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Based on interview, record review and review of facility policy, "General Hospital Policies, Section 3, Risk Management and Safety Policies," reviewed date 05/2012, it was determined the facility failed to ensure hospital personnel responded as required in section A.6 to an allegation by a patient of sexual abuse for one (1) of ten (10) patients (Patient #1).

The findings include:

Review of the facility's policy, "General Hospital Policies, Section 3, Risk Management and Safety Policies," reviewed date 05/2012, revealed, in section A.5, Class 3 incidents were critical in nature and presented an immediate threat to a person's welfare and safety. The policy further stated reported or alleged abuse were Class 3 incidents. In addition, the policy revealed, in section A.6, certain responsibilities applied to any employee(s) who received the report of an incident, one (1) of which was the employee was to immediately report all incidents to his/her supervisor and the Shift Coordinator. It further revealed the employee would initiate the incident report form, and any employee who failed to immediately report abuse would be subject to disciplinary action up to and including dismissal. Further review of this policy, in section C.A, revealed the requirements for different levels of patient supervision by staff. Safety level with fifteen (15) minute checks would be utilized when the patient was at low risk for injury but still had identified risk factors present. This patient could not leave the unit for off-unit activities. The policy also stated support level supervision would allow the patient to leave the unit escorted by staff with observations by staff at least every thirty (30) minutes from 7:30 AM until 9:00 PM. In addition, the policy revealed every patient would be monitored with documentation at least every fifteen (15) minutes during the hours of 9:00 PM until 7:15 AM.

Review of the clinical record of Patient #1 revealed he/she was admitted on [DATE] under a seventy-two (72) hour court order with a diagnosis of Psychosis, Not Otherwise Specified. He/she had been sent to the facility from another facility where he/she had been a patient for five (5) days. The record further revealed Patient #1 had been hallucinating, was delusional, and threatening to others. In addition, the record stated this was Patient #1's third admission to this facility, the most recent being in 2007, and he/she had a history of bipolar and schizophrenic disorders. His/her initial level of supervision, ordered by the Physician, was safety, every fifteen (15) minutes, meaning Patient #1 was restricted to the unit and was being monitored/observed every fifteen (15) minutes. The record revealed Patient #1 showed some improvement in behavior and was changed to a support level of supervision on 01/22/13 at 3:00 PM per Physician order. This allowed the patient to leave the unit and participate in Recovery Mall therapies and reduced the required monitoring to every thirty (30) minutes from 7:30 AM to 9:00 PM. The record stated per "RN (Registered Nurse) Shift Assessment" that on 01/28/13, from 3:00 PM to 11:30 PM, Patient #1 was delusional, and no incident was documented; on 01/29/13 from 12:00 AM to 7:30 AM, RN #1 documented Patient #1 was engaged in aggressive behavior with visual hallucinations and was delusional and paranoid. The record further stated, on the Medication Administration Record (MAR) and "RN Shift Assessment," Patient #1 was given Benadryl 50 milligrams (mg) by mouth (PO), Vistaril 25 mg PO, and Haldol 5 mg PO on 01/29/13 at 1:00 AM for increased agitation. Further review of the "RN Shift Assessment," on 01/29/13 at 10:10 AM revealed Patient #1 stated he/she had been sexually assaulted earlier in the night, had told RN #1, and had been given the above medications.

Interview with RN #1, on 02/14/13 at 7:53 PM, revealed she did not know of any incident that occurred during the early morning hours of 01/29/13 involving Patient #1. She further revealed Patient #1 had been awake and at the nurses station redialing the telephone at this time, but he/she had not reported any incident of sexual abuse to her.

Interview with Mental Health Associate (MHA) #1, on 02/17/13 at 8:15 PM, revealed Patient #1 had reported an incident of sexual abuse to her in the early morning hours of 01/29/13, and she was sure Patient #1 told RN#1 and MHA #2 the same thing at the nurses station. MHA #1 further stated RN #1 gave Patient #1 some medications to calm him/her; after Patient #1 took the medications, he/she went to bed and rested well the remainder of the night. MHA #1 further revealed she did not report the allegation of sexual abuse by Patient #1 to RN #1 because she was so certain RN #1 had also heard the allegation and therefore, would report it. She stated she had been trained to report any allegation a patient told her that might be abuse to the supervising nurse. MHA #1 also revealed she did not witness any incident with Patient #1 and any other patient.

Interview with MHA #2, on 02/18/13 at 2:45 PM, revealed there were two (2) patients pacing in the hallway the early morning hours of 01/29/13, one (1) was Patient #1 and one (1) was unidentified. At about 1:00 AM, Patient #1 told RN #1 that the patient he was pacing with had kissed him/her. Then, MHA #2 reported RN #1 asked Patient #1 if he/she were sure and if he/she were delusional. MHA #2 stated everybody at the nurses station heard the conversation between RN #1 and Patient #1, and he did not think he needed to report the allegation to anyone because he was sure RN #1 had heard it and would respond to the allegation. He further revealed he did not witness any abuse occurring between Patient #1 and the unidentified patient.

Interview with the Nurse Manager of the unit, on 02/18/13 at 4:00 PM, revealed she first heard about the alleged incident on 01/29/13 at 10:10 AM during Patient #1's Recovery Team meeting, which he/she attended. At that meeting, the Nurse Manager stated Patient #1 related the alleged incident from the early morning hours. Patient #1 was moved to another wing at this time and an incident report completed and an investigation begun. The Nurse Manager further revealed Patient #1 stated he/she was not injured and refused to have any pictures taken. She stated there was annual training on awareness of the abuse policy, including reporting requirements, and this was done in the Fall of 2012. The Nurse Manager also revealed there were classes on the abuse policy and its requirements at orientation for new employees. She revealed her expectation would have been for RN #1 to have initiated the process for reporting alleged abuse with the Shift Coordinator as soon as the allegation was heard.

Interview with the Acting Director of Nursing, on 02/18/13 at 4:31 PM, revealed the facility taught personnel to report every allegation and not make judgments as to the validity of the allegation. He also stated there was training in November 2012 on abuse recognition and reporting. He revealed his expectation would have been for RN #1 to report the alleged incident involving Patient #1 to the Shift Coordinator. In addition, he stated he thought it was unrealistic for the MHA's to have reported the incident to the Shift Coordinator since both MHA #1 and #2 believed RN #1 had heard the allegation.