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.

BAPTIST BEAUMONT HOSPITAL 3080 COLLEGE STREET BEAUMONT, TX 77701 March 28, 2014
VIOLATION: QAPI Tag No: A0263
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based upon record review and interview, the facility failed to:


A. ensure that the Quality Management Director, in collaboration with the Patient Safety Officer, followed the facility's own policy for addressing adverse events. The Quality Management Director and Patient Safety Officer failed to conduct an investigation and Root Cause Analysis after becoming aware of a sexual assault of a [AGE] year old female patient.


B. ensure that the Quality Management Director provided guidance/education to behavioral health staff, as requested by e-mail, regarding the proper reporting of the failures that resulted in the sexual assault of a [AGE] year old female patient.


Refer to Tags A0286, A0309
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, the facility failed to enforce its policy titled, Patient Safety Program. The Quality Management Director failed to facilitate an assessment or respond appropriately to the reported sexual assault of a [AGE] year old patient.

A review of the policy titled "Patient Safety Program" revealed:
"Process:

The Quality Management Director, in collaboration with the Patient Safety Officer, will be responsible for the oversight of the Patient Safety Program, including, but not limited to:

Coordinating all patient safety activities

Facilitating assessment and appropriate response to reported events

Monitoring root cause analysis and resulting action plans

Serving as liaison among hospital departments and committees to ensure hospital-wide integration of the PSP


Definitions:

Adverse Event- An event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient.

Medical Error- The failure of a planned action to be completed as intended, the use of a wrong plan to achieve an aim, or the failure of an unplanned action that should have been completed, that results in an adverse event.

Reportable Event- A medical error or adverse event or occurrence which the hospital is required to report to the Texas Department of State Health Services (TDSHS). Reportable Events signal the need for a RCA, and in the case of an intentionally unsafe act, administrative action.

Root Cause Analysis- An interdisciplinary review process for identifying the basic or contributing causal factors that underlie a variation in performance associated with an adverse event or reportable event. It focuses primarily on systems and processes, includes an analysis of underlying cause and effect, progresses from special causes in clinical processes to common causes in organizational processes, and identifies improvements in processes or systems.


Staff are required to report internally the following events which may involve corrective or preventive action:

Medical Errors

Reportable Events-Defined by TDSHS:
The sexual assault of a patient during treatment or while the patient was on the premises of the hospital or facility."


A review of Rape, Abuse & Incest National Network defines sexual assault as "unwanted sexual contact that stops short of rape or attempted rape. This includes sexual touching and fondling."


A review of National Center for Victims of Crime states: "Sexual assault takes many forms including attacks such as rape or attempted rape, as well as any unwanted sexual contact or threats. Usually a sexual assault occurs when someone touches any part of another person's body in a sexual way, even through clothes, without that person's consent."


A review of the document from the Office of Women's Health, U.S. Department of Health and Human Services, revealed, Sexual assault and abuse is any type of sexual activity that you do not agree to, including, inappropriate touching, vaginal, anal, or oral penetration, sexual intercourse that you say no to, rape, attempted rape and child molestation.


Sexual assault can be verbal, visual, or anything that forces a person to join in unwanted sexual contact or attention.


The review of a document provided by the facility revealed a variance report (File ID: ) was entered into the facility's Variance System on 03/16/2014. The variance report was reporting an incident that happened on 03/15/2014. The variance report revealed a brief factual description: Another pt (patient #1) was lying in their own bed. The pt (patient #2) entered their room and was noted tugging at the pants leg of the other pt (patient #1). The pt (patient #2) was immediately redirected from the room with no injuries occurring. Notification Details, Type of Person Notified: Administrator (staff #6), Notes: House Supervisor, charge nurse, parent of the intruding patient, guardian of other patient and Doctor of both patients.


The review of a document provided by the facility revealed a variance report (File ID: ) was entered into the facility's Variance System on 03/19/2014. The variance report was reporting an incident that happened on 03/15/2014. The variance report revealed a brief factual description: Patient #1 was lying in open "obs qas"[sic] left unattended when patient #2 entered the room. A noise was heard at the nurse station and patient #2 was observed on the monitor kneeling over the bed pulling down patient #1 pants. Nurse and tech responded immediately and removed patient #2 from area. He was placed on 1:1. Guardian, parents and physician were notified. Notification Details, Type of Person Notified: Administrator, Name: staff #6, Date: 03/15/2014, Time:18:07, Notes: left message.


There was no evidence the Administrator-on-call (staff #6), referred to in the variance reports (File ID: and File ID: ) responded to the staff after they left messages, reporting the incident.


An interview was held with the Director of Quality (staff #1) on 3/26/2014, at approximately 10:00 AM, in the conference room at Behavioral Health. The interview revealed staff #1 became aware of the incident the morning of 3/19/2014 (4 days later). Staff #1 revealed the Assistant Director of Nurses/Patient Advocate (staff #5) reported the incident on 3/19/2014, after returning from two days of scheduled vacation. Staff#1 confirmed there was no action taken by Quality or Administration to investigate the incident until 3/19/2014 (4 days later). Staff#1 was asked to provide the Root Cause Analysis for review. Staff #1 revealed a Root Cause Analysis was not needed because it was clear staff #9 did not follow the One on One Policy by leaving patient #1 unattended.


An interview was held with the Director of Quality (staff #1) on 3/27/2014, at approximately 10:00 AM, in a small office located on Adolescent Unit at Behavioral Health. Staff #4 and staff #5 were present during the interview. Staff#1 stated all variance reports were reviewed by the Quality Department. Once the variance was reviewed it would be escalated and directed to the appropriate departments from the Quality Department. The interview revealed the variance report (File ID: ) was submitted by anonymous staff on 3/16/2014. The variance report was available to the Director of Quality and Administration on Monday 3/17/2014 for review. Staff#1 had not done a root cause analysis investigation of the incident reported in the variance reports(File ID: and File ID: ). Staff #1 had not identified or investigated the Quality Department as to why the process of reviewing and escalating variance report had failed.


An interview was held with the Chief Executive Office on 3/28/2014, at approximately 11:00AM. The interview confirmed the Quality Department failed to escalate the variance reports (File ID: and File ID: ). Staff #10 was not made aware of the incident until the morning of 3/27/2014 and only after staff #10 asked why surveyors were at the Behavioral Health Campus.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, the Governing Body failed to:

A. ensure that the Quality Management Director, in collaboration with the Patient Safety Officer, followed the facility's own policy for addressing adverse events. The Quality Management Director and Patient Safety Officer failed to conduct an investigation and Root Cause Analysis after becoming aware of a sexual assault of a [AGE] year old female patient.

The review of a document provided by the facility revealed a variance report (File ID: ) was entered into the facility's Variance System on 03/16/2014. The variance report was reporting an incident that happened on 03/15/2014. The variance report revealed a brief factual description: Another pt (patient #1) was lying in their own bed. The pt (patient #2) entered their room and was noted tugging at the pants leg of the other pt (patient #1). The pt (patient #2) was immediately redirected from the room with no injuries occurring. Notification Details, Type of Person Notified: Administrator (staff #6), Notes: House Supervisor, charge nurse, parent of the intruding patient, guardian of other patient and Doctor of both patients.

The review of a document provided by the facility revealed a variance report (File ID: ) was entered into the facility's Variance System on 03/19/2014. The variance report was reporting an incident that happened on 03/15/2014. The variance report revealed a brief factual description: Patient #1 was lying in open "obs qas" [sic] left unattended when patient #2 entered the room. A noise was heard at the nurse station and patient #2 was observed on the monitor kneeling over the bed pulling down patient #1 pants. Nurse and tech responded immediately and removed patient #2 from area. He was placed on 1:1. Guardian, parents and physician were notified. Notification Details, Type of Person Notified: Administrator, Name: staff #6, Date: 03/15/2014, Time: 18:07, Notes: left message.

There was no evidence the Administrator (staff #6), referred to in the variance reports (File ID: and File ID: ) responded to the staff after they left messages, reporting the incident.

A review of the hospital policy titled, "Patient Safety Program" revealed:

"Process: The Quality Management Director, in collaboration with the Patient Safety Officer, will be responsible for the oversight of the Patient Safety Program, including, but not limited to:

Coordinating all patient safety activities

Facilitating assessment and appropriate response to reported events

Monitoring root cause analysis and resulting action plans

Serving as liaison among hospital departments and committees to ensure hospital-wide integration of the PSP


Definitions:

Adverse Event- An event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient.

Medical Error- The failure of a planned action to be completed as intended, the use of a wrong plan to achieve an aim, or the failure of an unplanned action that should have been completed, that results in an adverse event.

Reportable Event- A medical error or adverse event or occurrence which the hospital is required to report to the Texas Department of State Health Services (TDSHS). Reportable Events signal the need for a RCA, and in the case of an intentionally unsafe act, administrative action.

Root Cause Analysis- An interdisciplinary review process for identifying the basic or contributing causal factors that underlie a variation in performance associated with an adverse event or reportable event. It focuses primarily on systems and processes, includes an analysis of underlying cause and effect, progresses from special causes in clinical processes to common causes in organizational processes, and identifies improvements in processes or systems.


Staff are required to report internally the following events which may involve corrective or preventive action:

Medical Errors

Reportable Events-Defined by TDSHS: The sexual assault of a patient during treatment or while the patient was on the premises of the hospital or facility.


A review of Rape, Abuse & Incest National Network defines sexual assault as "unwanted sexual contact that stops short of rape or attempted rape. This includes sexual touching and fondling."

A review of National Center for Victims of Crime states: "Sexual assault takes many forms including attacks such as rape or attempted rape, as well as any unwanted sexual contact or threats. Usually a sexual assault occurs when someone touches any part of another person's body in a sexual way, even through clothes, without that person's consent."

A review of the document from the Office of Women's Health, U.S. Department of Health and Human Services, revealed, sexual assault and abuse is any type of sexual activity that you do not agree to, including, inappropriate touching, vaginal, anal, or oral penetration, sexual intercourse that you say no to, rape, attempted rape and child molestation.

Sexual assault can be verbal, visual, or anything that forces a person to join in unwanted sexual contact or attention.

An interview was held with the Director of Quality (staff #1) on 3/26/2014, at approximately 10:00 AM, in the conference room at Behavioral Health. The interview revealed that staff #1 became aware of the incident the morning of 3/19/2014. Staff #1 revealed the Assistant Director of Nurses/Patient Advocate (staff #5) reported the incident on 3/19/2014, after returning from two days of scheduled vacation. Staff#1 confirmed not until 3/19/2014, was there any action taken by Quality or Administration to investigate the incident. Staff#1 was asked to provide the Root Cause Analysis for review. Staff #1 revealed a Root Cause Analysis was not needed because it was clear staff #9 did not follow the One on One Policy by leaving patient#1 unattended.

An interview was held with the Director of Quality (staff #1) on 3/27/2014, at approximately 10:00 AM, in a small office located on Adolescent Unit at Behavioral Health. Staff #4 and staff #5 were present during the interview. Staff#1 stated all variance reports were reviewed by the Quality Department. Once the variance was reviewed it would be escalated and directed to the appropriate departments from the Quality Department. The interview revealed the variance report (File ID: ) was submitted by anonymous staff on 3/16/2014. The variance report was available to the Director of Quality and Administration on Monday 3/17/2014 for review. Staff#1 had not done a root cause analysis investigation of the incident reported in the variance reports (File ID: and File ID: ). Staff #1 had not identified or investigated the Quality Department as to why the process of reviewing and escalating variance report had failed.

An interview was held with the Chief Executive Office on 3/28/2014, at approximately 11:00AM. The interview confirmed the Quality Department failed to escalate the variance reports (File ID: and File ID: ). Staff #10 was not made aware of the incident until the morning of 3/27/2014 and only after staff #10 asked why surveyors were at the Behavioral Health Campus.



B. ensure the Quality Management Director provided guidance/education to behavioral health staff, as requested by e-mail, regarding the proper reporting of the failures that resulted in the sexual assault of a [AGE] year old female patient.

A review of an e-mail sent to Quality Management Director (staff#1) on 3/19/2014 revealed: Received a report yesterday that a [AGE] year male entered into patient#1's room and preceded to remove her pants. The staff were alerted to his presence and responded quickly, but we may still have a potential problem. Patient #1 was ordered to be on 1:1 monitoring and was left unattended. We failed to follow our own monitoring policy. In doing so, I believe this may be construed as failure to provide a safe environment and neglect of the patient. Patient #1 is also in CPS custody so they are aware of the incident, but we want to know if we made an official report. How do you suggest I proceed?

A review of the hospital policy titled, Standards of Care: Levels of Patient Monitoring.

D. Levels of Monitoring

1. One-to-One (1:1)-continuous staff face-to-face observation of the patient.

a. The patient is assigned to competent staff member who will provide observation of the patient through continuous visual and physical proximity within arms' length.

(1) Observation of the patient will be continued during times when the patient is sleeping, participation in group activities, toileting, etc.

(2) Patients will be assigned to staff members of the same gender, if possible.


b. The provision of 1:1 observation will be based on the assessed needs of the patient and will be continued based on physician orders ... ...

A review of an e-mail sent by Quality Management Director (staff#1) on 3/19/2014 revealed:

Why was patient #1 a one on one?

Was that a physician order?

What DX is the 15y/o admitted with?

What did we do with the staff member who left her unattended?

Let me know when the variance is completed. Thanks!


A review of an e-mail sent to Quality Management Director (staff#1) on 3/19/2014 revealed:

Patient #1 has a neurological disorder that causes her to exhibit s/s of a paranoid schizophrenic. She also has increased impulsivity and was stripping. The physician ordered 1:1.

Patient#2 is diagnosed with psychotic disorder, ADHD, borderline intellect and autism. He has been moved from several schools due to being sexually inappropriate with females. Staff #6 spoke with the staff on Monday, but no formal action has been taken yet.

There were no other e-mails that provided evidence of guidance/education to behavioral health staff. Behavioral Health requested guidance and no evidence was provided the Quality Management Director responded.

An interview was held with the Director of Quality (staff #1) on 3/26/2014, at approximately 10:00 AM in the conference room at Behavioral Health. Multiple requests were made to provided e-mails to surveyor that would provide evidence the quality director had investigated or was investigating the incident. The above documented e-mails were not provided by the Director of Quality. No follow up to the above e-mails were provided by the Director of Quality (staff#1).

An interview was held with the Chief Executive Office on 3/28/2014 at approximately 11:00AM. The interview confirmed the Quality Department failed to escalate the variance reports (File ID: and File ID: ). Staff #10 was not made aware of the incident until the morning of 3/27/2014 and only after staff #10 asked why surveyors were at the Behavioral Health Campus.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review and interview, the facility failed to provide appropriate monitoring of 2 of 2 (Patients #1, #2) patients to prevent them from harming themselves and others.

Patient #1 who was assigned a 1:1 monitoring was left unattended by the staff which resulted in attempted sexual assault of patient #1 by patient #2. According to hospital policy, a 1:1 monitoring is a continuous staff face-to- face observation of the patient, through continuous visual and physical proximity within arms' length. The administrator on-call, failed to respond to staffs' phone calls to report the incident resulting in the incident not being reported to Quality Management or Patient Safety for investigation.

Refer to tag A0144
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, the facility failed to provide appropriate monitoring of 2 of 2 (Patients #1, #2) patients to prevent them from harming themselves and others.

Patient #1 who was assigned a 1:1 monitoring was left unattended by staff which resulted in attempted sexual assault of patient #1 by patient #2. According to the hospital policy, a 1:1 level of observation is a continuous staff face-to-face observation of the patient, through continuous visual and physical proximity within arms' length.

The administrator on-call, failed to respond to staffs' phone calls to report the incident resulting in the incident not being reported to Quality Management or Patient Safety for investigation.

It was determined that these deficient practices created an Immediate Jeopardy situation, resulting in attempted sexual assault of patient #1 by patient #2, creating the likelihood of harm, serious injury, and subsequent death to all patients on the child/adolescent psychiatric unit.


Review of the following resources revealed definitions of sexual assault:

A review of Rape, Abuse & Incest National Network defines sexual assault as "unwanted sexual contact that stops short of rape or attempted rape. This includes sexual touching and fondling".

A review of National Center for Victims of Crime states: "Sexual assault takes many forms including attacks such as rape or attempted rape, as well as any unwanted sexual contact or threats. Usually a sexual assault occurs when someone touches any part of another person's body in a sexual way, even through clothes, without that person's consent".

A review of the document from the Office of Women's Health, U.S. Department of Health and Human Services, revealed: "Sexual assault and abuse is any type of sexual activity that you do not agree to, including, inappropriate touching, vaginal, anal, or oral penetration, sexual intercourse that you say no to, rape, attempted rape and child molestation. Sexual assault can be verbal, visual, or anything that forces a person to join in unwanted sexual contact or attention".

A review of patient #1's medical record revealed that patient was a [AGE] year old female admitted on [DATE], with a diagnosis of: Bipolar Disorder, Rhombencephalosynapsis (developmental midline defect affecting the cerebellar vermis), Schizophrenia paranoid, MR(mental retardation). Patient had a history of stripping off clothes, banging head, spitting on people, and assaulted a teacher x2. Patient was placed on 1:1 monitoring (continuous staff face to face observation of the patient) on admission because of stripping clothes, aggressive with peers and adults, bangs head, throwing chairs, defiant, and threatens to harm self and others.

A review of patient #2's medical record revealed; "Patient was a [AGE] year old male admitted on [DATE] with a diagnosis of Psychotic Disorder, Not otherwise specified, Attention Deficit Hyperactivity Disorder, Autism Spectrum Disorder, and Borderline Intellectual Functioning. He is in the 9th grade Life Skills, Special Education. Patient has had several admissions to facility with last admission February 2013. He has also had in-patient and outpatient services provided at other facilities. He has seen Dr. #12 in the past and a therapist. Family history of drug use with his father and his mother has "slowed thinking". His father is in jail for other issues, but patient has history of molestation by his father. Pt. has no contact with his father. He has been raised by his mother and grew up with younger siblings. He has had problems since he was young with animals and becoming aggressive with siblings and his mother and peers at school. In the past, when patient would harm the kittens, his mother did not want to get rid of them as suggested, because she was worried he would begin harming his siblings. He has been out of control at home at times and mother cannot manage him. He is admitted due to trying to jump out a moving car. He has been having temper tantrum when he does not get his way. He placed the cat in the dryer and he placed his finger in the cat's rectum. He burnt the guinea pig on the gas stove and then threw it in the bathtub acting like nothing happened. He has stolen cars, damaged property and laid out 5 knives with intent to harm 5 people. It was also reported that he sees people who disappear when they look at him. He hears voices telling him to touch young girls inappropriately. His mother reported that he has done this several time, but denies hearing or seeing things at this time. He has been off medication for 1 year per his mother. On admission, patient was placed on close observation (staff monitoring every 15 minutes) for suicide and aggression.

A review of a written statement by the patient care technician (staff #9) providing the 1:1 monitoring for patient #1 revealed: on 3/15/14 at 12:30 PM after pt. finished eating lunch, she asked to go to the quiet room because she was sleepy. I covered patient #1 and she turned sideways and closed her eyes. Two or three minutes later, I went to get some water. I was headed back to the room when staff #11 saw patient #2 on the monitor and we ran in the quiet room where patient #2 was kneeling on the floor taking patient #1 pants off. Staff #11 removed patient #2 from the room.

A review of the hospital policy titled "Standards of Care: Levels of Patient Monitoring revealed the following:

D. Levels of Monitoring

1. One-to-One (1:1)-continuous staff face-to-face observation of the patient.

a. The patient is assigned to competent staff member who will provide observation of the patient through continuous visual and physical proximity within arms' length.

(1) Observation of the patient will be continued during times when the patient is sleeping, participation in group activities, toileting, etc.

(2) Patients will be assigned to staff members of the same gender, if possible.


b. The provision of 1:1 observation will be based on the assessed needs of the patient and will be continued based on physician orders. Continuation of 1:1 observation will be assessed at least every 24 hours and will be discontinued only on the physician's order.


c. Patient behavior will be observed continuously. A trained staff member will document on the Precaution Flow Sheet at least every 15 minutes the location and behavior of the patient and any interventions required.


e. An alternate staff member with identified competency for providing 1:1 observation will be assigned for coverage of the patient during the primary staff's break/meal times.


A review of education documents revealed staff #9 had the required annual training, Abuse and Neglect-Psych. This education module included training for the monitoring of the patient on a 1:1.


An interview with staff #5 revealed that the census on the Child and Adolescent Unit was 10 patients. One of those patients required a 1:1 monitoring (patient #1). The hospital staffing plan required 2 licensed staff. Those two staff were RNs. The hospital staffing plan required three unlicensed staff. The unlicensed staff consisted of one experienced staff assigned fulltime to the Child and Adolescent Unit. Two of the staff members were from other units and were not regularly assigned to the Child and Adolescent Unit. Staff #9 was one of the staff members that were not regularly assigned to the Child and Adolescent Unit. Staff #9 had recently worked on the unit and was familiar with patient #1. Patient #1 would act out and become aggressive towards new caregivers and staff #9 had worked with patient #1 in the past. The decision was made to assign staff #9 to the 1:1 care of patient #1. Staff #5 revealed staff #9 had the 1:1 training but had never done 1:1 care of a patient before.


An interview was conducted on 03/26/2014, at approximately 2:00 PM, with staff #11 at the nurses' station, located on the Child and Adolescent Unit. Staff #11 reported that she had been caring for a patient. As staff #11 came from the hallway and entered into the nurses' station, voices were heard. At the point in which staff #11 was standing, the staff had a view of both the open door into the patient seclusion area and the monitor. Upon hearing voices, the staff could see patient #2 kneeling at the foot of patient #1's bed. Patient#2 was pulling at patient #1's pants legs. Immediately staff #11 yelled help and headed for the seclusion room. Staff #11 stated, by the time I approached the door staff #9 was at the door coming from my right. I immediately removed patient#2 from the room. Staff#7 (primary care nurse for patient #1) and staff#9 were in the room with patient#1 when I was leaving the room with patient #2.


A review of a written statement by staff #11 revealed, I heard voices coming from obs room. I looked at the monitor; I saw patient #2 kneeling on the floor taking off patient #1's pants. Staff #9 was heading to room at the same time. We both went into the room. I removed patient #2 from room, while staff #9 and staff #7 (charge nurse) attended to patient #1. This written statement confirmed what staff #11 stated during her interview.


The review of a document provided by the facility revealed a variance report (File ID: ) was entered into the facility's variance tracking system on 03/16/2014. The variance report was reporting an incident that happened on 03/15/2014. The variance report revealed a brief factual description: Another pt (patient #1) was lying in their own bed. The pt (patient #2) entered their room and was noted tugging at the pants leg of the other pt (patient #1). The pt (patient #2) was immediately redirected from the room with no injuries occurring. Notification Details, Type of Person Notified: Administrator (staff #6), Notes: House Supervisor, charge nurse, parent of the intruding patient, guardian of other patient and Doctor of both patients.



The review of a document provided by the facility revealed a variance report (File ID: ) was entered into the facility's variance tracking system on 03/19/2014. The variance report was reporting an incident that happened on 03/15/2014. The variance report revealed a brief factual description: Patient #1 was lying in open "obs qas" [sic] left unattended when patient #2 entered the room. A noise was heard at the nurse station and patient #2 was observed on the monitor kneeling over the bed pulling down patient #1 pants. Nurse and tech responded immediately and removed patient #2 from area. He was placed on 1:1. Guardian, parents and physician were notified. Notification Details, Type of Person Notified: Administrator, Name: staff #6, Date: 03/15/2014, Time:18:07, Notes: left message.



There was no evidence that the Administrator on-call for 3/15/2014 (staff #6 DON (Director of Nurses) of Behavioral Health), referred to in the variance reports (File ID: and File ID: ) responded to the staff after they left messages, reporting the incident.



An interview was held with the Director of Quality (staff #1) and the COO/CNO (staff#4) on 3/26/2014 at approximately 01:00 PM in the conference room at Behavioral Health. The interview revealed that Staff #6 had not provided any documentation or evidence to the investigation of the sexual assault of patient #1. Staff #6 was the Administrator on-call at the time of the incident on 03/15/2014. The interview confirmed staff #6 who is the DON of Behavioral Health, did not communicate with the Director of Quality or COO/CNO the events of the incident. During the interview with Director of Quality and COO/CNO, the need to interview staff#6 was discussed. The Director of Quality and COO/CNO revealed staff #6 was off from work due to illness and had rather her not be bothered at home with an interview.



An interview was held with the Director of Quality (staff #1) on 3/26/2014 at approximately 10:00 AM in the conference room at Behavioral Health. The interview revealed that staff #1 became aware of the incident the morning of 3/19/2014(4 days later). Staff #1 revealed that the Assistant Director of Nurses/Patient Advocate (staff #5) reported the incident on 3/19/2014 after returning from two days of scheduled vacation. Staff#1 confirmed no action was taken by Quality or Administration to investigate the incident until 3/19/2014(4 days later).



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