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MAYO CLINIC HEALTH SYSTEM - MANKATO
PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT
Tag No.: A0145
Based on interview and document review, the hospital failed to report in a timely manner an allegation of patient/patient sexual abuse to the State Agency (SA) for 2 of 2 patients (P1, P2) in the sample who were receiving treatment on the behavioral health (BH) unit.
Findings include:
Review of a vulnerable adult (VA) report dated 2/5/20, at 8:00 a.m. for P1 and P2. The report indicated P1 and P2 were found in the shower room together after P2 requested to use the shower. The report indicated that only one patient is allowed in the shower room at a time. P2 denied any sexual contact with P1. P1 stated he "made out" with P2. P1 and P2 are both patients on the BH unit and have diagnosis of impaired judgement and reasoning. The VA report indicated the incident occurred on 2/1/20, at 8:30 p.m. but was not submitted to the SA until 2/5/20, at 8:00 a.m. (4 days after the incident occurred).
Interview on 2/13/20, at 8:15 a.m. registered nurse (RN)-A confirmed the VA report was not submitted until 2/5/20. RN-A stated she was unsure when a VA should be reported. RN-A further revealed she asked RN-B, who directed her to wait until after the weekend, to discuss with management. RN-A confirmed she received annual abuse/neglect training to when a VA report should be filed.
Interview on 2/13/20, at 1:30 p.m. RN-B indicated he notified the behavioral health unit manager (UM) immediately after the incident occurred, but did not get direction on when to file the VA report. RN-B further included he was unsure when a VA should be reported, but confirmed he had received annual training on abuse/neglect that would include when a VA should be filed.
Interview on 2/13/20, at 2:00 p.m. the UM confirmed she had not given RN-B direction to file the VA report on 2/1/20, and rather told RN-B it would be discussed later. The UM confirmed the VA report should have been filed within 24 hours after the incident.
Review of the facility Maltreatment of Vulnerable Adults Procedure dated 12/8/17, directed staff to report suspected abuse encounters to the SA within 24 hours. The procedure further indicated the hospital social worker is available to assist staff with questions regarding the reporting process.
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