HospitalInspections.org

Based on medical record review, policy review, staff and patient interview the facility failed to ensure that each patient has the right to receive care in a safe setting. This affected one patient (Patient 10). The total census was 31 patients.

Findings included:

Patient 10 was admitted on 3/25/10 with diagnoses of respiratory failure with chronic lung disease, psychosis, paranoid schizophrenia, mental retardation and generalized anxiety disorder. On entrance 4/22/10, Staff B stated patient 10 failed to tolerate having the trach removed last night. The patient had to be reintubated by the contracted hospital rapid response team and transferred to the hospital ICU. The record revealed the physican progress note dated 4/12/10 that the patient walked out of the building and was over to Community College yesterday. Staff F confirmed this finding and stated a care plan was developed to include more frequent monitoring of the patient.

The patient had a tracheostomy that was capped for weaning which, in addition, allowed speech. Staff B revealed in interview 4/21/10 the patient was known to this unit and this was a second admission for this patient. The patient agreed to an interview with the surveyors on 4/21/10. Staff B brought the SP to the conference room, with a portable oxygen tank, after a physical therapy treatment patient stated in interview with the surveyors on 4/21/10 at 11:15 AM, that Staff E was strictly a gentleman. The patient stated he/she had an infection of the throat. The patient stated he/she was aware of the difference between sexual consent and non consent. The patient stated she had been raped in the past by parents. The patient became tearful. The patient stated she had received mental services from a professional building in the past. The patient stated whenever he/she talks to men, women surround them and then he/she backs out and prays.

Staff A's investigation folder notes revealed on 4/16/10 night shift, the patient passed a hand written letter to Staff D that included a sentence which stated: Please (Staff E) forgive me about yesterday sometimes I get scared of sexual rape. I thought maybe I had aids of the throat. The letter was reviewed by the surveyors. The patients hand writing was difficult to read. Staff D confronted Staff E with the letter and the allegation of sexual assault on patient 10. Staff G was heard yelling in the nurses station at approximately 01:00 AM as documented in Staff B's notes of the investigation. Staff E told Staff G that Staff D accused him/her of sexual assault with patient 10. Staff G stated he/she had read the letter and did not feel the letter had indicated an assault, but seemed to be an apology. Staff G documented in a memo to Staff H and Staff B that Staff E flipped and was going to leave. Staff G spoke with Staff E about behavior and choice of words and told Staff E he/she would be sited with abandonment if he/she left. Staff G revealed in interview on 4/22/10, that Staff E did not have his/her electronic locator on and was instructed to obtain the locator while on break.

Staff D documented patient 10 refused to talk about the letter when approached. Staff D stated the patient had been upset during day shift. Staff D stated in interview with the surveyor on 4/22/10 at 8:15 AM the patient was not examined, the physician was not informed, the accused staff was not removed, and the administrator was not called after the discovery.

The call to the administrator took place on the next shift at 7:05 AM on 4/17/10 by Staff F at which time Staff E and Staff D were placed on paid leave until completion of the investigation. Staff F stated she observed Physician P visit the patient around 12:00 PM on 4/17/10. The progress note dated 4/17/10 and dictated 2:56 PM lacked an entry regarding the allegation. The summary written by Staff F revealed the patient was interviewed and asked if "anyone was not doing right by her?" The answer was no, everything was fine. Staff F stated she did examine the patient and saw no signs of sexual assault.

The facility did have an abuse policy which defined abuse as any incident of physical, sexual, or verbal abuse, neglect, and/or mistreatment that is reported by the patient or family;or is witnessed, reported, or suspected by an employee. The employee who first becomes aware of a patient who is said to be abused must take all appropriate steps necessary to protect the patient including but not limited to, reassignment of staff, removal of staff from patient care, and restriction of visitors policy stated the administrator and physician must be called. This policy was not followed by Staff G after discovery of alleged abuse.

Based on interview the facility failed to ensure the practitioner's privileges were not expired. This had the potential to affect all 31 patients who required a visit from this practitioner. (Physician O)

Findings included:

Review of the medical record for patient #10 revealed the patient requested to see a psychiatrist on 4/3/10. Physician O consulted with the patient on 4/3/10. Without request, Staff A, stated an oversight had occurred and Physician O's privileges had expired in 11/09. Staff A stated temporary privileges were granted as of today 4/21/10.