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The Condition of Participation was not met based on medical record review, review of hospital documentation, review of local authority reports, review of hospital policies, observations and interviews, for one of four patients (P #1) who had a diagnostic ultrasound (US), the hospital failed to ensure that the patient was not sexually abused and failed to timely investigate and report a patient complaint or grievance. The Hospital failed to have an abuse policy in place for persons between the ages of 18 through 59. As a result of the system failure, a delay in response to Patient #1's allegation of sexual abuse was identified which placed additional patients at risk for harm.

Please reference A145.

Based on observation, review of clinical records, review of facility documentation, police reports, interviews, and facility policies, for one fo four patients who had a diagnostic ultrasound (US), the hospital failed to ensure that the patient was not sexually abused and failed to timely investigate and report a patient complaint or grievance. The Hospital failed to have an abuse policy in place for persons between the ages of 18 through 59. As a result of the system failure, a delay in response to Patient #1's allegation of sexual abuse was identified which placed additional patients at risk for harm. The finding includes:


a. Patient #1 had an ultrasound of the bladder and kidneys performed on 9/22/21 by US Tech #1. Observation of the ultrasound area on 12/13/21 at 9:26 AM identified one ultrasound room in the far end of a long hallway of the Musculoskeletal Institute with one ultrasound machine and a stretcher bed.

Review of the initial police report by Police Officer (PO) #1 dated 9/23/21 noted Patient #1 reported that on 9/22/21 ultrasound Tech #1 touched and moved Patient #1's genitals while performing an ultrasound procedure, asked him/her to cough while cupping Patient #1's genitals and asked Patient #1 questions regarding sexual functions and urination causing Patient #1 to feel uncomfortable. The report further identified, in part, that Patient #1 was provided with the phone number for Patient Relations.

Hospital phone logs dated 9/22/21 through 9/24/21 indicated, in part, that Patient #1 left a 6 minute and 13 second phone message to the Patient Relations department on 9/23/21 at 5:49 PM and the patient's phone call was returned by RN #1 on 9/24/21 at 12:52 PM lasting 6 minutes and 23 seconds.

Grievance documentation for Patient #1's complaint was dated as received on 9/24/21 and noted that Patient #1 "feels that the ultrasound appointment was inappropriate and will write a letter".

The documentation further noted that Patient #1 submitted the written letter on 10/21/21. Patient #1's letter identified ultrasound Tech #1 gripped and manipulated Patient #1's genitals during the ultrasound of the bladder, asked about sexual functions, if it hurt when Patient #1 urinated, and cupped Patient #1's genitals directing the patient to cough during the ultrasound of the kidneys. Risk Management was notified on 10/21/21 and ultrasound Tech #1 was suspended on 10/22/21.

An email from Manager #1 dated 10/21/21 identified that Administration was notified of the abuse allegation (27 days after Patient Relations became aware of the allegation), and ultrasound Tech #1 was suspended on 10/22/21.

Timecard documentation for ultrasound Tech #1 indicated he worked during the period of 9/23/21 to 10/18/21 (total of 20 shifts) in the Musculoskeletal Institute ultrasound department.

The arrest warrant application by the Local Authorities dated 12/2/21 and signed by the Superior Court Judge on 12/3/21 indicated due to the many uncertain responses by ultrasound Tech #1 during police questioning on 11/22/21, the Local Authorities believed that ultrasound Tech #1 subjected Victim #1 (V/P #1) to sexual contact causing Victim #1 (P #1) alarm and requested an arrest warrant be issued for ultrasound Tech #1. Ultrasound Tech #1 was arrested on 12/7/21.

Police Officer #1 was no longer employed by the investigating Local Authority and was unavailable for interview. Ultrasound Tech #1 was unavailable for interview regarding details of the ultrasound testing at the time of the investigation per legal advisement.

Interview with Patient #1 on 12/10/21 at 3:02 PM indicated Patient #1 left a detailed voice message for Patient Relations on 9/23/21 and someone from patient relations called back the next day and said, "you need to write this down".

Initial interview with RN #1 (Patient Relations Quality Assurance Specialist) on 12/10/21 at 11:57 AM identified Patient #1 called, noted Patient #1 was not sure if the procedure was appropriate and instructed Patient #1 to provide Patient Relations with the details in writing. RN #1 further stated she did not question Patient #1 about the inappropriateness of the test.

Additional interview with RN #1 on 12/14/21 at 8:07 AM indicated Patient #1 left a voice mail to Patient Relations on 9/23/21, alleged inappropriate touching of Patient #1's "private area" during an ultrasound and referenced a question asked by ultrasound Tech #1 to Patient #1 regarding sexual function. RN #1 added that she was new to the position, was unaware of the proper procedure for a bladder and kidney ultrasound and discussed the allegation with a co-worker and Manager #1.

Interview with Manager #1 (Patient Relations Administrative Program Coordinator) on 12/14/21 at 8:21 AM noted she was made aware of Patient #1's allegations and was not sure of the proper procedure for the ultrasound and wished she would have "jumped on it".

Although review of phone records and interviews with Patient Relations staff on 12/14/21 indicated they were aware of the alleged sexual abuse on 9/24/21, there was a 27-day delay by the staff in reporting the alleged abuse to Administration and the Grievance Committee thereby delaying the investigation. The delay also placed additional patients at risk for abuse from 9/24/21 to when ultrasound Tech #1 last worked on 10/18/21.

The delay in reporting the sexual assault allegation by Patient Relations to Hospital Leadership and/or the Grievance Committee placed additional patients at risk for 20 additional days in which ultrasound Tech #1 worked at the Hospital.

Interview with ultrasound Tech #2 on 12/13/21 at 10:15 AM indicated an ultrasound of the bladder and kidneys did not entail touching the patient below the waist. She further identified the reason for the testing would be evident in the patient's medical record and the only question that would be asked would be if the patient needed to use the bathroom before testing commenced.

Interview with the Senior Director of Accreditation and Regulatory Affairs on 12/10/21 at 12:33 PM and review of Hospital policies identified the Hospital did not have an abuse policy to direct staff for alleged abuse for persons between the ages of 18 and 59 to include prevention, intervention, reporting and investigation.

The Hospital Pamphlet entitled Patient Rights and Responsibilities identified a right to receive care in a safe and secure environment free from all forms of abuse, neglect or mistreatment. The Hospital policy entitled Rules of Conduct identified "engaging in any form of sexual contact in the workplace" as prohibited.

The Hospital policy entitled Patient Complaints and Grievances identified a grievance as a written or verbal complaint by a patient or patient's representative regarding patient care, abuse or neglect. The policy further identified Patient Relations conducts a grievance review and response to include, in part, sending a written response to the patient or patient representative within 7 business days of receipt of written grievance or conversation. The policy indicated Patient Relations will send a written grievance (letter/email/summary) to appropriate leadership and the Grievance Committee. The policy did not direct staff to delay investigation or reporting until a written patient response was submitted.

The Hospital job description entitled Registered Nurse Patient Relations Quality Assurance Specialist identified duties to include investigates, resolves, documents, communicates and reports patient/visitor complaints and grievances; ensures regulatory compliance.

The Hospital job description entitled Patient Relations Administrative Program Coordinator identified a duty to ensure incoming complaints are triaged (answered, assigned, investigated and responded to) in a timely and empathetic manner.

A review of hospital policies and staff training with the Senior Director of Accreditation and Regulatory Affairs identified that the abuse training provided to all staff upon initial orientation included sexual assault and harassment geared mostly towards employee to employee, abuse cases to be reported to the State of Connecticut Department of Public Health, as well as code of conduct expectations. The required training received by all staff was not specific to abuse prevention. In addition, the review and interview identified the Hospital was unable to provide documentation of ongoing abuse training.

On 12/10/21, the hospital submitted an immediate action plan to the Department that included: Email sent to all managers, directors and hospital leadership directing immediate notification to the nurse supervisor, on-call administrator and chief operating officer of any allegation of patient abuse or inappropriate act toward a patient. The plan also included an emergency meeting to be held on 12/13/21 to discuss policy formulation (comprehensive abuse policy) and education.


2. Based on a review of grievance documentation, review of hospital policy, review of staff emails and interviews for two of three patients (P #1 and P #6) who filed a grievance, the hospital failed to conduct a thorough review and/or provide written response to the patient as per hospital policy. The findings include:

a. Patient #1 submitted a written grievance letter dated 10/21/21 and alleged sexual abuse by ultrasound Tech #1 during an ultrasound performed on 9/22/21. Grievance documentation for Patient #1 identified a response letter to the grievance was sent to Patient #1 on 11/8/21, (thirteen business days after the grievance was received). Investigation of the allegation by the hospital grievance process could not be provided.


b. P #6 submitted a complaint to Patient Relations on 11/10/21 regarding lab services received on 10/29/21. An email to Patient Relations from the Associate Lab Director dated 11/15/21 identified she phoned P #6 regarding the complaint on 11/12/15 and P #6 stated a staff member was rude and the lab draw site bled and ruined his/her shirt. The email further noted P #6 alleged s/he was not provided privacy from another patient when the lab tech checked and placed a dressing on the arm. The email indicated the Associate Lab Director questioned the 10/29/21 lab staff regarding any patient problems and lab staff denied that problems had occurred.

P #6's grievance documentation identified that P #6 was reimbursed for the shirt and a closure letter response was provided on 12/3/21. A closure letter could not be provided by the Hospital. An investigation for staff rudeness toward P #6 and lack of patient privacy were not documented as addressed.

Interview with the Senior Director of Accreditation and Regulatory Affairs on 12/15/21 at 10:13 AM noted Patient Relations categorized this as a complaint, not a grievance and therefore a closure letter was not sent.

The hospital policy entitled Patient Complaints and Grievances identified a compliant as a written or verbal expression of dissatisfaction regarding care or services provided which can be resolved in a timely manner by staff present. A grievance is a written or verbal complaint by a patient or patient's representative regarding the patient's care, abuse or neglect. The policy further indicated a written (email/mail) acknowledgement to the patient or patient's representative will be sent within 7 business days of receipt of the written grievance and/or conversation with the patient or representative. The policy identified the procedure included to collaborate with appropriate departments to obtain a thorough review.