HospitalInspections.org

Based on medical record reviews, review of Hospital documentation, interviews, and review of Hospital policies, for one of ten patients reviewed for patient rights (Patient #1) the Hospital failed to ensure that staff followed hospital policies subsequent to a patient allegation of sexual assault, failed to ensure constant observations were maintained, and failed to ensure that all allegations related to an assault were reported to hospital management. The finding includes:

1. Patient #1 was transferred from Hospital #1 to Hospital #2 on 2/7/22 and admitted on the evening shift for long term treatment of schizoaffective disorder with profound delusions.

Admission physician orders dated 2/7/22 directed constant observation with female staff only for 24 hours due to history of rape allegations.

The admission nursing assessment dated 2/7/22 at 6:15 PM noted Patient #1 reported "unable to sit due to the rapes" and a body audit was refused.

Nursing narratives dated 2/7/22 noted Patient #1 reported being raped at another hospital last night (Hospital #1).

Hospital #2's incident report dated 2/7/22 identified Patient #1 stated "I was raped in my facility last night". The report further indicated MD #1 and Supervisor #1 were notified of the allegation at 6:45 PM and 6:50 PM respectively. The incident report or nursing narratives failed to identify the Division Director was not notified of Patient #1's allegation on 2/7/22.

A progress note by MD #1 dated 2/7/22 at 7:05 PM identified Patient #1 had a history of rape allegations and had no accusatory behavior at this time. The progress note failed to identify that Patient #1 was assessed for sexual assault and failed to identify if changes to the plan of care were warranted (whether or not to send Patient #1 to another Hospital for evaluation).

The medical record lacked a nursing assessment by Supervisor #1. The medical record failed to identify that Patient #1 was assessed for sexual assault at the time of the allegation.

MD #2's progress note dated 2/8/22 indicated Patient #1 reported being raped twice at Hospital #1 and was sent to Hospital #3's emergency department (ED) for testing.

Patient #1's documentation from Hospital #3 by the Sexual Assault Nurse Examiner (SANE) dated 2/9/22 indicated the test kit was given to Troop C and Patient #1 refused an internal exam. The SANE documentation further noted no acute injuries were noted with all body parts/areas examined. The results of the test kit were unavailable at the time of the investigation.

Interview with the Director of Regulatory Compliance on 2/23/22 at 11:50 AM noted Patient #1's allegation was discussed at morning report on 2/8/22 and following the report, Patient #1 was sent to Hospital #3 for evaluation, and that staff was educated regarding reporting all patients' allegations. The Director of Regulatory Compliance further identified that the staff were confused about what to do because Patient #1 alleged being sexually assaulted at another hospital. In addition, interview with the Director of Regulatory compliance on 2/23/22 at 1:15 PM indicated the Division Director was not notified of Patient #1's allegation on 2/7/22 as the hospital policy directed.

The hospital failed to ensure that a patient was evaluated timely in accordance with hospital policy following an allegation of sexual assault.

The Hospital policy entitled Sexual Assault identified the following: 1. The Supervising Nurse/Unit Director will notify the Division Director. 2. A clinical assessment of the alleged victim is conducted by the Attending Psychiatrist or covering physician 3. Immediately notify the Infection Control Practitioner for required testing 4. Encourage the alleged victim to go to Hospital #3 if the alleged assault occurred within the last thirty-six (36) hours.



2. Patient #1 was transferred from Hospital #1 to Hospital #2 on 2/7/22 on the evening shift for long term treatment of schizoaffective disorder with profound delusions. Physician orders dated 2/7/22 at 6:45 PM directed constant observation with female staff only for 24 hours due to history of rape allegations.

The constant observation sheet identified Patient #1 appeared to be sleeping at 6:30 AM and Patient #1 was being monitored as an intervention. A review of the video recording from 2/7/22 at 8:15 PM to 2/8/22 at 6:33 PM was conducted on 2/23/22 at 12:17 PM with the Performance Improvement Manager. The review identified a female staff was with Patient #1 as they exited Patient #1's room at 6:29 AM on 2/8/22 and the staff member waited outside a closed bathroom door until 6:33 AM when Patient #1 opened the bathroom door and exited. The staff member failed to ensure visualization of Patient #1 for the three minutes Patient #1 was in the bathroom.

Interview with the Performance Improvement Manager on 2/23/22 at 1:04 PM noted the bathroom door should have been left ajar to ensure constant observation was maintained.

The Hospital policy entitled Special Observation identified, in part, continuous observation is observation in which the nursing staff assigned provides for safety by maintaining unimpeded access and visualization to the patient.



3. Patient #1 was transferred from Hospital #1 on 2/7/22 on the evening shift for long term treatment of schizoaffective disorder with profound delusions.

MD #2's progress note dated 2/8/22 indicated Patient #1 reported being raped twice at Hospital #1 and was transferred to Hospital #3 for evaluation and testing.

Nursing narratives dated 2/8/22 identified Patient #1 was transported to Hospital #3 by two emergency medical technicians and one hospital employee (MHA #1).

Patient #1 returned from Hospital #3 with documentation dated 2/9/22 that identified Patient #1 had been talking in the ED with MHA #1 and the Patient Advocate and stated to them that a paralyzed individual lay on top of him/her and raped him/her at Hospital #2 (not Hospital #1 as originally stated). The note further identified MHA #1 responded that Patient #1 was on a nursing unit with all same sex individuals and did not have any encounter with staff of the accused gender.

An incident report dated 2/10/22 indicated that Management staff were notified of the allegation on 2/10/22 and, following immediate investigation, the allegation was unsubstantiated.

Interview with MHA #1 on 3/1/22 at 2:35 PM indicated that she did not report Patient #1's allegation to management staff because Patient #1 was on a nursing unit with all same sex individuals, on constant observation "sit", and the allegation was not credible because Patient #1's unit did not have any paralyzed patients.

The hospital failed to ensure that all allegations related to an assault were immediately reported to hospital management.

The Hospital policy entitled Sexual Assault identified the staff person who witnessed or received the report on the incident immediately reports the sexual assault to the Head Nurse/designee.