HospitalInspections.org

.
Based on interview and document review, the hospital failed to protect patient rights for care in a safe environment by:

1. Not implementing its policies and procedures for investigating and reporting sexual behavior between patients for 2 of 6 records reviewed (Patients #1302 and #1306).

2. Not implementing observation alerts based on history, observation and interview of patients upon admission to the hospital for 1 of 6 patients reviewed (Patient #1301).

3. Not ensuring a portion of the Noisy Activity Room on the adolescent unit is visible on camera or by staff unless they enter the room.

Failure to ensure that staff members follow policy and procedure for investigating and reporting sexual activity on the unit or failing to include appropriate observation alerts in the patient record puts patients at risk for physical and psychological harm. Failure to be able to observe patients in activity rooms puts patients at risk for physical and psychological harm.

Findings included:

1. Document review of the hospital's policy, "Sexual Aggression and Sexual Victimization: Prevention and Response & Notification Plan," dated 01/18/21 showed that:

a. The Charge Nurse and facility leadership immediately separate patients upon discovery of sexual behavior or who are alleged to have engaged in sexual behavior.

b. The Charge Nurse or designee will notify the parents/guardians as applicable. Most sexual allegations will need to be reported to the parents or guardians of those clients involved.

c. Risk Manager or designee notifies the Local/State Police in all sexual assault, intercourse cases that involve a minor.

d. Risk Manager or designee notifies State Agencies, i.e.: Child Protective Services (CPS) as required by state statutes.

e. Risk Manager or designee oversees documentation in the medical record re: the alleged incident, notifications, staff interventions, and patient response.

2. Review of Patient #1302's medical record by Investigator #13 showed that on 12/02/20 at 5:00 PM the patient reported to a social worker (Staff #1304)that he had sex with another patient (Patient # 1306) on 11/15/20 at 8:30 PM in the noisy activity room. Patient #1302 was afraid Patient #1306 might be pregnant.

3. During an interview with Investigator #13 on 01/29/21 at 2:25 PM, Staff #1304 showed that:

a. Staff #1304 interviewed both Patient #1302 and Patient #1306 together about the sexual encounter.

b. Staff #1304 did not notify parents of either Patient #1302 or #1306, as they had declined to have their parents called.

c. Staff #1304 did not notify CPS or police of the incident because she believed age 13 was the age of consent. One patient involved in the incident was 16 years old and the other patient was 14 years old.

4. During an interview with Investigator #13 on 02/05/21 at 10:00 AM , the Director of Quality/Interim Risk Manager (Staff #1303):

a. Verified that the parents were not called, nor were CPS or police notified of the incident. Staff #1303 stated that the hospital's policy was not followed.

b Staff #1303 stated that during the investigation the two involved patients told Staff #1303 where the encounter took place and that the patients were aware that it was not visible on the video cameras.

5. Observation by Investigator #13 on 04/21/21 of the Noisy Activity Room on the Adolescent Unit showed an angled wall that prevents direct observation from the hall or nurse's station.

6. During an interview with Investigator #13 on 01/29/21 at 10:30 AM, a mental health technician (Staff #1301) stated there are a couple of corners in the activity room that are not visible.

7. During an interview with Investigator #13 on 02/05/21 at 10:00 AM stated that during the investigation, all video tapes were reviewed and nothing was seen.

8. During an interview with Investigator #13 on 04/22/21 at 9:45 AM Staff #1305 verified that a portion of the Noisy Activity Room on the Adolescent Unit is not visible without entering the room.

9. Document review of the hospital's policy, "Sexual Aggression and Sexual Victimization: Prevention and Response at & Notification Plan," number 500.05F,dated 01/18/21 showed that:

a. Action Steps included early identification by Intake/Admission staff for patients with potential for sexual aggression and potential for sexual victimization.

b. The Intake/Admission staff/Unit Nurse completes the high risk visual notification alert and identifies either sexual aggression and /or sexual victimization and conducts a hand off with the RN accepting the admission on the unit.

c. The Nursing Staff assesses patient risk factors for sexual aggression/Victimization and places patient on SAO- Aggression or SA)O- Victim Precautions.

10. On 11/07/20 patient #1301 was admitted to the adolescent unit with suicidal ideation. The Intake Assessment dated 11/07/20 documents sexual molestation by family members and current legal process underway.

11. The psychiatric evaluation dated 11/08/20 at 8:34 AM describes the history of sexual abuse and victimization.

12. Patient #1301's medical record does not include Sexual Victimization precautions.

13. Patient #1301's medical record does not include Sexual Victimization as part of the treatment plan.

14. During an interview on 04/21/21 at 9:00 AM with the Medical Director, Staff #1311, stated that the patient should have been placed on precautions and the sexual victimization should have been included in the discussion with the treatment team.
.

.
Based on record review and interview, the hospital failed to protect patient rights by ensuring that all team members are aware of patient's need for specialized observation based on history, observation and interview with the patient.

Failure to ensure clear communication of patients need for specialized observation, i.e., sexual aggression or sexual victimization precautions, may cause serious physical or psychological harm to patients.

Findings included:

1. Hospital policy titled, "Sexual Aggression and Sexual Victimization: Prevention and Response & Notification Plan" number 500.05F dated 01/18/21 showed that:

a. Early identification by intake/admission staff assesses patients for history of being sexually abused/assaulted, using historical data from the patient, family/guardian, previous hospitalizations/placements, referral/custodial agencies, and available medical, social and legal history.

b. Intake/admission staff/Unit nurse completes the high risk visual notification alert and identifies either sexual aggression of sexual victimization, as appropriate, then conducts a hand-off with the RN accepting the admission on the unit.

c. The nursing staff assess patient risk factors for sexual aggression/victimization and places patient on SAO-Aggression or SAO-Victim Precautions.

2.. On 11/07/20 patient #1301 was admitted to the adolescent unit with suicidal ideation. The Intake Assessment dated 11/07/20 documents sexual molestation by family members and current legal process underway.

3. The psychiatric evaluation dated 11/08/20 at 8:34 AM describes the history of sexual abuse and victimization.

4. Patient #1301's medical record does not include Sexual Victimization precautions.

5. Patient #1301's medical record does not include Sexual Victimization as part of the treatment plan.

6. During an interview with investigator #13 on 04/21/21 at 9:00 AM with the Medical Director, Staff #1311, the doctor stated that the patient should have been placed on precautions and the sexual victimization should have been included in the discussion with the treatment team.

7. On 11/10/20 at 8:35 PM the Spokane Police visited the hospital regarding a police report taken from Patient #1301 being bitten on the breast and pinned to a chair by afoot in her crotch during her hospitalization. The alleged perpetrator was Patient #1302. No charges were filed.

8. Hospital policy titled "Suspected or Confirmed Cases of Patient Sexual Activity" policy #500.43 dated 10/01/18 showed that:

a. information regarding continued risk of sexual activity with another patient will be communicated by instituting Sexual Agggression and/or Victimization Precautions.

b. Treatment team to initiate sexually inappropriate behavior treatment plan; the plan could include discharge.

9. Six medical records were reviewed by Investigator #13 (Patients #1302, #1306, #1309, #1310, #1311 and #1312). 3 of 4 were not put on sexual familiarity or sexual aggression or sexual victimization precautions after sexually acting out (Patients #1309, #1310 and #1312).

10. Five of 6 medical records reviewied by Investigator #13 showed that the treatment plans were not updated after sexualy acting out behavior (Patients
#1302, #1309, #1310, #1306, and #1312).

11. During an interview with Investigator #13 on 04/22/21 at 12:45 PM, the Director of Quality, Staff #1303 verified that not updating observation precautions and treatment plans after sexually acting out did not follow hospital policy.
.

.
Based on record review and review of hospital policy and procedures, the hospital failed to modify the patient's plan of care after placing patients in restraints or seclusion for 3 of 3 records reviewed (Patient #301, #302, #303).

Failure to modify care plans for patients are in restraints or seclusion puts patients at risk of harm by not meeting their physical and emotional needs.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion," policy # 300.22, last reviewed 09/20, showed that a review and modification of the treatment plan is indicated when an episode of restraint/seclusion occurs. The registered nurse will review and update the treatment plan within 8 hours.

2. On 04/21/21, Investigator #3 conducted a clinical record review of 3 patients who were placed in seclusion or restraints. In 3 of 3 patient records reviewed (Patient #301, #302, #303), staff failed to update the patient's care plans to reflect seclusion/restraint interventions.

3. During an interview with the Director of Quality, Staff #1303 on 04/22/21 at 12:45 PM, the restraint and seclusion record review findings were discussed. Staff #1303 verified that hospital policy was not followed.
.



.

.
Based on document review and interviews, the hospital failed to fully develop and implement its Performance Improvememt Plan related to preventing sexual acting out behavior among patients.

Failure to include all members of the treatment team and ensure all members are educated may lead to physical or psychological harm to patients.

Findings included:

1. The Performance Improvement Project (PIP) titled "Prevention of Sexual Acting Out Behaviors Action Plan" dated 11/17/20 included educating patients using "STOP, THINK, TALK". The plan included only educating Mental Health Technicians (MHTs) on "STOP, THINK, TALK".

2. The plan did not include all members of the treatment team to be educated about "STOP, THINK TALK".

3. A printed outline of the course content was provided to Investigator #13 that had a hand written note in the upper right corner stating that all social workers had been educated on 01/14/21.

4. During an interview with Investigator #13 on 04/20/21 at 9:10 AM, the Director of Clinical Services,Staff #1305 stated that the Social Workers had been trained on "STOP, THINK, TALK".

5 There is no sign in roster for the training. There is no evidence in the electronic education tracking system that education was provided.

6. During an interview with Investigator #13 on 04/22/21 at 9:42 AM, a Registered Nurse, Staff #1309 stated she was aware of the "STOP, THINK, TALK" program, but had been educated at her previous employer. Staff #1309 had received no training at this hospital on the program.