HospitalInspections.org

Based on record review and interview the facility failed ensure 2 of 2 medical records reviewed were accurate and complete (Patient #'s 1 and 2).

Findings include:
Patient ID # 1 was admitted a the above facility on 4/26/12 for psychiatric problems in the Psychiatric Intensive Care Unit (PICU) and was discharged on 5/8/12.
Patient ID # 2 was admitted a the above facility on 4/26/12 for psychiatric problems in the Psychiatric Intensive Care Unit (PICU) and was discharged on 5/16/12.

Review of physican's order dated 4/26/12 and 5/4/12 for patients 1 and 2 on 6/13/12 revealed they were on every 15 minutes monitoring.

Review of incident/complaint log dated 5/8/12 confirmed both patients 1 and 2 were caught having sexual intercourse in patient #2 ' room.

Review of nurse ' s dated 5/8/12 on 6/13/12 revealed for both patients 1 and 2 they were caught having sex in #2 ' s room between 10:23 am to 10:32 am. Per the nursing documentation dated 5/8/12, patient #s 1 and 2 were discovered by psychiatric technician (PT) #54.


Review of the activity schedule for Saturdays and Sundays for adult psychiatric intensive care unit posted on the wall on 6/13/12 revealed " 10:00 am to 10:30 am Vital Signs and Snacks " .

Review of facility security camera dated 5/8/12 on 6/13/12 at 11:32 am in the Plant Operations Director ' s office with staff #50 revealed the following:
10:14 am- Physician making rounds, a few patients walking in the hallway
10:20 am patient #1 went into his room
10:22 am patient #1 out of his room, observed in the hallway
10:22 am a tech in the hallway
10:23 am patient #1 in the hallway talking to the tech, tech went back to the day room
10:23:33am patient #1 went into patient #2 ' s room
10:23:57am patient #1 stuck his head out and looked, then went back in patient #2 ' s room
10:25 am LVN walking down the hall with another patient, a therapist came out of the therapy room
10;28:19 am two patients observed, one making phone call, the other one waiting
10:32:28 am PT # 54 walking down the hall with vital signs equipment, #54 went into patient #2 ' s room. Patient #1 was observed coming out of patient #2 ' room.

Interview with employee #52 on 6/13/12 at 12:37 pm in the conference room revealed he was informed that both patients (1 and 2) were caught having sexual intercourse on 5/8/12 in patient #2 ' room. This employee stated " there was no warning signs or flirtation between the two patients, it just happened " . " Both patients were upset, stating they are both adults and can do whatever they want " . This employee also said patient #2 was transferred to another unit and patient #1 was discharged that same evening.

Interview with employee #53 on 6/13/12 at 12:50pm in the conference room revealed he was on 500 unit relieving another tech and when he came back to the unit at the same time the incident was unfolding. This staff person said that patient #1 said that " that ' s my girl " ; and this staff said both patients were instructed they were not to do such a thing in this place. Employee #53 said that both patients were upset because they were not allowed to finish, " we just started patient " #1 told employee #53.

Interview with employee #54 on 6/13/12 at 1:00 pm in the conference room revealed " I was doing vital signs and it became quiet and I went to #2 ' s room first to take her vital signs and then saw both of them in bed " . This staff added " patient #1 was on the bed and had his back toward me and his pants were down, as soon as I walked in, he jumped off the bed and pulled his pants up; he was very upset and said I just started " . Staff #54 stated during this interview that both patients were on 15 minutes check and that he documented the times in thier medical records.

Interview with staff #55 on 6/13/12 at 1:15 pm in the conference room revealed she was on duty the day the incident happened. " Staff #54 was doing his 15 minutes checks when he saw patients 1 and 2 having sexual intercourse in patient #2 ' room " . Staff #55 stated " They were just starting the male patient said and walked out of the room mad " . All the four employees interviewed said they have not had such an incident in their facility before.

Review of 15 minutes check sheets dated 5/8/12 for patients 1 and 2 on 6/13/12 revealed staff #54 documented both patients were in the day room from 10:00am and 10:30am when he made rounds. Patient #1 was not seen in the security camera, in the hallway or out of her room between 10:14 am and 10:32 am (security video recording), she was in her room during the times listed above.

During an interview with staff #50 several times when the security video was being reviewed on 6/13/12 between 11:32 am to 12:01pm this staff confirmed that patient #2 was in her room and added " we do not allow them to close their rooms, we usually open the doors if we see them closed " .