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.

UNIVERSITY OF MINNESOTA MEDICAL CENTER, FAIRVIEW 2450 RIVERSIDE AVENUE MINNEAPOLIS, MN 55454 Dec. 30, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interviews and review of the emergency room medical records of child patient #1 and adult patient #2, it was determined that the hospital failed to promote and protect the rights of child patient #1 when adult patient #2 was not adequately monitored and supervised and entered child patient #1's room on several occasions during a night shift (per video) and kissed, fondled and masturbated in front of child patient #1.

Findings include:

The hospital did not meet the Condition of Participation of Patient Rights at 42 CFR 482.13.

Based on observation, documentation and interviews, the hospital failed to protect all children patients from abuse and harassment when adult patient #2 was not adequately monitored/supervised and entered child patient #1's room on several occasions during a night shift and kissed, fondled and masturbated in front of a child patient in one of twenty-two records (child patient #1) reviewed.

Based on observation, documentation and interviews, the hospital failed to ensure that one of twenty-two patients (child patient #1) was free from abuse and harassment.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on observation, documentation and interviews, the hospital failed to protect all patients from abuse and harassment when adult patient #2 was not adequately monitored and supervised and entered a child patient's room on several occasions during a night shift and kissed, fondled and masturbated in front of a child patient in twenty-two patients (child patient #1) reviewed.

Findings include:

Review of child patient #1's 11/8/16 Emergency Department (ED) admission history and physical and documentation revealed that child patient #1 arrived at the ED via ambulance at 5:36 p.m. The child patient #1 has a history of mood disorder, fetal alcohol syndrome, bilateral hearing impairment, vision impairment, self injurious behavior and running away. The child patient had been feeling depressed and exhibiting suicidal behavior prior to child patient #1's family member's call to the police pertaining to child patient #1's condition. Child patient #1 was admitted to the ED (room 12) for stabilization because an adolescent inpatient mental health bed was not available at the time of admission. Child patient #1 was placed on every thirty minute suicide checks which the record indicated were completed.

Review of adult patient #2's 11/8/16 ED admission history and physical and documentation revealed that patient #2 had a history of bipolar disorder and auditory hallucinations. Patient #2 arrived at the ED at 8:35 p.m. on 11/8/16 via ambulance following a display of aggressive behavior and suicidal ideation. Patient #2 was admitted to the ED (room 15) for stabilization and was placed on every thirty minute suicide checks which the record indicated were completed. Patient #2's room (15) was located in an alcove area which was adjacent to and in close proximity to child patient #1's room (12). Patient #2 was to be transferred to the hospital's psychiatric unit following his admission to the ED.

An 11/10/16 hospital security report, completed by security officer (G), was reviewed. The report stated the time frame of the assault of child patient #1 by patient #2 was from 1:12 a.m. to 1:40 a.m. on 11/9/16. The report indicated (G) also found patient #2 sitting in child patient #1's room (12) at 1:28 a.m. on 11/9/16. Patient #2 was fully clothed and watching child patient #1's television. Security officer-G escorted patient #2 back to his room (15), but a 1:1 staff was not assigned to monitor patient #2's wandering behaviors. The report stated security officer-G and psychiatric associate-H both viewed patient #2 sitting in child patient #2's room via the camera system again at 1:39 a.m. on 11/9/16. Patient #2 was sitting in the chair next to child patient #1 and his pants were around his ankles, and he was touching his penis. Security officer-G entered child patient #1's room and grabbed patient #2 and removed him from child patient #1's room. In addition, the doucment indicates patient #2 kissed, groped the child patient #1 and patient #2 materbated in the child patient's room. The police were called and patient #2 was arrested.

The hospital's Increasing Level of Patient Supervision, including 1:1 Attendant-UMMC/UMMCH policy, dated November 2002, was reviewed and states patient situations that may require increased level of supervision and need for 1:1 attendant includes a pattern of wandering into other patients rooms.

Physician (E) was interviewed by phone on 12/28/16 and he stated he was assigned to the ED during the night shift of 11/9/16. He stated he provided care to child patient #1 following the assault by patient #2. He did not have any physical findings when he examined child patient #1. Child patient #1 said patient #2 only touched her breasts, and she denied that he touched any other area of her body. Physician (E) stated he examined patient #2 at the time of his admission to the ED and patient #2 said he was having hallucinations. Physician (E) determined that patient #2 was appropriate for admission to the Mental Health Unit.

Administrative RN-L was interviewed by phone on 12/29/16 and stated she was the supervisor on 11/9/16 night shift when the incident involving child patient #1 occurred. She stated she interviewed child patient #1, and child patient #1 told her patient #2 entered her room multiple times during the 11/9/16 night shift. Administrative RN-L also viewed the video that contained the assault of child patient #1 by patient #2. She further stated that child patient #1 had cognitive deficits and was a minor, and (L) stated she was concerned that child patient #1 was alone in the ED. Administrative RN-L also voiced a concern about the cameras not being monitored on an ongoing basis in the ED.