HospitalInspections.org

30526

Based on record review and staff interview it has been determined that the hospital failed to ensure patient safety by allowing patient ID# 1 to be unsupervised on the ground level of the facility, in the absence of any means of surveillance or the presence of staff to ensure the patient's safety.

Findings are as follows:

Record review for patient ID# 1 revealed that this 24-year-old was admitted to the hospital's Zambarano unit on 9/8/2017 with relevant diagnoses of respiratory failure with tracheotomy, substance abuse, and developmental delay with mild intellectual disability. Review of the history and physical from 9/12/2017, revealed that the patient was alert and oriented to person, place and time. The patient was placed on a secured unit at Zambarano due to having eloped and removed his/her trach at the previous hospital. A behavior plan, dated 10/27/2017, states the patient has a history of trauma, with anxiety and distress when s/he feels overwhelmed or unsafe. "S/he copes by spending time alone, engaging in arts and crafts and some other activities s/he enjoys off the unit".

The patient care plan, dated 6/17/2017, states that the patient has "privileges: for unsupervised inside of hospital; supervised community." Hospital staff/psychology evaluated the patient and, after 2 weeks of being on the secured unit, placed a wanderguard on the patient and allowed him/her unsupervised off unit privileges.

The patient's staff behavioral specialist (Staff A), was interviewed on 12/7/2017 at 10:50 AM. Staff A stated that she met with the patient numerous times per week to work on coping skills, etc. On 12/5/2017, at approximately 2:30 PM, during staff A's session with the patient, s/he stated "I have to tell you something, I am going to be in trouble". The patient then told Staff A that s/he had sexual relations with a security guard sometime in October. S/he further stated that it was consensual and that s/he did not want to get the security guard into trouble. The patient then showed Staff A text messages and facebook posts from the security officer, which were very sexual in nature. Staff A stated that she immediately reported this allegation to her supervisor, the psychologist, Staff B.

The patient's staff psychologist (Staff B) was interviewed on 12/7/2017 at 1:10 PM. She stated that the patient did not like being on the locked unit, so would spend much of the time in activities during the day. At night after dinner, the patient would go to the lower level of the hospital to the resident/family visiting room to watch television. This area of the hospital doesot have a staff presence nor any mechanism for surveillance of these areas, which patients are allowed to independently access.

Staff B further stated that, when she spoke with the patient, the patient stated that the security guard said "let's go into the chapel where there are no cameras". The psychologist stated that, after the patient had told her that, the psychologist felt that the security guard knew what s/he was doing.

The surveyor toured the ground level of the Zambarano unit with the Administrator on 12/8/2017 at 9:20 AM. It was noted that the patients are allowed independent access to this area via stairs or elevator. The Administrator told the surveyor that the chapel, activities room and patient/family lounge (TV room), are open for patient use. The activities room is locked by the activity staff when they leave for the day, around 4:00 PM, and the security officer locks the chapel around 8:00 PM.

The patient lounge is open 24 hours a day and is never locked. Upon review of the area on the ground level, there is no staff on that floor and there is no mechanism for surveillance of this room. When questioned, the administrator informed the surveyor that the kitchen staff are the last to leave on the ground level at 6:30 PM. She stated that they do not have surveillance cameras or a way to monitor the patient lounge. When questioned about patient safety, as patients can go to this area independently, the Administrator was unable to provide evidence that the hospital was providing for patient safety, without staff or surveillance of this area.

The hospital failed to protect and promote the patient's right to receive care and services in a safe setting by allowing the patient to be unsupervised on the ground level where there was no surveillance or staff.

Based upon staff interview, it has been determined that the hospital failed to ensure that the services performed under a contract are provided in a safe and effective manner relative to security officers.

Findings are as follows:

During a complaint investigation on 12/7/2017 at the hospital's Zambarano unit, it was reported that patient ID #1 engaged in sexual relations (sometime in October 2017) in the chapel on the lower level with a security guard (Staff C).

During surveyor interview with the Administrator of the hospital's Zambarano Unit on 12/8/2017 at 11:00 AM, she was unable to produce evidence that the security guard, Staff C, had received performance evaluations and referred the surveyors to the Administrator of Environmental Care for the information.

The surveyor interviewed the Administrator of Environmental Care, who oversees the contracted security service, on 12/12/2017 at 12:05 PM. He was unable to provide any records for staff C relative to performance evaluations.

Staff C was hired August 28, 2013 by the contracted agency and has been working at the Zambarano unit as the security officer.

The hospital failed to ensure that the services performed under a contract are provided in a safe and effective manner relative to security services.


30526

Based on staff interview and surveyor observation, it was determined that the hospital failed to provide care in an environment that protected a patients physical safety and security for patient ID #1.

Findings are as follows:

During a complaint investigation on 12/7/2017 at the hospital's Zambarano unit, it was reported that patient ID #1 engaged in sexual relations, (sometime in October 2017) in the chapel on the lower level with a security guard (Staff C).

Medical record review revealed that the patient has a history of trauma and anxiety and copes by spending time alone. A care plan dated 6/17/2017 states that the patient has privileges to be unsupervised inside of the hospital.

The surveyor toured the ground level of the Zambarano unit with the Administrator on 12/8/2017 at 9:20 AM. It was noted that the patients are allowed independent access to this area via stairs or elevator. The Administrator told the surveyor that the chapel, activities room and patient/family lounge (TV room), are open for patient use. The activities room is locked by the activity staff when they leave for the day, around 4:00 PM, and the security officer locks the chapel around 8:00 PM.

The patient lounge is open 24 hours a day and is never locked. Upon review of the area on the ground level, there is no staff on this floor and there is no mechanism for surveillance of this room. When questioned, the administrator informed the surveyor that the kitchen staff are the last to leave on the ground level at 6:30 PM. She stated that they do not have surveillance cameras or a way to monitor the patient lounge. When questioned about patient safety, as patients can go to this area independently, she was unable to provide evidence that the facility was providing for patient safety, without staff or surveillance of this area.

The hospital failed to protect the patient and failed to provide for physical safety of patients who have unsupervised privileges to access areas of the hospital which lack any staff or surveillance monitoring.