HospitalInspections.org

Based on clinical record review, facility documents staff interview and policy review, the hospital failed to ensure 1 of 4 patient's right to be free from abuse or harassment. The interdisciplinary team failed to develop a care plan with interventions to address Patient #4 behavior of sexual harassment, and manage risk factors upon admission.

The findings include:

Clinical record review for Patient #4 revealed the 17 year old patient was admitted to the Hospital on 03/01/2015 under the Baker Act for suicidal ideations; admitting diagnoses includes depressive disorder and Attention Deficit Hyperactivity Disorder. Review of an initial intake assessment dated 02/01/15 and Psychiatric Evaluation dated 02/02/15 revealed the patient had recently been expressing violent tendencies towards others and was recently arrested for sexual harassment and aggravated assault. Mental examination revealed the patient is alert and oriented x 3 with limited judgement and insight. An admitting physician's order/Initial Treatment Plan dated 02/01/15 specifies observation every 15 minutes and special precaution for suicidal, assault, homicidal and elopement. An interdisciplinary Master Treatment Plan for Patient #4 dated 02/03/15 failed to identify specific intervention to manage the patient recent history of sexual harassment behaviors reported upon admission.

A review of the hospital documents regarding an occurrence with Patient #4 revealed; on 02/16/15 Patient #3, a minor, alleged having oral sex with Patient #4 on 02/15/15 during recreational therapy group. Both patients' are under observations every 15 minutes. The 15 minute observation records for Patients #3 and #4 reveal both patients were present at recreational therapy from 12:15 PM to 12:45 PM on 02/15/15.

Facility documents of the alleged occurrence reveal Video Camera in the location shows: Patient #3 entered back room to Recreation Room at 12:40 PM.; Patient #4 entered back room to Recreation Room at 12:41 PM.; Patient #3 left the back room at 12:46 PM; Patient #4 left the backroom at 12:50 PM.

The alleged event occurred during 12:40 PM. and 12:50 PM. on 02/15/15. Why both patients departure was not observed by staff conducting recreational therapy, nor those conducting therapy, direct visual observations is undetermined, however the lack of staff action is evident of the failure to adequately supervise/monitor high risk patients.

The hospital Risk Manager stated on 04/28/15 at 2:30 PM. during recreational therapy, Patients #3 and #4 were not visible to the Recreational Therapist and the Mental Health Technician conducting the activity when they were in the computer room on 02/15/15. Security video recording of the recreation room on 02/15/15 did not include inside surveillance of the computer room (back room).

The facility policy titled: Prevention of sexual aggression/Victimization requires an assessment to identify patients who are at risk for sexual aggression or victimization. The patient admission process includes screening for sexual aggression/victimization to be completed upon admission. High risk patient is identified on the high risk alert and patient observation sheets. When a patient is identified as exhibiting boundary violation or high risk behaviors the treatment team establishes interventions as soon as possible and observation levels are changed as necessary to maintain safety.

Based on clinical record review of facility event record, staff interview and policy review, the hospital failed to develop a nursing care plan with nursing interventions to address sexual behaviors identified during an admission assessment and after an alleged sexual occurrence with a peer. This failure affected 1 of 4 sampled patients (Patient #4).

The findings include:

Clinical record review for Patient #4 revealed the 17 year old patient was admitted to the Hospital on 03/01/2015 under Baker Act for suicidal ideations, with admitting diagnoses of depressive disorder and Attention Deficit Hyperactivity disorder. Review of an initial intake assessment 02/01/15 and Psychiatric evaluation dated 02/02/15 reveal the patient had recently been expressing violent tendencies towards others and was recently arrested for sexual harassment and aggravated assault. Mental Examination on 02/01/15 revealed the patient is alert and oriented x 3 with limited judgement and insight.

An admitting physician's order/Initial treatment plan dated 02/01/15 specifies observation every 15 minutes and special precaution for suicidal, assault, homicidal and elopement. An interdisciplinary Master Treatment Plan for Patient #4 dated 02/03/15 failed to identify specific intervention to manage the patient ' s recent behaviors of sexual harassment as reported upon admission.

A review of the hospital record of an event revealed on 02/16/15 Patient #3 a minor, alleged having oral sex with Patient #4 on 02/15/15 during recreational therapy group. The patients' observations every 15 minutes record reveal both patients were present at recreational therapy at 12:15 PM to 12:45 PM on 02/15/15.

The hospital Risk Manager stated on 04/28/15 at 2:30 PM. during recreational therapy, Patient #3 and #4 were not visible to the Recreational Therapist and a Mental Health Technician when they were in a computer (back room to Recreation Room) on 02/15/15. Security video recording of the recreation room on 02/15/15 did not include surveillance of the computer room (back room).

In an interview with the Director of Nursing (DON) on 04/28/15 at 2:30 PM, the DON reviewed the clinical record and stated the care plan does not include the patient ' s sexual behavior history. Surveyor review did not disclose, nor does the plan contain approaches to manage sexual risk factors.

During an interview with the RN in charge of the Adolescent Unit, on 04/28/15 at 3:45 PM, the nurse stated a patient who exhibits inappropriate sexual behavior/ boundary is ordered special precaution and the patient is closely observed when interacting with peers.

The facility policy titled: Prevention of sexual aggression/Victimization requires an assessment to identify patients who are at risk for sexual aggression or victimization. The patient admission process includes screening for sexual aggression/victimization to be completed upon admission. High risk patient is identified on the high risk alert and patient observation sheets. When a patient is identified as exhibiting boundary violation or high risk behaviors, the treatment team establishes interventions as soon as possible and observation levels are changed as necessary to maintain safety.