HospitalInspections.org

The Hospital was out of compliance for the Condition of Participation for Patient Rights.

Findings included:

The Hospital failed to ensure for one (Patient #5) of 10 sampled patients that the Hospital provided care in a safe setting.

Refer to TAG: A-0144.

Based on interviews and records reviewed the Hospital failed for one (Patient #6) patient of 10 sampled patients to provide implementation of preventative actions to all hospital staff in both the Department of Public Health (DPH) licensed units and the Department of Mental Health (DMH) licensed units, after Patient #6 was able to get out of his/her room on the DMH unit, while on a 1:1 observation for hypersexual behaviors and sexually assaulted another patient.

See A-0286

Based on interviews and records reviewed the Hospital failed for one (Patient #5) patient of 10 sampled patients to provide care in a safe setting, after Patient #6 was able to get out of his/her room on the Department of Mental Health (DMH) unit, while on a 1:1 observation for hypersexual behaviors and sexually assaulted Patient #5.

Findings include:

Review of the Hospital's One to One Observation Policy, dated 6/1/2018, indicated that a patient may be placed on a 1:1 observation when they are assessed to be a threat to themselves or others.

The goal of this assignement is to provide for the safety of the patient and others.

A. The "Responsibilities Assigned to Staff" are:

1. On the medical surgical units: The staff person assigned to a patient must remain in close proximity to the patient at all times. If clinically indicated, 1:1 must be at arm's length and specified by a doctor's order.

2. On the Impatient Psychiatric Units: The staff person assigned to a patient must remain within arm's length of the patient at all times unless clinically contraindicated and specified by a doctor's order. If the order is not at arm's length, the staff member must remain close enough to intervene, within approximately six feet of the patient.

B. The staff person is to remain in or at the doorway of the bedroom of the patient who is placed on 1:1 observation when he/she is sleeping, but must continue to be within visual contact, unless otherwise clinically indicated and then specified by a Licensed Independent Practitioner (LIP).

F. The assigned staff person is not to leave the patient unobserved for any reason. The assigned staff person must not read, listen to radio or television or participate in any activities other than directly observing the patient unless those activities actively involve the patient. Conversation with other staff is to be kept to a minimum and only as needed for hand off communication.

Patient #5 was admitted to the Hospital in 4/2019 with a diagnosis of schizoaffective disorder.

On 7/10/2021, Patient #5 was sexually assualted by Patient #6 when he/she was able to get by his 1:1 constant observers. Patient #5 was heard yelling for help by nursing staff. Patient #5 was able to call the police him/herself and endorsed high emotional distress to the nursing staff after the sexual assault.

Patient #6 was admitted to the Hospital on 8/2/2018 with diagnoses of schizoaffective disorder, bipolar type and diabetes mellitus.

Patient #6 had a history of sexually problematic behavior and had been treated medically for such in the past. Patient #6 was admitted to the Hospital in one of 6 the Inpatient Psychiatric Units licensed by DMH.

Review of Patient #6's medical record indicated that on 7/7/21, Patient #6 was hypersexual with another patient. He/she was observed putting his/her arms around another patient and "humping" the other patient. Patient #6 was put on 1:1 observation to prevent the touching of others. The patient was then transferred to another unit.

Review of Patient #6's Clinician Orders, dated 7/8/21, 7/9/21 and 7/10/21 indicated that Patient #6 was on a 1:1 observation for hypersexual behavior.

Review of Patient #6's Discharge Summary, dated 7/10/21, indicated that after Patient #6 was transferred to a new unit, he/she was restricted to the unit and placed on one-to-one surveillance when out of his/her room, with constant observation when he/she was alone in his/her room, shower or bathroom. On 7/10/21, he/she evidently left his/her room and went into the room of a female patient. The staff realized this when they heard screams from Patient #5. Charges were pressed and Patient #6 was discharged to the police.

During an interview on 7/30/21 at 9:00 A.M., the Director of Quality and Risk for the Hospital's psychiatric units said that when an incident of this nature takes place, they notify the Department of Mental Health (DMH) and DMH does an investigation. The Hospital does their own internal work to determine what happened and how to prevent it from happening again. The Director of Quality and Risk said that the Hospital determined that the constant observation policies were not followed as expected and by the staff members which in turn lead to the patient being able to leave his/her room. She said that the two staff members responsible for the 1:1 constant observation during the time frame of the event were both contracted agency staff and were immediately put on administrative leave. The investigation internally has not been able to identify how the patient was able to get by the 1:1 observer or exactly when Patient #6 was able to exit his/her room unnoticed.

During an interview on 7/30/21 at 9:00 A.M. with the interim Chief Operating Officer (COO) of the DMH units, the COO said that on 7/10/21 she was notified of the assault. She went to the Hospital and started her initial investigation. She said that the Hospital immediately started to retrain staff on the integrity of one-to-one and constant observation policies. The interim COO said that the DPH staff were not part of the retraining and implementation of new process.

During an interview on 7/30/21 at 1:30 P.M., Certified Nurse's Aid #1, who works on a DPH unit, said that he has had training on constant observation, but hasn't been specifically trained as a result of the assault on 7/10/21 on the DMH unit.

During an interview on 7/30/21 at 1:35 P.M. with Nurse #1 who works on a DPH unit, said that he hasn't been trained as a result of the assault that took place on 7/10/21. He said that when he has a patient on a one-to-one observation, he communicates with the staff doing the observation why the patient requires that level of observation and that he monitors the staff for proper procedure.

The Hospital failed to keep Patient #5 safe from sexual assault when the Mental Health Workers failed to maintain constant observation on Patient #6 who was actively exhibiting hypersexual behaviors while admitted to the Hospital and able to sexually assault Patient #6.

Based on interviews and records reviewed the Hospital failed for one (Patient #6) patient of 10 sampled patients to provide implementation of preventative actions to all hospital staff in both the Department of Public Health (DPH) licensed units and the Department of Mental Health (DMH) licensed units, after Patient #6 was able to get out of his/her room on the DMH unit, while on a 1:1 observation for hypersexual behaviors and sexually assaulted another patient.

Findings include:

Review of the Hospital's One to One Observation Policy, dated 6/1/2018, indicated that a patient may be placed on a 1:1 observation when they are assessed to be a threat to themselves or others.

A. The "Responsibilities Assigned to Staff" are:

1. On the medical surgical units: The staff person assigned to a patient must remain in close proximity to the patient at all times. If clinically indicated, 1:1 must be at arm's length and specified by a doctor's order.

2. On the Impatient Psychiatric Units: The staff person assigned to a patient must remain within arm's length of the patient at all times unless clinically contraindicated and specified by a doctor's order. If the order is not at arm's length, the staff member must remain close enough to intervene, within approximately six feet of the patient.

B. The staff person is to remain in or at the doorway of the bedroom of the patient who is placed on 1:1 observation when he/she is sleeping, but must continue to be within visual contact, unless otherwise clinically indicated and then specified by a Licensed Independent Practitioner (LIP).

F. The assigned staff person is not to leave the patient unobserved for any reason. The assigned staff person must not read, listen to radio or television or participate in any activities other than directly observing the patient unless those activities actively involve the patient. Conversation with other staff is to be kept to a minimum and only as needed for hand off communication.

Patient #6 was admitted to the Hospital on 8/2/2018 with diagnoses of schizoaffective disorder, bipolar type and diabetes mellitus.

Patient #6 had a history of sexually problematic behavior and had been treated medically for such in the past. Patient #6 was admitted to the Hospital in one of 6 the Inpatient Psychiatric Units licensed by DMH.

Review of Patient #6's medical record indicated that on 7/7/21, Patient #6 was hypersexual with another patient. He/she was observed putting his/her arms around another patient and "humping" the other patient. Patient #6 was put on 1:1 observation to prevent the touching of others. The patient was then transferred to another unit.

Review of Patient #6's Clinician Orders, dated 7/8/21, 7/9/21 and 7/10/21 indicated that Patient #6 was on a 1:1 observation for hypersexual behavior.

Review of Patient #6's Discharge Summary, dated 7/10/21, indicated that after Patient #6 was transferred to a new unit, he/she was restricted to the unit and placed on one-to-one surveillance when out of his/her room, with constant observation when he/she was alone in his/her room, shower or bathroom. On 7/10/21, he/she evidently left his/her room and went into the room of a female patient. The staff realized this when they heard screams from the patient. Charges were pressed and the patient was discharged to the police.

During an interview on 7/30/21 at 9:00 A.M., the Director of Quality and Risk for the Hospital's psychiatric units said that when an incident of this nature takes place, they notify the Department of Mental Health (DMH) and DMH does an investigation. The Hospital does their own internal work to determine what happened and how to prevent it from happening again. The Director of Quality and Risk said that the Hospital determined that the constant observation policies were not followed as expected and by the staff members which in turn lead to the patient being able to leave his/her room. She said that the two staff members responsible for the 1:1 constant observation during the time frame of the event were both agency staff and were immediately put on administrative leave. The investigation internally has not been able to identify how the patient was able to get by the 1:1 observer or exactly when Patient #6 was able to exit his/her room unnoticed.

During an interview on 7/30/21 at 9:00 A.M. with the interim Chief Operating Officer (COO) of the DMH units, the COO said that on 7/10/21 she was notified of the assault. She went to the Hospital and started her initial investigation. She said that the Hospital immediately started to retrain staff on the integrity of one-to-one and constant observation policies. The interim COO said that the DPH stafe were not part of the retraining and implementation of new process.

During an interview on 7/30/21 at 1:30 P.M., Certified Nurse's Aid #1, who works on a DPH unit, said that he has had training on constant observation, but hasn't been specifically trained as a result of the assault on 7/10/21 on the DMH unit.

During an interview on 7/30/21 at 1:35 P.M. with Nurse #1 who works on a DPH unit, said that he hasn't been trained as a result of the assault that took place on 7/10/21. He said that when he has a patient on a one-to-one observation, he communicates with the staff doing the observation why the patient requires that level of observation and that he monitors the staff for proper procedure.

The Hospital failed to train all staff in all units of the Hospital. The new implementations developed by the Director of Nursing of the DMH unit to prevent a like occurrence were only provided to the 6 DMH licensed units. The Hospital failed to communicate the findings and implementation of the education with the DPH licensed units and therefore, failed to educate the employees on the 6 DPH licensed units.