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.

WESTCHESTER GENERAL HOSPITAL 2500 SW 75TH AVE MIAMI, FL 33155 Jan. 23, 2019
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review and interview, the facility failed to provide care in a safe setting, and the patient right to be free from all forms of abuse in 1 (SP #3) out of 4 sample patients (SP). The hospital's failure to implement employee screening to ensure the minimum training qualification of employees providing care and services were qualified to supervise and monitor patient's experiencing a mental health crisis, the lack of oversight and accountability resulted in an employee having sexual intercourse with a patient. The hospital's failure to implement patient monitoring/rounding to ensure patients are free from abuse, sexual assault by employees providing care and services resulted in a findings of immediate jeopardy beginning on 12/31/2018 and removed on 01/23/2019, creating a situation that is likely to result in serious injury, harm, impairment, or death to patients and requires immediate correction action on the part of the hospital.

(Refer to A-0144, A-0145 and A-283, A-286)
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to provide care in a safe setting in 1 (SP #3) out of 4 sampled patients. The hospital's failure to implement employee screening to ensure the minimum training qualification of employee providing care and services were qualified to supervise and monitor patient's experiencing a mental health crisis, the lack of oversight and accountability resulted in an employee having sexual intercourse with a patient. The hospital's failure to implement effective strategies to ensure a safe setting to provide care for 1 of 4 sampled patients (SP #3). These failures resulted in a findings of immediate jeopardy beginning on 12/31/2018 and removed on 01/23/2019, creating a situation that is likely to result in serious injury, harm, impairment, or death to patients, and requires immediate corrective action on the part of the hospital.

The Findings include:

The Census: on 12/31/2018 to 01/01/2019 was 21 patients with 11 females.

1. Clinical Record review of sample patient (SP) #3, the focus of this investigation, revealed she arrived in the ER (emergency room ) on 12/30/2018 at 12: 35 PM. She was Baker Acted on 12/30/2019 at 9:36 PM for severe depression/ suicidal ideation. She was admitted on [DATE] at 8:30 AM.

Record review of SP #3 Psychiatric Progress Notes with a date of visit for 1/1/2019 showed the Mental Status Examination revealed: During my rounds this morning the patient was found to be very upset as she states that last night someone from the staff (she is talking about a male member) groped her in her patient room. He put his hand over her mouth and he penetrated her. This is exactly what she said. This incident was already reported to administration from the hospital and administration from the psychiatric unit. Now this incident is under investigation from the police department criminal section department to find out exactly what happened with our patient last night. She states feeling very unsafe in the hospital. Since that incident last night, she could not sleep all night and feels afraid that the incident will happen again. That is why she said she could not come out from her patient room and let nursing staff know that the incident happened.

The Patient Care Notes of the (Charge Nurse) Staff - A, documented on 1/1/19 at 8:04 AM that the patient states last night she was lying in bed when "el tecnico me toco y me penetro en mi cama", translated by Staff - A: MHT (Mental Health Technician) touched me and penetrated in my bed.

In an interview with the Director of Risk Management on 1/8/2019 at 11:17 AM revealed, that the nursing supervisor asked the patient why did you report only now and the patient's response was she is afraid because all were male employees.

Documentation on the Special Observation Record showed that SP #3 was under close observation every 15 minutes, interviews of the 7pm to 7am shift Staff - A, B, D, and E, who worked with Staff - C on 12/31/2018 revealed, they did not hear or see anything unusual that night of 12/31/2018. Staff A, B, D and E were interviewed by phone on 1/9/2019 from 1:30 PM to 2:20 PM.

Review of the Special Observation Record for SP #3 showed the close observation record documented at 22:00 by Staff - D, and the close observation record documented at 22:15pm, and 22:30 pm by Staff - E on 12/31/2018 which does not match with the video recording captured on 12/31/2018 during those times. The Video recording at 22:11pm showed Staff- C was seated outside the door, in front of room 105 A & B, (there were 2 beds in one room) the room for SP #2 and SP #3.

On 1/9/2019 at 1:30 PM - phone interview with (Mental Health Technician (MHT) Staff D it was stated, (MHT) Staff C ( the alleged perpetrator) told me that he felt sick with a headache, fever, flu like, so I took the rounding (rounding task). At that time all patients, already had their medications. What we do at that time, all elderly were assisted back in their rooms. Staff C was sick. I had to help (MHT) Staff E because of a heavy patient, after that time. Everything was quiet. Nobody was screaming. Staff C took a chair, placed it in front of room 105 (SP #3 room), and placed himself, and he sat there.

The Director of Risk Management on 1/23/2019 at 12:30 PM acknowledged, while in the Behavioral Health Unit (BHU) office, that the rounding documented on the Special Observation Record for SP #3 does not match with the video recording captured on 12/31/2018.

Phone interview with the local Police Department Special Victims Bureau Detective on 1/10/2019 at 9:59 AM revealed, she and another detective conducted the investigation about the incident on New Year's Eve. Statements from the patient, Staff - C, the patient's roommate, and all the personnel were obtained. The Detective reviewed the video monitoring for that night. She stated, Staff - C confessed to having sex with the patient. She reported on the arrest warrant that the defendant walked into the doorway checking to see if anyone was coming from the hallway. When it was clear, the defendant subsequently re-entered her room, covered her mouth and forced penile/vaginal intercourse. Staff -C was arrested after he was served with a warrant, he was locked up in jail, but was released after he posted bail.

2. Review of the Position Description for Mental Health Technician's showed the qualification/education requirements included: Eligible for the Certification as Behavioral Health Technician (CBHT) by the Florida Certification Board.

On 1/9/2019 at 03:42 pm, the HR (Human Resources) Director stated, that MHT -Staff C (the alleged perpetrator) had 742.25 hours. A MHT needs 1,000 hours to be eligible for the CBHT certification.

Staff C was not screened and did not have the required training/ qualifications to be a CMHT and therefore was not qualified to function as a MHT.

The policy with the title: "Alleged Abuse, or Sexual Misconduct/ Abuse Against Patient by Hospital Staff Member", (review/revision date: 1/17) states for the Abuse Protection Program. Prevention- adequate staff (qualified, trained, and experienced) 24/7 to take care of individual needs of the patient.

The policy with the title: "Patient Bill of Rights: Behavioral Health Services", (Date 7/10) states the patient has a right to receive care in a safe setting. The patient has a right to be free from all forms of abuse or harassment.

The Behavioral Health Services Policy & Procedure Manual titled: Routine Patient Checks, (date: 8/10) states it is the policy of Behavioral Health Services that each patient will be observed at a minimum of fifteen (15) minutes, twenty-four hours a day. All assigned staff member makes visual checks on every patient, and when appropriate, verbal contact and documents these checks on the check sheet. All staff members are responsible for monitoring the mood of the unit and reporting any significant change to the charge nurse and for monitoring the environment to assess potential safety hazards on the unit. This facility policy was not followed.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interviews, policy and record reviews the facility failed to ensure the patients right to be free from all forms of abuse in 1 (SP #3) out of 4 sampled patients posing a serious risk to the patients safety. The hospital's failure to implement patient monitoring/ rounding to ensure patients are free from abuse, a sexual assault by an employee providing care and services was qualified to supervise and monitor patients experiencing a mental health crisis. The lack of oversight and accountability resulted in an employee having sexual intercourse with a patient. The hospital continued to implement ineffective strategies to ensure a safe setting to provide care for 1 of 4 sampled patients (SP) #3. These failures resulted in a findings of ongoing immediate jeopardy beginning on 12/31/2018 and removed on 01/23/2019, creating a situation that is likely to result in serious injury, harm, impairment, or death to patients and requires an immediate corrective action on the part of the hospital.

The Findings include:

The Census: on 12/31/2018 to 01/01/2019 was 21 patients with 11 females.

1. Clinical Record review of sample patient (SP) #3, the focus of this investigation, revealed she arrived in the ER (emergency room ) on 12/30/2018 at 12: 35 PM. She was Baker Acted on 12/30/2019 at 9:36 PM for severe depression/ suicidal ideation. She was admitted on [DATE] at 8:30 AM.

Record review of SP #3 Psychiatric Progress Notes with a date of visit for 1/1/2019 showed the Mental Status Examination revealed: During my rounds this morning the patient was found to be very upset as she states that last night someone from the staff (she is talking about a male member) groped her in her patient room. He put his hand over her mouth and he penetrated her. This is exactly what she said. This incident was already reported to administration from the hospital and administration from the psychiatric unit. Now this incident is under investigation from the police department criminal section department to find out exactly what happened with our patient last night. She states feeling very unsafe in the hospital. Since that incident last night, she could not sleep all night and feels afraid that the incident will happen again. That is why she said she could not come out from her patient room and let nursing staff know that the incident happened.

The Patient Care Notes of the (Charge Nurse) Staff - A, documented on 1/1/19 at 8:04 AM that the patient states last night she was lying in bed when "el tecnico me toco y me penetro en mi cama", translated by Staff - A: MHT (Mental Health Technician) touched me and penetrated in my bed.

In an interview with the Director of Risk Management on 1/8/2019 at 11:17 AM revealed, that the nursing supervisor asked the patient why did you report only now and the patient's response was she is afraid because all were male employees.

Documentation on the Special Observation Record showed that SP #3 was under close observation every 15 minutes, interviews of the 7pm to 7am shift Staff - A, B, D, and E, who worked with Staff - C on 12/31/2018 revealed, they did not hear or see anything unusual that night of 12/31/2018. Staff A, B, D and E were interviewed by phone on 1/9/2019 from 1:30 PM to 2:20 PM.

Review of the Special Observation Record for SP #3 showed the close observation record documented at 22:00 by Staff - D, and the close observation record documented at 22:15pm, and 22:30 pm by Staff - E on 12/31/2018 which does not match with the video recording captured on 12/31/2018 during those times. The Video recording at 22:11pm showed Staff- C was seated outside the door, in front of room 105 A & B, (there were 2 beds in one room) the room for SP #2 and SP #3.

On 1/9/2019 at 1:30 PM - phone interview with (Mental Health Technician (MHT) Staff D it was stated, (MHT) Staff C ( the alleged perpetrator) told me that he felt sick with a headache, fever, flu like, so I took the rounding (rounding task). At that time all patients, already had their medications. What we do at that time, all elderly were assisted back in their rooms. Staff C was sick. I had to help (MHT) Staff E because of a heavy patient, after that time. Everything was quiet. Nobody was screaming. Staff C took a chair, placed it in front of room 105 (SP #3 room), and placed himself, and he sat there.

The Director of Risk Management on 1/23/2019 at 12:30 PM acknowledged, while in the Behavioral Health Unit (BHU) office, that the rounding documented on the Special Observation Record for SP #3 does not match with the video recording captured on 12/31/2018.

Phone interview with the local Police Department Special Victims Bureau Detective on 1/10/2019 at 9:59 AM revealed, she and another detective conducted the investigation about the incident on New Year's Eve. Statements from the patient, Staff - C, the patient's roommate, and all the personnel were obtained. The Detective reviewed the video monitoring for that night. She stated, Staff - C confessed to having sex with the patient. She reported on the arrest warrant that the defendant walked into the doorway checking to see if anyone was coming from the hallway. When it was clear, the defendant subsequently re-entered her room, covered her mouth and forced penile/vaginal intercourse. Staff -C was arrested after he was served with a warrant, he was locked up in jail, but was released after he posted bail.

On 1/1/2019 at 20:02 pm, sample patient #3 arrived at the Rape Treatment Center (RTC) with a 1:1 female sitter. The sevices received included: Specimens were obtained and treatment/medications.

After this incident involving a patient and staff member, the facility started on purposeful rounding where it was noted only a few staff have signed to indicate they read what purposeful rounding means, surveillance /random monitoring of the video recording to make sure staff/ met are seated correctly in the TV room or hallway; they monitored 2 days randomly.

Only 22 of 67 Registered Nurses (RN) and MHT staff received the inservice as of 1/22/2019 on Purposeful Rounding.


2. Review of the Position Description for the Mental Health Technician's showed the qualification/education requirements included: Eligible for the Certification as Behavioral Health Technician (CBHT) by the Florida Certification Board.
On 1/9/2019 at 03:42 pm, the HR (Human Resources) Director stated, the MHT -Staff C (the alleged perpetrator) had 742.25 hours. A MHT needs 1,000 hours to be eligible for the CBHT certification and to be a MHT.
Review of Staff C employment history provided by the background screening dated 7/18/2018 showed that he had no previous experience in healthcare.

Review of staff C's "Competency Assessment/ Checklist dated 10/26/2018 showed, the method used to verify competency was PI- preceptor/instructor. There were no D- for demonstration showing staff C completed a return demonstration and was competent in his job duties.
The "New Employee Topics of Orientation" (day one) dated 07/26/2018 showed Staff C read and completed the general orientation test packet. Which included patient safety, patient rights and abuse.

Review of the "Clinical Orientation Checklist- for an MHT dated 07/30/2018 showed Staff C was oriented by 2 MHT's.
The policy subject: "Orientation", (revision date 10/17) states Video tape or orientation book with test packet of the General Orientation (Day one only) is available for new employees and new contracted staff that have completed the pre-employment process and be cleared to work. Attendance at day two of orientation will still be required of the ER, psychiatric service staff and certain nursing staff, as instructed. All new workers and contracted staff will be provided with a copy of the organization's employee handbook during the orientation session. Human resource will stress the importance of reading all sections of this handbook. Employees must sign a statement indicating that they have received and read the handbook and will abide by its rules, terms and provision.

The policy titled: "Alleged Abuse, or Sexual Misconduct/ Abuse Against Patient by Hospital Staff Member", (review/revision date: 1/17) states patients have a right to be treated in a manner which is free from abuse, or sexual misconduct/ abuse by hospital personnel.
Sexual Misconduct - means violation of relationship through which a member of the Hospital personnel uses such relationship to engage or attempt to engage the patient, immediate family member, guardian or representative of the patient, or attempt to induce such person to engage in verbal or physical sexual activity outside the scope of the professional practice of such health care profession. Sexual misconduct in the practice of a health care profession is prohibited regardless of the consent of the patient. The policy further states for the Abuse Protection Program. Prevention- adequate staff (qualified, trained, and experienced) 24/7 to take care of individual needs of the patient.

The policy titled, "Patient Bill of Rights: Behavioral Health Services", (Date 7/10) states the patient has a right to receive care in a safe setting. The patient has a right to be free from all forms of abuse or harassment.
VIOLATION: QAPI Tag No: A0263
Based on record review and interview the facility failed to fully implement the Quality Assessment and Performance Improvement Action Plan aimed at performance improvement as a result of an incident of sexual assault involving a patient and staff member and ensure clear expectations for patient safety were established prior to the incident involving 1 (sample patient #3) of 4 sampled patients. (Refer to A-0283 and A-0286).
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on record review and interview, the facility failed to fully implement the Quality Assessment and Performance Improvement Action Plan aimed at performance improvement as a result of an incident involving a sexual assault between a patient and a staff member and ensure clear expectations for patient safety were established prior to the incident involving 1 (sample patient #3) of 4 sampled patients.

The findings included:

1. Record review of SP #3 Psychiatric Progress Notes with a date of visit for 1/1/2019 showed the Mental Status Examination revealed: During my rounds this morning the patient was found to be very upset as she states that last night someone from the staff (she is talking about a male member) groped her in her patient room. He put his hand over her mouth and he penetrated her. This is exactly what she said. This incident was already reported to administration from the hospital and administration from the psychiatric unit. Now this incident is under investigation from the police department criminal section department to find out exactly what happened with our patient last night. She states feeling very unsafe in the hospital. Since that incident last night, she could not sleep all night and feels afraid that the incident will happen again. That is why she said she could not come out from her patient room and let nursing staff know that the incident happened.

The Patient Care Notes of the (Charge Nurse) Staff - A, documented on 1/1/19 at 8:04 AM that the patient states last night she was lying in bed when "el tecnico me toco y me penetro en mi cama", translated by Staff - A: MHT (Mental Health Technician) touched me and penetrated in my bed.

In an interview with the Director of Risk Management (RM) on 1/8/2019 at 11:17 AM, she stated that as soon as the patient (SP #3) complained on 1/1/2019 at 8:05 AM, immediately the patient was placed with a 1:1 female sitter. The employee involved, staff C, a Mental Health Technician (MHT) was not in the facility so the security department notified the employee not to come back to the facility. The patient, with the 1: 1 female sitter was transported to the Rape Treatment Center (RTC) afterwards.

On 1/2/2019, education of all staff of the psychiatric unit and all hospital staff was started with an emphasis on maintaining professionalism at all times, communicating to charge nurse if staff/patient is not behaving appropriately, meaningful rounding every 15 minutes, and hall rounding and location of chairs where the MHT can sit. Individual re- education of employees hospital-wide about Florida Statute 394.4593: a felony of second degree for an employee who engaged in sexual misconduct, were conducted. The Risk Manager drafted a power point presentation for the Patient Safety Workshop as part of their ongoing correction of this incident to be presented to all the staff as soon as possible.
The Director of Risk Management on 1/23/2019 at 12:30 PM acknowledged, while in the Behavioral Health Unit (BHU) office that the rounding documented on the Special Observation Record for SP #3 did not match with the video recording captured on 12/31/2018.

The facility started on purposeful rounding where only a few staff members have signed to indicate they read what purposeful rounding means, surveillance /random monitoring of the video recording to make sure staff are seated correctly in the TV room or hallway, the facility monitored 2 days randomly.

On 1/22/2019, another on-going re-education was started on purposeful rounding.

During an interview with the Director of Risk Management on 1/23/2019 at 2:00 PM, she stated that a video surveillance monitoring tool was created and will be conducted by the Director of the BHU, the Nursing Supervisor, and by her. In addition, as a result of their continuing and on-going evaluation as to the effectiveness of their actions, they changed the hiring practices; changed orientation practices; changed the policies and procedures for the placement of the MHT, and changed the rounding policy for both nurses and Mental Health Technicians. They are going to change documentation practices from nursing documentation once a day, to one nursing documentation every shift. She continued to state that they did a lot of re-education. We are also strengthening our Charge Nurses. They will be attend a Charge Nurse Development workshop. This will be rolled out next week. No documentation or plan was provided for changed of the hiring practices; changed orientation practices, and change of documentation practices from nursing documentation once a day to one nursing documentation every shift.

On 01/22/2019 to 01/23/2019 revealed:

Policy: QAPI program, (review/ revised 5/18)

A QAPI 2018 and 2019 Plan,

Video Surveillance Monitoring- on the South Unit-2019, the surveyors documentation noted this occurred on 1/15/2019 at 5:00 am to 7:30 am and 1/22/2019 from 21:00 pm to 23:59 pm. Also noted will start this week.

Quality Assessment/ Performance Improvement 2019 for purposeful rounding - this was initiated January 2019 & ongoing.

Quality Assessment/ Performance Improvement Plan 1st QTR is in progress - The Patient will be free from all forms of abuse and harassment (sexual molestation) this is ongoing,

Quality Assessment/ Performance Improvement Plan 1st QTR in progress - Human Resources - training on sexual misconduct, and sexual misconduct orientation attestation completion of ongoing (copy of annual update in-service self-study program test packet 2019 which includes a test with true/ false for patient rights/ abuse.

A Performance Improvement Proposal - for the Behavioral Health Unit(south wing) - was submitted.

January 2019 purposeful rounding, MHT placement during assignment (TV Room, Dining Room, Hallway), RN Presence on the unit, Documentation to support actions.- pending the next QAPI committee January.

Immediate Actions taken for Patient Protection: incident management, education, Patient Assessment, Personnel file, Staffing file, Staffing Assignment, Orientation, leadership oversight.
Florida Statute 394.4593- mental Health: sexual misconduct and sexual activity signed by employees on 1/9/2019 to 1/23/2019 acknowledging that they have read and understood the above statue.
Education: Topic Alleged sexual misconduct dated 01/2/2019-1/6/2019 and signed by staff

Purposeful Rounding inserviced on 1/22/2019 signed by 22 of 67 RN and MHT staff: all patients will be observed at a minimum of every 15 minutes.
1. MHT assigned to perform rounds must ensure the whereabouts and safety of their patients.
2. Assigned staff members must make visual checks on every patient Q 15.
3. If the door to the room is closed-knock and present yourself. Visually check on the patient.
4. During the night, if the door to the room is closed, quietly open the door so as not to wake up the patient (s). If the patient is sleeping, assess the patient's wellbeing- check for breathing.
5. If the patient is in the bathroom- knock and make sure the patient is okay- verbally check on patient (make sure to return to room for visual check)
Documentation: Document in real time, Do not chart ahead. Do not wait to chart until the end of the shift. Document accurate behavior and location.
( Copy of "Special Observation Record" provided)

Copy of Patient Safety Workshop 1st Quarter 2019 draft.

Copy of the Patient Rights, Employee Accident/ Workmen's Compensation, Abuse/ neglect/ Exploitation training for new hires and annually starts February 2019.

Copy of incident report with notes

Copy of a letter to SP #3 stating that as is our policy, we are doing a full investigation regarding this incident. The letter is dated 01/22/2019.

QAPI/ Medical Records Committee meeting sign in sheets: July, September, November 2018.



2. Review of the Position Description for Mental Health Technician's showed the qualification/ education requirements: eligible for the Certification as Behavioral Health Technician (CBHT) by the Florida Certification Board.
On 1/9/2019 at 03:42 pm, the HR (Human Resources) Director stated that MHT -Staff C (the alleged perpetrator) had 742.25 hours. A MHT needs 1,000 hours to be eligible for the CBHT certification.

Review of Staff C employment history provided by the background screening dated 7/18/2018 showed that he had no previous experience in healthcare.

Review of staff C "Competency Assessment/ Checklist dated 10/26/2018 showed that the method used to verify competency was PI- preceptor/instructor. There were no D- for demonstration showing staff C completed return demonstration.
The "New Employee Topics of Orientation" (day one) dated 07/26/2018 showed Staff C read and completed the general orientation test packet. Which include patient safety, patient rights and abuse.

Review of the "Clinical Orientation Checklist- MHT dated 07/30/2018 showed Staff C was oriented by 2 MHT's.

The policy titled: "Orientation", (revision date 10/17) states Video tape or orientation book with test packet of the General Orientation (Day one only) is available for new employees and new contracted staff that have completed the pre-employment process and be cleared to work. Attendance at day two of orientation will still be required of the ER, psychiatric service staff and certain nursing staff, as instructed. All new workers and contracted staff will be provided with a copy of the organization's employee handbook during the orientation session. Human resource will stress the importance of reading all sections of this handbook. Employees must sign a statement indicating that they have received and read the handbook and will abide by its rules, terms and provision.

Interview with Quality Assurance and Performance Improvement Coordinator on 1/23/2019 at 9:55 AM revealed Human Resources proposes changes such as policies, revised qualifications of MHT, and the new hire packet will have an attestation related to the statute, and existing employees included.

A copy of a revised policy for the position description for MHT and CMHT (Certified Mental Health Technician) was provided. No documentation was corrective action was provided for the hiring practices and the supervision of new staff.


Review of the policy titled, "Alleged Abuse, or Sexual Misconduct/Abuse Against Patient by Hospital Staff Member", (review/revision date: 1/17) needs to be updated with a process for screening and hiring qualified staff.

Only 22 of 67 RN and MHT staff received the inservice as of 1/22/2019 on Purposeful Rounding.

The policy titled: Quality Assessment Performance Improvement Program (review/ revision date: 5/2018) states the [named] hospital will promote a culture of safety to maintain a safe and secure therapeutic environment. Standardized policies and procedures to prevent and or minimize all health hazards will be place for protection of the patients and employees. Analysis of patient safety events will be performed and reported with a follow up action plan that is measured for effectiveness. Safety education will be provided to all employees at time for new hire, annually and on an as needed basis. Organizational leadership will be kept informed about patient safety issues and Quality Improvement process to assure that safety issues are addressed and that patient safety is improved.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on record review and interview, the governing body failed to ensure clear expectations for patient safety were established prior to and as the result of an incident (sexual abuse) involving 1 (sample patient #3) of 6 sample patients.


The findings:

1. Record review of SP #3 Psychiatric Progress Notes with a date of visit for 1/1/2019 showed the Mental Status Examination revealed: During my rounds this morning the patient was found to be very upset as she states that last night someone from the staff (she is talking about a male member) groped her in her patient room. He put his hand over her mouth and he penetrated her. This is exactly what she said. This incident was already reported to administration from the hospital and administration from the psychiatric unit. Now this incident is under investigation from the police department criminal section department to find out exactly what happened with our patient last night. She states feeling very unsafe in the hospital. Since that incident last night, she could not sleep all night and feels afraid that the incident will happen again. That is why she said she could not come out from her patient room and let nursing staff know that the incident happened.

The Patient Care Notes of the (Charge Nurse) Staff - A, documented on 1/1/19 at 8:04 AM that the patient states last night she was lying in bed when "el tecnico me toco y me penetro en mi cama", translated by Staff - A: MHT (Mental Health Technician) touched me and penetrated in my bed.

In an interview with the Director of Risk Management (RM) on 1/8/2019 at 11:17 AM, she stated that as soon as the patient (SP #3) complained on 1/1/2019 at 8:05 AM, immediately the patient was placed with a 1:1 female sitter. The employee involved, staff C, a Mental Health Technician (MHT) was not in the facility so the security department notified the employee not to come back to the facility. The patient, with the 1: 1 female sitter was transported to the Rape Treatment Center (RTC) afterwards.

On 1/2/2019, education of all staff of the psych unit and all hospital was started with emphasis on maintaining professionalism at all times, communicating to charge nurse if staff/patient is not behaving appropriately, meaningful rounding every 15 minutes, and hall rounding and location of chairs where the MHT can sit. Individual re- education of employees hospital-wide about Florida Statute 394.4593: a felony of second degree for employee to engage in sexual misconduct, were conducted. Risk Manager drafted a power point presentation for the Patient Safety Workshop as part of their ongoing correction of this incident to be presented to all the staff as soon as possible.
The Director of Risk Management on 1/23/2019 at 12:30 PM acknowledged while in the BHU office that the rounding documented on the Special Observation Record for SP #3 does not match with the video recording captured on 12/31/2018.
The facility started on purposeful rounding where very few staff have signed to indicate they read what purposeful rounding means, surveillance /random monitoring of the video recording to make sure staff/ met are seated correctly in the TV room or hallway ; they monitored 2 days randomly.

On 1/22/2019, another on-going re-education was started on purposeful rounding.

On an interview with the Director of Risk Management on 1/23/2019 at 2:00 PM, she stated that this video surveillance monitoring tool was created and will be conducted by the Director of the BHU, the Nursing Supervisor, and by her. In addition, as a result of their continuing and on-going evaluation as to the effectiveness of their actions, they changed the hiring practices; changed orientation practices; change of policies and procedures which is the placement of the MHT, and changed the rounding policy for both nurses and Mental Health Tech. They are going to change documentation practices from nursing documentation once a day to one nursing documentation every shift. She continued to state that they did a lot of re-education. We are also strengthening our Charge Nurses. They will be attend a Charge Nurse Development workshop. This will be rolled out next week. No documentation or plan was provided for the change of the hiring practices; changed orientation practices, and change of documentation practices from nursing documentation once a day to one nursing documentation every shift.

On 01/22/2019 to 01/23/2019 revealed:

A QAPI 2018 and 2019 Plan,

Video Surveillance Monitoring- on the South Unit-2019, the surveyors documentation noted this occurred on 1/15/2019 at 5:00 am to 7:30 am and 1/22/2019 from 21:00 pm to 23:59 pm. Also noted will start this week.

Quality Assessment/ Performance Improvement 2019 for purposeful rounding - this was initiated January 2019 & ongoing.

Quality Assessment/ Performance Improvement Plan 1st QTR is in progress - The Patient will be free from all forms of abuse and harassment (sexual molestation) this is ongoing,

Quality Assessment/ Performance Improvement Plan 1st QTR in progress - Human Resources - training on sexual misconduct, and sexual misconduct orientation attestation completion of ongoing (copy of annual update in-service self-study program test packet 2019 which includes a test with true/ false for patient rights/ abuse.

A Performance Improvement Proposal - for the Behavioral Health Unit(south wing) - was submitted.

January 2019 purposeful rounding, MHT placement during assignment (TV Room, Dining Room, Hallway), RN Presence on the unit, Documentation to support actions.- pending the next QAPI committee January.

Immediate Actions taken for Patient Protection: incident management, education, Patient Assessment, Personnel file, Staffing file, Staffing Assignment, Orientation, leadership oversight.
Florida Statute 394.4593- mental Health: sexual misconduct and sexual activity signed by employees on 1/9/2019 to 1/23/2019 acknowledging that they have read and understood the above statue.
Education: Topic Alleged sexual misconduct dated 01/2/2019-1/6/2019 and signed by staff

Purposeful Rounding inserviced on 1/22/2019 signed by 22 of 67 RN and MHT staff: all patients will be observed at a minimum of every 15 minutes.
1. MHT assigned to perform rounds must ensure the whereabouts and safety of their patients.
2. Assigned staff members must make visual checks on every patient Q 15.
3. If the door to the room is closed-knock and present yourself. Visually check on the patient.
4. During the night, if the door to the room is closed, quietly open the door so as not to wake up the patient (s). If the patient is sleeping, assess the patient's wellbeing- check for breathing.
5. If the patient is in the bathroom- knock and make sure the patient is okay- verbally check on patient (make sure to return to room for visual check)
Documentation: Document in real time, Do not chart ahead. Do not wait to chart until the end of the shift. Document accurate behavior and location.
( Copy of "Special Observation Record" provided)

Copy of Patient Safety Workshop 1st Quarter 2019 draft.

Copy of the Patient Rights, Employee Accident/ Workmen's Compensation, Abuse/ neglect/ Exploitation training for new hires and annually starts February 2019.

Copy of incident report with notes

Copy of a letter to SP #3 stating that as is our policy, we are doing a full investigation regarding this incident. The letter is dated 01/22/2019.

QAPI/ Medical Records Committee meeting sign in sheets: July, September, November 2018.


2. Review of the Position Description for Mental Health Technician's showed the qualification/education requirements included: Eligible for the Certification as Behavioral Health Technician (CBHT) by the Florida Certification Board.
On 1/9/2019 at 03:42 pm, the HR (Human Resources) Director stated that MHT -Staff C (the alleged perpetrator) had 742.25 hours. A MHT needs 1,000 hours to be eligible for the CBHT certification. Staff C was not qualified.

Review of Staff C employment history provided by the background screening dated 7/18/2018 showed that he had no previous experience in healthcare.

Review of staff C "Competency Assessment/ Checklist dated 10/26/2018 showed that the method used to verify competency was PI- preceptor/instructor. There were no D- for demonstration showing staff C completed return demonstration.
The "New Employee Topics of Orientation" (day one) dated 07/26/2018 showed Staff C read and completed the general orientation test packet. Which include patient safety, patient rights and abuse.

Review of the "Clinical Orientation Checklist- MHT dated 07/30/2018 showed Staff C was oriented by 2 MHT's.

The policy titled: "Orientation", (revision date 10/17) states Video tape or orientation book with test packet of the General Orientation (Day one only) is available for new employees and new contracted staff that have completed the pre-employment process and be cleared to work. Attendance at day two of orientation will still be required of the ER, psychiatric service staff and certain nursing staff, as instructed. All new workers and contracted staff will be provided with a copy of the organization's employee handbook during the orientation session. Human resource will stress the importance of reading all sections of this handbook. Employees must sign a statement indicating that they have received and read the handbook and will abide by its rules, terms and provision.

Interview with Quality Assurance and Performance Improvement Coordinator on 1/23/2019 at 9:55 AM revealed, Human Resources proposes changes such as policies, revised qualifications of MHT, and the new hire packet will have an attestation related to the statute, and existing employees included.

A copy of a revised policy for the position description for MHT and CMHT (Certified Mental Health Technician) was provided. No documentation was provided with the corrective action for the hiring practices and the supervision of new staff.

Review of the policy titled, "Alleged Abuse, or Sexual Misconduct/Abuse Against Patient by Hospital Staff Member", (review/revision date: 1/17) needs to be updated with a process for screening and hiring qualified staff.

Only 22 of 67 Regisitered Nurses (RN) and MHT staff received inserviced as of 1/22/2019 on Purposeful Rounding.

The policy titled: Quality Assessment Performance Improvement Program (review/ revision date: 5/2018) states the [named] hospital will promote a culture of safety to maintain a safe and secure therapeutic environment. Standardized policies and procedures to prevent and or minimize all health hazards will be place for protection of the patients and employees. Analysis of patient safety events will be performed and reported with a follow up action plan that is measured for effectiveness. Safety education will be provided to all employees at time for new hire, annually and on an as needed basis. Organizational leadership will be kept informed about patient safety issues and Quality Improvement process to assure that safety issues are addressed and that patient safety is improved.