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Based on facility policy review, medical record review, staffing assignment review and interview the facility failed to ensure the patient's right to be free from abuse was protected after an allegation of sexual assault was reported. (A145) The cumulative affect of this systemic practice resulted in the facility's inability to ensure patient right's were promoted and protected. This affected one patient (#3) of ten reviewed with the potential to affect all 136 patients receiving care in the facility.

Based on facility policy review, medical record review, staffing assignment review and interview the facility failed to ensure the patient's right to be free from abuse was protected after an allegation of sexual assault was reported. This affected one (Patient #3) of ten patient records reviewed with the potential to affect all 136 patients.

Findings include:

The facility policy titled "Mandatory Reporting" was reviewed on 11/24/17. According to the policy, under the category of Sexually Assaulted Patient, staff are instructed to contact local law enforcement immediately.

The facility policy titled "Standards of Conduct and Performance" was reviewed on 11/24/17. According to the policy it is sometimes necessary to use administrative leave as a means of ensuring a timely and objective investigation that protects the safety of employees, patients and residents and preserves confidentiality.

Review of Patient #3's medical record revealed the patient was admitted to a private room on 2 West at 9:46 PM on 10/25/17 related to a small bowel obstruction.

Review of an event filed on 10/30/17 revealed that on 10/30/17 at approximately 5:30 PM a patient reported waking up the morning of 10/30/17 with IV tubing wrapped around his/her neck, gown over his/her head. The patient reported feeling "weird," like he/she had had sex. The report further stated the patient saw his/her nurse leaving the room.

Review of a Nurse's Note signed by Staff D on 10/30/17 at 01:57 AM read: "Received a call from the PCA (patient care assistant) that the patient's IV was beeping. I went in the patient's room to put the oxygen tubing back on do to him/her removing the tubing in his/her sleep continually. While assessing the situation I found the cord tangled around his/her neck. I removed the tubing and made a joke saying "that is not where that goes." I informed the patient that I would put the tubing back on correctly and proceeded to do so. The patient stopped me and asked for the PCA that originally answered the patient's call. I called the PCA to the room. The patient stated to PCA "I woke up with this cord around my neck, my gown pulled up, and my underwear turned sideways..." Clinical and Charge nurse aware. Telesitter placed in room for safety. Clinical nurse suggested Charge nurse to assess the patient." The Charge nurse assessed the patient and noted "no signs of physical trauma."

A Nurse's Note written by the Charge nurse at 02:29 AM stated that the Clinical nurse suggested that RN's be switched from Staff D due to the patient's statement.

Staffing assignment sheets from 2 West were reviewed on 11/24/17 at 9:30 AM. Staff D was noted to care for Patient #3 until 03:00 AM on 10/30/17 when the care of Patient #3 was transferred to another nurse. Staff D continued to care for two female patients until shift end, at 7:00 AM. Assignment sheets revealed that Staff D worked next on 11/01/17. This full time nurse also worked on 11/06/17, 11/09/17, 11/15/17, 11/17/17, 11/19/17, 11/21/17, and 11/23/17.

Staff A, the Director of Quality, was interviewed on 11/24/17 at 02:00 PM. It was confirmed that the patient's concerns noted on 10/30/17 at 01:57 AM should have immediately triggered an investigation including contacting local authorities and sexual assault nurse examiner. Staff A stated that he/she was unaware of the patient's concerns at 01:57 AM and was only aware of the patient's concerns noted at approximately 5:30 PM the evening of 10/30/17. It was also confirmed that the alleged staff member continued to care for patients in the interim.

Staff B, Clinical Director Patient Care Services, was interviewed on 11/21/17 at 02:45 PM. He/She stated: "We took this patient's complaint very seriously." Staff B reported that the challenge of this allegation was that it took so long for the patient to report the alleged incident. Staff B stated: "He/She didn't report this until about 5:30 PM when allegedly, it happened at about 1:50 AM." Staff B reported that the alleged nurse did not corroborate the patient's story and continues to work.

The medical record noted local authorities and the sexual assault nurse examiner were at the bedside of the patient at 9:00 PM, more than 19 hours after the above mentioned nurse's note dated 10/30/17 at 01:57 AM.