HospitalInspections.org

Based on document review, video review, and interview, it was determined that the Hospital failed to comply with Condition for Coverage 42 CRF 482.13, Patient Rights.

Findings include:

1. The Hospital failed to effectively monitor behavioral health patients by conducting safety rounds every 15
minutes per facility policy, resulting in the sexual assault of Pt #6 by Pt #5. (A-144)

The Immediate Jeopardy (IJ) began on 12/10/24 due to the facility's failure to effectively monitor behavioral health patients by conducting safety rounds every 15 minutes per facility policy, resulting in the sexual assault of Pt #6 by Pt #5. The IJ was identified on 1/27/25 under 42 CFR 482.13, Patient Rights. The IJ was announced on 1/27/25 at 4:30 PM during a meeting with VP Quality, Chief Nursing Officer, Nursing Director Emergency Department, Chief Quality Officer, Chief of Hospital Operations, and Director of Quality and was not removed by the survey exit date of 1/27/25

Based on observation, document review and interview, it was determined that the facility failed to monitor behavioral
health patients by conducting safety rounds every 15 minutes per facility policy for two of two patients (Pt #5 and Pt #6) in a sample of 10, resulting in the sexual assault of Pt #6 by Pt #5.

Findings include:

1. Policy BH-40 Management of Sexual Misconduct and Aggression (approved 10/8/2024) was reviewed on 1/22/2025 at 3PM and it states: "PROCEDURE A. All patients are assessed upon admission for recent or past history of sexual misconduct or sexual aggression. The following information is collected, but not limited to: 1. Previous history of sexual acting out behaviors ...3. Preoccupation with sexual matters. 4. Current seductive behaviors and inappropriate undressing ...B. Patients assessed (as above) to have a history of or current behavior indication actual or potential sexual misconduct is placed on "Sexual Inappropriate Behavior Precautions (SIBP) ...C. "Sexual Inappropriate Behavior Precautions" status will be entered in the plan of care and in the EMR (Electronic Medical Record). D. Interventions may include, but not limited to: 1.Private room 2.Bedside sitter for additional monitoring 3. Individualized programming..."

2. Policy BB-14 Suicide Prevention (approved 10/4/2024) was reviewed on 1/22/2025. The policy states, " ...2. Ligature Resistant Settings (Behavioral Health Inpatient) Risk Mitigation Plan. General considerations for Ligature Resistant Settings: ...c. Safety Rounds are completed approximately every 15 minutes at a minimum of 4 times an hour. The level of precautions are indicated on the behavioral health precautions flow sheet or electronic device ..."

3. Review of Pt#6's medical record revealed that Pt #6 presented to the Hospital's Emergency Department (ED) on 12/10/24 via ambulance at 9:01 AM. The Patient Care Timeline included, "Stated Reason for Visit: EMS (Emergency Medical Services) sts (states) pt (patient) took 8 effexor (medication used to treat adults with anxiety and depression) 75mg (milligrams) between 1430 (2:30 PM)- 1500 (3:00 PM) yesterday. Sts took to make feel better and harm self ...Suicide Risk-Initial: High Risk."

-Suicide Precaution Orders on Pt #6's record noted, "High/Moderate Risk Ligature Resistant Environment (Inpatient Mental Health/ED Psych area) *Safety Rounding *Scrubs without strings or cords *Remove all personal items *Consider Safety meal trays *Reassess risk level every shift ..."

-Staff Progress Note dated 12/10/24 at 4:08 PM written by E #3 stated, "This RN (Registered Nurse) was made aware at this time that this (Pt #6-minor female) was in a room with (Pt #5-adult male) ... The other patient (Pt #5) and this patient (Pt #6) exited the room the male (Pt #5) walked directly to his room BH2, where this patient (Pt #6) walked to the desk of BH ... I immediately called my Charge nurse... I was directed by my manager (E #1) to ask the patient if (Pt #6) wants to press charges and notify PD (Police Department) if so. It was also agreed to notify legal guardian of the patient as well ...I asked if (Pt #6) wanted to press charges and (Pt #6) said yes ...After the discussion I ...called (Police Department), then I called the legal guardian to notify him of the incident ..."

- ED Provider Note dated 12/10/24 at 4:13 PM written by Medical Doctor (MD- E #4) stated, "1604 (4:04 PM) Patient was seen and evaluated by SASS (Screening Assessment Support Services) ...1650 (4:50 PM) Patient was awaiting transfer to (Mental Health Facility) I was informed by the ED staff at some point while waiting here in the Emergency behavioral health unit another patient from a room entered the patient's room. That is some point while the two were in the room together they were eventually noted to be engaging in oral sex. The patient was delivered in {sic} the oral sex to the other patient. When this was discovered, the patients were separated. The patient wishes to file charges against the other patient stating that this was a nonconsensual encounter. I went with one of the ED managers and the charge nurse and the patient wishes to have an evidence kit per the patient's wishes."

-Pt #6's record indicated on 12/10/25 at 5:24 PM SANE (Sexual Assault Nurse Examiner) was contacted and Pt #6 was evaluated and treated per Sexual Assault policy. Police contacted and was at bedside.

-Pt #6 was discharged from Hospital on 12/11/24 at 7:52 AM to a Mental Health Facility.

-The Patient Safety Companion Frequent Observation Flowsheet-ED dated 12/10/24 that started at 1:03 PM for Pt #6 was reviewed. No staff signature is noted during the following times to indicate the observational checks were completed by hospital staff for Pt #6: 1:30 PM, 1:45 PM, and 4:00 PM.

4. The medical record of Pt#5 was reviewed during the entire survey. Pt#5 was an adult male patient that presented to the Emergency Department on 12/10/24 at 09:47 AM for a psychiatric evaluation. A panel of laboratory work was ordered, and Pt#5 was cleared medically for a psychiatric evaluation. Pt#5 was admitted to the Behavioral Health (BH) Unit in the ER, room 2 (two). ED Provider Note written by Advanced Practice Registered Nurse (E#5) and dated 12/10/24 at 9:59 AM stated, "MENTAL HEALTH ADMISSION: This patient is a danger to themselves and/or others ..."

-Progress Note written by Registered Nurse (E#6) and dated 12/10/24 at 10:12 AM stated, "Presenting Concerns ...-pt attempting sexual acts with (family). Has been turning off all the home lights and laughing ...Recently diagnosed with depression, take fluoxetine." Past family history of schizophrenia ...COLLATERAL RESPONSE: (Family) ...reports (sibling) stated "(Pt #5) pulled (Pt #5) di*k out. Reports (family) told (Pt#5) to go to (Pt #5's) room but (Pt#5) came down there and was repeating "can you help me, can you help me" and had a condom on. Reports "(Pt#5) was trying to rape my (child) ...SAFETY/RISK CONSIDERATIONS ... Sexual Misconduct: Yes-attempted sexual acts with (family)."

-Staff Progress Note written by Registered Nurse (E#3) on 12/10/24 at 4:08PM stated, "This patient was found in the BH5 (Behavioral Health room 5) with a female pediatric patient without knowledge of our BH staff ...after this the patient received a 1 (one) to 1 sitter to stay with the patient at all times. This patient had performed sexual acts on the patient that was in BH5. (Police Department) notified of this patient's behaviors. This patient also gave this RN permission to discuss their actions today with family. Family reported to me on the phone (Pt#5) was sick and apologized for them ..."

-Progress Note written by Health Care Tech (E#7) dated 12/10/24 at 7:36 PM stated, "Upon returning back from doing a transfer with another patient, (E#7) saw Pt#5 on camera in another patient's room [Pt #6's room]. (E#7) went into the room the patient was in and told the patient to leave as they can't be in another patient's room. Patient [Pt #5] got up and left the room and returned to their room."

- Pt #5's "Patient Safety Companion Frequent Observation Flowsheet" indicated 15-minute rounds monitoring was started on 12/10/24 at 9:50 AM. The record lacked monitoring at 1:30 PM, 1:45 PM, 4:00 PM, and 5:30 PM. The record lacked monitoring on 12/11/24 at 2:15 PM and 2:30 PM.

5. An interview with the Nurse Manager Emergency Department (ED) (E#1) on 1/24/25 at approximately 10:15 AM. E #1 reviewed Pt #5 and Pt #6's "Patient Safety Companion Frequent Observation Flowsheet" and verbally agreed the records lacked the monitoring as required. E #1 was also interviewed regarding the policy "BH-40 Management of Sexual Misconduct and Aggression." E #1 stated, "Patients are assessed ... (Pt #5) was placed in a private room, but the bedside sitter was not implemented until after the incident occurred with (Pt#6)."

6. On 1/22/25 at 12:00 PM an observation of the video footage from the incident on 12/10/2024 involving Pt #5 and Pt #6 was conducted with Security Officer (E #14). Identity of Pt #5 and Pt #6 were verified on video by E #14.

-Pt#5 entered room of Pt#6 at 3:46PM while Pt#6 was standing in hallway
-Pt#6 enters their room at 3:47PM
-Pt #6 got on their knees in front of Pt #5 and performed oral sex on Pt #5 at 3:52PM
-Staff open door to Pt#6's room at 4:07PM
-4:08PM Pt#5 exits Pt#6's room

7. An interview was conducted with Emergency Department (ED) Nurse Manager (E #1) on 1/21/25 at approximately 1:15 PM. While discussing the process of how they monitor the cameras in the Behavioral Health Unit (BH) E #1 stated, "Our staff checks the cameras every 15 minutes, but that is not their sole job. They have other responsibilities as well. We do not have designated staff on the BH Unit watching cameras 24 hours a day. We would like to change that. Our security in the ED is watching the cameras continuously on all shifts unless they are needed elsewhere. Security will alert staff if they see anything on the cameras that needs to be addressed. We can't lock patients in their rooms without a physician's order, but we do expect patients to stay in their rooms. Patients can walk out of their room to the nurse's station if they need something. When a patient scores High on the Columbia Suicide Severity Rating Scale (Suicide Risk Assessment), the interventions put in place on the BH Unit are patient's belongings are taken, they are given paper scrubs, and jewelry is removed. 15-minute checks are completed on all patients via the BH Tech watching the video monitors." While discussing Pt #6, E #1 stated, "Because (Pt #6) was on a ligature free unit, which is a locked unit, a sitter was not required."