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.

FINLEY HOSPITAL 350 NORTH GRANDVIEW AVENUE DUBUQUE, IA 52001 Oct. 5, 2017
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on document review and staff interviews, the hospital's administrative staff failed to ensure 2 of 2 patients involved in patient-to-patient sexual contact (Patient #1 and Patient #2) received testing for sexually transmitted infections (STIs). The hospital's administrative staff identified an initial census of 9 patients in the older adult mental health unit and 2 patients who had engaged in sexual contact.

Failure to perform testing for STIs following patient-to-patient sexual contact could potentially result in the hospital staff failing to detect the transmission of a STI. Failure to detect the transmission of a STI could potentially result in a patient developing life-threatening complications of the STI, which the hospital staff could prevent if the patient received medication for the STI shortly after they got infected with the STI.

Findings include:

1. During an interview on 10/2/17 at 2:27 PM, Social Worker D stated Patient #1 and Patient #2 had sexual intercourse on 9/14/17. Neither patient had the mental capacity to make medical decisions. Social Worker D contacted the person responsible for making each patient's medical decisions. Social Worker D obtained consent from the patients' medical decision maker to perform STI testing on the patient and release the STI test results to the medical decision maker for the other patient.

2. During an interview on 10/3/17 at 8:00 AM, the Director of Quality and Compliance stated the hospital staff could not identify any orders in Patient #1's or Patient #2's medical record where anyone ordered Patient #1 or Patient #2 to receive STI testing.

3. During an interview on 10/4/17 at 2:35 PM, Psychiatrist K, who was treating Patient #1 and Patient #2, was not aware of any requests by the hospital staff to perform STI testing on either Patient #1 or Patient #2.

4. During an interview on 10/3/17 at 8:00 AM, Program Director B stated staff members contacted the local police department after Patient #1 and Patient #2 had sexual intercourse. The nursing staff took Patient #2 down to the Emergency Department (ED) to possibly undergo a specialized examination to collect evidence of a possible sexual assault. Program Director B stated the local police department sent an officer to the hospital. The police officer asked to interview Patient #2. Patient #2 indicated she had consensual sexual intercourse with Patient #1. The police officer then asked to interview Patient #1. Patient #1 indicated he had consensual sexual intercourse with Patient #2. The police officer determined a criminal act did not occur, so he would not file criminal charges and did not need the hospital staff to perform an exam to collect evidence of a possible sexual assault. Program Director B initially stated she discussed the decision to not perform STI testing on the patients with the Director of Compliance and Quality. The Director of Quality and Compliance, present at the time of the interview, denied Program Director B discussed with her about not performing STI testing on the patients. The Director of Quality and Compliance stated she would defer any decisions on STI testing to a physician or nurse practitioner. Program Director B then stated since the police did not need the hospital staff to perform an exam to collect evidence of a possible sexual assault, the hospital staff did not perform any STI testing on either Patient #1 or Patient #2. Program Director B acknowledged the patients could spread a STI even if the sexual intercourse was consensual. Program Director B acknowledged the staff did not perform any STI testing on Patient #1 or Patient #2.

5. During an interview on 10/3/17 at 8:00 AM, the Director of Compliance and Quality stated the hospital lacked a policy addressing how the staff should react if patients engaged in patient-to-patient sexual contact, including if the patients should receive STI testing.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review, observation, and staff interview, the acute care hospital's administrative staff failed to:

1. Ensure policies and procedures existed for monitoring sexual behaviors in geriatric behavioral health patients resulting in 2 of 9 patients in the older adult mental health unit engaging in sexual intercourse. Please refer to A-0144.

2. Ensure the nursing staff followed the hospital's policies and procedures for observation status recording in the older adult mental health unit. Please refer to A-0144.

3. Ensure the hospital had policies addressing testing patients for Sexually Transmitted Infections (STIs) and performed STI testing on 2 patients who engaged in sexual intercourse. Please refer to A-0144.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to ensure the safety of patients in the older adult mental health unit. The hospital's administrative staff identified an initial inpatient census on the older adult mental health unit of 9 patients.


II. During the investigation of incident -I, the on-site survey team identified an Immediate Jeopardy (IJ) situation (a crisis situation that placed the health and safety of patients at risk) related to the Condition of Participation for Patient Rights (42 CFR 482.13).

1. The administrative staff failed to initially develop and implement a corrective action plan to ensure the older adult mental health unit staff could identify, intervene, and monitor sexual behaviors by patients.

2. While on-site, the survey team identified an Immediate Jeopardy (IJ) situation and notified the administrative staff on 10/4/17. The administrative staff promptly took action to remove the immediacy of the situation. The hospital staff removed the immediacy prior to the survey team exiting the complaint investigation when the administrative staff took the following actions:

a. The hospital administrative staff developed and/or updated policies and procedures for addressing sexuality on the older adult mental health unit and throughout the hospital.

b. The older adult mental health unit administrative staff developed and/or updated policies and procedures, including observation status definitions and levels.

c. The older adult mental health unit staff will use a newly developed tool for assessing sexual indicators to identify changes in patient behaviors and identify increased needs of the patients.

d. The administrative staff began educating the nursing staff on the new policy changes and new procedures on 10/4/17. The nursing staff received the education prior to the start of their next shift.

e. The hospital educational staff incorporated the policy changes into the new hire nursing orientation.

f. The hospital administrative staff implemented a system to monitor ongoing compliance. The Program Director and Nurse Manager of the older adult mental health unit will perform monitoring to ensure ongoing compliance.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


I. Based on document review, and staff interviews, the hospital's administrative staff failed to ensure 2 of 9 patients (Patient #1 and Patient #2) in the inpatient older adult mental health unit did not engage in sexual intercourse during their hospitalization by recognizing early warning signs the patients displayed prior to engaging in sexual intercourse. The hospital's administrative staff identified an initial census of 9 patients in the older adult mental health unit.

Failure by the staff to identify and intervene when they first noticed Patient #1 engaging in sexual behaviors resulted in the staff allowing Patient #1 and Patient #2 to engage in sexual intercourse.

Findings include:

1. During an interview on 10/2/17 at 3:00PM, Activities Coordinator E stated she recalled approximately a week prior to 9/14/17 (when Patient #1 had sexual intercourse with Patient #2), during a group session, when the patients wrote compliments down for each person. Patient #1 said to Patient #2 that she had nice breasts, and then told Activities Coordinator E she had nice breasts. Activities Coordinator E told Patient #1 the statement was inappropriate. Activities Coordinator E reported Patient #1's behavior to Program Director B because Activities Coordinator E thought Patient #1 should receive Premarin (a hormone to decrease the male sex drive).

2. During an interview on 10/2/17 at 2:27 PM, Social Worker D stated she received a message from Patient #1's daughter at approximately 8:00 AM on 9/13/17 (the day before the pateints had sexual intercourse). Patient #1's daughter told Social Worker D that Patient #1 left a message on Patient #1's daughter's phone. The message was "vulgar, the phone call stated there was oral intercourse between [Patient #1's name] and another patient."

3. During an interview on 10/3/17 at 10:00 AM, Volunteer F stated at breakfast on 9/14/17 (the morning of the incident) she took Patient #1 his tray in the dining area and helped Patient #1 open his food. Volunteer F asked if she could do anything else for Patient #1. Patient #1 asked if he could play with Volunteer F's leg. Patient #1 laughed at the statement. Volunteer F told Patient #1 the statement was inappropriate and went to the Nurse's Station to tell Activities Coordinator E about Patient #1's statements, so Activities Coordinator E could record Patient #1's statements in his medical record. Volunteer F recalled another staff member stating that Patient #1 asked about touching her breasts on the morning of 9/14/17 (the day of the incident).

4. During an interview on 10/2/17 at 11:15 AM, Mental Health Tech (MHT) J stated on the morning of 9/14/17 (the day of the incident) she asked Patient #1 if there was anything else he needed at breakfast. Patient #1 stated, "Ya, I'd like to play with them big boobs." Mental Health Tech J stated she told Registered Nurse G, (RN, and the charge nurse). RN G told Patient #1 the statement was inappropriate to say on the unit because it made everyone uncomfortable. Mental Health Tech J reported that Patient #2 normally laid down after breakfast and Patient #1 helped the nursing staff clean up dishes. However, on the morning of 9/14/17, Patient #1 did not help clean up the breakfast dishes.

5. During an interview on 10/3/17 at 8:45 AM, Mental Health Nurse Practitioner (MHNP) H (a nurse with advanced training in treating mental health issues) stated she could not recall when or by whom, but that staff members informed her Patient #1 and Patient #2 whispering together, however nobody was worried about what the Patients were whispering about.

6. During an interview on 10/3/17 at 9:07 AM, LPN I stated she performed the 15 minute checks (where staff round the floor and ensure patient safety, the rounds should occur on a slightly random time and path) on 9/14/17 at 9:30 AM. When LPN I located Patient #2, she was laying in her bed, fully clothed. Patient #1 was attending a group therapy session with other patients.

7. During an interview on 10/3/17 at 10:00 AM, Volunteer F stated at approximately 9:40 AM on 9/14/17 (5 minutes before staff normally check on patients), she began gathering patients for a group activity. She attempted to locate Patient #1 to attend the group and knocked on his door. When she went to the next room, on the same side of the hallway, she knocked on Patient #2's door. She did not hear an answer, so she attempted to open the door. She could not open the door and Patient #1 told her "one sec." Patient #1 stated he went into the wrong room and was using the bathroom. Volunteer F stated she left Patient #2's doorway and went immediately to the nurses' station. Volunteer F informed the nurses that Patient #1 was in Patient #2's room and Volunteer F could not open Patient #2's door.

8. During an interview on 10/2/17 at 3:30PM, RN G stated Volunteer F came to the Nurses' Station on 9/14/17 at approximately 9:40 a.m. and informed RN G that Volunteer F could not find Patient #1 and went to Patient #2's room. Patient #1 answered when Volunteer F knocked on the door to Patient #2's room. RN G went into Patient #2's room through the connecting bathroom. When RN G entered Patient #2's room, she saw Patient #2 tucking in her clothes and Patient #2's hair was a mess. RN G noted this was unusual, as Patient #2 normally kept herself well groomed. Patient #1 was leaning on the main door into Patient #2's room. Patient #1's hand was on the button on his pants and his shoes lay on the floor, next to Patient #2's bed. RN G removed Patient #1 from Patient #2's room.

9. During an interview on 10/3/17 at 8:45 AM, MHNP H stated she spoke with Patient #1 about an hour after the nursing staff found him in Patient #2's room. Patient #1 indicated he had sexual intercourse with Patient #2. MHNP H stated after Patient #1 had sex with Patient #2, her only intervention was to place Patient #1 on Premarin (a female hormone to decrease the male sex drive) and start Patient #1 on Paxil (an antidepressant with the side effect of decreasing the male sex drive).

10. During an interview on 10/2/17 at 11:15 AM, Mental Health Tech J stated when Patient #1 had sex with Patient #2 she was giving another patient a shower. When MHT J emerged from the shower room, RN G informed her that Patient #1 was not allowed to go near any female patients and the staff needed to watch how Patient #1 interacted with other patients and staff. The staff moved Patient #1 to a room away from all of the other patient rooms. Patient #1 was not allowed to go past the Nursing Station (and near any of the other patient rooms). MHT J stated the staff should increase their awareness of Patient #1's location and behavior.

11. During an interview on 10/3/17 at 10:00 AM, Volunteer F stated after the staff discovered Patient #1 and Patient #2 had sexual intercourse, the staff had an increased awareness of Patient #1's behavior. The staff provided observation of Patient #1, but Patient #1 was allowed to attend the same group therapy sessions as Patient #2 and the staff allowed Patient #1 to sit next to Patient #2. During a group therapy session after the patients had sexual intercourse, Volunteer F recalled the patients discussed things that made them happy and sad. Patient #1 stated not having good sex made him sad. Patient #1 continued to answer questions with answers about sex and not having sex. Patient #2 laughed at Patient #1's comments. The staff did not implement any additional precautions after Patient #1 continued to make sexual comments.

12. During an interview on 10/3/17 at 8:00 AM, the Director of Quality and Compliance stated the staff had forewarning for Patient 1's sexual behavior with Patient #2. The Director of Quality stated Patient #1 made an inappropriate statement on 9/13/17 (the day before the patients had sexual intercourse). When Patient #1 made the inappropriate statement, the nursing staff should have recognized the warning sign and increased their supervision of Patient #1. The Director of Quality and Compliance stated Patient #1 had not previously made sexually inappropriate comments. Patient #1 had sexual intercourse with Patient #2 the morning following him making sexually inappropriate comments.

13. During an interview on 10/3/17 at 11:20 AM, Nurse Manager A stated when Patient #1 commented on Patient #2's breasts at breakfast on 9/14/17 (the day of the incident), the staff should have identified the statement as a "big red flag." Nurse Manager A confirmed the staff failed to implement interventions at the time Patient #1 began exhibiting sexual behaviors, which would have prevented Patient #1 from engaging in sexual intercourse with Patient #2.

14. Review of the "inpatient Program Policy and Procedure Manual," copyright 2015 and revised 3/2016, revealed the hospital lacked a policy addressing sexual behavior by patients, including potential warning signs of sexual behavior by patients, procedures for staff to follow if a patient began exhibiting warning signs of sexual behavior, or procedures for staff to follow after patients had sexual intercourse.

15. During an interview on 10/3/17 at 8:00 AM, the Director of Quality and Compliance stated the hospital staff had never experienced patients engaging in sexual intercourse on the inpatient mental health unit. When the Director of Quality and Compliance checked with the inpatient mental health nursing staff about sexual behavior between patients, the nursing staff all responded, "that's not allowed" and did not identify any further interventions.
The Director of Quality and Compliance checked with the national management group that provided oversight to the hospital's inpatient mental health unit. The national management group agreed they lacked a policy or information from other facilities on how to handle sexual behavior between patients. The Director of Quality and Compliance originally questioned the necessity of a policy addressing patient sexual behavior, due to the infrequency of patient sexual behavior occurring.

The Director of Quality and Compliance originally reviewed the hospital's abuse policy and was not sure if 2 patients engaging in sexual intercourse fit the hospital's definition of abuse.

Since the incident did not meet the criteria for abuse, the Director of Quality and Compliance did not feel the hospital needed to update any policies. The Director of Quality and Compliance stated she planned to provide education to the nursing staff on patient sexual behavior, but had not scheduled the date or determined exactly the information the training would include.

16. During an interview on 10/3/17 at 11:20 AM, Nurse Manager A stated she frequently received inappropriate sexual comments from male patients and a male patient would occasionally grab staff sexually. Nursing Manager A stated the hospital lacked a formal plan to address sexual behavior by the patients since the nursing staff frequently received inappropriate sexual comments from the patients "that don't go anywhere."

17. During interviews with multiple staff members during 10/2/17 and 10/3/17, the inpatient mental health unit staff members, mental health nurse practitioners, and psychiatrists (physicians with specialized training in treating mental health issues) all failed to identify any corrective actions taken by the hospital's administrative staff to prevent patients from engaging in sexual behavior or intercourse.

18. Review of the document, "Finley Hospital Behavioral Health Unit Action Plan Post Event 9/14/17," (MDS) dated [DATE] (3 weeks after the patients had sexual intercourse) revealed the hospital staff intended to develop a new policy addressing patient sexual behavior on 10/11/17 (4 weeks after the patients had sexual intercourse). The document revealed the hospital staff planned to provide education to the inpatient mental health nursing staff on the new policy on 10/18/17 (5 weeks after the patients had sexual intercourse).

II. Based on document review, staff interviews, and observations, the hospital's administrative staff failed to ensure 1 of 1 inpatient older adult mental health unit staff followed the existing observation policies and ensure 1 of 1 inpatient older adult mental health unit had current policies addressing current observation practices. The hospital's administrative staff identified an initial census of 9 patients in the older adult mental health unit.
Failure to follow the existing policies and ensure the unit had current policies addressing patient monitoring could potentially allow patients to engage in sexual behavior or attempt suicide between scheduled staff rounds.

Findings include:

1. Review of the policy "Observation Levels," revised 3/2016, revealed the staff should "observe and check in with the patient at least every 15 minutes and document the patient's location and status each interval." The policy lacked a requirement for the staff to perform the checks at times varying from 15 minutes and follow different routes through the older adult mental health unit, to prevent patients from recognizing the pattern and engaging in sexual behavior or attempting to harm themselves between staff rounds.

2. Observations of the staff performing the 15-minute safety checks revealed the staff member always started by observing the patients in the day room. The staff member walked across the hall to observe patients in the dining area, and then walked down the hallway with the patient rooms, before returning to the nursing station.

3. During an interview on 10/3/17 at 11:20 AM, Mental Health Nurse Practitioner (MHNP) H stated Patient #1 told her he had sexual intercourse with Patient #2. Patient #1 knew the staff performed checks every 15 minutes, so he and Patient #2 would not have much time to engage in sexual intercourse between the 15-minute checks by the staff.

4. During an interview on 10/3/17 at 2:48 PM, Nurse Manager A stated after Patient #1 had sexual intercourse with Patient #2, the staff placed Patient #1 on Continuous Observation. Nurse Manager A defined Continuous Observation as a staff member was responsible for maintaining constant visual observation of Patient #1 whenever Patient #1 was out of his room.

5. Review of Patient #1's medical record revealed a form titled "Finley Hospital Behavioral Observation Log," revised 12/2013. The form provided space for the staff member to indicate if the patient was on "close observation ... 15 minute [checks by staff]" or "constant observation ... 1:1 [with a staff member constantly nearby the patient]." The form had space for the staff to document the date of the observations. The form had the times of the 15-minute rounds pre-printed and did not allow the staff to document the actual time they preformed the safety check on the patient.

6. Review of the policy "Observation Levels," revised 3/2016, revealed the policy lacked an observation level for "continuous observation" or an observation level that allowed the staff to visually monitor a patient only when they left their room.

7. During an interview on 10/3/17 at 2:48 PM, Nurse Manager A and Program Director B stated they reviewed the policy on observation levels and identified the policy did not contain an observation level for "continuous observation." Nurse Manager A stated the staff created an observation level not contained in the existing policies. Nurse Manager A acknowledged the policy must reflect the practice by the nursing staff members.
Nursing Manager A acknowledged the staff members should vary the timing and pattern of the 15-minute safety checks so the patients could not identify a pattern and prevent the staff members from discovering the patients engaging in sexual behavior or a patient attempting to hurt themselves. Nurse Manager A acknowledged the "Finley Hospital Behavioral Observation Log" forms contained preprinted times and did not allow the staff members to document the actual time they preformed the safety check, which would indicate the staff member varied the time between safety checks.