HospitalInspections.org

Based on interview and document review, the hospital failed to ensure appropriate measures were implemented to ensure patient protection after an allegation of sexual abuse was verbalized by 1 of 1 patients (P1) who reported sexual abuse during the provision of care. The alleged perpetrator(s) (AP) were not inteviewed, removed from the schedule, placed on supervised care after the allegation was reported which met the criteria of sexual assault and/or abuse, nor was a thorough investigation into the allegation completed. As a result, the hospital was found out of compliance with the Condition of Participation - Patient Rights at 42 CFR 482.13.

A condition-level deficiency was issued.

Findings include:

See A-0145; Based on interview and document review, the hospital failed to ensure appropriate measures were implemented to ensure patient protection after an allegation of sexual abuse was verbalized by 1 of 1 patients (P1) who reported sexual abuse by staff during the provision of care. The alleged perpetrator(s) (AP) were not interviewed, removed from the schedule, placed on supervised care after the allegation was reported which met the criteria of sexual assault and/or abuse, nor was a thorough investigation into the allegation completed. This had the potential to affect all patients receiving care within the hospital.

Based on interview and document review, the hospital failed to ensure appropriate measures were implemented to ensure patient protection after an allegation of sexual abuse was verbalized by 1 of 1 patients (P1) who reported sexual abuse by staff during the provision of care. The alleged perpetrator(s) (AP) were not interviewed, removed from the schedule, placed on supervised care after the allegation was reported which met the criteria of sexual assault and/or abuse, nor was a thorough investigation into the allegation completed. This had the potential to affect all patients receiving care within the hospital.

The IJ began on 11/8/22, when facility leadership reviewed an in-organizational concern form from the facility Compass system (a facility wide reporting system) which identified P1 reported she was sexually assaulted during the provision of care. The Chief Nursing Officer (CNO), Vice President (VP) of Operations, System Program Manager for Regulatory and Accreditation, and three nursing directors were notified of the IJ finding on 11/29/22, at 3:34 p.m. The IJ was removed on 11/30/22, at 12:50 p.m. after verification of an acceptable removal plan.

Findings include:

A Vulnerable Adult Maltreatment Report, received 11/8/22, identified P1 expressed sexual abuse concerns to a medical provider while she was a patient at another facility, in which the facility determined the incident may have occurred between 7/27/22, through 8/1/22. A facility follow-up response to a State Agency (SA) triage email which requested additional information, dated 11/9/22, identified P1 expressed concerns during provision of toileting cares when three staff were rough with her and yanked her on her stomach. These staff proceeded to be "grabby," held her down, and were "forceful" despite P1 telling them to stop while she screamed and cried from the pain. During this encounter, P1 stated she "felt fingers both anally and vaginally penetrate" her despite her not requiring cares that required penetration. P1 identified the three staff by description; however, the report did not provide AP names and did not identify details related to the facility's investigation into the allegation.

P1's ED (Emergency Department) Hospital record, dated 7/22/22, to 8/5/22, identified P1 admitted to the hospital from the ED on 7/22/22, and discharged on 8/5/22. P1's medical diagnosis included Guillain-Barre syndrome, newly diagnosed epilepsy with seizure activity and hyperesthesia (excessive physical sensitivity, especially of the skin) of lower abdomen and back, along with depression, anxiety, and PTSD (post-traumatic stress disorder).

During interview on 11/28/22, at 12:24 p.m. registered nurse (RN)-A stated she was notified of P1's allegations on 11/8/22, after a Compass (an in-organizational wide reporting system) event report was brought to her attention. RN-A stated during the dates of 11/9/22, through 11/11/22, she conversed with the Compass event report creator via e-mail to gather more information, and she completed a review of P1's medical record. Based on this gathered information, she, along with staff from human resources (HR) and Risk Management, determined the alleged abuse potentially occurred between 7/27/22, and 8/1/22. RN-A explained a plan was formulated for her, and her alone, to interview the identified potential APs due to the sensitive nature of the allegation and P1's limited AP descriptions. RN-A denied she performed the identified staff interviews, nor had she conversed with P1 or P1's representative, due to being away from work for a period of time and other assigned duties which took her away from her unit's nurse manager role. RN-A was unable to identify actions taken to ensure patient safety once the facility identified a time frame and potential APs. RN-A denied identified staff were removed from the schedule and she confirmed the AP could still be working with patients. RN-A stated staff were challenged in their AP determination based on P1's AP descriptions, P1's use of mental status altering medications, and that HR and Risk Management wanted to ensure the "right person" was removed from the schedule "in the setting of [their] diversity." RN-A stated it was very important to investigate allegations of abuse as soon as possible to ensure patient safety.

On 11/28/22, at 1:17 p.m. P1 and her representative were interviewed via telephone. P1 stated during an episode of night-time toileting cares three staff (two females and one male) were "really rough" with her despite her crying and telling them to stop. P1 explained staff told her she had to be cleaned up and when they proceeded with the cares she felt her rectal and vaginal areas being "penetrated." P1 and her representative denied facility staff contacted them related to the allegation.

When interviewed 11/29/22, at 12:42 p.m. RN-B stated during the dates of the allegation, she worked nights on the observation unit. RN-B denied she was interviewed by leadership in relation to any abuse allegations.

During interview on 11/29/22, at 12:53 p.m. RN-C stated during the dates of the allegation, she worked nights on the observation unit. RN-C denied she was interviewed by leadership in relation to any abuse allegations.

When interviewed on 11/29/22, at 1:45 p.m. the chief nursing officer (CNO) stated she was made aware of P1's allegations on 11/8/22. The CNO stated she was aware RN-A, HR, and Risk Management met to discuss P1's allegation; however, she acknowledged she recently learned staff were not interviewed. The CNO stated she expected staff to be interviewed "fairly quickly" and for the facility abuse policy to be followed. She explained the facility had 24 hours to report the allegation to the SA in which the investigation process was to begin within that time frame. The CNO confirmed she expected staff involved in P1's allegation would have already been interviewed in order to protect staff's recollection of event details, to provide patient safety, and to remove potential AP(s) from the schedule in order to provide protection to all patients.

When interviewed 11/29/22, at 6:45 p.m. RN-E stated during the dates of the allegation, he worked nights on the observation unit. RN-E stated if there was an allegation of abuse immediate action was necessary to protect patients from harm. RN-E denied he was interviewed by leadership in relation to any abuse allegations prior to that afternoon.

A copy of the Compass event report and the facility's investigation were requested; however, this information was not provided.

An Investigation of Abuse, Neglect, Harassment of Patients or Visitors policy dated 8/30/22, identified all allegations of abuse of patients were to be "thoroughly and timely" investigated and all necessary and "prompt" actions were to be taken to protect all patients. A link within this policy, directed the user to an Investigation of Abuse, Neglect, Harassment of Patients or Visitors procedure policy, dated 8/30/22. This policy directed staff to take "immediate" actions to ensure safety of all patients when there was an allegation of abuse and to protect patients during the investigation. In addition, the policy directed staff to conduct an interview with the person who alleged abuse and to complete a staffing review for potential AP(s). Potential AP(s) interviews were to be conducted before the person returned to work.

The IJ was removed on 11/30/22, at 12:50 p.m. after the following actions were completed: the facility began an investigation into the allegation, potential AP(s) were interviewed, P1 and her representative interviews were attempted, current interviewable observation unit patients were interviewed, and leadership staff were educated on the facility's abuse investigation policy and expected procedures.