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.

Based on observation, interview, and record review the facility failed to provide a safe envionment for a patient (Patient #1) following an investigation of a staff member (Staff A) entering the shower/tub room when Patient #1 was showering.

Failure to implement security protections for patient safety puts patients at risk for possible continued harm, abuse and /or exploitation.

Findings include:

1. Observations of the shower/tub room revealed all staff could enter the shower/tub room from the staff hallway.

2. Review of Staff A''s job description revealed they provided counseling for mental health issues. Staff A did not provide care for patients' personal care needs for activites of daily living (ADL's) which would include showers.

3. On 1/11/2017 it was reported by another staff member Staff A entered the shower/tub room while Patient #1 was in the area. The incident was reported to the investigation department the same day the allegation was reported. The investigation was started on 1/11/2017. Staff A was removed that day from direct patient care.

4. Review of Patient #1's record revealed they were being treated for a mental health condition at the time of incident. The patient was scheduled to be transferred to another ward in the facility as result of their improvement prior to the allegation. After the allegation/incident the patient became suicidal and was put on a 1:1 watch with a staff member for several weeks. The record showed the patient making statements "its all my fault" and " I do not want to talk about it now". When the patient was asked about if someone was in the shower with them, the patient replied "no" but indicated someone might have been in the tub room area.

5. On 5/9/2017 at 1:25 PM Staff B a licensed nurse was interviewed. Staff B provided care to Patient #1 before and after the incident. Staff B stated that Patient #1 became suicidal after the incident investigation involving Staff A. Staff B stated, Staff A did not provide care for ADL's and should not have been in an area where this would occur.

6. On 5/8/2017 at 1:10 PM Staff C a physician was interviewed. Staff C stated the patient began to decompensate after the incident on 1/11/2017. The patient became less verbal and began to express wanting to harm themself. The patient was put on 1:1 monitoring with a staff member to prevent self harm. The patient would only say about the incident they would talk "when the time is right". Staff C had concerns about what may have occurred between Staff A and Patient#1. Staff C was not consulted about allowing Staff A to return to the same ward as Patient #1 at the conclusion of the investigation. Staff C felt the patient's behavior change was a direct result of the alleged incident with Staff A.

7. On 5/9/2017 at 3:45 PM Staff D a physician was interviewed. Staff D stated they were not consulted about allowing Staff #A to return to the ward at the conclusion of the investigation. Staff D indicated they had contacted administration about the allegations involving Patient #1 and Staff A but they were not included in the decision to allow Staff A back on the ward.

8. On 5/10/2017 at 1:10 PM the above information was reviewed with Staff E the Deputy Director of Operations. Staff E stated changes were going to be made to include physicians in the investigative process. The decision to return an employee to the ward would not rest with the staff member's manager but with an independent review in the future.

9. On 5/18/2017 at 8:00 AM, the Center Director for Forensic Services (Staff M) was interviewed about the decision to return Staff A to the unit. Staff M made the decision to return Staff A since the allegation was not substantiated despite the fact the patient had decompensated directly after the alleged incident. Staff M did not consult with the patient's physicians about the return of Staff A to the ward.
Based on interview, record review and review of facility policies and procedures the facility failed to adequately protect a patient (Patient #1) from an incident of possible exploitation in the shower/tub area of the patient's (Patient #1) care ward.

Failure to immediately assess the situation when brought ot the attention of the staff places patients at risk for further exploitation.

Findings include:

1 .The facility policy "Abuse and Neglect Program", policy 7.03 read in part, "WSH (Western State Hospital) has a program to detect and prevent the occurrence of abuse and negelct to include: Prevention, Screening, Identification, Training, Protecting, Investigatiing and Reporting and Responding"

2.. Review of Patient #1's record revealed on 1/11/2017 it was reported Staff A had entered the shower/tub area while Patient #1 was in the shower. The charge nurse (staff B) went to the door to ask Patient #1 if they were ok and if anyone was in the shower with them. The patient replied no one was in shower with them. The charge nurse then called the nursing supervisor about the incident.

3. On 5/9/2017 at 1:25 PM, Staff B was interviewed. Staff B stated they remembered asking the patient if anyone was in the shower with them. The patient peeked their head out of the shower room and said no one was with them. Staff B went on to say they should have inspected the shower area and tub room area immediately when the allegation was made.

4. On 5/10/2017 at 11:00 AM, the above events were reviewed with the nurse manager (Staff F). Staff F stated Staff B should have done an immediate search of the area when the allegation was made.