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.

PEACHFORD BEHAVIORAL HEALTH SYSTEM OF ATLANTA 2151 PEACHFORD ROAD ATLANTA, GA 30338 June 19, 2014
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review and interviews, the facility failed to protect one (1) patient (#1) of the ten (10) sampled patients.



Cross refer for details: 482.13(c)(2) Patient Rights
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the facility failed to provide protection for one (1) patient (#1) of the ten (10) sampled patients.

Findings include:

Review of the medical record for patient #1 revealed an admission date of [DATE] with a diagnosis of Schizophrenia exhibiting increased agitation, threatening behaviors and homicidal ideation. The patient was responding to internal stimuli and a history of Mental Retardation and Sleep Apnea.

Review of the physician admission orders dated 2/14/14 revealed patient #1 was to be assessed/monitored every fifteen (15) minutes, due to the Potential for Suicidal/Self Harm.

Review of a form titled, "The Risk Management Worksheet/Incident Report" dated 3/1/14 at 12:50 a.m. revealed a Mental Health Assistant (MHA) #6 found patient #1 and patient #4 in the quiet room together. MHT #6 reported to Registered Nurse (RN) #5.

RN #5, assessed both patients. Patient #4 informed RN #5 they had oral sex. RN #5 separated patients #1 and #4, and instructed them not to go around each other. Patient #1 informed RN #5 that patient #4 threatened to beat him/she if he/she did not pull his/her pants down.

Review of medical record for patient #1 on the 24 hour Observation Sheets revealed patient #1 observation status was changed from every 15 minutes to Constant (within eyesight/or within fifteen (15) feet) observation status on 3/4/14 at 7:15 a.m. The patient was checked as a Potential for Sexual Aggression added on 3/4/14 in addition to Potential for Suicidal/Self Harm already listed on 2/14/14.

Review of a Video, dated 3/1/14 from 12:30 a.m. to 1:00 a.m. revealed on the Geriatric Unit hallway, however the video did not include the quiet room area. Per the video observation patient #1 and patient #4 were passing each other in the hallway then sitting and talking to each other fully dressed wearing their personal clothing. Patient #1 got up from sitting in the hallway and walked into another patient's room for a few minutes then exited the other patient's room and handed something to patient #4. A few minutes later patient #1 went into the quiet room, 20-30 seconds later patient #4 went into the quiet room.

Continued review of the video revealed MHA #6 checking patients' rooms, looking in the quiet room for a minute when passing the room, then checked a few other rooms and a couple minutes later returning to the quiet room with the RN #5.

Continuous review of the Video revealed RN #5 standing outside the quiet room. looking inside the room talking. A few minutes later patient #1 and patient #4 came out of the quiet room into the hallway. Patient #4 walked towards the nursing station and patient #1 went in the opposite direction into a room.

Interview on 6/17/14 at 3:15 p.m. with RN #5 revealed MHT #6 reported that patient #4 stated having oral sex in the quiet room with patient #1. Patient #1 reported that patient #4 threatened physical harm if patient #1 did not remove his/her pants. RN #5 stated both patients were assessed with no apparent injury. RN #5 confirmed failure to increase the observation status for patient #1 and #4 due to sexual behavior.

Review of the facility policy entitled, Patient Sexual Familiarity Prevention Guidelines", revised 6/14 indicated, response to alleged sexual familiarity occurrences staff would take all reports seriously and patients who alleged sexual assault would be placed on 1:1 observation., and that 1:1 observation would be discontinued by a physician.

Thus the facility failed to protect patient #1 even after observation of a sexual act, and the patient expressing fear, the MHT failed to immediately intervene, then the facility failed to increase observation status of patient #1, until three (3) days after the occurance.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on record review, the nursing staff failed after an alleged unwanted sexual act for patient #1, failed to provide observation to protect the patient from the alleged offender.


Cross refer for details:
482.13 Patient rights: Care in a safe setting
482.23 (b ) (4 ) Nursing Care Plan
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility staff failed to develop and implement a safety plan for a patient who had alleged an unwanted sexual act, and fear from the alleged offender for one (1) patient (#1) of the ten (10) sampled patients.

cross reference for details: 482.13(c)(2)

Findings include:

Review of the medical record for patient #1 revealed an admission date of [DATE] with a diagnosis of Schizophrenia exhibiting increased agitation, threatening behaviors and homicidal ideation. The patient was responding to internal stimuli and a history of Mental Retardation and Sleep Apnea.

Review of the admission physician orders revealed patient #1, was to be observed every fifteen (15) minutes. Review of the treatment plan revealed patient #1 at risk for Suicidal/Self Harm.

Review of a form titled, "The Risk Management Worksheet/Incident Report" dated 3/1/14 at 12:50 a.m. revealed a Mental Health Assistant (MHA) #6 found patient #1 and patient #4 in the quiet room together. MHT #6 reported to Registered Nurse (RN) #5.

RN #5, assessed both patients. Patient #4 informed RN #5 they had oral sex. RN #5 separated patients #1 and #4, and instructed them not to go around each other. Patient #1 informed RN #5 that patient #4 threatened to beat him/she if he/she did not pull his/her pants down.

Review of the 24 hour Observation Sheets revealed patient #1 observation status was changed from every 15 minutes to Constant (within eyesight/or within fifteen (15) feet) observation status on 3/4/14 at 7:15 a.m. three (3) days after the allegation of a sexual encounter.

According to the Treatment Plan Problem Sheet initiated on 2/14/14 thru patient #1's discharge on 3/7/14 included self- harming thoughts and behavior with no evidence of for sexual aggression.

Interview on 6/17/14 at 3:15 p.m. with RN #5 confirmed that above findings.

Review of the facility policy entitled, Patient Sexual Familiarity Prevention Guidelines", revised 6/14 indicated, response to alleged sexual familiarity occurrences staff would take all reports seriously and patients who alleged sexual assault would be placed on 1:1 observation., and that 1:1 observation would be discontinued by a physician.