HospitalInspections.org

I. Based on observation, document review, and staff interviews, the Critical Access Hospital's (CAH's) administrative staff failed to separate a physician acused of abusing a patient during a pelvic exam from providing care to other patients at the CAH. The cumulative effect of the systemic failure resulted in the CAH's inability to ensure staff protected all patients at the CAH from all forms of abuse when the CAH's administration failed to separate 1of 1 staff member (Physician A) from patients after the CAH staff received an allegation of abuse on 10/29/19. The CAH's administrative staff identified 59 patients seen in the CAH's provider based clinic by Physician A from 10/29/19 - 10/31/19.



II. While on-site, the survey team identified an Immediate Jeopardy situation and notified the administrative staff on 11/01/19 at 11:10 AM. The hospital staff removed the immediacy on 11/04/19 at 12:00 PM, prior to the survey team exiting the complaint investigation, when the administrative staff took the following actions:

a. Developed and implemented a policy that addressed patient abuse by a staff member or physician and the process of reporting the incident of abuse.

b. A hard copy of the new policy was distributed to all departments at the CAH, all employees will be requireed to acknowledge the new policy through the Policy Stat program at the CAH. All department directors will be trained individually on 11/04/19 and will train their staff members individually throughout the month of November.

c. The staff member involved was removed from direct patient care until the Medical Executive Comittee of the CAH had conducted an investigation and made a subsequent recommendation.

Based on document review and staff interview the Critical Access Hospital's (CAH) administrative staff failed to promptly prevent 1 of 1 staff member accused of sexually abusing a patient (Physician A) from providing care to patients. Failure to promptly prevent a staff member accused of sexually abusing a patient resulted in the CAH's administrative staff allowing Physician A to continue providing patient care and perform medical procedures similar to those that resulted in the initial allegation of abuse. Physician A provided care to 59 patients during 10/29/19 to 10/30/19 (when the CAH staff knew Physician A was accused of abusing a patient at the CAH).

Findings include:

1. During an interview on 11/4/19 at 1:59 PM, the Director of Quality revealed that they received an email from the CAH's patient satisfaction survey provider on Monday 10/28/19 at 2:19 PM regarding Patient #1's experiences at the CAH on 10/26/19. The Director of Quality did not open the email until Tuesday 10/29/19 at approximately 3:53 PM.

When the Director of Quality opened the email, she read the information and entered it into an incident reporting system. The incident reporting system sent a copy of what the Director of Quality entered to several people, including the CAH's Chief Executive Officer (CEO), the CAH's Emergency Department (ED) Director.


2. Review of the patient satisfaction survey results, received by the CAH staff on Monday 10/28/19, revealed Patient #1 notified the CAH staff that Patient #1 felt Physician A inappropriately touched Patient #1 during a pelvic examination at the CAH on 10/26/19.


3. During an interview on 11/4/19 at 10:45 AM, the ED Director revealed they received Patient #1's allegation of abuse on Tuesday 10/29/19 at 3:55 PM (approximately 22 hours after the CAH staff first received the allegation of abuse) from the Director of Quality. The ED Director emailed the Director of Quality "stating I reviewed the complaint and patient chart and said it was a very concerning complaint, and I would talk with the nurse [who cared for Patient #1] right away."

On Wednesday 10/30/19, the ED Director spoke with the ED Medical Director and spoke with Patient #1 about Patient #1's allegation of abuse against Physician A. Around 4:00 PM on Wednesday 10/30/19, after speaking with Patient #1, the ED Director notified the CAH's Chief Executive Officer (CEO) about Patient #1's allegation of abuse against Physician A (approximately 50 hours after the CAH staff first received the allegation of abuse). The CEO requested the ED Director also notify the Chief Nursing Officer (CNO) about Patient #1's allegation of abuse against Physician A.


4. During an interview on 10/31/19 at 4:04 PM, the CEO revealed they first became aware of Patient #1's allegation of abuse against Physician A on Wednesday 10/30/19 at approximately 4:00 PM (approximately 50 hours after the CAH staff first received the allegation of abuse). After hearing Patient #1's allegation of abuse against Physician A, the CEO determined Physician A could still provide care to patients, as long as Physician A had a nurse in the room when Physician A performed pelvic exams (the same circumstances under which Patient #1 alleged Physician A committed abuse during the pelvic exam on 10/26/19).


5. During an interview on 10/31/19 at 12:57 PM, Physician A revealed they continued to provide care to patients at the CAH, even after the CAH staff (and Physician A) became aware that Patient #1 had accused Physician A of abuse during Physician A's pelvic exam of Patient #1. Physician A revealed they performed a pelvic exam, under similar conditions as Patient #1 alleged Physician A abused Patient #1, between the time the CAH staff became aware of Patient #1's allegation of abuse and the interview with Physician A. At the time of the interview, the CAH staff still allowed Physician A to provide care to patients at the CAH (approximately 71 hours after the CAH staff first received the allegation of abuse).


6. During an interview on 11/1/19 at 8:00 PM, the CNO revealed the CAH lacked a policy which provided guidance to the CAH staff on which steps to take when someone accused a staff member or physician of abusing a patient. The CNO acknowledged that, because the CAH lacked a policy addressing situations involving a staff member or physician accused of abusing a patient, the CAH staff allowed Physician A to continue providing care to patients at the CAH for approximately 75 hours after the CAH staff first received the allegation of abuse, and allowed Physician A to perform a pelvic exam on a patient under the same circumstances as Patient #1 alleged Physician A abused Patient #1 during a pelvic exam.