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.

ADVENTIST HEALTHCARE BEHAVIORAL HEALTH & WELLNESS 14901 BROSCHART ROAD ROCKVILLE, MD May 8, 2012
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the medical record of patient #1, policies and procedure, staff interviews, and other pertinent documentation, it was determined that the hospital failed to evaluate the allegation of abuse based on the policy and procedure.

Patient #1 is a [AGE] year old female who was admitted on [DATE] from SGAH on involuntary admission. The patient was taken from the group home and Emergency Petitioned by the police for assaulting a client at the group home. The patient's other diagnoses include obesity with weight at 234-lbs and asthma. The patient also exposed herself at the group home. The patient was admitted again on 4/12/12 for similar behaviors in the community.

The hospital initiated the requirments of its abuse, neglect, and exploitation policy as required. The staff reported the patient's allegation of rape that occurred during her previous admission of 3/28/12 to the charge nurse who then reported to the nursing supervisor. The nursing supervisor documented in the House Supervisor Rounds Report that the patient had made an allegation of rape. There is no documentation in the medical record that the physician had been notified of the patient's allegations. The supervisor did not follow the policy for reporting suspected abuse. This policy requires the reporting of the allegation to the Director of Quality Improvement and Risk Management who reports to the President of Adventist Behavioral Health, the Clinical Supervisor, the Chief Nursing Officer, and the Director of Human Resources. The policy does not ensure that the patient is seen by the physician and notification of the patient's attending physician.

The medical record indicated that the patient was sexually provocative, exposing herself to patients and staff, as well as being aggressive at times during the 3/28/12 admission. This was also consistent with her current admission of 4/12/12. There were no indication that the patient's sexually provocative behavior was being addressed in her treatment plan nor was the patient assessed by the physician post her allegation. The progress notes written regarding the allegation did not indicate that the patient was assessed by the physician nor what actions were taken by the nursing staff to provide the patient with a safe environment. The mother of patient #1 was informed by the patient of the allegation. The mother reported the event to the police and called the hospital. The police did present to the hospital within twenty-four hours of the abuse being reported. The hospital's administrative staff once aware of the allegation began the investigation process that included a meeting with the patient's mother. The patient was moved on Monday 4/16/12, to a room closer to the nurse's station. The alleged staff member was removed from the schedule.

There was no documentation to reflect that the hospital had addressed the patient sexually provocative behavior, the allegation of rape, assessment of the patient post the allegation, actions taken by the hospital to provide a safe environment for the patient. Hospital staff also failed to follow the abuse/neglect policy.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the medical record of patient #1, policies and procedures, staff interviews and other pertinent documentation, it was determined that the hospital failed to accurately document the allegation of abuse and actions taken to investigate the allegation.

Patient #1 is a [AGE] year old female who was admitted on [DATE] from SGAH on involuntary admission. The patient was taken from the group home and Emergency Petitioned by the police for assaulting a client at the group home. The patient's other diagnoses include obesity with weight at 234-lbs and asthma. The patient also exposed herself at the group home. The patient was admitted again on 4/12/12 for similar behaviors in the community.

On 4/14/12 the patient reported that a staff came into her room during the last hospitalization and had sex with her twice. The first time without protection and the second time with a glove. The patient stated it happened in the night and promised he was going to bring something nice to her and will meet with her after her discharge. The staff reported this to the charge nurse on 0/4/14/12 at 2:30 pm. No staff signature was documented nor was the note dated and timed. Therefore, it was unclear when the patient reported the incident. The next note written by the charge nurse on 4/15/12 at 1:00 am stated during the evening shift today (again no time mentioned), the Senior Care Associate (SCA) on duty today informed the writer of an allegation that a female patient had made to him. This female patient had told him that during her previous admission prior to her recent discharge, a male staff entered her room and had sex with her during the night shift. The writer immediately notified supervisor(again no date or time that notification was made). Per supervisor's advice, a grievance form was made available to female patient, who put her grievance on paper. The SCA was also asked to document what the female patient told him.

The documentation does not include specifics like dates and times of events including notification of administrative staff and actions taken by the nursing staff and supervisor including assessment tthrough to the protection of the patient. This lack of documentation makes it difficult to develop a timeline of events and revealed that hospital failure to follow its abuse/neglect policy and procedure.