HospitalInspections.org

Based on interview and record review, it was determined that the hospital failed to promote and protect each patients' rights.

Findings include:

The hospital failed to ensure each patient had the right to be free from all forms of abuse or harassment. (Refer to tag A-145)

Based on interview and record review it was determined the hospital failed to ensure each patient had the right to be free from all forms of abuse or harassment. Specifically, for 1 of 11 sampled patients, who was identified as needing increased monitoring, staff left unattended and during this time an allegation of sexual assault was made. (Patient identifier's: 5 and 8.)

Findings include:

1. Patient 5 was admitted to the hospital on 6/10/19 and discharged on 6/21/19, with a diagnosis of depression.

A physician order dated 6/11/19 indicated patient 5's observation status was line of sight (LOS) while awake, due to sexually acting out.

A physician order dated 6/16/19 indicated the following, "Patient to be on a line of sight until discharged."

An incident report regarding patient 5 dated 6/14/19 revealed the following incident at approximately 6:00 PM, "..a patient went into (name of patient 5)'s room unwelcomed. Tech (technician) was grabbing Q's (observations of all patients on the unit done every 15 minutes by hospital staff) and answering a phone call. Tech went to get patient and took patient out of (name of patient 5)'s room. Tech talked to (name of patient 5) to see if she was okay but all she wanted was water. 15 minutes later (name of patient 5) started screaming that the patient raped her."

2. Patient 8 was admitted to the hospital on 6/9/19 with diagnoses which included schizoaffective disorder, bipolar, and developmental delay.

A "Witness Statement" form completed on 6/14/19 regarding patient 8 and his interaction with patient 5 revealed the following, "I took Pt (patient) to the 100 hall w/ (with) nurse (name of nurse). We asked him if he had sex w/a female Pt. and he said 'yes.' We asked if she gave him permission and he said 'no.' We then asked him if she asked him if the female pt told him to stop and he said 'yes.' We kept (name of patient 8) on a unit all alone and called police."

The following physician order dated 6/14/19 at 12:45 PM was found in patient 8's medical record, "LOS while awake - walking into female pt's rooms." (Note: This order was placed approximately five hours prior to the incident with patient 5.)

3. The hospital's "Levels of Observation" policy revealed the following information under "Line-of-Sight": "The patient should be within visual range of the assigned staff at all times."

4. On 6/26/19 at 1:57 PM, an interview was conducted with the hospital's acting director of nursing (ADON). The ADON stated patient 5 had an order to be in the line of sight of staff due to an incident between her and another adolescent patient. The ADON stated the initial order for line of sight for patient 5 was placed on 6/11/19 and was in place until 6/17/19 when she was then changed to a one to one observation status. The ADON stated line of sight meant patient 5 needed to be in staffs' vision, and the difference between line of sight and one to one was the space allowed between the staff and the patient.

On 6/26/19 at 2:43 PM, an interview was conducted with the hospital Director of Clinical Services (DCS), ADON, and Chief Executive Officer (CEO). The ADON stated patient 8 had asked staff members to get him some linen. The ADON stated the technician left the unit to get linen for patient 8 and answered the unit phone which was ringing. The ADON stated when the technician came back onto the unit; she saw patient 5 and patient 8 standing in the doorway of patient 5's room. The ADON confirmed both patient 5 and 8 were supposed to be in the line of sight of a staff member at all times. The ADON also confirmed the technician should not have left the patients unattended. The CEO stated "immediate education and in-service" was completed for hospital staff following the incident between patient 5 and 8. The ADON provided the survey team with a form which listed the following:

"6/14/19: Effective Immediately

1. There must be a tech or a nurse on each unit at all times. Patients are not to be left alone under any circumstance.

2. All doors are to be locked prior to PM shift change.

3. Techs will give each other report on the unit.

4. Techs are not allowed to visit or stay in the nurse's station

Due to patient and staff safety any violation of this directive will result in disciplinary action." The ADON stated the information above was posted and it was her expectation that staff read the form and signed the signature sheet prior to working.

On 6/26/19 at approximately 4:00 PM, an interview was conducted with the hospital ADON and CEO. The ADON stated the training that had been provided to staff was still "ongoing" and that all direct care staff had not yet received training. The ADON confirmed the education provided did not address the levels of observation.