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 observation, interview and document review, the hospital failed to ensure the patient's right to request or refuse treatment, for 1 of 1 patients reviewed (P1), who was not offered a sexual assault examination after alleging she was sexually assaulted by an employee.
Findings include:

P1's Emergency Department (ED) record indicated P1 (MDS) dated [DATE] at 10:34 p.m., with suicidal ideation with a plan and a means to carry out the plan. P1 had been discharged the previous day of 02/27/15 from the hospital's inpatient mental health Unit NE8, the least acute mental health unit. Within 24 hours of discharge, P1's auditory hallucinations and ideations of self-harm returned so P1 called an ambulance to take her to the hospital. ED staff performed a crisis assessment and it was determined that P1 would be admitted for inpatient psychiatric services as soon as a bed was available. On 03/02/15 at 2:05 p.m., P1 was admitted to Unit NE7 for stabilization of P1's schizoaffective disorder and borderline personality disorder.The psychiatric history, dated 03/02/15, indicated that P1 had a longstanding history of physical and sexual abuse by males that had resulted in self-injurious behavior as a means to seek attention, feelings of persecution, flashbacks of sexual abuse to adolescent years, and frequent accusations of sexual inappropriateness by men. At 7:05 p.m. on 03/02/15, P1 cut her wrists with a pop can tab to prove to NE7 staff that she was suicidal and needed a higher level of care than NE7. At 7:14 p.m. on 03/02/15, P1 was immediately transferred to Unit NE4, the hospital's highest acuity inpatient mental health unit. P1's room on NE4 was located directly across from the nurse's station for closer supervision of her self-injurious behavior.

Observations on 04/22/15 at 10:15 a.m. indicated that Unit NE4 has 20 private inpatient rooms. Thirteen video cameras provide continuous surveillance of the unit's common areas, hallways, and entrances to patient rooms. All patient rooms have an exterior window with a blind housed between double window-panes. Only staff can open or close the blinds, which requires insertion of a hex key to maneuver the blinds. A video camera is located directly above the doorway to the private room P1 was in, which is 20 feet in direct view from the nurses' station.

The physician progress notes, dated 03/04/15, indicated that during a routine therapy encounter on 03/04/15 at 2:45 p.m., P1 told her psychiatrist that Mental Health Associate (MHA)/(K) had sexually assaulted her on the afternoon of 03/04/15. Initially P1 told the psychiatrist that MHA/(K) had sex with her in her room on 03/04/15, but as the psychiatrist probed for further details, P1 changed her statements and indicated she was possibly having a flashback of past experiences. The psychiatrist noted that P1 was angry and rambling about difficulties with her family, "men" in general, and a fiance who wasn't coming to visit her while she was hospitalized .
P1's medical record provided no evidence that a sexual assault examination was completed or offered or refused by P1, after P1 made the allegation of sexual assault by an employee.

The personnel file of Mental Health Associate (MHA)/(K) revealed exemplary job performance and zero patient-care complaints, which was consistent with the review of Unit NE4 patient grievances.

RN/(G) was interviewed on 04/22/15 at 9:30 a.m. RN/(G) stated that she interviewed P1 on the afternoon of 03/04/15 immediately after P1 told the psychiatrist she was sexually assaulted that day by MHA/(K). What P1 told RN/(G) about the assault was different than what P1 had related to the psychiatrist a half hour earlier. P1 told RN/(G) that MHA/(K) had fondled her breasts during the evening of 03/03/15 and had sex with her in her room during the afternoon of 03/04/15. P1 could not provide RN/(G) with any details regarding the assault, even when RN/(G) asked P1 for specific details. RN/(G) reported P1's allegation to RN/(F).

RN/(F) was interviewed on 04/22/15 at 11:00 a.m. RN/(F) stated she immediately reported P1's allegation to Security and Patient Safety for further investigation. RN/(F) also interviewed P1 on 03/04/15. P1's statements to RN/(F) were inconsistent with what P1 told the psychiatrist and RN/(G) about the assault. P1 told RN/(F) that MHA/(K) fondled her breasts during the morning of 03/04/15 and had sex with her in her room during the afternoon of 03/04/15. P1 could not provide any details about the assault even when prompted. RN/(F) stated that MHA/(K) works the day shift from 7:00 a.m. to 3:00 p.m. MHA/(K) did work NE4 on the day shift of 03/04/15, but MHA/(K) did not work the evening shift of 03/03/15. MHA/(K) was already gone from duty on 03/04/15 when P1 made the allegation. RN/(F) and Security personnel immediately reviewed nine hours of videotape from the cameras on NE4, which showed that MHA/(K) was in P1's room twice on the afternoon of 03/04/15, once from 1:49 p.m. to 1:50 p.m. and a second time from 1:52 p.m. to 1:55 p.m. When RN/(F) interviewed MHA/(K) about the allegation, MHA/(K) denied the allegation and had reasonable explanations for his presence in P1's room on the afternoon of 03/04/15, the first time for one minute and the second time for three minutes. RN/(F) stated that P1's statements about the assault had been inconsistent three times, none of which coincided with videotape review. P1's allegation was referred to local law enforcement consistent with hospital policy and P1 was placed on 1:1 supervision with female staff only until her discharge on 03/11/15. P1 did not receive a sexual assault examination by a SANE (Sexual Assault Nurse Examiner), after P1 made the allegation. RN/(F) did not know why a SANE exam wasn't offered to P1, which is the standard practice for allegations involving sexual assault.

MHA/(K) was interviewed on 04/24/14 at 9:50 a.m. MHA/(K) denied the allegation and stated he never made any physical contact with P1 on any occasion. MHA/(K) stated he was not assigned to monitor P1 on 03/04/15. All patients on NE4 are monitored a minimum of every fifteen minutes. MHA/(K) briefly assisted P1 twice on the afternoon of 03/04/15, in response to P1's request for staff help. The first time MHA/(K) was in P1's room, he assisted P1 with marking menu selections for her meals. The second time MHA/(K) was in P1's room, P1 wanted the blinds on the window opened so she could see her art material more clearly. MHA/(K) adjusted the blinds with his hex key, assisted P1 with setting up her art supplies, and then left P1's room.

P1 was interviewed on 04/23/14 at 12:00 p.m. P1 stated she was sexually assaulted twice by MHA/(K) on 03/04/15. The first time MHA/(K) assaulted her was at 9:00 a.m. when MHA/(K) came in her room and caressed her breasts. After MHA/(K) left her room, P1 did not see MHA/(K) again until 2:00 p.m. when MHA/(K) came into her room a second time. MHA/(K) closed the blinds. MHA/(K) caressed her breasts and forced his hand down her pants. MHA/(K) pushed her into the bathroom, put on a condom, and had sex with her. MHA/(K) told her not to tell anyone. MHA/(K) left her room after five or 10 minutes. P1 stated she told the nurse right away about MHA/(K)'s assault of her, but no one from the hospital ever followed up with her. P1 did not undergo a sexual assault examination. P1 wasn't aware she was entitled to evaluation by a SANE nurse. P1 stated that the hospital staff never told her about it or offered a SANE exam.

The hospital's policy on Patient Alleging Sexual Assault, reviewed September 2013, indicated that allegations of sexual assault of a patient by a staff member "are to be taken seriously...ascertain the patient's appropriateness and willingness to have a Sexual Assault Nurse Examiner (SANE) exam. If the patient is unwilling to have an exam conducted, document the conversation in the medical record...document the facts about the event in the medical record."