HospitalInspections.org

Based on interview and review of facility policy/procedure it was determined the facility failed to ensure staff reported allegations of suspected sexual abuse immediately to the Hospital Director or Designee as required. A facility Social Worker did not report a patient's allegation of sexual abuse until a second patient reported the same incident one (1) week later. As a result of the failure to report the allegation of sexual abuse, the alleged perpetrator remained in patient care for an additional week.

The findings include:

Review of the hospital's policy/procedure, "Risk Management and Safety, Section 3" revealed as soon as the Hospital received initial information regarding the health, safety, and welfare of the patient and the incident itself, the Hospital must ensure that all reasonable causes of suspicion that an adult or child had suffered abuse, neglect or exploitation, as well as injuries of unknown source, were reported immediately to the Hospital Director or Designee.

Review of the facility's investigation of the allegation of sexual abuse revealed the allegation had initially been reported to the Social Worker assigned to Gragg 2, on or about October 20, 2010. The Social Worker reported the allegation on October 26, 2010, after the allegation had been reported to the Social Worker by a second patient.

Interview on 10/03/10, at 2:55 PM, with the Social Worker assigned to Gragg 2, revealed a client on Gragg 2 reported an incident to the Social Worker. According to the Social Worker, Patient #3 reported an incident to her during a conversation on or around October 20, 2010. The Social Worker stated Patient #3 reported to her another patient (Patient #1) had been sexually abused by a staff member. The Social Worker stated that at the time of the conversation, Patient #3 had not been adherent to the treatment plan and had not been taking prescribed medications. The Social Worker stated she had assumed the allegation was part of the patient's ramblings and did not give credence to the allegation. The Social Worker reported on October 26, 2010, Patient #2 had contacted the Social Worker to inform her that the patient's apartment had been burglarized during the patient's hospitalization. The Social Worker stated during the conversation Patient #2 reported an allegation of sexual abuse of Patient #1 by a male staff member. According to the Social Worker, at that time she reported the allegation to the Risk Manager. The Social Worker stated staff were required to report allegations of abuse immediately but she had assumed the allegation reported by Patient #3 was part of the patient's paranoid ramblings and did not report until the second patient brought up the allegation.

Interview with the Risk Manager on 11/04/10, at 9:45 AM, revealed the Risk Manager was informed of the allegation on October 26, 2010. According to the Risk Manager, the Social Worker on Gragg 2 reported an allegation of sexual abuse. The Risk Manager stated he went to the unit and spoke to the Social Worker. The Risk Manager stated the Social Worker informed him the allegation had been reported to the Social Worker by Patient #3 on or about October 20, 2010 but had discounted the allegation because it appeared to be interwoven in the patient's delusions. The Risk Manager stated the Social Worker informed him she had received a telephone call from Patient #2 and during the conversation, Patient #2 reported the same allegation. At that time, the Social Worker reported the allegation to the Risk Manager and the facility reported to the required agencies and started an investigation. According to the Risk Manager, staff were required to report allegations of abuse, neglect or exploitation immediately. The Risk Manager stated that as soon as the facility was informed of the allegation the staff member was removed from care.

Interviews on 11/03-04/10 throughout the survey with eight (8) Mental Health Aides (MHA), three (3) Registered Nurses and one (1) Licensed Practical Nurse, revealed the staff were aware of the facility's policy/procedure that required reporting of any allegation of abuse, neglect or exploitation.