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.
|CRESTWYN BEHAVIORAL HEALTH||9485 CRESTWYN HILLS COVE MEMPHIS, TN 38125||Dec. 5, 2018|
|VIOLATION: PATIENT RIGHTS||Tag No: A0115|
|Based on policy review, medical record review, and interview, the hospital failed to follow the policy for Patient Rights, develop and implement policies to protect patients from patient to patient abuse, implement interventions to protect patients from real/perceived abuse, and keep family members informed of violations of Patient Rights..
The findings included:
The hospital failed to ensure necessary policies and interventions were in place to protect patients from abuse and provide care in a safe setting.
Refer to A-144
|VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING||Tag No: A0144|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on policy review, medical record review, and interview, the hospital failed to ensure all patients were protected from any form of abuse and received care in a safe setting to protect their emotional health and safety for 1 of 1 (Patient #1) patients reviewed whose Patient Rights were violated.
The findings included:
1. The hospital's policy, "Patient's Rights" revealed, "...Patients have the right to be treated with consideration, respect and full recognition of their dignity and individuality...have the right to be protected by the licensee from neglect; from physical, verbal and emotional abuse..."
The hospital's policy, "ABUSE AND NEGLECT, PATIENT" revealed, "...shall protect patients from real or perceived abuse, neglect, or exploitation from anyone, including...other patients...The family should be kept informed of what is happening to the patient at all times..."
There was no documentation in the policy of procedures and interventions to protect patients from patient to patient abuse.
2. Medical record review revealed Patient #1 was involuntarily admitted to the facility on [DATE] with diagnoses which included Bipolar Disorder and Mania. The Emergency Involuntary Admission process had been started on 10/4/18 after the patient had attempted to pick her children up from school and made comments her husband was going to kill the children, and Patient #1 was unable to contract for safety.
Medical record review revealed Patient #2 was admitted to the facility on [DATE] with diagnosis of Schizoaffective Disorder, Bipolar Type.
The records revealed both Patient #1 and Patient #2 resided on the same unit at the hospital.
2. Review of the Nursing Reassessment for Patient #1 dated 10/5/18 at 2:50 PM revealed, " ...reported... male patient [Patient #2] on the unit touched her inappropriately...[Patient #1] walked to the [nurse's] desk calm and stated that she wants something done...was also made aware that this will be handled ..."
Review of the Nursing Reassessment for Patient #1 dated 10/6/18 revealed, " ...@ approx. [at approximately] 1147 [11:47 AM] pt. [patient] notified staff that she had engaged in an alleged sexual event [symbol for with] a male peer [Patient #2] that made her feel uncomfortable. Pt [Patient #1] was taken to a private area to discuss the interaction ... [symbol for with] staff therapist...Pt. was offered to go to the ER [emergency room ] for eval [evaluation] and treatment, pt. refused transfer..."
Review of the facility's investigation dated 10/6/18 at 2:50 PM revealed Patient #2 had told the hospital staff that sexual contact had occurred between himself and Patient #1 and that is was consensual.
After the alleged incident by Patient #1, Patient #2 remained on the same unit with Patient #1 until he was discharged on [DATE]. There was no documentation of interventions being implemented to protect patient #1 from complaints of being inappropriately touched sexually.
There was no documentation in Patient #1's medical record the patient's family was notified of the patient's complaint of being inappropriately touched by another patient. There was no documentation in the medical record that Patient #1's family was notified that she had refused to go to the emergency room for evaluation and treatment.
3. In an interview in the hospital's Chapel on 11/19/18 at 12:30 PM, the Risk Manager verified the facility does not have a written policy, procedure or interventions for patient to patient abuse.
In a telephone interview with Patient #1 on 11/19/18 at 11:12 AM, the patient complained of concerns of males and females residing on the same unit at the hospital. The patient complained the hospital didn't separate the alleged "perpetrator" from her after the alleged incident. The patient stated the hospital lacked "general concern" after the alleged incident had been reported.
In a telephone interview with the patient's husband on 11/19/18 at the time of the conversation with the patient, the husband stated his main concern was his wife had been forced to be admitted to the hospital because "she was out of her mind". The husband stated therefore she couldn't make a decision to refuse to go to an emergency department and be checked out. The husband denied being called by the hospital and informed of the patient's allegation of inappropriately being touched by a male hospital patient.
In a telephone interview on 11/27/18 at 6:09 PM Registered Nurse #1 verified she did not recall informing Patient #1's family the patient had refused to go to the emergency room after the alleged incident on 10/6/18.
In a telephone interview on 11/30/18 at 11:26 AM the Risk Manager stated the hospital Psychiatrist had evaluated Patient #1 regarding the alleged sexual incident on 10/5/18, however the Risk Manager stated the Psychiatrist did not document the evaluation and did not increase the level of onsite observations for Patient #1 following the alleged incident.