|EASTERN STATE HOSPITAL||1350 BULL LEA ROAD LEXINGTON, KY 40511||Oct. 6, 2017|
|VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING||Tag No: A0144|
|Based on observation, interview, and review of facility Policy, it was determined the facility failed to ensure the patient had the right to receive care in a safe setting for three (3) of ten (10) sampled patients, Patient #5, Patient #6, and Patient #7.
On 09/28/17 at 7:38 PM, Patient #5 was in the Admissions Assessment Area, waiting to be evaluated by a Medical Provider, for possible admission. Patient #6, who was also waiting to be evaluated crossed the waiting room and began to kiss Patient #5. There was no facility staff in the Admissions Assessment Area at the time of the incident. A Qualified Mental Health Professional (QMHP) which was not a staff member of the facility, saw the incident and immediately notified facility staff who separated the patients.
Subsequently, on 09/28/17 at 8:31 PM, Patient #6 began kissing Patient #7 and then climbed on Patient #7's lap in the Admissions Assessment Area. Again there was no staff in the Admissions Assessment Area and the facility was unaware of this incident until reviewing video camera footage.
The findings include:
Review of the Policy #MLI0012 "Patient Rights and Responsibilities", undated, revealed patients had the right to receive care in a safe environment, free from all forms of abuse.
Observation on 10/05/17 at 11:08 AM, of the Admissions Assessment Area, revealed a single female waiting to be evaluated by a Medical Provider. Further observation of the staff area revealed a large glass communication window that would allow staff to sit and monitor individuals or communicate with them; however, there was not a staff member present.
Review of the facility "Report of Unusual Incident", revealed on 09/28/17 at 7:38 PM, there was an incident of Suspected/Alleged Sexual Abuse/Assault with Patient #6 the aggressor; and Patient #5, the victim. Per the Report, while in the Admissions Assessment Area, Patient #6 walked over to Patient #5 and kissed him/her several times on the lips, and they were immediately separated. Further review of the Report, revealed Patient #5 was moved to another area in the Admissions Suite and assessed, and an investigation was initiated. The Report revealed the Risk Management Investigator was notified on 09/28/17, and she notified the Department of Community Based Services (DCBS) and the Office of Inspector General (OIG) of the incident on 09/29/17.
Review of the facility "Report of Unusual Incident", revealed on 09/28/17 at 7:53 PM, there was an incident of Suspected/Alleged Sexual Abuse/Assault with Patient #6, the aggressor; and Patient #7, the victim. Per the Report, on 09/28/17 around 8:20 PM, the Shift Coordinator was reviewing video footage of another incident and found Patient #6 kissing Patient #7, then Patient #6 climbed on Patient #7's lap and Patient #7 placed his/her hand down the back of Patient #6's pants. Further review of the Report, revealed Patient #7 was immediately moved to another area in the Admissions Suite, and both individuals were assessed. The Report revealed the Risk Management Investigator was notified on 09/28/17, and she notified the Department of Community Based Services (DCBS) and the Office of Inspector General (OIG) of the incident on 09/29/17.
Interview with Patient #7, on 10/06/17 at 8:24 AM, revealed Patient #6 did "come on to him/her" by kissing him/her on the mouth. Continued interview revealed he/she did not want to hurt Patient #6's feelings so he/she kissed Patient #6 back.
Interview with Patient #5, on 10/06/17 at 3:32 PM, revealed he/she remembered Patient #6 kissed him/her, on the mouth, in the Admission Assessment Area. Per interview, he/she did not know that individual and didn't know why he/she kissed him/her.
Interview with the Advanced Registered Nurse Practitioner (ARNP), on 10/06/17 at 2:57 PM, revealed Patient #6 was not able to be interviewed because it would be detrimental to his/her treatment progress.
Interview with the QMHP, on 10/06/2017 at 4:44 PM, revealed she witnessed Patient #6 kiss Patient #5 in the Admissions Assessment waiting area and reported it to facility staff immediately.
Interview with the Assistant Director of Nursing, on 10/05/17 at 11:08 AM, revealed staff was not usually physically present in the staff area of the Admissions Assessment Area, but staff did have the ability to monitor that area from the staff work room via video monitors. However, per interview there was no process in place to ensure staff continuously monitored
the Admissions Assessment Area where Patients were waiting to be seen by a Medical Provider, and possibly admitted to the facility.
Interview with the Admissions Manager, on 10/06/17 at 12:42 PM, revealed all client supervision began when they were escorted to the Admissions Assessment Area, regardless of admission status at that time. Per interview, clients in the waiting area were either waiting to be evaluated or had the admission process completed and were waiting to be escorted to the floor. She stated supervision/observation of this area could be directly visual or per video monitor. Per interview, staff tried to do a visual check of the Admissions Assessment Area waiting room every fifteen (15) minutes; however, there was no documentation of this check.
Further interview with the Admissions Manager, revealed there was not a process stating that clients had to be continuously observed while in the Admissions Assessment Area. Continued interview revealed the area could be empty for hours and it would not be efficient to have a staff member present at all times to just view this Area. She further stated Patient #5 and Patient #6 were separated immediately when observation of the contact was made by the Qualified Mental Health Professional (QMHP) on 09/28/17. She further stated, with the initial information staff had at the time, by separating Patient #5 and Patient #6 immediately, staff felt they had protected the clients. However, there was a subsequent incident where Patient #6 began kissing Patient #7 and there were no staff in the Area at the time.
Interview with the Risk Management Investigator, on 10/06/17 at 5:02 PM, revealed she had reviewed the recorded video on 09/28/17 related to the incident between Patient #5 and #6 and saw Patient #6 walk across the room and kiss Patient #5. Per interview, Patient #5 did not push Patient #6 away and did not seem distressed. She stated the QMHP witnessed the contact and reported it immediately to staff who separated Patient #5 and #6. Per interview, staff assisted Patient #5 to a different room, and left Patient #6 in the Admission Assessment Area. Further interview revealed staff were unaware there was another incident in the Admissions Assessment Area until the video was watched on 09/28/17, and they realized Patient #6 kissed Patient #7, which was about an hour later after the first incident.
Interview with the Director of Quality/Safety and Risk Management, on 10/06/17 at 4:50 PM, revealed potential admission individuals were escorted up from the Intake lobby, searched, triaged and escorted to the Admissions Assessment Area. Per interview, an individual's admission status was unknown at that time, but all individuals were monitored in the Admission Assessment Area. She stated individuals in the waiting area were observed, at a minimum of every fifteen (15) minutes, but there was no written documentation process for the observations. Continued interview revealed they recognized there was a trend during the investigation because Patient #6 had kissed two (2) patients and a root cause analysis was to be conducted with staff from appropriate departments when all involved parties could meet. However, further interview revealed they had not yet met to conduct a root cause analysis of both incidents or implemented any interventions related to the incident.