The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on electronic medical record review and staff interviews, the facility failed to notify family or legal guardian of an alleged sexual assault for 1 (#7) of 7 sampled patients , to give them the option and information to make an informed consent to either consent, refused, or request treatment elsewhere.

The findings include:

A medical record review revealed that Patient #1 was admitted through the emergency room on [DATE] for altered mental status and schizophrenia. Patient #1 was noted with poor hygiene, disheveled and would only answer questions with short yes or no answers.
A review of the face sheet for Patient #1 revealed that there was next of kin listed, but the contact person was listed as none per Patient #1 request after being admitted through the emergency room with altered mental status and schizophrenia.
Review of the medical record revealed the admitting Psychiatrist filed for a petition for adjudication of incompetence to consent to treatment appointment of a guardian advocate on 11/16/12.
A Staff interview with the 5 South Pavilion Nurse Manager on 12/17/12 at 1:18 pm revealed that adverse incident reports follow the chain of command. The physician and patient's family are notified. She also stated that upon discharge the facility where the patient will be going is informed of any incidents or new concerns regarding the patients.
A staff interview with the Senior Vice President of Operation on 12/17/12 at 1:25 pm revealed that nurses will notify a patient's family of an adverse incident, after the chain of the command is started with the notifications within the facility.
A staff interview with 5 South Pavilion Nurse Manager on 12/17/12 at 1:50 pm revealed that the incident with Patient #1 happened after Mental Health Technician (MHT) rounds. Patient #1 and Patient #9 s rooms were located across the hall from each other. Upon entrance into the room by the MHT, Patient #9 was observed by the facility staff with his pants down around his ankles, and getting off of Patient #1. Patient #1 was reportedly naked and lying face down on the bed. The MHT immediately called for help from other staff members. The charge nurse on duty called the unit manager and the psychiatrist to report the incident. The 5 South Pavilion Nurse Manager stated that she was told that there was no family to contact information for Patient #1 in the chart. Jacksonville Sheriff Officer (JSO), Department of Children and Families (DCF), and the Sexual Assault and Rape Crisis Team were notified to see Patient #1. The 5 South Pavilion Nurse Manager stated that the facility tried to obtain consent for the examination and treatment of Patient #1 prior to her getting treatment. The admitting Psychiatrist gave the consent for the patient to receive the examination from the SARC team, after the incident. The 5 South Pavilion nurse manager stated that her priority was to ensure the patients ' safety.
A staff interview on 12/17/12 at 2:04 pm with a 5 South Pavilion staff nurse revealed that when an adverse incident occurs the staff working on the unit is notified first to alert, then the admitting physician, then the director and so on. The family or facility where patient came from will also be notified and whoever is taking care of the patient when they are not hospitalized . If the patient does not have information on the chart for family then the assisted living facility (ALF) is contacted to obtain the contact information for the patient ' s family.
On 12/17/12 at 3:28 pm, the Admitting Psychiatrist returned the call to the surveyor: He stated that he sees patients once a month through a behavioral treatment program. He was alerted by the nursing staff of a possible sexual assault on 11/9/12. The physician stated that he arrived to the hospital one hour later to evaluate the patient. The Psychiatrist stated that he reviewed the history of Patient #9 and saw that there was a history of aggression. The Psychiatrist had the police called and Patient #9 was immediately removed from the facility. He stated that he did not notify the ALF immediately. He also stated that he has seen the patient since her discharge from the hospital and that the patient is in stable condition. The Admitting Psychiatrist stated that he does not call family to notify them of incidents of this nature; that social service is supposed to contact the legal guardian and the care giver to inform them of the incidents with the patient.
A staff interview with the Director of the Pavilion on 12/18/12 at 10:41 am revealed the chart is reviewed after an adverse incident to determine who the contact person is for the patient. On the psychiatric unit, a discussion would be conducted to determine who would make the phone call for family or the care giver. The contact attempts will be documented in the chart in the nursing notes or the social worker notes depending on who is designated make the contact attempts to call the family.