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 May 20, 2015
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on medical record review, interviews, policy search and quality data, it was determined that the facility failed to protect one of ten patients (patient #6) from potential threat or harm of abuse by not reporting or investigating the allegation per protocol.

Finding include:


Review of medical record #6 revealed documentation on 2/12/2015 that "patient fixated on staff member "raping me ".
During an interview on 5/19/2015 at 13:10, Registered Nurse (RN) #10 (charge nurse) revealed that the patient was calling out "I was raped by a big black man" multiple times. The charge nurse stated that the nurse manager, (RN #8) was present and went to talk to patient at that time, and that he/she thought that the patient recanted the allegation and that no incident report was made to the best of his/her knowledge. He/she related that he/she did not document any of this in the patient's chart.
In an interview on 5/19/2015 at 14:00, the Nurse Manager (RN #8) stated that he/she interviewed the patient on 2/12/2015 after hearing his/her claim that he/she was "sexually assaulted". The patient stated "a big black guard comes in at night and they put the cream on", but he/she refused to give any other details to the Nurse Manager (NM), so the NM requested that the charge nurse speak with the patient since the charge nurse had a better rapport with patient and might get more information. The NM revealed that he/she reported this incident to the oncoming nurse supervisor for the evening shift. The NM followed up the next day (2/13/2015) with patient who denied the allegations at that time. The NM revealed that he/she did not document any of the above.
In an interview on 5/20/2015 at 10:25 am, Mental Health Associate (MHA) #18 revealed that when he/she came in on 2/13/2015, he/she was changed to the "other side" due to the allegations. He/she stated that the charge nurse said "we want you to be safe"- [patient #6] alleged you sexual something or touch something to that effect". Work on the other side until things clear up". MHA #18 stated that he/she went back to the original unit when [patient #6] recanted the allegation. Patient #6 was still on the unit at that time.
Policy entitled "Alleged Patient Abuse, Neglect, Exploitation" documented in part "... to report all incidents of patient abuse ..." , "...if an incident rises to the level of a reportable conduct the facility should upon inquiry by a staff person call the Risk Management Department and seek advice ..." , "...there is a duty to report incidents that occur at a facility when one 'reasonably believes or who knows of information' that would reasonably cause a person to believe such abuse or neglect has, is or will occur ..." The policy included a procedure as follows:
1) Report to Director of nursing
2) Document information
3) Document collection, retainment, and safeguarding of evidence that has been released by the patient in the patient record.
4) Document legally required notification and release of information to authorities
5) Document referrals made to private or public community agencies for victims of abuse in the patient record.
6) Nursing management representative notified immediately shall immediately contact the CEO and/or Administrator, Patient Advocate and the DON.
7) The facility designee or director must make a verbal report to the Georgia Department of Health within 24 hours.
8) An internal investigation shall be conducted and a report of findings written by the Patient Advocate or designee. Documentation shall be maintained in a central file by the Patient Advocate.
Review of the facility's documented Quality reports failed to reveal documentation of the above incident and reported interventions. No documentation was provided by the facility.
Based on review of medical records, staff interviews, facility policies facility's quality data records, it was determined that the allegation could be substantiated. Deficiencies were cited.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on medical record review, interviews, policy search and quality data, the facility failed to protect patient #6 from potential threat or harm of sexual abuse by not reporting or investigating the allegation per protocol.

Finding include:


Review of medical record #6 revealed documentation on 2/12/2015 that "patient fixated on staff member "raping me ".
During an interview on 5/19/2015 at 13:10, Registered Nurse (RN) #10 (charge nurse) revealed that the patient was calling out "I was raped by a big black man" multiple times. The charge nurse stated that the nurse manager, (RN #8) was present and went to talk to patient at that time, and that he/she thought that the patient recanted the allegation and that no incident report was made to the best of his/her knowledge. He/she related that he/she did not document any of this in the patient's chart.
In an interview on 5/19/2015 at 14:00, the Nurse Manager (RN #8) stated that he/she interviewed the patient on 2/12/2015 after hearing his/her claim that he/she was "sexually assaulted". The patient stated "a big black guard comes in at night and they put the cream on", but he/she refused to give any other details to the Nurse Manager (NM), so the NM requested that the charge nurse speak with the patient since the charge nurse had a better rapport with patient and might get more information. The NM revealed that he/she reported this incident to the oncoming nurse supervisor for the evening shift. The NM followed up the next day (2/13/2015) with patient who denied the allegations at that time. The NM revealed that he/she did not document any of the above.
In an interview on 5/20/2015 at 10:25 am, Mental Health Associate (MHA) #18 revealed that when he/she came in on 2/13/2015, he/she was changed to the "other side" due to the allegations. He/she stated that the charge nurse said "we want you to be safe"- [patient #6] alleged you sexual something or touch something to that effect". Work on the other side until things clear up". MHA #18 stated that he/she went back to the original unit when [patient #6] recanted the allegation. Patient #6 was still on the unit at that time.
Policy entitled "Alleged Patient Abuse, Neglect, Exploitation" documented in part "... to report all incidents of patient abuse ..." , "...if an incident rises to the level of a reportable conduct the facility should upon inquiry by a staff person call the Risk Management Department and seek advice ..." , "...there is a duty to report incidents that occur at a facility when one 'reasonably believes or who knows of information' that would reasonably cause a person to believe such abuse or neglect has, is or will occur ..." The policy included a procedure as follows:
1) Report to Director of nursing
2) Document information
3) Document collection, retainment, and safeguarding of evidence that has been released by the patient in the patient record.
4) Document legally required notification and release of information to authorities
5) Document referrals made to private or public community agencies for victims of abuse in the patient record.
6) Nursing management representative notified immediately shall immediately contact the CEO and/or Administrator, Patient Advocate and the DON.
7) The facility designee or director must make a verbal report to the Georgia Department of Health within 24 hours.
8) An internal investigation shall be conducted and a report of findings written by the Patient Advocate or designee. Documentation shall be maintained in a central file by the Patient Advocate.
Review of the facility's documented Quality reports failed to reveal documentation of the above incident and reported interventions. No documentation was provided by the facility.
Based on review of medical records, staff interviews, facility policies facility's quality data records, it was determined that the allegation could be substantiated. Deficiencies were cited.