HospitalInspections.org

Based on record review and interview, the facility failed to ensure 2 0f 3 (#1, #2) patients reviewed were provided care, free from physical/sexual abuse. Patient #1 and #2 were sexually assaulted by a male patient (#3). The facility failed to follow physician's orders to keep patient #3 separated from female patients for safety.

Refer to Tag A-144


The facility failed to have a process in place for investigating allegations of abuse. The facility also failed to thoroughly investigate allegations of abuse by Patient #3 as reported by Patient #1. Due to the lack of investigation of the alleged sexual assault of patient #1, patient #2 was sexually assaulted by patient #3 the following day.

Refer to Tag A145

Based on record review and interview, the facility failed to ensure 2 0f 3 (#1, #2) patients reviewed were provided care, free from physical/sexual abuse. Patient #1 and #2 were sexually assaulted by a male patient (#3). The facility failed to follow physician's orders to keep patient #3 separated from female patients for safety.

Review of medical record #1 revealed patient was a 59 year old female admitted on 10/06/11 with diagnoses of Bipolar Disorder and Opioid Dependence. Patient was also receiving treatment for hypertension and electrolyte imbalance. Review of nurses notes dated 11/14/11 at 1710 (5:10 pm) revealed the following: " At 0710 (7:10 am), patient reported an alleged sexual assault on her at around 0610 (6:10 am) this morning. Patient ' s physician overheard report and investigation was started. Orders were given, noted and completed to transfer patient to an acute care facility for examination of sexual assault. Patient was then admitted to acute care facility due to increased ammonia levels. Patient was discharged. "

Review of the Psychiatrist progress note dated 11/14/11 at 8:00am revealed " she was anxious, quiet and told staff that someone came to her room and touched her inappropriately and then forced her on the floor. She could not tell whether he had sexual intercourse with her or not. Send patient to emergency room for rape kit. "

Review of multidisciplinary progress notes revealed a note dated 11/14/11 at 12:30 pm written by the Program Director, Staff #2, which stated " Nurse from acute care facility reported that rape kit was performed. Report made to the police department and adult protective services. Patient will be admitted to acute care facility for increased ammonia levels " .

Review of report written by the emergency room nurse dated 11/14/11 received in this agency ' s department by hotline revealed the following: " Patient (#1) stated that another resident in her facility, (Patient #3), put his penis in her mouth, vagina, and anus earlier this morning. Patient (#1) had stool inside her vagina. Patient (#1) is only orient to person, is confused. However, she is extremely consistent with her assault outcry. Patient received medical /forensic exam, medical screening and admission to the hospital for medical reasons. "

Review of the medical record of patient #3 revealed patient was admitted involuntarily on 11/9/11 from the personal care home due to aggressive homicidal behavior toward staff at the personal care home. He was telling a staff person at the home that he would kill him and attempted to stab the staff person. Patient was reportedly a danger to others but not at risk for harming himself. Patient was admitted with orders for " assault precautions " and unit restriction.

Review of the multidisciplinary progress notes of patient #3 dated 11/14/11 at 10:40 am revealed a note by the attending psychiatrist. The note read " Very psychotic. Incoherent, nonsensical speech. Accused by a female psychotic patient of having sex with her. Patient absolutely denies having any sex with anyone here. He seems too psychotic to go through the motions of having sex. " Progress note written by the Program Director on 11/14/11 at 10:00 am revealed " Female patient (#1) on unit 5 reported to nursing staff this AM, that patient #3 went into her room and sexually assaulted her in the bathroom. Patient #3 denies this occurred, he said he does not know who the female patient is and did not go into anyone else ' s room. Psychiatrist questioned patient (#3) 3 times and patient was able to verbalize he understood the question - he continued to deny this occurred. Patient is transferring to Unit 9. Remains on 15 min. close observation. "

Review of physician ' s orders of patient #3 dated 11/14/11 at 11:00 am. revealed the following: " Transfer to Unit 9 - 10 feet separation from females " . Nurses ' notes dated 11/14/11 at 11:45am. revealed " patient #3 was received from unit 5. "

Review of incident report for patient #1 dated 11/14/11 at 7:05 am, revealed the following: " Patient #1 approached charge nurse and reported she had been sexually assaulted while in her bathroom. She reported it happened about an hour ago. She reported she thought the man was wearing mickey mouse pants. She reported it happened during smoke break and snack time. Physician on the unit this AM immediately following report. Physician interviewed patient and wrote an order for her to be examined at an acute care facility emergency room for alleged sexual assault. Review of the section on the incident report titled to be completed by risk management included a section to document findings of investigation and recommendations had been completed by the administrator. Documented in this section was the following: " Inconclusive. Unable to support patient allegation. "

An interview was conducted with the Administrator on 11/29/11 at 1:30 pm. The Administrator reported that patient #3 was moved to Unit 9, which is a 6 bed unit and
had only male patients. The Administrator further reported that Unit 9 was an overflow unit when the Adult unit was at capacity. The Administrator reported that on 11/15/11 the census dropped to 20 patients on the adult unit and when the census drops to 22 or lower, Unit 9 was closed and all patients, including Patient #3, on Unit 9 were transferred to Unit 5. The Administrator reported patients were moved from Unit 9 to Unit 5 on 11/15/11 late afternoon. The Administrator was unable to provide a policy related to the closing of units or transfer of patients to other units. The Administrator further reported that the rape examination on patient #1 was inconclusive and the incident reported between patient #1 and patient #3 was an " alleged " assault and since patient #1 did not return to the facility, it was felt there wasn ' t a problem for the patient to return to Unit 5. The Administrator was unable to provide any documentation of the results of the rape examination. The Administrator reported an order was not obtained from the Physician to move the patient from Unit 9. The Administrator reported the decision to close the unit and transfer the patients from Unit 9 to another unit was done as a cost saving measure for the facility.

Review of the Multidisciplinary Notes for patient #2 dated 11/15/11 at 2100 (9:00pm) revealed the following: About 1915 (7:15 pm), Patient #3 observed in a female patient ' s (#2) restroom leaning over a naked female patient (#2); patient (#3) was fully clothed. Male Mental Health Technician removed patient (#3) from the restroom and escorted him back to his room. Both patients (#2 and #3) were placed on one to one monitoring for safety. Attempted to talk to patient(#3). Patient (#3) stated " I can ' t stay away from the women " . Patient (#3) became increasingly aggressive, combative, cursing and attempting to hit staff. "

Review of the nurses ' notes in patient #2 ' s medical record dated 11/15/11 at 1920 (7:20 pm) revealed the following: Went to patient ' s room to find her crying, stating male peer had come into her room while she showered, pushed her down, and penetrated her vagina and rectum with his fingers. Patient offered reassurance and support in effort to calm her down. Psychiatrist notified of incident.

An interview was conducted with Staff #5 on 11/29/11 at 3:00 pm. Staff #5 was the staff person who found patient #3 in the bathroom of patient #2 ' s patient room. Staff #5 reported the following: " Patient #2 was not in the day room and I remembered she was going to take a shower and I wanted to check on her because she had fallen the day before and had a very unsteady gait. About the same time, a staff person reported they had not seen patient #3 for a while and went to look for him. Staff #5 went to patient #2 ' s room and the door was closed and so was the bathroom door. When opening the bathroom door, I found patient #3 hovering over the naked body of patient #2 who was lying on the floor on her stomach. Patient #2 was crying and trying to yell for help but patient #3 covered her mouth. A male staff person arrived and removed patient #3 from the room of patient #2. Patient #2 reported to Staff #5 that patient #3 had come into her bathroom, pulled her out of the shower and pushed her to the ground at which time he covered her mouth where she could not yell for help, and penetrated her with his fingers in her rectum and vagina. Staff #5 reported she assisted the patient to her feet, helped her dress and stayed with her until she had calmed down. " Review of incident report dated 11/15/11 written by Staff #5 confirmed the details Staff #5 had reported in an interview.

Based upon record review and interview, the facility failed to have a process in place for investigating allegations of abuse. The facility also failed to thoroughly investigate allegations of abuse by Patient #3 as reported by Patient #1. Due to the lack of investigation of the alleged sexual assault of patient #1, patient #2 was sexually assaulted by patient #3 the following day.

Review of multidisciplinary progress notes revealed a note dated 11/14/11 at 12:30 pm written by the Program Director, Staff #2, which stated " Nurse from acute care facility reported that rape kit was performed. Report made to the police department and adult protective services. Patient will be admitted to acute care facility for increased ammonia levels " .

Review of report written by the emergency room nurse dated 11/14/11 received in this agency ' s department by hotline revealed the following: " Patient (#1) stated that another resident in her facility, (Patient #3), put his penis in her mouth, vagina, and anus earlier this morning. Patient (#1) had stool inside her vagina. Patient (#1) is only orient to person, is confused. However, she is extremely consistent with her assault outcry. Patient received medical /forensic exam, medical screening and admission to the hospital for medical reasons. "

Review of the medical record of patient #3 revealed patient was admitted involuntarily on 11/9/11 from the personal care home due to aggressive homicidal behavior toward staff at the personal care home. He was telling a staff person at the home that he would kill him and attempted to stab the staff person. Patient was reportedly a danger to others but not at risk for harming himself. Patient was admitted with orders for " assault precautions " and unit restriction.

Review of the multidisciplinary progress notes of patient #3 dated 11/14/11 at 10:40 am revealed a note by the attending psychiatrist. The note read " Very psychotic. Incoherent, nonsensical speech. Accused by a female psychotic patient of having sex with her. Patient absolutely denies having any sex with anyone here. He seems too psychotic to go through the motions of having sex. " Progress note written by the Program Director on 11/14/11 at 10:00 am revealed " Female patient (#1) on unit 5 reported to nursing staff this AM, that patient #3 went into her room and sexually assaulted her in the bathroom. Patient #3 denies this occurred, he said he does not know who the female patient is and did not go into anyone else ' s room. Psychiatrist questioned patient (#3) 3 times and patient was able to verbalize he understood the question - he continued to deny this occurred. Patient is transferring to Unit 9. Remains on 15 min. close observation. "

Review of physician ' s orders of patient #3 dated 11/14/11 at 11:00 am. revealed the following: " Transfer to Unit 9 - 10 feet separation from females " . Nurses' notes dated 11/14/11 at 11:45am. revealed " patient #3 was received from unit 5. "

Review of incident report for patient #1 dated 11/14/11 at 7:05 am, revealed the following: " Patient #1 approached charge nurse and reported she had been sexually assaulted while in her bathroom. She reported it happened about an hour ago. She reported she thought the man was wearing mickey mouse pants. She reported it happened during smoke break and snack time. Physician on the unit this AM immediately following report. Physician interviewed patient and wrote an order for her to be examined at an acute care facility emergency room for alleged sexual assault. Review of the section on the incident report titled to be completed by risk management included a section to document findings of investigation and recommendations had been completed by the administrator. Documented in this section was the following: " Inconclusive. Unable to support patient allegation. "

An interview was conducted with the Administrator on 11/29/11 at 1:30 pm. The Administrator reported that patient #3 was moved to Unit 9, which is a 6 bed unit and
had only male patients. The Administrator further reported that Unit 9 was an overflow unit when the Adult unit was at capacity. The Administrator reported that on 11/15/11 the census dropped to 20 patients on the adult unit and when the census drops to 22 or lower, Unit 9 was closed and all patients, including Patient #3, on Unit 9 were transferred to Unit 5. The Administrator reported patients were moved from Unit 9 to Unit 5 on 11/15/11 late afternoon. The Administrator was unable to provide a policy related to the closing of units or transfer of patients to other units. The Administrator further reported that the rape examination on patient #1 was inconclusive and the incident reported between patient #1 and patient #3 was an " alleged " assault and since patient #1 did not return to the facility, it was felt there wasn ' t a problem for the patient to return to Unit 5. The Administrator was unable to provide any documentation of the results of the rape examination. The Administrator reported an order was not obtained from the Physician to move the patient from Unit 9. The Administrator reported the decision to close the unit and transfer the patients from Unit 9 to another unit was done as a cost saving measure for the facility. The Administrator also reported in an e-mail correspondence on 12/9/11 that the facility did not have a policy in place to ensure the thorough investigation of abuse or neglect.

Review of the Multidisciplinary Notes for patient #2 dated 11/15/11 at 2100 (9:00pm) revealed the following: About 1915 (7:15 pm), Patient #3 observed in a female patient ' s (#2) restroom leaning over a naked female patient (#2); patient (#3) was fully clothed. Male Mental Health Technician removed patient (#3) from the restroom and escorted him back to his room. Both patients (#2 and #3) were placed on one to one monitoring for safety. Attempted to talk to patient(#3). Patient (#3) stated " I can ' t stay away from the women " . Patient (#3) became increasingly aggressive, combative, cursing and attempting to hit staff. "

Review of the nurses' notes in patient #2's medical record dated 11/15/11 at 1920 (7:20 pm) revealed the following: Went to patient ' s room to find her crying, stating male peer had come into her room while she showered, pushed her down, and penetrated her vagina and rectum with his fingers. Patient offered reassurance and support in effort to calm her down. Psychiatrist notified of incident.

An interview was conducted with Staff #5 on 11/29/11 at 3:00 pm. Staff #5 was the staff person who found patient #3 in the bathroom of patient #2 's patient room. Staff #5 reported the following: " Patient #2 was not in the day room and I remembered she was going to take a shower and I wanted to check on her because she had fallen the day before and had a very unsteady gait. About the same time, a staff person reported they had not seen patient #3 for a while and went to look for him. Staff #5 went to patient #2 ' s room and the door was closed and so was the bathroom door. When opening the bathroom door, I found patient #3 hovering over the naked body of patient #2 who was lying on the floor on her stomach. Patient #2 was crying and trying to yell for help but patient #3 covered her mouth. A male staff person arrived and removed patient #3 from the room of patient #2. Patient #2 reported to Staff #5 that patient #3 had come into her bathroom, pulled her out of the shower and pushed her to the ground at which time he covered her mouth where she could not yell for help, and penetrated her with his fingers in her rectum and vagina. Staff #5 reported she assisted the patient to her feet, helped her dress and stayed with her until she had calmed down. " Review of incident report dated 11/15/11 written by Staff #5 confirmed the details Staff #5 had reported in an interview.

Based on record review and interview, the facility failed to ensure 2 0f 3 (#1, #2) patients reviewed were provided care, free from physical/sexual abuse. Patient #1 and #2 were sexually assaulted by a male patient (#3). The facility failed to follow physician's orders to keep patient #3 separated from female patients for safety.

Review of medical record #1 revealed patient was a 59 year old female admitted on 10/06/11 with diagnoses of Bipolar Disorder and Opioid Dependence. Patient was also receiving treatment for hypertension and electrolyte imbalance. Review of nurses notes dated 11/14/11 at 1710 (5:10 pm) revealed the following: " At 0710 (7:10 am), patient reported an alleged sexual assault on her at around 0610 (6:10 am) this morning. Patient ' s physician overheard report and investigation was started. Orders were given, noted and completed to transfer patient to an acute care facility for examination of sexual assault. Patient was then admitted to acute care facility due to increased ammonia levels. Patient was discharged. "

Review of the Psychiatrist progress note dated 11/14/11 at 8:00am revealed " she was anxious, quiet and told staff that someone came to her room and touched her inappropriately and then forced her on the floor. She could not tell whether he had sexual intercourse with her or not. Send patient to emergency room for rape kit. "

Review of multidisciplinary progress notes revealed a note dated 11/14/11 at 12:30 pm written by the Program Director, Staff #2, which stated " Nurse from acute care facility reported that rape kit was performed. Report made to the police department and adult protective services. Patient will be admitted to acute care facility for increased ammonia levels " .

Review of report written by the emergency room nurse dated 11/14/11 received in this agency ' s department by hotline revealed the following: " Patient (#1) stated that another resident in her facility, (Patient #3), put his penis in her mouth, vagina, and anus earlier this morning. Patient (#1) had stool inside her vagina. Patient (#1) is only orient to person, is confused. However, she is extremely consistent with her assault outcry. Patient received medical /forensic exam, medical screening and admission to the hospital for medical reasons. "

Review of the medical record of patient #3 revealed patient was admitted involuntarily on 11/9/11 from the personal care home due to aggressive homicidal behavior toward staff at the personal care home. He was telling a staff person at the home that he would kill him and attempted to stab the staff person. Patient was reportedly a danger to others but not at risk for harming himself. Patient was admitted with orders for " assault precautions " and unit restriction.

Review of the multidisciplinary progress notes of patient #3 dated 11/14/11 at 10:40 am revealed a note by the attending psychiatrist. The note read " Very psychotic. Incoherent, nonsensical speech. Accused by a female psychotic patient of having sex with her. Patient absolutely denies having any sex with anyone here. He seems too psychotic to go through the motions of having sex. " Progress note written by the Program Director on 11/14/11 at 10:00 am revealed " Female patient (#1) on unit 5 reported to nursing staff this AM, that patient #3 went into her room and sexually assaulted her in the bathroom. Patient #3 denies this occurred, he said he does not know who the female patient is and did not go into anyone else ' s room. Psychiatrist questioned patient (#3) 3 times and patient was able to verbalize he understood the question - he continued to deny this occurred. Patient is transferring to Unit 9. Remains on 15 min. close observation. "

Review of physician ' s orders of patient #3 dated 11/14/11 at 11:00 am. revealed the following: " Transfer to Unit 9 - 10 feet separation from females " . Nurses ' notes dated 11/14/11 at 11:45am. revealed " patient #3 was received from unit 5. "

Review of incident report for patient #1 dated 11/14/11 at 7:05 am, revealed the following: " Patient #1 approached charge nurse and reported she had been sexually assaulted while in her bathroom. She reported it happened about an hour ago. She reported she thought the man was wearing mickey mouse pants. She reported it happened during smoke break and snack time. Physician on the unit this AM immediately following report. Physician interviewed patient and wrote an order for her to be examined at an acute care facility emergency room for alleged sexual assault. Review of the section on the incident report titled to be completed by risk management included a section to document findings of investigation and recommendations had been completed by the administrator. Documented in this section was the following: " Inconclusive. Unable to support patient allegation. "

An interview was conducted with the Administrator on 11/29/11 at 1:30 pm. The Administrator reported that patient #3 was moved to Unit 9, which is a 6 bed unit and
had only male patients. The Administrator further reported that Unit 9 was an overflow unit when the Adult unit was at capacity. The Administrator reported that on 11/15/11 the census dropped to 20 patients on the adult unit and when the census drops to 22 or lower, Unit 9 was closed and all patients, including Patient #3, on Unit 9 were transferred to Unit 5. The Administrator reported patients were moved from Unit 9 to Unit 5 on 11/15/11 late afternoon. The Administrator was unable to provide a policy related to the closing of units or transfer of patients to other units. The Administrator further reported that the rape examination on patient #1 was inconclusive and the incident reported between patient #1 and patient #3 was an " alleged " assault and since patient #1 did not return to the facility, it was felt there wasn ' t a problem for the patient to return to Unit 5. The Administrator was unable to provide any documentation of the results of the rape examination. The Administrator reported an order was not obtained from the Physician to move the patient from Unit 9. The Administrator reported the decision to close the unit and transfer the patients from Unit 9 to another unit was done as a cost saving measure for the facility.

Review of the Multidisciplinary Notes for patient #2 dated 11/15/11 at 2100 (9:00pm) revealed the following: About 1915 (7:15 pm), Patient #3 observed in a female patient ' s (#2) restroom leaning over a naked female patient (#2); patient (#3) was fully clothed. Male Mental Health Technician removed patient (#3) from the restroom and escorted him back to his room. Both patients (#2 and #3) were placed on one to one monitoring for safety. Attempted to talk to patient(#3). Patient (#3) stated " I can ' t stay away from the women " . Patient (#3) became increasingly aggressive, combative, cursing and attempting to hit staff. "

Review of the nurses ' notes in patient #2 ' s medical record dated 11/15/11 at 1920 (7:20 pm) revealed the following: Went to patient ' s room to find her crying, stating male peer had come into her room while she showered, pushed her down, and penetrated her vagina and rectum with his fingers. Patient offered reassurance and support in effort to calm her down. Psychiatrist notified of incident.

An interview was conducted with Staff #5 on 11/29/11 at 3:00 pm. Staff #5 was the staff person who found patient #3 in the bathroom of patient #2 ' s patient room. Staff #5 reported the following: " Patient #2 was not in the day room and I remembered she was going to take a shower and I wanted to check on her because she had fallen the day before and had a very unsteady gait. About the same time, a staff person reported they had not seen patient #3 for a while and went to look for him. Staff #5 went to patient #2 ' s room and the door was closed and so was the bathroom door. When opening the bathroom door, I found patient #3 hovering over the naked body of patient #2 who was lying on the floor on her stomach. Patient #2 was crying and trying to yell for help but patient #3 covered her mout