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This Citation pertains to Complaint # MI 347

Based on interview and record review, the facility failed to investigate and report an allegation of sexual abuse to the appropriate authorities in a timely manner for one (Patient #1) of three patients investigated for abuse/neglect out of a total sample of 11, resulting in patient distress and the potential failure to detect and prevent additional abuse. Findings include:

On 06/19/17, an unannounced investigation of complaint number MI 347 was conducted at the facility.

On 06/19/17 at 1240, review was done of Patient#1's clinical record and facility investigations into Patient #1's allegation that she was raped, and revealed the following information:

Patient #1 was a [AGE] year old female admitted into the facility by court order (involuntary commitment) on 4/1/17, and discharged on [DATE]. diagnoses included [DIAGNOSES REDACTED]]. A Psychiatry Admission Evaluation, dated 4/5/17, multiple Nursing Notes, and Social Work Progress notes documented that Patient #1 had disorganized speech and thought process, and had auditory, visual and tactile delusions and hallucinations. An Admission assessment dated [DATE], the Psychiatry Admission Evaluation, dated 4/5/17, and multiple Social Work notes all documented that Patient #1 had hallucinations/delusions of demons and of being involved in "demonic warfare."

Review of Patient #1's medical record revealed that the patient had made an allegation of rape, documented in an updated patient Interdisciplinary Treatment plan on 410/17, but the facility policy on investigation of abuse allegations was not followed. No incident report, facility investigation or police report was done by the facility when the allegation was made.

Patient #1's Interdisciplinary Treatment Plan, signed by Staff N on 4/10/17 (no time indicated), noted as a "psychiatric problem: members sexually molested her,that one exposed himself to her, and that another "raped her". A Social Work Progress note on 4/11/17 at 2000, documented that the patient telephoned her sister and told her that she was raped by facility staff and asked her sister to telephone the police, "Patient wanted to call 911 but called her sister, and had her sister call the police to investigate alleged assaults. She was tearful talking about it."

A Nursing note dated 4/11/17 documented, "Patient called her sister and told her to call police. Two officers from the sheriff's office came to talk to patient. Reported to officers that she had been sexually assaulted by two male staff on two separate occasions."

On 4/19/17 at 1445, Patient #1's case manager/social worker, Staff N was interviewed. Staff N stated that when Patient #1 reported that a staff member raped her, she reported it to the staff nurse, Staff K. Staff N was unable to state exactly when the allegation was first reported to her, but noted that she documented it when she updated the care plan on 4/10/17. When queried, Staff N stated that she did not fill out an incident report, or notify the police, the Risk Manager or her supervisor of the allegation. Staff N reported that she had since been counseled by her supervisor for failing to report the allegation to the police, the Risk Manager, and her supervisor and for not filling out an incident report. Staff N stated then when she told Staff K about Patient #1's allegation of rape he allegedly told her that Patient #1 had "made these allegations that were unsubstantiated."

On 4/19/17 at 1500, Staff K was interviewed and stated that he did not remember the patient clearly, but did remember that she often wore a hospital gown and slept in the lounge. Staff K reported that he did not remember anything about Patient #1's allegations that she was raped, or of the social worker reporting a rape allegation to him.

On 4/19/17 at 1515, the Adult Unit Manager, Staff C was interviewed, and reported no clear memory of Patient #1 and no knowledge of the rape allegation.

On 4/19/17 at 1520, the Adolescent Unit Manager, Staff D was interviewed, and reported no clear memory of Patient #1 and no knowledge of the rape allegation.

On 4/19/17 at 1530, the facility investigation of Patient #1's allegation of rape was reviewed with the Risk Manager, Staff B, who was also interviewed at this time. Documentation was provided that the police arrived at the facility on 4/11/17, opened a case file, and conducted an investigation into Patient #1's allegation that she was raped by staff.

An attempt was made to contact the Sheriff's Deputies on 4/19/17 at 1420, but the officers did not return the call by survey exit. The Facility Investigation conclusion was that the allegation could not be substantiated. When asked if the facility had done anything to investigate or report Patient#1's allegation of rape before the police arrived to investigate it, Staff B stated, "unfortunately, no." When asked if the allegation would have been investigated if Patient #1's sister had not called the police, Staff B said, "Unfortunately, the first we heard about it in administration was when the police arrived at the hospital." When asked if Patient #1 was assessed for evidence of rape, Staff B stated, "No." Review of the clinical record with Staff B revealed there was no documentation of any physical assessment for evidence of rape after the allegations.

On 4/19/17 at 1550, the facility chief executive officer, Staff A was interviewed regarding Patient #1's rape investigation and the facility's failure to notify the police and start an investigation in a timely manner. Staff A stated, "It should have been reported to the police at our side rather than the client's. It should have been reported on the June 10 th, when she made the allegation." Staff A stated that the social worker who documented the allegation but failed to notify the Risk Manager, fill out an incident report or report the allegation to the police, had been counseled, but was unable to provide requested documentation of this by survey exit. Staff A stated that all staff had received an "inservice" (education) on reporting suspected or alleged abuse, but when requested to provide documentation of this, provided minutes of a staff meeting with no notations of any discussion or education regarding abuse.

On 4/19/17 at 1700, review of the facility policy entitled, "Alleged Patient Abuse, Neglect, and Exploitation", revised 03/15 revealed the following statements, "Any hospital staff with knowledge of abuse or neglect is responsible for reporting such incidents. Allegations of assault, physical and/or sexual or homicide perpetrated on an individual constitute potential criminal abuse and must immediately be reported to the law enforcement agency."
Based on observation, interview and record review, the facility failed to ensure physician orders for behavioral restraints were authenticated according to hospital policy for 2 (#10, 11) of 2 patients reviewed for restraints out of a total sample of 11 patients resulting in the potential for improper or unintended use of restraints for all patients needing restraints who are served by the facility. Findings include:

On 6/19/2017 at 1445, review Patient #10's medical record revealed an emergency order via telephone was obtained on 6/1/2017 at 0830 for physical, chemical and mechanical restraints from Physician Staff Q. A signature authenticating the order was present; however, it was not dated or timed. On 6/6/2017 at 1700, an emergency order via telephone was obtained for physical restraint from Staff P. This order was not authenticated by signature, date or time. On 6/6/2017 at 1730, and emergency order via telephone was obtained for physical restraint from Staff Q. This order was authenticated by signature; however, it was not dated or timed.

Review of Patient #11's medical record on 6/19/2017 at 1500 revealed an emergency order via telephone was obtained on 3/13/2017 at 1555 for physical and chemical restraints from Staff Q. A signature authenticating the order was present; however, it was not dated or timed.

On 6/19/2017 at 1525, Staff C confirmed the above findings for Patient #10 and #11. Staff C was queried as to how a telephone order should be authenticated to which she replied, "They should be dated, timed and signed."

On 6/19/2017 at 1530, facility policy #PC 18 "Use of Seclusion/Restraint" last revised 3/ was reviewed. Policy states, "The psychiatrist shall authenticated the telephone/verbal order within 24 hours...The psychiatrist's order for use of restraint will be recorded in the medical record and include the following...appropriate dates and times."