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Based on staff interview, policy and record review, the hospital failed to investigate the allegation of sexual misconduct for 1 (Patient #1) of 2 patients reviewed for abuse. The facility failed to protect patients' rights when Patient #1 was allegedly sexually assaulted twice on 11/15/19 by Staff A RN after he administered Ativan (a medication used to treat anxiety, insomnia, acute seizures, sedation and aggression) intravenously (into the vein),

The facility became aware of the sexual assault on 11/19/19 by local law enforcement and failed to thoroughly investigate the abuse allegation and report the allegation to the Florida Department of Health as required (A145). The facility did not present the allegation of sexual misconduct/abuse to the Grievance Committee for review (A119).

The hospital's failure to thoroughly investigate Patients #1's sexual abuse allegation from hospital staff could result in the hospital failure to take actions to prevent abuse from occurring again. Sexual abuse/assault have serious psychological emotional and physical effect on survivors.

These systemic failures constitute an immediate jeopardy situation.

On 6/16/20 at 1:25 p.m., The Chief Executive Officer (CEO) was informed of the Immediate Jeopardy which began 11/15/19. The Immediate Jeopardy was removed 6/18/20.

The cumulative deficits place the patients at risk when allegations of sexual assault/abuse are not thoroughly investigated, brought to the grievance committee and report to the Department of Health an allegation of sexual assault resulting in the Condition of Participation being out of compliance.

Refer to A119, Patient Rights - Grievance review and A145, Patient Rights - Free from Abuse.

Based on staff interview and policy review, the facility failed to ensure 1 (Patient #1) of 4 patients reviewed for grievances/complaints had their grievances/complaint thoroughly investigated. The facility failed to protect patients' rights when Patient #1 was sexual assaulted twice on 11/15/19 by Staff A (Registered Nurse (RN) after he administered Ativan intravenously, a medication used to treat anxiety, insomnia, acute seizures and the sedation of hospitalized or aggressive patients. The facility became aware of the sexual assault on 11/19/19 by local law enforcement and failed to thoroughly investigate the allegation of sexual assault/abuse and report the allegation of alleged sexual assault/abuse to the Grievance Committee, this could result in the hospital's failure to take actions to prevent future assault/abuse from occurring to other patients at the hospital. Sexual abuse/assault can have serious psychological, emotional and physical effects on the survivor.

This systemic failure constitutes an immediate jeopardy situation. Refer to A115, The Condition of Participation for Patient Rights.

On 6/16/20 at 1:25 p.m., the Chief Executive Officer (CEO) was informed of the Immediate Jeopardy (IJ) situation which began 11/15/19. The jeopardy was determined removed 6/18/20.

The findings included:

In an interview on 6/10/20 at 9:30 a.m., the Risk Manager (RM) said the facility had 1 allegation of sexual assault/abuse in the past year. She said a police detective came to the facility on 11/19/19 around 7:00 p.m. to speak with Staff A RN. The RM said she was the Administrator on duty that night, so she spoke with the police detective who told her Patient #1 had filed a complaint with law enforcement against Staff A RN for sexual assaulting her while she was in the hospital on 11/15/19. The police detective told her Patient #1 said in her complaint against Staff A RN, he had blocked her hospital room door with his computer and sexually assaulted her twice in her hospital bed the night of 11/15/19 after he had administered Ativan, a medication used for sedation. The police detective told the risk manager she needed to bring Staff A RN to the police station for questioning. The RM said she spoke with the night supervisor who determined Staff A RN was not working that night. She told the night supervisor Staff A RN was suspended as of that time until further notice.

The Risk Manager said the next morning (11/20/19) at around 8:15 a.m., Staff A RN called the Director of Human Resource (DHR) and told her he heard he was being accused of raping a hospital patient and he wanted to resign. She said the DHR told him if he wanted to resign, he had to send her an email stating he wanted to resign, and she gave him her office email address. The DHR also told Staff A she could not discuss the allegation of rape with him. The RM said she was told on 11/20/19 at around 9:00 a.m. by DHR, Staff A RN had called her that morning telling her he had heard about the allegation of him raping a patient at the hospital and wanted to resign. She said she reviewed the staffing sheet and confirmed Staff A was Patient #1's nightshift nurse on 11/14/19 and 11/15/19. The RM said she had reviewed the security camera recording for 11/14/19 and observed Staff A RN going into Patient #1's room twice during the night.

She said she also conducted staff interviews and had written the nursing staff interviews/statements on the back of the nursing scheduling sheets for those nights. The RM said she is unable to provide any documentation the facility had conducted a thorough investigation into the allegation of sexual assault/abuse against Patient #1 on 11/15/19 because the staff interviews she conducted were thrown away by the unit manager and she did not keep a copy of the staff interviews she had conducted in the risk management office. She further said she doesn't remember who she interviewed about the alleged sexual assault/abuse and has no documentation risk management had completed a thorough investigation into the alleged sexual assault/abuse of Patient #1. She also said she did not preserve the security camera recording for the night of 11/14/19 that she had viewed related to her investigation into the 11/15/19 alleged sexual assault/abuse.

In an interview on 6/10/19 at 11:54 a.m., the Director of Human Resource (DHR) stated Staff A RN was suspended on 11/19/19 due to an allegation of sexual assault of a hospital patient while he was at work. She said Staff A RN called her around 8:15 a.m. on 11/20/19 stating he heard he was being accused of raping a patient in the hospital and he wanted to resign. She said she told him to send her an email with his resignation and that she could not speak to him about the rape allegation. She spoke with the RM around 9:00 a.m. on 11/20/19 and told her she had just spoken with Staff A RN and that he wanted to resign so she gave him her email address. She was told to review his employee file to ensure they had completed his background check as per their policy and procedure. She said the RM did a national background check on Staff A RN nursing license and found out he was reprimanded/censured for a breach of confidentiality for a non-sexual dual relationship or boundary violation in North Carolina on 3/12/19 and was reprimanded by the Board of Nursing in Oregon for failing to maintain professional boundaries, and violating a person's right of privacy and confidentiality on 11/14/18. Since Staff A RN did not disclose his previous disciplinary actions in North Carolina and Oregon on his Employment Application, the hospital terminated his employment with the hospital on 12/5/19. She said she was told only to review Staff A RN's employee file and was not involved in the investigation into the alleged sexual misconduct between Staff A RN and Patient #1.

On 6/11/20, a review of the facility's Grievance/Complaint Process created 9/2010 and approved by the Governing Board on 1/2017 stated a prompt resolution of a patient grievance regarding an alleged violation of patient rights as mandated by Center for Medicare/Medicaid Services. It further states a patient grievance is defined as a written or verbal concern by a patient, or patient's representative regarding the patient's care, abuse or neglect.

The Governing Board will establish a Grievance Committee who is responsible for assuring the effective operation of the grievance process and conducting a review of grievances and assuring the prompt resolution of those grievances. The Grievance Committee shall be led by the Risk Manager, as appointed by the Administrator.

On 6/11/20, a review of the Sexual Misconduct policy created 4/98 and approved by the Governing Board on 4/24/18 stated the Administration, Risk Management and law enforcement will be immediately notified of all accusations or allegations of abuse or sexual misconduct occurring within the facility or on facility grounds. The policy states every allegation of sexual misconduct made against any member of the facility's staff will be investigated if the sexual misconduct occurred at the facility or facility grounds.

In an interview on 6/11/20 at 9:30 a.m., the RM confirmed the facility's Grievance/Complaint policy stated a prompt resolution of a patient grievance regarding an alleged violation of patient rights and is defined as a written or verbal concern by a patient, or patient's representative regarding the patient's care, abuse or neglect. She said since Patient #1 did not tell the hospital of the alleged sexual assault/abuse and since the police detective is not Patient #1's legal representative, they had not considered the allegation of a sexual assault at the hospital as a grievance/complaint therefore, the allegation of sexual assault was not investigated and/or brought to the Grievance Committee to review as per their policy. She further said no one from the hospital tried to contact Patient #1 about the alleged sexual assault/abuse because the police detective told her on 11/19/19 not to contact Patient #1 since it is an open police investigation.

In an interview on 6/13/20 at 3:00 p.m., the RM said she just discovered she had viewed the wrong security camera recording related to the alleged sexual assault of Patient #1 on 11/15/19. She had viewed the security camera recording for 11/14/19 not the date of the alleged sexual assault. She said since she viewed the incorrect security camera recording she does not know when and/or how many times Staff A RN went into Patient #1's hospital bedroom the night of the alleged sexual assault/abuse. She said the security camera recording for 11/14/19 and 11/15/19 are no longer available for review because it was erased.

In an interview on 6/15/20 at 8:50 a.m., Patient #1 said Staff A RN was her nurse on 11/14/19 and 11/15/19. She said he was very friendly to her on 11/14/19 and when she was feeling anxious and could not sleep on 11/15/19 he suggested she take some Ativan to help her sleep. After he gave her the Ativan medication to help her sleep, he blocked her hospital room door with his computer cart and sexually assaulted her 2 times in her hospital room. She said she was physically weak and could not fight him off. She said she was scared he might kill her during the night and that is why she did not tell anyone about the rape while she was in the hospital. She said she has always been distrustful of hospitals, but because she was raped by Staff A RN while she was a patient in the hospital, she is now fearful of all hospitals. She further said she doesn't know why the hospital never tried to contact her about the rape because when she told the police they said they would be informing the hospital about her being sexually assaulted in the hospital.

In an interview on 6/15/20 at 3:00 p.m., the police detective said she went to the hospital on 11/19/19 to speak with Staff A related to an allegation of sexual assault which occurred on 11/15/19 at the hospital. She told the RM a patient had filed a complaint stating Staff A RN had sexually assaulted her twice in the hospital on 11/15/19 after giving her Ativan medication. The police detective said she never told the RM she could not interview the patient and would think the RM would have done a complete and thorough investigation into the alleged sexual assault.

In an interview on 6/16/20 at 12:30 p.m., the CEO said he was told on 11/20/19 Staff A RN had allegedly sexually assaulted Patient #1 in the hospital on 11/15/19. He stated the facility's Grievance/Complaint policy states a prompt resolution of a patient grievance regarding an alleged violation of patient rights and is defined as a written or verbal concern by a patient, or patient's representative regarding the patient's care, abuse or neglect. He said as of this time Patient #1 has not told them of the alleged sexual assault/abuse and since the police detective is not Patient #1's legal representative they did not considered the allegation of the alleged sexual assault/abuse at the hospital as a grievance/complaint.

The CEO said after he talked with the corporate office on 11/20/19, he determined since Patient #1 did not make the allegation of sexual assault herself to the hospital, and they suspended Staff A, then terminated Staff A on 12/5/19, the patients at the hospital were safe and the allegation of sexual misconduct was resolved.

The CEO said he was instructed by the corporate lawyers the allegation of sexual misconduct/abuse was a Human Resource issue. He confirmed the facility did not treat Patient #1 allegation of sexual assault as a grievance/complaint, so they did not investigate the allegation of sexual assault/abuse as a grievance/complaint as noted in their Grievance/Complaint Process. He also said the Risk Manager did not inform the Grievance Committee of the grievance/complaint allegation of the sexual assault as required in their Grievance/Complaint Process policy and procedure.

The CEO stated law enforcement notified the Risk Manager, who was the representative for Administration on the evening of 11/19/19. Patient #1 filed a complaint/allegation of sexual assault against Staff A RN while she was a patient in the hospital on 11/15/19 and he was informed of the allegation of sexual assault/abuse on 11/20/19. He said since the corporate lawyer and himself determined the allegation of sexual assault was a Human Resource issue, he instructed the Risk Manager not to do an investigation into Patient #1's allegation of sexual assault at the hospital on 11/15/19. The Risk Manager did not investigate the allegation of sexual assault as a complaint/grievance and the allegation of sexual assault was not brought to the Grievance Committee for their review as required per their Grievance/Complaint Process policy.
Refer to A115, The Condition of Participation for Patient Rights

Based on staff interview, policy and record review, the hospital failed to investigate the allegation of sexual misconduct/abuse for 1 (Patient #1) of 2 patients reviewed for abuse. The facility failed to protect patients' rights when Patient #1 was sexually assaulted twice on 11/15/19 by Staff A Registered Nurse (RN)after he administered Ativan intravenously, a medication used to treat anxiety, insomnia, acute seizures and the sedation of hospitalized or aggressive patients. The facility became aware of the sexual assault on 11/19/19 by local law enforcement and failed to thoroughly investigate the abuse allegation and report the allegation of alleged sexual assault/abuse to the Florida Department of Health as required by their policies and Florida state law.

The hospital's failure to thoroughly investigate Patients #1's sexual abuse allegation against Staff A RN and failure to report the allegation of sexual assault/abuse to the Florida Department of Health as required by state law could result in the hospital failure to take actions to prevent sexual assault from occurring again. Sexual abuse/assault have serious psychological emotional and physical effects on survivors.

This systemic failure constitutes Immediate Jeopardy.
On 6/16/20 at 1:25 p.m., the Chief Executive Officer (CEO) was informed of the Immediate Jeopardy (IJ) situation which began 11/15/19. The jeopardy was determined removed 6/18/20.

The findings include:

In an interview on 6/10/20 at 9:30 a.m., the Risk Manager (RM) said the facility had 1 allegation of sexual assault/abuse in the past year. She said a police detective came to the facility on 11/19/19 around 7:00 p.m. to speak with Staff A RN. The RM said she was the Administrator on duty that night, so she spoke with the police detective who told her Patient #1 had filed a complaint with law enforcement against Staff A RN for sexual assaulting her while she was in the hospital on 11/15/19. The police detective told her Patient #1 said in her complaint against Staff A RN, he had blocked her hospital room door with his mobile computer cart and sexually assaulted her twice in her hospital bed the night of 11/15/19 after he had administered Ativan, a medication used for sedation. The police detective told her she needed to bring Staff A RN to the police station for questioning. The RM said she spoke with the night supervisor who determine Staff A RN was not working that night. She told the night supervisor Staff A RN was suspended as of that time until further notice.

The RM said the next morning (11/20/19) at around 8:15 a.m., Staff A RN called the Director of Human Resource (DHR) and told her he heard he was being accused of raping a hospital patient and he wanted to resign. She said the DHR told him if he wanted to resign, he had to send her an email stating he wanted to resign, and she gave him her office email address. The DHR also told Staff A RN she could not discuss the allegation of rape with him. The RM said she was told on 11/20/19 at around 9:00 a.m. by DHR, Staff A RN had called her that morning telling her he had heard about the allegation of him raping a patient at the hospital and wanted to resign. She said she reviewed the staffing sheet and stated Staff A RN was Patient #1's nightshift nurse on 11/14/19 and 11/15/19. The RM said she had reviewed the security camera recording for 11/14/19, which showed Staff A RN going into Patient #1's room twice during the night. She said she also conducted staff interviews and had written the nursing staff interviews/statements on the back of the nursing scheduling sheets for those nights. The RM said she is unable to provide any documentation the facility had conducted a thorough investigation into the allegation of sexual assault/abuse against Patient #1 on 11/15/19 because the staff interviews she conducted were thrown away by the unit manager and she did not keep a copy of the staff interviews she had conducted in the risk management office. She further said she doesn't remember who she interviewed about the alleged sexual assault/abuse and has no documentation risk management had completed a thorough investigation into the alleged sexual assault/abuse of Patient #1. She also said she did not preserve the security camera recording for the night of 11/14/19 that she had viewed related to her investigation into the 11/15/19 alleged sexual assault/abuse.

In an interview on 6/10/19 at 11:54 a.m., the Director of Human Resource (DHR) confirmed Staff A RN was suspended on 11/19/19 due to an allegation of sexual assault of a hospital patient while he was at work. She said Staff A RN called her around 8:15 a.m. on 11/20/19 stating he heard he was being accused of raping a patient in the hospital and he wanted to resign. She said she told him to send her an email with his resignation and that she could not speak to him about the rape allegation. She spoke with the RM around 9:00 a.m. on 11/20/19 and told her she had just spoken with Staff A RN and that he wanted to resign so she gave him her email address. She was told to review his employee file to ensure they had completed his background check as per their policy and procedure. She said the RM did a national background check on Staff A RN's nursing license and found out he was reprimanded/censured for a breach of confidentiality for a non-sexual dual relationship or boundary violation in North Carolina on 3/12/19 and was reprimanded by the board of nursing in Oregon for failing to maintain professional boundaries, and violating a person's right of privacy and confidentiality on 11/14/18. Since Staff A RN did not disclose his previous disciplinary actions in North Carolina and Oregon on his Employment Application, the hospital terminated his employment with the hospital on 12/5/19. She said she was told only to review Staff A RN's employee file and was not involved in the investigation into the alleged sexual misconduct between Staff A RN and Patient #1.

On 6/11/20 a review of the facility's "Abuse & Neglect: Procedure for Reporting & Testing", most recently approved by the Governing Body on 4/24/18 stated "all hospital personnel and medical staff will report any suspected abuse or neglect to the appropriate authorities according to state laws."

Florida Statute Chapter 395.0197(9)D states the hospital will report to the Florida Department of Health every allegation of sexual misconduct, as defined in chapter 456.

Florida Statue Chapter 456.063 (3) states licensed health care practitioners shall report allegations of sexual misconduct to the department, regardless of the practice setting in which the alleged sexual misconduct occurred.

On 6/11/20 a review of the Sexual Misconduct policy formulated 4/98 and approved by the Governing Board on 4/24/18 stated the Administration, Risk Management and law enforcement will be immediately notified of all accusations or allegations of abuse or sexual misconduct occurring within the facility or on facility grounds. The policy states every allegation of sexual misconduct made against any member of the facility's staff will be investigated if the sexual misconduct occurred at the facility or facility grounds. The policy also stated the facility is required to report every allegation of sexual misconduct to the Department of Health.

In an interview on 6/11/20 at 9:30 a.m., the RM confirmed the facility's Sexual Misconduct policy, Abuse and Neglect policy and Florida state law state all allegations of sexual misconduct made against any member of the facility staff will be investigated if the sexual misconduct occurred at the facility or on facility grounds and all allegation of sexual misconduct will be reported to the Florida Department of Health as per Florida state law. She said since Patient #1 did not tell the hospital of the alleged sexual assault/abuse and since the police detective is not Patient #1's legal representative, they had not considered the allegation of a sexual assault at the hospital an allegation of sexual misconduct made against the hospital so the hospital did not do a thorough risk management investigation of the allegation of sexual assault and did not contact the Florida Department of Health to inform them of the allegation of sexual assault/abuse against Staff A RN as required by Florida state statue. She further said she has not attempted to contact Patient #1 for additional information and/or assist Patient #1 with any medical contacts as needed because the police detective told her on 11/19/19 not to interview or contact Patient #1 since it is an open investigation.

In an interview on 6/13/20 at 3:00 p.m., the RM said she just discovered she had viewed the wrong security camera recording related to the alleged sexual assault of Patient #1 on 11/15/19. She had reviewed the security camera recording for 11/14/19 not the date of the alleged sexual assault. She said since she reviewed the incorrect security camera recording, she does not know when and/or how many times Staff A RN went into Patient #1's hospital bedroom the night of the alleged sexual assault/abuse. She said the security camera recording for 11/14/19 and 11/15/19 are no longer available for review because it was erased.

In an interview on 6/15/20 at 8:50 a.m., Patient #1 said Staff A RN was her nurse on 11/14/19 and 11/15/19. She said he was very friendly to her on 11/14/19 and when she was feeling anxious and could not sleep on 11/15/19 he suggested she take some Ativan to help her sleep. After he gave her the Ativan medication to help her sleep, he blocked her hospital room door with his computer and sexually assaulted her 2 times in her hospital room. She said she was physically weak and could not fight him off. She said she was scared he might kill her during the night and that is why she did not tell anyone about the rape while she was in the hospital. She said she has always been distrustful of hospitals, but because she was raped by Staff A RN while she was a patient in the hospital, she is now fearful of all hospitals. She further said she doesn't know why the hospital never tried to contact her about the rape because when she told the police they said they would be informing the hospital about her being sexually assaulted in the hospital.

In an interview on 6/15/20 at 3:00 p.m., the police detective said she went to the hospital on 11/19/19 to speak with Staff A RN related to an allegation of sexual assault which occurred on 11/15/19 at the hospital. The police officer told the RM, a patient had filed a complaint stating Staff A RN had sexually assaulted her twice in the hospital on 11/15/19 after giving her Ativan medication. The police detective said she never told the RM she could not interview the patient and would think the RM would have done a complete and thorough investigation into the alleged sexual assault.

In an interview on 6/16/20 at 12:30 p.m., the CEO said he was told on 11/20/19 Staff A RN had allegedly sexually assaulted Patient #1 in the hospital on 11/15/19. He stated the facility's Grievance/Complaint policy states a prompt resolution of a patient grievance regarding an alleged violation of patient rights and is defined as a written or verbal concern by a patient, or patient's representative regarding the patient's care, abuse or neglect. He said as of this time Patient #1 has not told them of the alleged sexual assault/abuse and since the police detective is not Patient #1's legal representative they did not considered the allegation of the alleged sexual assault/abuse at the hospital as a grievance/complaint.

The CEO stated the Sexual Misconduct Policy which states the Administration, Risk Management and law enforcement will be immediately notified of all accusation or allegations of abuse or sexual misconduct occurring within the facility, the Florida Department of Health would be notified of any allegation of sexual misconduct and every allegation of sexual misconduct against facility staff will be investigated. He said the facility did not notify the Florida Department of Health and the risk management department did not investigate the allegation of sexual misconduct against Staff A RN as required per their policy.

The CEO said after he talked with the corporate office on 11/20/19 he determined since Patient #1 did not make the allegation of sexual assault to the hospital, and they suspended, then terminated Staff A RN on 12/5/19 the patients at the hospital were safe and the allegation of sexual misconduct was resolved. He stated they did not conduct a risk management investigation to determine if there were any other patients Staff A RN might have assaulted at the hospital.

The CEO said he also was instructed by the corporate lawyers the allegation of sexual assault/abuse was a Human Resource issue and should be investigated by Human Resource.

The CEO stated law enforcement notified the Risk Manager, who was the representative for Administration on the evening of 11/19/19, Patient #1 filed a complaint/allegation of sexual assault against Staff A RN while she was a patient in the hospital on 11/15/19. He said he was informed of the allegation of sexual assault/abuse on 11/20/19. He said since the corporate lawyer and himself determined the allegation of sexual assault was a Human Resource issue, he instructed the Risk Manager not to do an investigation into Patient #1's allegation of sexual assault at the hospital on 11/15/19. He stated the hospital did not contact the Florida Department of Health regarding the allegation of sexual misconduct/assault against Staff A RN as required by their Sexual Misconduct policy and Florida state law when they were informed of the allegation of sexual assault by law enforcement on 11/19/19.

Refer to A115, The Condition of Participation for Patient Rights.

Based on record review, hospital policy, and interview, the facility failed to obtain physician's orders within one hour of initiation of restraints and then after 24 hours when restraints were being continued for longer than 24 hours for two of three patients surveyed for restraints (Patient #11 and Patient #12.) The lack of a physician's orders placed patients at risk for their rights not being honored in restraining the patient without an appropriate reason per assessment and order of a physician.

Findings include:

Review of the hospital policy, "Restraints: Non-Violent Behavior" formulated 10/13 and reviewed 2/2018, reads, "Time Limits For Orders-Non-Violent Restraints or Non-Self Destructive
1. If restraints are applied by an RN [Registered Nuse], the attending physician is consulted as soon as possible and no longer than 1 hour of initiation and an order is obtained at that time.
2. A written order based on examination of the patient by the physician is entered into the patient's medical record within 24 hours of initiation of restraint.
3. Continued use of restraint beyond the first 24 hours is authorized by the physician after examination of the patient and renewing the original order or the issuing a new order. This is done no less than once each calendar day."

1. Review of Patient #11's medical record showed soft wrist restraints were applied to the patient on 6/8/20 at 8:00 a.m. A physician's order for soft wrist restraints was not obtained for Patient #11 until 6/9/20 at 8:29 p.m.

The patient's medical record shows soft wrist restraints were continuously applied from 6/8/20 through 6/12/20. A second physician's order to continue restraints on Patient #11 was not obtained until 6/11/20 at 12:52 a.m.

On 6/12/20 at 2:30 p.m., the Risk Manager (RM) stated a physician's order had not been obtained within one hour of initiating soft wrist restraints on Patient #11 and the restraints continued for 28 hours and 23 minutes without the physician reevaluating and reinitiating the restraint order for patient #11. The RM verified the hospital policy was not followed by nursing staff in restraining a non-violent patient.

2. Review of Patient #12's medical record showed staff applied soft wrist restraints to the patient from 6/08/20 at 3:35 p.m. to 6/10/20 at 10:00 a.m. The initial order for restraining the patient was obtained at 3:35 p.m. on 6/08/20. The order was not renewed until 6/10/20 at 10:53 a.m.

On 6/12/20 the RM stated nursing staff had failed to obtain another physician's order for patient #12 with 24 hours of the continuation of the use of soft wrist restraints. The RM said there was a 12-hour period when staff were applying wrist restraints without an appropriate physician's order.

Refer to A115, The Condition of Participation for Patient Rights.

Based on record review, interview with clinical staff and administrative staff, and review of policy and procedure, the hospital's Quality Assurance Program failed to ensure that the program reflected the complexity of the hospital's organization and services; failed to involve all hospital departments and services (including those services furnished under contract or arrangement); and failed to focus on indicators related to improved health outcomes and the prevention and reduction of staff sexual abuse.

The Risk Manager (RM) failed to thoroughly investigate the allegations of sexual misconduct of Registered Nurse, Staff A RN which was reported to her by police investigation of the staff member. Both the Chief Executive Officer (CEO) and the Risk Manager were aware of the allegations and failed to ensure the allegations were investigated and reported to the Quality Assurance and the governing body of the hospital. The CEO and the RM failed to report the allegations of sexual abuse to Department of Health.

The Quality Assurance Program of the hospital failed to protect patients from all forms of sexual abuse and misconduct from staff and placed other patients at potential risk of sexual abuse from staff by the lack of investigation and actions of the CEO, and RM.

Refer to A273, Data Collection and Analysis.

Based on staff interview, policy and record review, the hospital's Chief Executive Officer (CEO) and the Risk Manager (RM) failed to thoroughly investigate the allegations of sexual misconduct of Registered Nurse, Staff A RN which was reported by police investigation of the staff member on 11/19/19. Both the Chief Executive Officer (CEO) and the Risk Manager were aware of the allegations and failed to ensure the allegations were investigated and reported to the Quality Assurance and the governing body of the hospital.

The CEO and the RM failed to report the allegations of sexual abuse to Florida Department of Health. The Quality Assurance Program failed to protect patients from all forms of sexual abuse and misconduct from staff, and placed other patients at potential risk of sexual abuse from Staff A RN due to the lack of investigation and actions by the CEO, and RM

The findings included:

In an interview on 6/10/20 at 9:30 a.m., the Risk Manager (RM) said the facility had 1 allegation of sexual assault/abuse in the past year. She said a police detective came to the facility on 11/19/19 around 7:00 p.m., to speak with Staff A RN. The RM said she was the Administrator on duty that night, so she spoke with the police detective who told her Patient #1 had filed a complaint with law enforcement against Staff A RN for sexual assaulting her while she was in the hospital on 11/15/19. The police detective told her Patient #1 said in her complaint against Staff A, he had blocked her hospital room door with his computer and sexually assaulted her twice in her hospital bed the night of 11/15/19 after he had administered Ativan, (a medication used for sedation). The police detective told the RM the detective needed to bring Staff A RN to the police station for questioning. The RM said she spoke with the night supervisor who determine Staff A RN was not working that night. She told the night supervisor Staff A RN was suspended as of that time until further notice.

The Risk Manager said the next morning (11/16/19) at around 8:15 a.m., Staff A RN called the Director of Human Resource (DHR) and told her he heard he was being accused of raping a hospital patient and he wanted to resign. She said the DHR told him if he wanted to resign, he had to send her an email stating he wanted to resign, and she gave him her office email address. The DHR also told Staff A RN she could not discuss the allegation of rape with him.

The RM said she was told on 11/20/19 at around 9:00 a.m. by DHR, Staff A RN had called her that morning telling her he had heard about the allegation of him raping a patient at the hospital and wanted to resign. She said she reviewed the staffing sheet and confirmed Staff A RN was Patient #1's nightshift nurse on 11/14/19 and 11/15/19. The RM said she had viewed the security camera recording for 11/14/19, which showed Staff A RN going into Patient #1's room twice during the night. She said she also conducted staff interviews and had written the nursing staff interviews/statements on the back of the nursing scheduling sheets for those nights. The RM said she is unable to provide any documentation the facility had conducted a thorough investigation into the allegation of sexual assault/abuse against Patient #1 on 11/15/19 because the staff interviews she conducted were thrown away by the unit manager and she did not keep a copy of the staff interviews she had conducted in the risk management office. She said she doesn't remember who she interviewed about the alleged sexual assault/abuse and has no documentation risk management had completed a thorough investigation into the alleged sexual assault/abuse of Patient #1. She also said she did not preserve the security camera recording for the night of 11/14/19 that she had viewed related to her investigation into the 11/15/19 alleged sexual assault/abuse.

A review of the facility's "Abuse & Neglect: Procedure for Reporting & Testing", most recently approved by the Governing Body on 4/24/18 stated "all hospital personnel and medical staff will report any suspected abuse or neglect to the appropriate authorities according to state laws."

Florida Statute Chapter 395.0197(9)D states the hospital will report to the Florida Department of Health every allegation of sexual misconduct, as defined in chapter 456.

Florida Statue Chapter 456.063 (3) states licensed health care practitioners shall report allegations of sexual misconduct to the department, regardless of the practice setting in which the alleged sexual misconduct occurred.

A review of the Sexual Misconduct policy formulated 4/98 and approved by the Governing Board on 4/24/18 stated the Administration, Risk Management and law enforcement will be immediately notified of all accusations or allegations of abuse or sexual misconduct occurring within the facility or on facility grounds. The policy states every allegation of sexual misconduct made against any member of the facility's staff will be investigated if the sexual misconduct occurred at the facility or facility grounds. The policy also stated the facility is required to report every allegation of sexual misconduct to the Florida Department of Health.
Review of the "Hospital Safety Plan 2020" reads, "The Patient Safety Program is an organizational-wide program that includes and integrates all activities with the organization which contributes to the maintenance and improvement of the patient safety, healthcare quality and healthcare outcomes. The Scope of the Patient Safety Program involves an ongoing assessment, using internal and external knowledge and experience, to prevent occurrence of errors, and maintain and improve patient safety. Patient Safety event information from aggregated data reports will be reviewed by Patient Safety Committee to prioritize organizational patient safety activity efforts.

In addition to internal knowledge and experience, the services provided will be reviewed and evaluated to include: unsafe behavior evaluations, and raise safety awareness through the internal action plans from root cause analysis, and monthly comprehensive risk assessments.

Types of patient safety events, adverse outcomes, or medical/healthcare care errors included in data analysis are Criminal Events such as sexual assault of a patient within or on the grounds of the health care facility.

Patient safety occurrences requiring a report to an external agency such as ...the State Florida Department of Health, should be reported to the Patient Safety Committee."

In an interview on 6/11/20 at 9:30 a.m., the RM confirmed the facility's Sexual Misconduct policy, Abuse and Neglect policy and Florida State Law showed all allegations of sexual misconduct made against any member of the facility staff will be investigated if the sexual misconduct occurred at the facility or on facility grounds, and all allegation of sexual misconduct will be reported to the Florida Department of Health as per Florida State Law. She said since Patient #1 did not tell the hospital of the alleged sexual assault/abuse and since the police detective is not Patient #1's legal representative, they had not considered the allegation of a sexual assault at the hospital an allegation of sexual misconduct made against the hospital. Therefore, the hospital did not do a thorough risk management investigation of the allegation of sexual assault and did not contact the Florida Department of Health to inform them of the allegation of sexual assault/abuse against Staff A RN as required by Florida state statue. She further said she has not attempted to contact Patient #1 for additional information and/or assist Patient #1 with any medical contacts as needed because the police detective told her on 11/19/19 not to interview or contact Patient #1 since it is an open investigation.

On 6/11/20 at 4:00 p.m., the Florida Department of Health investigator stated the hospital reported the allegations of sexual abuse by Staff A RN on 06/10/2020. This statement verified the hospital failed to report the allegations of abuse to the Florida Department of Health until the state survey agency, Agency for Health care Administration complaint survey.

On 6/12/20 at 9:20 a.m., the Quality Assurance Director said the allegations of sexual abuse was never reported to Quality Assurance (QA) or the Patient Safety Committee. The Quality Assurance Director said would not have reported the incident to QA or the Patient Safety Committee unless they had completed a root cause analysis of the incident. The Quality Assurance director said she had first heard of the allegations of sexual abuse about a week ago when it was reported by local news organizations.

In an interview on 6/15/20 at 3:00 p.m., the police detective said she went to the hospital on 11/19/19 to speak with Staff A RN related to an allegation of sexual assault which occurred on 11/15/19 at the hospital. The police officer told the RM, a patient had filed a complaint stating Staff A RN had sexually assaulted her twice in the hospital on 11/15/19 after giving her Ativan medication. The police detective said she never told the RM she should not interview the patient and would think the RM would have done a complete and thorough investigation into the alleged sexual assault.

In an interview on 6/16/20 at 12:30 p.m., the CEO said he was told on 11/20/19 Staff A RN had allegedly sexually assaulted Patient #1 in the hospital on 11/15/19. He stated the facility's Grievance/Complaint policy states a prompt resolution of a patient grievance regarding an alleged violation of patient rights and is defined as a written or verbal concern by a patient, or patient's representative regarding the patient's care, abuse or neglect. He said as of this time Patient #1 has not told them of the alleged sexual assault/abuse and since the police detective is not Patient #1's legal representative they did not considered the allegation of the alleged sexual assault/abuse at the hospital as a grievance/complaint.

Refer to A263, The Condition of Participation, QAPI.