HospitalInspections.org

I. Based on document review and staff interviews, the Board of Governors failed to:


1. Ensure the nursing staff provided adequate supervision and oversight of patient activities on the adult unit resulting in the failure to identify and prevent patients from engaging in inappropriate sexual behavior. Please refer to A-0395.


2. Ensure the nursing staff provided adequate supervision, assessment, and evaluation of care for patients on the adult unit inpatient behavioral health unit. Please refer to A-0395.

3. Ensure the nursing staff provided adequate supervision and oversight of patient activities on the adolescent unit resulting in the failure to identify and prevent patients from engaging in inappropriate sexual behavior. Please refer to A-0395.


4. Ensure the nursing staff provided adequate supervision, assessment, and evaluation of care for patients on the adolescent unit inpatient behavioral health unit. Please refer to A-0395.


The cumulative effect of the systemic failure and deficient practices resulted in the hospital's inability to effectively carry out the responsibilities of the hospital to ensure patients received appropriate care and treatment in a safe setting and ensure quality health care provided to patients. The Hospital's administrative staff identified a total census of 31 patients at the beginning of the survey.

The patient has the right to receive care in a safe setting, see A-0144. Based on document review, staff interviews, and video surveillance the hospital administrative staff failed to ensure that patients have a right to care in a safe setting by evidence of female patients having been sexually assaulted.

The hospital failed to ensure behavioral health patients received care in a safe setting without possible abuse from other patients. Please see A-0144.

1. Ensure the nursing staff provided adequate supervision and oversight of patient activities on the child and adolescent unit. Please refer to A-0395.

2. Ensure the nursing staff provided adequate supervision, assessment, and evaluation of care to patients on the adult and adolescent units. Please refer to A-0395.


The cumulative effect of these failures and deficient practices resulted in the hospital's inability to provide adequate patient care and supervision for adolescents, and adults, which resulted in adolescents and adults engaging in inappropriate sexual behaviors, and could potentially result in self-harm, harm to others and death to the patient. The hospital administrative staff identified a census of 31 patients on entrance.

Based on document review, staff interviews, and video surveillance review the Hospital Administrative staff failed to ensure the hospital staff were sufficiently trained in observations and precautions to provide adequate supervision and oversight of patient activities.

Findings include:

Based on document review, staff interviews, and video surveillance review the Hospital Administrative staff failed to ensure the hospital had adequate training on sexually acting precautions and level of observation with adequate supervision resulted in the nursing staff failing to identify and prevent patient from engaging in inappropriate sexual behavior and could potentially also result in self-harm, harm to others and death to the patient. The Hospital Administrative Staff identified a current census of 15 patients on the adult unit at the beginning of the survey. The Hospital Administrative Staff identified a census of 16 on the adolescent unit at the beginning of the survey.


1. Review of the policy 1000.23, "Sexually Acting Out Status" approved by the Governing Board on June 12th 2020, states under Procedure, #4. states "SAO precautions will be addressed on the Treatment Plan", and # 8. Documentation, a., states "Treatment plan entry made and dated documenting the patients change in status ..." made a for Patient # 1, based on review treatment plan in the chart, no documentation of his sexually acting was included on the treatment plan.

2. Review of the policy 1000.23, "Sexually Acting Out Status" approved by the Governing Board on June 12th 2020, states under Procedure, # 5. "The patient may be placed on a higher level of observation if determined to be at risk for sexual acting out behavior.", based on chart review of Patient #1, Patient # 1 remained on every 15-minute checks, when documentation in the medical record indicated an escalation of sexually acting out behavior.

3. During an interview with Nurse B it was stated that Nurse B "did not know what the Sexually Acting Out Precautions were. Nurse B has not had training on precautions and can't say what the SAO precautions would be".

4. During an interview with Nurse C, it was stated, that when Patient #1 was acting inappropriate, staff would separate Patient #1 to unit 600, were Patient # 1 would be separated from the other patients. Then staff were told by administration to return Patient # 1 back to unit 500 back around other patients again, Patient #1 would return to unit 500 and back on 15 minute checks, "if Administration would have only listened to us, when we removed Patient #1 from the unit to 600, when Patient # 1 was inappropriately sexually acting out, staff thought he should be more closely monitored or be isolated, Patient #1 behavior was very inappropriate" .

5. During an interview with MHT D "knew this was going to happen eventually. Patient #1 would act out, staff would put him on 600 then Administration would make us bring him back to 500 and Patient #1 had no extra precautions in place". MHT D stated "I am concerned about how we are handling some of these situations".

6. A review of the Police report revealed, Patient # 1 was arrested and removed from the Eagle View facility, for Patient # 3 and Patient #4 charged with indecent exposure, assault with intent to commit sex abuse, and an additional charge with Patient #3 of 3rd degree sexual abuse.

7. During an interview with Nurse E stated during a group session on the adolescent unit Nurse E learned from patients there has been a patient that was crossing boundaries and inappropriately touching other patients. That patient was identified as Patient #2. After the group discussion Nurse E had a discussion with Patient #2 and confessed to having inappropriately touching other females. Specifics on this was grabbing Patient # 5's breast. Patient # 7 wrapped arms around Patient # 7's waist, and had attempted to get in the shower with Patient # 7, both dressed. Patient #6 was pulled into the bed by Patient #2, and grabbed Patient # 6's breast.

During the investigation of complaints and, the on-site survey team identified an Immediate Jeopardy (IJ) situation (a crisis situation that placed the health and safety of patients at risk) related to the Condition of Participation for Patient Rights (CFR 482.13). The hospital failed to provide adequate nursing supervision and oversight of patient activities.


1. While on-site, the survey team identified an Immediate Jeopardy (IJ) situation and notified the administrative staff on 12/28/22 at 1:00 P.M. The hospital staff acted and removed the immediacy of the situation prior to the survey team exiting the complaint investigation when the hospital administrative staff took the following steps:

2. Provided reeducation of all staff on each of the policy on Sexually Acting Out Precautions changes prior to their next scheduled shift.

3. Provided education to all RN's, MHT's, House Supervisors, on the sexually acting out precaution policies, staffing expectations, and reassessment/documentation expectations.


The following Condition level deficiency remained for the Condition of Participation for Patient Rights (42 CFR 482.13).

Based on document review, staff interviews, and video surveillance review the Hospital Administrative staff failed to ensure the hospital had adequate training on sexually acting precautions and level of observation with adequate supervision resulted in the nursing staff failing to identify and prevent patient from engaging in inappropriate sexual behavior and could potentially also result in self-harm, harm to others and death to the patient. The Hospital Administrative Staff identified a current census of 15 patients on the adult unit at the beginning of the survey. The Hospital Administrative Staff identified a census of 16 on the adolescent unit at the beginning of the survey.

Findings:


1. Review of the policy 1000.23, "Sexually Acting Out Status" approved by the Governing Board on June 12th 2020, states under Procedure, #4. states "SAO precautions will be addressed on the Treatment Plan", and # 8. Documentation, a., states "Treatment plan entry made and dated documenting the patients change in status ..." made a for Patient # 1, based on review treatment plan in the chart, no documentation of his sexually acting was included on the treatment plan.

2. Review of the policy 1000.23, "Sexually Acting Out Status" approved by the Governing Board on June 12th 2020, states under Procedure, # 5. "The patient may be placed on a higher level of observation if determined to be at risk for sexual acting out behavior.", based on chart review of Patient #1, Patient # 1 remained on every 15-minute checks, when documentation in the medical record indicated an escalation of sexually acting out behavior.

3. During an interview with Nurse C, it was stated, that when Patient #1 was acting inappropriate, staff would separate Patient #1 to unit 600, were Patient # 1 would be separated from the other patients. Then staff were told by administration to return Patient # 1 back to unit 500 back around other patients again, Patient #1 would return to unit 500 and back on 15 minute checks, "if Administration would have only listened to us, when we removed Patient #1 from the unit to 600, when Patient # 1 was inappropriately sexually acting out, staff thought he should be more closely monitored or be isolated, Patient #1 behavior was very inappropriate" .

4. During an interview with MHT D "knew this was going to happen eventually. Patient #1 would act out, staff would put him on 600 then Administration would make us bring him back to 500 and Patient #1 had no extra precautions in place". MHT D stated "I am concerned about how we are handling some of these situations".

5. A review of the Police report revealed, Patient # 1 was arrested and removed from the Eagle View facility, for Patient # 3 and Patient #4 charged with indecent exposure, assault with intent to commit sex abuse, and an additional charge with Patient #3 of 3rd degree sexual abuse.

6. During an interview with Nurse E stated during a group session on the adolescent unit Nurse E learned from patients there has been a patient that was crossing boundaries and inappropriately touching other patients. That patient was identified as Patient #2. After the group discussion Nurse E had a discussion with Patient #2 and confessed to having inappropriately touching other females. Specifics on this was grabbing Patient # 5's breast. Patient # 7 wrapped arms around Patient # 7's waist, and had attempted to get in the shower with Patient # 7, both dressed. Patient #6 was pulled into the bed by Patient #2, and grabbed Patient # 6's breast.

7. A review of the Patient Handbook under Patient Rights, To Be Free states 'have right to be free from mental, physical, sexual and verbal abuse ...".

8. A review of the Police report revealed, Patient # 1 was arrested and removed from the Eagle View facility, for Patient # 3 and Patient #4 charged with indecent exposure, assault with intent to commit sex abuse, and an additional charge with Patient #3 of 3rd degree sexual abuse.

Based on document review, staff interviews, and video surveillance review the Hospital Administrative staff failed to ensure the hospital had adequate training on sexually acting precautions and level of observation with adequate supervision resulted in the nursing staff failing to identify and prevent patient from engaging in inappropriate sexual behavior and could potentially also result in self-harm, harm to others and death to the patient. The Hospital Administrative Staff identified a current census of 15 patients on the adult unit at the beginning of the survey. The Hospital Administrative Staff identified a census of 16 on the adolescent unit at the beginning of the survey.

Findings include:

1. Review of the policy 1000.23, "Sexually Acting Out Status" approved by the Governing Board on June 12th 2020, states under Procedure, #4. states "SAO precautions will be addressed on the Treatment Plan", and # 8. Documentation, a., states "Treatment plan entry made and dated documenting the patients change in status ..." made a for Patient # 1, based on review treatment plan in the chart, no documentation of his sexually acting was included on the treatment plan.

2. Review of the policy 1000.23, "Sexually Acting Out Status" approved by the Governing Board on June 12th 2020, states under Procedure, # 5. "The patient may be placed on a higher level of observation if determined to be at risk for sexual acting out behavior.", based on chart review of Patient #1, Patient # 1 remained on every 15-minute checks, when documentation in the medical record indicated an escalation of sexually acting out behavior.

3. During an interview with Nurse B it was stated that Nurse B "did not know what the Sexually Acting Out Precautions were. Nurse B has not had training on precautions and can't say what the SAO precautions would be".

4. During an interview with Nurse C, it was stated, that when Patient #1 was acting inappropriate, staff would separate Patient #1 to unit 600, were Patient # 1 would be separated from the other patients. Then staff were told by administration to return Patient # 1 back to unit 500 back around other patients again, Patient #1 would return to unit 500 and back on 15 minute checks, "if Administration would have only listened to us, when we removed Patient #1 from the unit to 600, when Patient # 1 was inappropriately sexually acting out, staff thought he should be more closely monitored or be isolated, Patient #1 behavior was very inappropriate" .

5. During an interview with MHT D "knew this was going to happen eventually. Patient #1 would act out, staff would put him on 600 then Administration would make us bring him back to 500 and Patient #1 had no extra precautions in place". MHT D stated "I am concerned about how we are handling some of these situations".

6. During an interview with Nurse E stated during a group session on the adolescent unit Nurse E learned from patients there has been a patient that was crossing boundaries and inappropriately touching other patients. That patient was identified as Patient #2. After the group discussion Nurse E had a discussion with Patient #2 and confessed to having inappropriately touching other females. Specifics on this was grabbing Patient # 5's breast. Patient # 7 wrapped arms around Patient # 7's waist, and had attempted to get in the shower with Patient # 7, both dressed. Patient #6 was pulled into the bed by Patient #2, and grabbed Patient # 6's breast.