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.

MOUNTAIN VIEW HOSPITAL 3201 SCENIC HIGHWAY GADSDEN, AL June 19, 2014
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review a the letter from Patient Identifier (PI) # 1, medical record review, review of policies and procedures and interviews, nursing staff failed to document and report an allegation of sexually inappropriate behavior reported by Patient Identifier (PI) # 1 to staff involving another patient (PI # 2) to Administration. As a result of this deficient practice, the allegation was not investigated and interventions implemented (if the allegation had been validated) during the patient's hospitalization . This deficient practice affected one of ten sampled patients, but had the potential to affect all patients hospitalized on the Adult Unit.

Findings Include:

A review of a letter dated 6/3/14, written by PI # 1, was forwarded to the State Agency when the hospital self reported the incident. PI # 1 alleged sexual harassment by a male peer while hospitalized . PI # 1 reportedly informed the "first shift" and the night shift about the allegation, but documents no action was taken by staff. No date, time or names were documented in the letter. According to the letter, PI # 1 reported the concern to the hospital on [DATE] after discharge from the facility.


Medical Record Review:

1. A review of PI # 1's medical record revealed the patient was admitted on [DATE] with a diagnosis of Major Depressive Disorder and was discharged on [DATE].


A review of the Nursing Notes dated 5/29/14 through 6/2/14 revealed no documentation regarding PI # 1's report of sexually inappropriate behavior by a male patient (PI # 2) to nursing staff.


A review of the Physician's Progress Notes (5/29/14 through 6/2/14) revealed no documentation regarding PI # 1's report of sexually inappropriate behavior to medical staff.



2. A review of PI # 2's medical record revealed the patient was admitted on [DATE] with a diagnosis of Major Depressive Disorder without Psychotic Features and was discharged on [DATE].


A review of the Nursing Notes dated 5/21/14 through 6/3/14 revealed no documentation that PI # 2 exhibited sexually inappropriate behavior. There is no documentation of any discussion with PI # 2 by nursing staff regarding PI # 1's allegation of sexually inappropriate behavior.



Policies and Procedures:

Identifying and Reporting Patient Abuse and Neglect:
Policy: PC. 010
Effective Date: 4/10/95
Revised Date: Not documented

Policy: " ...any instances of physical, psychological, sexual or any other abuse by any employee or any professional staff or contracted staff toward a patient will not be tolerated...

Procedure:

A. Each employee, while in orientation, should be made aware of the Incident Report and its use...

E. Staff Responsibilities:

A. Staff receiving or witnessing an incident of patient abuse...must report the incident to their immediate supervisor or the Chief Executive Officer by filing an Incident Report...

d. Anyone approached by a patient who complains that his/her rights have been violated, but is unsure as to how to process the complaint, has the responsibility to:

1. Inform the patient that you will notify the Registered Nurse (RN) on their unit.

2. The RN explores the complaint with the patient to determine if it is pertinent to a patient rights matter.

3. If applicable, the RN will inform the patient that the Program Manager will be contacted for them.

4. The Program Manager will contact Director of Patient Services to further investigate the issue... "

2. Adult Admission Information:

Patient Rights: " It shall be the policy of this Hospital that all staff members shall support and protect the fundamental human, civil, constitutional and statutory rights of each patient. Further, each patient shall be informed of his/her rights...and receive a written statement of the Patient ' s Bill of Rights.

Basic Rights: ... To be treated with dignity and respect and with the utmost professional care...

Additional Rights...the right to be free from verbal and/or physical abuse...

3. Adult Unit Guidelines:

...Sexually inappropriate behavior is not allowed... "


Quality Assurance Reporting

Policy # EEC

Effective Date: 7/1/94

Revised Date: 4/20/11

"Purpose: To provide a mechanism for reporting hospital occurrences related to patient/employee safety.

Policy: All occupancies...should be reported to an immediate supervisor/physician and documented in the patient record when appropriate. A Quality Assurance Report will will be completed and forwarded to the Risk Manager for follow-up.

The following occurrences should warrant completion of 'an' Quality Assurance Report, but is not inclusive:

1. Patient injury, patient abuse or patient emergency...

11. Any breach of patient rights.


Patient Bill of Rights and Organizational Ethics
Policy: RI. 014
Effective Date: 9/1/91
Revised Date: 3/11/99

"Policy: To ensure that program staff understand and respect such rights for all patients and to ensure that all patients are aware of their rights while hospitalized in this facility...

Procedure:

A. All staff members will review "Patient Rights" during their orientation...

Patient's Bill of Rights

I. It shall be the policy of this hospital that all staff members shall support and protect the fundamental human, civil, constitutional, and statutory rights of each patient...

A. Basic Rights: ...
2. To be treated with dignity and respect, and with the utmost professional care..."


Reassessment, Nursing Care:
PC. 220
Effective Date: 10/1/02
Revised Date: Not documented

"Policy: It is the policy...to reassess all patients during each shift and with any significant change in a patient's condition...Reassessment determines a patient's response to care.

Reassessment should be documented on the Twenty-Four Hours Nursing Flowsheet with any abnormalities noted in detail in a Nurse's Note...Any significant change in a patient's condition should be reported to the physician immediately.

Procedure: Proper completion of the Twenty-Four Hour Nursing Flowsheet includes acknowledging all questions or prompts for information..."


Interviews

During an interview on 6/17/14 at 4:00 PM, the Director of Clinical Services, Employee Identifier (EI) # 6, verified there is no specific policy that addresses allegations/incidents related to patient on patient harassment and /or abuse.

During an interview on 6/17/14 at 5:10 PM, the Registered Nurse (RN), 7:00 AM to 7:00 PM Shift, Employee Identifier (EI) # 4, stated she did not recall if an allegation of sexually inappropriate behavior had been reported to her by PI # 1.

During an interview on 6/18/14 at 9:12 AM, the RN, 7:00 AM to 7:00 PM Shift, Employee Identifier (EI) # 1, stated another patient reported PI # 1 was, "Saying a lot of stuff in the phone room. I walked by to check and overheard the patient (PI # 1) talking on the phone. She did not approach me directly." The RN described PI # 1's affect as angry. As the RN walked by the room on 6/1/14 she overheard PI # 1 yelling, "That's sexual harassment." PI # 1 told the RN a male patient (PI # 2) "flashed" her. According to the RN, there is no camera in the telephone room. EI # 1 said she remembered talking to PI # 2 who denied flashing PI # 1 and/or making sexually inappropriate comments to PI # 1.

EI # 1 (RN) stated she was assigned to care for PI # 1 on 5/31/14 and 6/1/14, but did not document the allegation in PI # 1's medical record.
The RN was asked if she completed an incident report and she said no.


During interviews on 6/18/14 at 10:50 AM and 12:00 PM, the Clinical Coordinator / Patient Advocate, EI # 2, stated she received a telephone call from PI # 1 regarding an allegation of sexually inappropriate behavior by a male peer the day after PI # 1 was discharged from the hospital. On 6/4/14 PI # 1 presented to the hospital to further discuss the allegation. The Coordinator said she had no knowledge about the allegation prior to PI # 1's contact via telephone on 6/3/14.

EI # 2 (Coordinator) said she watched the video tapes (dates of PI # 1's hospitalization : 5/26/14 - 6/2/14) and saw no inappropriate behavior by PI # 2 as alleged by PI # 1. The Coordinator determined staff was checking the patients every 15 minutes. EI # 1 also interviewed the two nurses (PI # 1 and PI # 4) who were mostly involved with PI # 1. "They (nurses to whom PI # 1 allegedly reported allegation) did not take her (PI # 1) seriously. Did not report." According to the Coordinator, she (PI # 1) made a complaint and we (Hospital) didn't address it."


During an interview on 6/18/14 at 1:20 PM, PI # 1's Attending Physician/ Medical Director, EI # 3, stated he was notified of the allegation after the patient reported it to the Clinical Coordinator.


During an interview on 8/18/14 at 9:32 PM, the Night Shift RN, 7:00 PM to 7:00 AM Shift, EI # 9, stated she could not remember any allegation of sexually inappropriate behavior reported to her by PI # 1.


During an interview on 8/18/14 at 9:40 PM, the Psychiatric Technician, 7:00 PM to 7:00 AM Shift, EI # 10, said PI # 1 did not report any allegation of sexually inappropriate behavior by a male peer to him.


Hospital's Action Plan in response to internal investigation of PI # 1's complaint:

1. Mandatory Staff Training for Direct Care Staff on 6/26/14: How to Recognize and Respond to Patient Boundary Violations.

2. Individual education of PI # 1 and PI # 4, regarding reporting of patient allegations to Administration and completion of Incident Reports for allegations/incidents.