CMS found low staffing levels led to sexual misconduct at Brentwood Hospital

Brentwood Hospital in Shreveport, LA was cited by the Centers for Medicare and Medicaid Services (CMS) for condition level deficiencies after CMS found six instances of alleged sexual misconduct among patients and four instances of inadequate staffing levels. CMS concluded that “[t]he number of staff present was not adequate to ensure the safety of all patients as evidenced by the alleged sexual misconduct that was allowed to occur between patients.”

Acting on a complaint, CMS spent six days in February 2014 reviewing documents, interviewing staff and observing patients and staff at Brentwood Hospital. CMS determined that the facility failed to meet the Conditions of Participation for Patient Rights and Nursing Services, as well as standards related to staffing, care in a safe setting, freedom from abuse and harassment, patient grievance procedures, patient directives, psychiatric treatment planning and psychiatric nursing requirements. CMS found that “failure[s] to ensure additional staff were present” contributed in several instances to the violation of patients’ “right to be free from all forms of abuse and harassment.”

In its review, CMS found six instances of alleged sexual misconduct that occurred among patients in a nine-week period from November 28, 2013 to February 3, 2014. Twelve patients from the Adult Psychiatric Unit, and Youth Enhanced Unit were involved in these incidents, all of whom were found to have had “physician orders for specific precautions (i.e. Suicide, Behavioral, Assault, Sexual Acting Out, Elopment, etc.)” at the time of the sexual misconduct. The youngest of these patients was 8 years old.

In one of these incidents, a 13-year-old male patient (Patient #2) who had a history of sexual abuse by his older half brother reported to staff that his 17-year-old roommate (Patient #7) “made me touch and suck his penis.” Video evidence showed that the patients were alone in their room at the time of the alleged assault, even though Patient #7 had been ordered 1:1 observation, which requires a staff member to stay with the patient at all times. CMS’s review of staffing records showed the hospital did not add the extra staff needed to perform the 1:1 observation.

In another incident, a 27-year-old female patient reported that a male patient came into her bathroom and had sex with her while she was taking a shower. This allegation was corroborated by the male patient, and by video evidence which showed him going into the female patient’s room and staying for approximately 30 minutes. Review of patient records and staffing schedules showed that during the shift in question, six new patients were admitted to the unit, which was staffed by only one LPN and one RN. With the patient census growing from 7 patients to 13 patients, the facility should have added an additional staff member according to its own staffing grid).

CMS also cited Brentwood Hospital for two additional instances where “the hospital failed to ensure there were enough staff members present … to provide patients with nursing care/monitoring based on their various acuities.” When CMS visited the Adult Psychiatric Unit for observation, the unit’s three staff members were responsible for monitoring 15 patients, including one who required 1:1 monitoring and three who required Close Visual Observation. CMS observed that one of the staff members “was in and out of the medication room,” and the other “was sitting next to the door of the group therapy room,” where the patient requiring 1:1 monitoring was located. The three patients requiring Close Visual Observation were lying down in their rooms. The third staff member was away on a break with no additional staff to fill in. Inadequate staffing was also found on the Adolescent Unit.

CMS determined:

Review of the hospital’s staffing grid failed to account for increased acuity in patients, i.e. 1:1 observations, Close Visual Observations; although the Director of Nursing based nursing staff on the staffing grid, they failed to ensure patient acuity was also included in the determination of additional staff.

In addition, none of the six sexual misconduct incidents were reported to the relevant state agency in a timely manner, and four of the six incidents were not reported at all. While reviewing hte facility’s Grievance Policy, CMS found that “[t]he telephone number listed for reporting allegations of abuse/neglect to the state agency (Health Standards Section) was for a Bahamas vacation.” The facility also failed to notify the parents of the 27-year-old female patient about the incident she reported, even though her parents had obtained formal guardianship through the District Court in the state of Kansas.

Finally, CMS found that patients who submitted complaints to the facility would have to wait an unreasonable amount of time to receive a response. The facility’s Risk Manager revealed in an interview that the Grievance Committee held meetings to determine the outcome of complaint investigations only once every three months, with patients notified after the meetings.

To address its deficiencies, Brentwood Hospital was required to submit a Plan of Correction to CMS.