed the 9-13-16 administrative documentation failed to indicate an interview with patient #1 was conducted. Staff A8 confirmed the administrative documentation failed to indicate the allegations documented in the MR for patient #1 were investigated by staff A9.

9. At 1410 hours on 11-2-16, the director of quality, staff A3 confirmed the administrative documentation by security staff A9 indicated an interview with patient #3 was not conducted due to the patient having been discharged before the facility was notified of the allegations of inappropriate sexual behavior. Staff A3 confirmed that the administrative documentation failed to indicate an investigation was conducted into the patient's allegations of sexual misconduct by security investigator A7 or investigator A10 before the event was closed on 9-15-16 by the risk management and regulatory compliance officer, staff A6, and confirmed that no other documentation was available.

Based upon document review and interview, the registered nurse failed to supervise the care of all behavioral health unit patients and ensure documentation of patient observations was maintained for 1 of 10 medical records (MR) reviewed (patient #2).

Findings include:

1. The policy/procedure Fifteen Minute Observation (approved 6-15) indicated the following: "Observe each patient every 15 minutes at a minimum while on the Behavioral Health units... Document the patient's location every 15 minutes on the Patient Safety Record."

2. Review of the MR for patient #2 failed to indicate a Patient Safety Record dated 9-12-16 was available.

3. At 1110 hours on 11-3-16, the nursing manager, staff A4 confirmed the MR for patient #2 lacked documentation on 9-12-16 indicating the every 15 minute checks were performed.