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Based upon facility policy and procedure review, medical record reviews, Quality Assessment Reports(QAR) and physician, administration and staff interviews the facility failed to conduct timely investigation of patient to patient exploitation for one of two patients, (Pt #7).

Findings Include:

Review of Abuse: Prevention and Investigation of Abuse, Neglect and/or Theft of Patient Property While in (name of hospital), revised January 2015, revealed "IF ABUSE IS SUSPECTED 1. Each employee is responsible for reporting suspected patient manager. 2. Immediate medical attention will be provided to the patient following assessment, if applicable. 3. The manager is responsible for notifying the senior nursing/clinical leader, Risk Management and Employee Relations immediately...5. Documentation in the medical record will include any information pertinent to assessment of the patient including objective findings, interventions, patient's response to interventions and who reported the situation. 6. Protection and emotional support will be provided to the patient. If the patient is abused by another patient, the patients will be physically separated...INVESTIGATIVE PROCEDURES 1. Once a report or allegation is made that abuse...likely occurred, the senior nursing/clinical leader will assure that a thorough, timely and objective investigation is conducted...3. Documentation of the investigation will include the patient's verbal reports as well as physical findings and observations".

1. Closed medical record review for Pt.# 7 revealed a [AGE] year old female involuntarily committed to the Behavioral Health A-Unit on 10/21/2015 with a diagnosis of severe depression and suicidal ideation (thoughts of killing herself). The named patient was admitted to a shared room with Patient #8. Review of nurse's note on 10/28/2015 at 0605 revealed "At 0330 patient upset due to wandering male patient entering her room. Patient stated the male touched her roommate's breast while she was sleeping. Wandering patient removed from room by staff. Charge nurse notified and spoke with patient in effort to calm her." Review of all available notes for patient #7 revealed nurses' notes on 10/28/2015 at 0902 revealed the patient #7 was refusing her medications and upset about a food issue. Nurse's note later that day, at 1532, revealed patient was "calm and cooperative that afternoon". Review of the psychiatrist note dated 10/28/2015 at 1402 revealed "patient was irritable and oppositional" due to food issue and had refused her morning medications. Review of the Social Worker note dated 10/28/2015 at 1427 revealed conversation revolved around refusal of medications. None of these notes contained additional information or any reference to the 0330 event. Review of the Interdisciplinary Plan of Care on 10/29/2015 at 1037 revealed discussion around her refusal of medications on the morning of 10/28/2015, a change in discharge date from 10/30 to 11/05/2015 and no changes in the previous Interdisciplinary Plan of Care dated 10/23/2015 at 1118. Review or Certified Nursing Assistant (CNA) sheet, reflecting visual safety checks done every 15 minutes, dated 10/28/2015 at 0330- 0430, revealed the named patient was in her room and "appropriate". CNA checks performed from 0445-0545, revealed patient was in her room and resting. Safety checks were documented every 15 minutes throughout the admission.

Interview with RN (registered nurse) Clinical Supervisor on 04/12/2016 at 1500 revealed she recalled hearing about the incident and thinks "the roommate denied the experience" ... "I would have called the House Supervisor, notified her doctor, investigated with the roommate and filled out a QAR"-(Quality Assessment Report, an event report done for real or potential injuries). Interview confirmed no other investigation documentation was available.

Interview with Pt. #7 and #8 psychiatrist on 04/13/2016 at 1000 revealed he had no knowledge of this event occurring. The psychiatrist stated "would have liked to follow-up with the patient on this issue and...yes, it is possible that the increased irritability and agitation seen the next morning was related to this event."

Interview with Director of Behavioral Health Units on 04/13/2016 at 1151 revealed that when she continued the follow-up on this event, it was because a QAR had been filled out on the roommate (Patient #8). "No QAR had been filled out on patient #7 because she said the male patient had touched the roommate's breast. So we thought there was no harm to her...we missed her mental distress having a man in her room may cause." When asked about the documentation she would expect to find regarding this event the interview further revealed "I would not necessarily have expected to find the event investigated in both patient records...we obviously need re-education on documenting the investigation and how that event effects both their care." Interview confirmed no other investigation, assessing and monitoring documentation was available for this event. Director responded immediately developing education to be provided to all staff including CNAs, nurses, social workers and therapists. No dates for the re-education to be completed was provided.

Interview via phone on 04/13/2016 at 1555 with RN for patient #7 involved with the event revealed she recalled "reassuring and comforting" the patient, could not recall details. Does recall removing the wandering patient from the room (because her note for that time stated this). She recalled notifying the charge nurse and reporting the event via a QAR for the roommate, Patient #8, but did not file a QAR for patient #7.

Surveyor attempted to interview the House Supervisor and Charge Nurse for 10/28/2016 night shift. Both conveyed that they were unable to recall the event regarding Patient #7.

NC 067