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Based on interview and document review, the hospital failed to ensure each patient was free from abuse for 1 of 10 patients reviewed (P1) when a physician (MD-Q) kissed her, fondled her breasts, and took photos of her. The hosptial was found to be out of compliance with the Condition of Participation of Patient Rights at 42 CFR 482.13. A condition level deficiency was issued.

Findings include:

A physican MD-Q, sexually assaulted a patient, P1 when he kissed her, fondled and kissed her breasts, and took photos of the patient's breasts. The patient was on narcotic medication at the time of the assault. See A144.

Based on interview and document review, the hospital failed to ensure each patient was free from abuse for 1 of 10 patients reviewed (P1) when a physician (MD-Q) kissed her, fondled her breasts, and took photos of her. This resulted in a condition level deficiency.

Findings include:

Medical record review revealed P1 was admitted to the hospital on 10/25/19, with diagnoses that included sepsis, end stage renal disease, and cutaneous abscess of right foot. P1's Emergency Department (ED) admission note, dated 10/25/19, revealed P1 was on dialysis, and had a open wound to her right foot. A nursing note dated 10/26/19, revealed P1 reported to a nurse that on 10/25/19, the previous evening, she had been sexually assaulted by MD-Q.

During an interview on 11/5/19, at 10:23 a.m. registered nurse (RN)-G stated she worked with P1 on 10/25/19. She stated she went into P1's room several times that shift, and she observed MD-Q in the patient's room twice, once at about 8:00 p.m., and again about 11:30 p.m. He was about an arm's length from the patient. She stated he was in the room for a while both times. The patient did not seem disturbed. After the first visit by MD-Q, the patient told her that MD-Q had been flirty with her and had given her a hug. The patient had Tylenol with codeine at about 9:30 p.m. that night for pain. RN-G stated she worked with P1 again on 10/26/19. During the shift P1 said she needed to talk to RN-G. RN-G stated P1 told her that on 10/25/19, at the 8:00 p.m. visit, MD-Q was flirty with her, complimented her body, hugged her several times, kissed her on the cheek, and kissed her on the mouth. He put his personal cell phone number in her phone so she could call him. P1 stated after the pain medications kicked in she was not herself. P1 stated she texted MD-Q "kissy faces." RN-G stated she saw the texts, and when P1 texted the kissy faces, MD-Q texted back asking if he could come back to her room. Once P1 reported the incident on 10/26/19, she called security and the patient called 911. RN-G stated she was uncomfortable when MD-Q was in the patient's room so late on 10/25/19, because that is unusual unless there was some kind of emergency. RN-G stated that on 10/25/19, P1 seemed drowsy, giggly and influenced by the pain medication. RN-G stated it was also unusual for a physician to give a patient their cell phone number.

During an interview on 11/6/19, at 11:45 a.m. RN-O stated she worked with P1 on 10/25/19, starting at 11:00 p.m. She stated she walked into P1's room at about 11:00 p.m. and a physician was in the room with P1. When she came back later, the physician was gone. P1 seemed "out of it" that night, and was joking with staff. RN-O stated she had never seen the doctor who was in P1's room before, but RN-O described the physician, and the description matched MD-Q. RN-O stated it was unusual to have a physician on the unit at that time of night. RN-O stated she worked with P1 again on 10/26/19, and P1 told her that the previous night MD-Q had kissed her, hugged her, kissed her nipples, and put his hands down her pants, but there was no penetration. P1 was upset and crying on 10/26/19. P1 said she felt shamed by the incident. P1 told her the Tylenol with codeine had made her loopy the night before, and she was never taking that again.

During an interview with P1 on 11/7/19, at 10:10 a.m. she stated MD-Q came to her room to do an admission for her. Initially her husband was in the room and the three of them were laughing. Eventually her husband left and MD-Q took a chair and sat by her. He said she was very beautiful and that he wanted to get to know her. He stood to give her a hug, like a relative's hug. P1 thought that was weird. They talked more and he kissed her cheek, then he looked at her in the eyes, and then kissed her on the mouth. He said he was off at midnight and would like to see her before he left. He gave her his cell number. Later she texted him hugs and kisses. MD-Q texted her back and then returned to her room at about 11:30 p.m. When he came back, he helped her stand, and kept rubbing her breasts. He stated he wanted to check a patch she had on her upper chest. He did so, then slipped his hand down to her breast. MD-Q asked if he could see her breasts, and then fondled them. He sucked her breasts and took photos of them. He tried to touch her vagina, and she pushed his hand away. After that he left. P1 stated she did not report it right away. She stated she felt emotional, and felt like her head was spinning that night. She was afraid she was going to lose her foot and was not feeling well. P1 stated she felt victimized by MD-Q.

Contact with law enforcement revealed there were text messages between P1 and MD-Q. Additionally, DNA swabs were taken from P1. MD-Q told law enforcement that he went back to P1's room after 11:00 p.m. on 10/25/19, to get her consent for dialysis signed, but she had signed that hours earlier. Although swabs were taken from P1 for DNA presence, and MD-Q's phone is being checked for photos of P1, the results of those inquiries are not back yet.

A review of P1's consent for dialysis revealed it was signed on 10/25/19, at 7:50 p.m., three hours prior to that second visit after 11:00 p.m.

A review of hospital video revealed a man resembling MD-Q entering P1's nursing unit on 10/25/19, at 7:47 p.m. and leaving at 8:27 p.m., and again coming onto the unit at 10:52 p.m. and leaving at 11:38 p.m.

An attempt was made to interview MD-Q, but he declined the interview.

The facility policy titled Vulnerable Adults: Identification and Reporting of Suspected Maltreatment of, dated effective 10/15/05, directed: Policy: Fairview Health Services (Fairview) will not condone patient abuse by anyone, including staff members, other patients, consultants, volunteers, family members, legal guardians, sponsors, friends or other individuals or staff of other agencies serving the patient. 5. Sexual abuse: Sexual abuse may include any form of forced sex or sexual degradation, such as: forcing someone into sexual behaviors when he/she is particularly vulnerable; when he/she is not fully conscious, is not asked, is afraid to say no, is sleeping, drugged or intoxicated.

Based on interview and document review, the hospital failed to ensure an acceptable level of equipment maintenance when they failed to document the reasons for their Alternative Equipment Maintenance (AEM) schedules for 2 of 2 pieces of medical equipment reviewed. The hospital was found to be out of compliance with the Condition of Participation of Physical Environment at 42 CFR 482.41. A Condition Level deficiency was issued.

Findings include:

The preventative maintenance AEM for the Medfusion high volume infusion pump (used in the hospital as an insulin pump) was completed every 5 years, and not yearly as the manufacturer recommended. The maintenance schedule for the SIGMA IV pump was only when the pump fails. The manufactures recommended yearly maintenance. The hospital staff could not locate any documentation that led to these decisions.

Based on interview and document review, the hospital failed to ensure an acceptable level of equipment maintenance when they failed to document the reasons for their Alternative Equipment Maintenance (AEM) schedules for 2 of 2 pieces of medical equipment reviewed.

Findings include:

A review of the services manual for the Medfusion high volume infusion pump undated, and provided by hospital staff revealed: Periodic Maintenance: This maintenance is required for the continued safe operation of the Medfusion Model 4000 pumps. The Medfusion Model 4000 pump must be tested annually, or whenever the pump has been damaged or dropped.

A review of the service manual for the SIGMA Spectrum IV pump, dated 10/23/12, and provided by hospital staff revealed: Preventative Maintenance Schedule:
* Preventative Maintenance is recommended a minimum of one annually on all pumps in service.
* Preventative Maintenance should be performed after any user facility maintenance.
* Preventative maintenance test should also be carried out whenever a pump is dropped, or suspected of having been otherwise damaged.

During the hospital tour, on 11/6/19, at 2:30 p.m. registered nurse (RN)-T stated the Medfusion device sometimes alarms that there is an occlusion when there is not one, and two Sigma IV pumps recently failed when she gave a patient a bolus, and two pumps pulled from the secondary IV instead of the primary IV as was required.

During an interview on 11/6/19, at 12:00 p.m. the manager of biomedical engineering (BEM)-R stated the preventative maintenance AEM for the Medfusion high volume infusion pump (used in the hospital as an insulin pump) was completed every 5 years, and not yearly as the manufacturer recommended. He stated the maintenance schedule for the SIGMA IV pump was only when the pump fails. When asked for the documentation that led the staff to conclude that a 5 year maintenance plan or no maintenance plan was an appropriate plan for these pieces of medical equipment, when the manufactures recommended yearly maintenance, the hospital staff could not locate any documentation that led to this decision.

When queried BEM-R stated on 11/7/19, at 9:30 a.m. that there were 577 Medfusion devices currently in service and 1,387 Sigma IV pumps currently in service in the hospital.

Lists of work orders for the last 6 months revealed there were 303 work orders for a failure of performance for the SIGMA IV Pump, and 36 work orders in the last 6 months for the Medfusion high volume infusion pump.

The facility document titled Fairview Clinical Engineering Service Bulletin dated 9/9/19, was reviewed and revealed: Hospitals that choose to employ alternate maintenance activities and/or schedules must develop, implement and maintain a documented AEM program to minimize risks to patients and others in the hospital associated with the use of facility or medical equipment.