HospitalInspections.org

Based on record review and interviews the facility failed to meet the Condition of Participation to keep patients safe by not ensuring that staff were monitoring patients' activity accurately

The findings are:

A. The facility failed to keep patients safe by not ensuring that staff were monitoring patients' activity accurately . Refer to tag A-0144.

Based on record review and interview the facility failed to provide written notice and resolution of the grievance for guardian or patient for 1 (P11 (Patient)) of 10 (P11 - 20) patients reviewed. This failed practice can lead to a violation of patients' rights due to a grievance not being addressed, no investigation being completed, and no resolution being sent to guardian or patient.

The findings are:

A. Record review of facility policy titled "Patient Grievance Policy" dated 01/2019 showed: "POLICY:
1 III. Grievance Defined: A patient grievance can be a verbal or written complaint or may be submitted by email or fax that is made to the hospital by a patient, or anyone representative, regarding the patient's care ...."
2 IV. Who May File a Grievance: A grievance may be filed by any patient of [facility name] or on behalf of a patient by any person who knows the patient and is interested in the patient's welfare, including a parent, guardian, relative, foster parent, court appointed advocate, guardian ad litem, [a person appointed by the court to represent the best interest of a child in a legal proceeding] case manager, personal support team member, patient designated advocate and others.
3 VIII. Filing a Grievance: Sources of grievances may also include complaints received by fax, email, satisfaction surveys or verbal or written allegations of abuse/neglect/staff misconduct or any other means. All grievances should be given to the Patient Advocate. Phone calls received by staff at the facility may also be a source of grievance. These calls should be referred to the Patient Advocate.
4 XI. Grievance Records, Logs, and Reports: The Patient Advocate maintains an accurate and complete record of each grievance filed, as well as summary information about the number, nature, and outcome of all grievances filed. Grievance records must be kept in a confidential setting, separate and apart from other patient records. A grievance tracking log is maintained by the Patient Advocate to track grievances as they progress through the system. The log should include the grievance number, patient's name, the date the grievance was submitted, the nature and outcome of the grievance, the date of the final resolution, and the level where it was resolved.

B. Record review of facility "Complaint and Grievance log" dated 07/01/2022 - 06/05/2023, P11's grievance could not be located on the log and no resolution or notice to patient/guardian could be found.

C. During an interview with S1, Chief Executive Officer, on 05/07/2023 at 2:10 pm, when asked if receiving a call from a guardian or parent of a patient would be considered a grievance, S1 answered "yes." When asked how a call would be processed, S1 answered, "I would document the call and may investigate myself asked if all complaints and grievances are documented, S1 answered, "yes." When provided information about a particular call received regarding a complaint/grievance from guardian ad litem for P11, and asked if S1 recalled receiving the call, S1 answered, "Yes, I remember speaking with her. She was appointed ad litem. When asked if there would be a reason the grievance was not documented, S1 answered, "Maybe because I took care of it. Maybe I didn't document it because I didn't think it was a grievance . . . . ."

Based on observation, record review and interview the facility failed to keep patients safe by not ensuring that staff were monitoring patients' activity accurately for 3 (P (patient)1, P2 and P3 of 10 (P1-P10) patients reviewed. This failed practice could put patients at risk for sexual abuse by other patients or expose them to sexual acts of other patients.

The findings are:

A. Record review of facility policy titled "Levels of Observation" policy number: 1000.25, effective date: 04/2023, stated on page 1 under definitions: "Levels of observation. 15 minute checks: Required for all patients. Staff makes visual contact with the patient and confirms that the patient is safe and in no physical distress at frequent and random intervals not to exceed 15 minutes apart. Whenever possible, verbally interact with patient to assess safety and well-being."

B. Record review of facility policy titled "Levels of Observation, Attachment B: Monitoring Level" stated "Sexual Acting/Sexual Aggressor. Intervene immediately to stop provocative behavior. Monitor closely late PM or early AM; shower time, shift changes & meals. Closely monitor patient hallways when patients are in their rooms. Watch for patients "sneaking" into other patient's rooms. Be aware of patient planned diversions to cover acting out. Change pattern of observation rounds. Patient bedroom door not to be closed except when changing clothes."

02/14/2023 Incident:
C. Record review of video camera N (North) .25 from Unit 6 North on 02/14/2023 starting at 19:30 (7:30 pm) showed P1 and P2 engaging in various forms of sexual acts until 20:06 (8:06 pm) in the day room. Sexual acts include: kissing, sexual stimulation using the hand under clothing and on top of clothing, and oral sex. P1 and P2 then meet later in P2 room from 20:27 (8:27 pm) to 20:31 (8:31 pm). There are also various unidentified patients that saw P1 and P2 engage in sexual acts.

D. Record review of [Facility Name] Incident Report Log with an incident date of 02/14/2023 and time of 2040 (8:40 pm) stated: "Patient found to be in male peers bathroom. Patients seperated [sic] right awat [sic] by staff ... Patient admitted to sneaking into peers room and then kissing him. Patient stated she also performed oral sex on peer. Patient said they were then caught ... Provider on call notified, orders patients to be seperated [sic] and for this patient to be placed on SAO (sexual acting out) precautions."

E. Record review of Patient Observation Rounds for P1 on 02/14/2023, showed that during the time of the above incident, P1 was noted as "Behavior: Lying/Sitting" and "Location: Day Room" "Precaution type: Suicide, SAO victim, SAO aggressor, Homicide/Assault."

F. Record review of video camera N.25 from Unit 6 North on 02/14/2023 between the time of 19:30 (7:30 pm) and 20:06 (8:06 pm), showed staff that completed the Patient Observation Rounds mentioned in finding D was either at the Nurse Station Counter with his back to the day room, behind the Nurse Station Counter, in a storage room, or down the hall. Most of the time is spent at the Nurse Station Counter which is approximately 20 feet from P1 and P2 location. There is no point during the video that the staff member approaches P1 or P2 to verbally interact with them as required per the policy mentioned in finding A. Staff is not observed carrying out any of the interventions mentioned in "Levels of Observation, Attachment B: Monitoring Level" for "Sexual Acting/Sexual Aggressor" in finding B.

03/05/2023 Incident:
G. Observation of video camera N.25 from 6 North Unit on 03/05/2023 between the time of 1427 (4:27 pm) and 1658 (4:58 pm) showed P1 and P3 engaging in various forms of sexual acts in the day room and in a patient room. Sexual acts include: sexual stimulation using the hand under clothing, kissing and sucking on body parts (arm and neck), oral sex and sexual intercourse. There are also various unidentified patients in the same room as P1 and P3 while sexual acts are being performed.

H. Record review of [Facility Name] Incident Report Log with an incident date of 03/05/2023 and time of 1645 (4:45 pm) stated: "Patient [P1] spoke with her insurance case manager on 03/07/2023 and reported engaging in sexual intercourse with a 13 y/o (year old) male patient on 03/05/2023. Both patients initially denied the event; however, after camera review was completed the event was substantiated."

I. Record review of [Facility Name] Incident Report Log with an incident date of 03/05/2023 and time of 1645 (4:45 pm) stated: "Patient [P1] was observed to have possible hickey on her neck ... Upon further questioning [P1] reported that her and [P3] did have sex over the weekend."

J. Record review of Patient Observation Rounds for P1 on 03/05/2023, showed that during the time of the above incident, P1 was noted as "Behavior: Cooperative, Awake/Alert, or Talking" and "Location: Day Room or Bathroom."

K. Observation of video camera N.25 from Unit 6 North unit on 03/05/2023 between the time of 1627 (4:27 pm) and 1658 (4:58 pm) showed 3 staff, 1 staff is noted going up and down the hall and interacting with 7 other patients in the dayroom, the other 2 staff are sitting at the nurse station. There was no point during the video that any of the staff members approach P1 or P3 to verbally interact with them as required per the policy mentioned in finding A. Staff is not observed carrying out any of the interventions mentioned in "Levels of Observation, Attachment B: Monitoring Level" for "Sexual Acting/Sexual Aggressor" in finding B.

L. During an interview on 06/06/2023 at 1 pm with S1, Chief Executive Officer, when asked about what went wrong that P1 was allowed to engage in multiple sexual encounters, S1 stated, "Protocols were ok, they just were not followed." When asked if staff standing at the nurse's station is the expectation of doing Q (every) 15 checks (Patient Observation Rounds), S1 stated: "No"