HospitalInspections.org

Based on record review, video review, and interview, the facility failed to ensure the patient's right to receive care in a safe setting and to be free from all forms of abuse in 1 out of 4 sample patients (SP #1) posing a serious risk to the patient's safety and required immediate corrective action on the part of the facility.
Immediate Jeopardy (IJ) was identified and cited at A-115 Patient Rights on 06/07/2021. The Immediate Jeopardy started on 05/10/2021.
The hospital Chief Executive Officer was notified about the finding of Immediate Jeopardy on 06/07/2021 at 12:20PM. The Immediate Jeopardy was Ongoing.

The findings included:

1. The facility failed to ensure the patient's right to receive care in a safe setting in 1 (SP #1) out of 4 sample patients posing a serious risk to the patient's safety. (Refer to A-144)

2. The facility failed to ensure the patient's right to be free from all forms of abuse in 1 (SP #1) out of 4 sample patients posing a serious risk to the patient's safety. SP #1 made an allegation of being sexually assaulted by a facility employee. (Refer to A-145)

Based on record review, video review, and interview, the facility failed to ensure the patient's right to receive care in a safe setting in 1 (SP #1) out of 4 sample patients posing a serious risk to the patient's safety.
Immediate Jeopardy (IJ) was identified on 06/07/2021. The Immediate Jeopardy started on 05/10/2021.
The hospital Chief Executive Officer was notified about the finding of Immediate Jeopardy on 06/07/2021 at 12:20PM. The Immediate Jeopardy was Ongoing.

The findings included:

1. Review of Sample Patient (SP) #1 Discharge Summary signed by her psychiatrist showed, the patient was admitted under Baker Act, (the Florida Mental Health Act) on 05/06/2021 at 4:15pm.

Record review of the Clinical Nursing Notes dated/timed 05/10/2021 at 8:00 AM revealed, upon arriving to the unit, the Mental Health Technician (MHT - B) approached the writer and the Unit Charge Nursing regarding a statement the patient (SP#1) had made to her.
Upon interviewing SP#1, she alleged the male, Mental Health Technician (MHT - C) from the previous night shift had sexually assaulted her.

Interview on 5/13/2021 at approximately 10:15AM with the Chief Executive Officer (CEO) about the incident with SP #1, revealed the patient (SP #1) complained to Mental Health Technician (MHT - B) that around 7:15AM to 7:30 AM on Monday morning on 05/10/2021 that the Mental Health Technician (MHT - C) entered her room while she was in the bathroom and proceeded to sexually assault her. After SP #1, made the sexual assault allegation, SP #1 was placed on 1:1 observation with a sitter from 7:30AM - 1:45PM on 05/10/2021.
She further stated that the Detective investigating the case told her that Mental Health Technician (MHT-C) confessed that it was consensual. On 05/10/2021, MHT - C was arrested and taken to the local police department.

A timeline of the patients admission was reviewed and revealed, on 05/06/2021 at 1:45AM, SP #1 was Baker Acted by a physician into another local hospital. SP #1 was admitted to this hospital at 4:15PM on 5/6/2021. SP #1 received psychiatric care and services at the hospital until 05/10/2021 at 1:50PM.
On 05/10/2021 at 1:50PM, SP #1 was discharged from the hospital and taken to a local rape treatment center. On 05/10/2021 at 2:46PM, SP #1 was admitted to a local rape treatment center.

A review of the facility's video with the CEO on 05/13/2021 at 1:50PM revealed, the recording of the 2 East hallway, where SP #1 resided, on 05/10/2021. The review of the video recording corroborated the time of the alleged sexual assault and showed Mental Health Technician (MHT-C) entering and leaving SP #1's room.

The facility's policy titled, "Alleged Abuse, or Sexual Misconduct/Abuse Against Patient by Hospital Staff Member", (Dated 06/2016) states patients have the right to be treated in a manner which is free from abuse, or sexual misconduct/abuse by Hospital personnel.

2. Review of Mental Health Technician (MHT - C's) "Employment Application: Experiences, Skills, and Qualifications" section, revealed MHT - C had experience working with the geriatric population in another country. MHT - C was hired on 04/01/2021.
During an interview on 05/13/2021 at 12:10 PM, the Human Resources (HR) Director provided information about the process of hiring a new employee. The HR Director reported, there was no way to confirm the high school from which Mental Health Technician (MHT-C) graduated from, and there was no way to confirm the experience that he wrote in the application, because the high school and former employer are located in another country. The HR Director reported, MHT - C was qualified for the MHT position based on their criteria.
The facility's criteria included: Minimum high school graduate, Eligible to take certification as Behavioral Health Technician (Preferred), Current heart saver certification (CPR), Previous work experience in Medical/Psychiatric hospital as a Mental Health Technician (Preferred), One (1) year experience with psychiatric or geriatric population (Preferred).

Review of the facility Policy, "Hiring Process" (Dated 12/2020) states, if the Department Head wishes to continue with the hiring process, Human Resources is to be contacted immediately to initiate reference and background checks and any licensure inquires...Upon receipt of reference and background check, the Director of Human Resource will review and sign the background check as verification of acceptable background. This policy was not followed.

Based on record review, video review, and interview, the facility failed to ensure the patient's right to be free from all forms of abuse in 1 (SP #1) out of 4 sample patients posing a serious risk to the patient's health and safety. SP #1 made an allegation of being sexually assaulted by a facility employee.
Immediate Jeopardy (IJ) was identified on 06/07/2021. The Immediate Jeopardy started on 05/10/2021.
The hospital Chief Executive Officer was notified about the finding of Immediate Jeopardy on 06/07/2021 at 12:20PM. The Immediate Jeopardy was Ongoing.

The findings included:

Review of Sample Patient (SP) #1 Discharge Summary signed by her psychiatrist showed, the patient was admitted under Baker Act, (the Florida Mental Health Act) on 05/06/2021 at 4:15pm.

Record review of the Clinical Nursing Notes dated/timed 05/10/2021 at 8:00 AM revealed, upon arriving to the unit, the Mental Health Technician (MHT - B) approached the writer and the Unit Charge Nursing regarding a statement the patient (SP#1) had made to her.
Upon interviewing SP#1, she alleged the male, Mental Health Technician (MHT - C) from the previous night shift had sexually assaulted her.

Interview on 5/13/2021 at approximately 10:15AM with the Chief Executive Officer (CEO) about the incident with SP #1, revealed the patient (SP #1) complained to Mental Health Technician (MHT - B) that around 7:15AM to 7:30 AM on Monday morning on 05/10/2021 that the Mental Health Technician (MHT - C) entered her room while she was in the bathroom and proceeded to sexually assault her. After SP #1, made the sexual assault allegation, SP #1 was placed on 1:1 observation with a sitter from 7:30AM - 1:45PM on 05/10/2021.
She further stated that the Detective investigating the case told her that Mental Health Technician (MHT-C) confessed that it was consensual. On 05/10/2021, MHT - C was arrested and taken to the local police department.

A timeline of the patients admission was reviewed and revealed, on 05/06/2021 at 1:45AM, SP #1 was Baker Acted by a physician into another local hospital. SP #1 was admitted to this hospital at 4:15PM on 5/6/2021. SP #1 received psychiatric care and services at the hospital until 05/10/2021 at 1:50PM.
On 05/10/2021 at 1:50PM, SP #1 was discharged from the hospital and taken to a local rape treatment center. On 05/10/2021 at 2:46PM, SP #1 was admitted to a local rape treatment center.

A review of the facility's video with the CEO on 05/13/2021 at 1:50PM revealed, the recording of the 2 East hallway, where SP #1 resided, on 05/10/2021. The review of the video recording corroborated the time of the alleged sexual assault and showed Mental Health Technician (MHT-C) entering and leaving SP #1's room.

The facility's policy titled, "Alleged Abuse, or Sexual Misconduct/Abuse Against Patient by Hospital Staff Member", (Dated 06/2016) states patients have the right to be treated in a manner which is free from abuse, or sexual misconduct/abuse by Hospital personnel.