HospitalInspections.org

.

Based on interview, record review, and review of the hospital's policies and procedures, the hospital failed to develop and implement policies and procedures to guide the hospital staff's response when there is an allegation of sexual assault/abuse between patients.

Failure to ensure that hospital provided staff with guidelines to respond to an allegation of a sexual assault between patients, including investigation, implementation of interventions, and documentation, places the patient at risk for serious harm or injury, and violates the patient's right to receive care in a safe setting.

Findings included:

1. Document review of the hospital's document titled, "Hospital Patient Rights," Form ESH-22, last revised 09/23/15, included the following Basic Patient Rights:

a. To safe care and a humane environment that provides protection from harm.

b. To be free from all forms of abuse and harassment, including neglect as a form of abuse.

Document Review of the hospital's policy and procedure titled, "Patient Abuse and Neglect Reporting," policy number #ESH 7.01, last revised 01/31/19, included the following:

a. Patient abuse may be perpetrated by an employee, visitor, or another patient and may include the following:

i. Physical abuse - including assaults and inappropriate touching.

ii. Sexual abuse - including invited or uninvited inappropriate touching and sexual verbal harassment.

b. Any employee witnessing an incident of patient abuse or having cause to suspect the unreported occurrence of patient abuse must report the incident, real or suspected, to the appropriate supervisor immediately.

c. The policy establishes procedures to guide staff when patient abuse is reported or discovered on admission.

d. At the time of the receipt of the suspicion or information concerning sexual abuse or assault of a patient, the person with the knowledge must immediately report it both to the appropriate supervisor and the Registered Nurse (RN) in charge of the ward.

e. If there is a question as to whether the abuse occurred, the physician determines if "reasonable cause" exists to suspect or believe abuse may have occurred. Reasonable cause is defined as the belief or suspicion that a patient has suffered abuse when there is evidence of one or more forms of abuse having occurred and there is not good reason to discount the evidence. The physician documented the findings and decision and directs the appropriate supervisor to complete an Unusual Occurrence Report (UOR).

f. The policy does not contain clear, specific guidelines to guide staff in their response to an allegation of a patient-to-patient sexual assault/abuse during the patient's admission to the hospital. Additionally, the policy does not outline staff's process for conducting an internal investigation into allegations of patient-to-patient sexual assault/abuse.

Document Review of the hospital's policy and procedure titled, "Unusual Occurrence Reporting (UOR)," policy number #ESH 7.102, last revised 11/30/19, included the following:

a. Unusual Occurrences (UOR) include events that inappropriately put people at risk and are incidents of situations involving harm or damage, or the threat of damage to people.

b. All unusual occurrences at the hospital shall be reported as part of the Quality Assurance Performance Improvement Plan to support data driven decision making and change.

c. The UOR is the official reporting mechanism for all unusual occurrences.

d. The supervisor shall:

i. Ensure imminent safety and security concerns are addressed.

ii. Ensure the details of the event are documented in the medical record, without mention of the UOR.

iii. Make verbal notifications to the Unit Director, COO, Physician, and Law Enforcement, if required.

e. Verification of the occurrence of abuse - If there is a question as to whether the abuse has occurred, the physician determines if reasonable cause exists. If reasonable cause exists, the physician documents the findings in the medical record, and instructs the appropriate supervisor to complete the required interventions.

f. If there is not reasonable cause to suspect the abuse occurred, the RN and the physician will both document their findings in the patient's record.

g. The policy does not refer to the process or guidelines for conducting an internal investigation into sexual assault/abuse allegations after the initiation of the UOR.

Document Review of the hospital's policy and procedure titled, "Patient Complaints," policy number #ESH 12.01, last revised 04/25/23, included the following:

a. If a patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, and/or requires an investigation, then the complaint is processed as a grievance.

b. Any complaint involving patient abuse, or a potential sexual assault is immediately forwarded to the Deputy CEO for investigation. All relevant documentation will be forwarded to the Deputy CEO for review by the Allegations of Abuse (AOA) team.

Review of the hospital's document titled, "ESH Allegation of Abuse and Neglect Process," version 1, dated 06/23 showed that the Allegations of Abuse (AOA) team was established as a workgroup under the Quality Council. Once the complaint/allegation is received, the Complaint Review Team (CRT) completes a UOR. The complaint/allegation is sent to the Deputy CEO, who then reviews the complaint with the other members of the AOA team. After the collection of any additional information, reasonable cause will be determined. If the complaint is internal (meaning the incident occurred at the hospital), the Deputy CEO will again review with the AOA team and if founded, Human Resources will be included and then submitted to the Behavioral Health Administration (BHA) Investigator. After the HR process is complete, the Deputy CEO will prepare a response letter/closure letter to the patient, and the Patient Advocate will deliver.

2. On 06/15/23, the Investigator requested a list of sexual assault/abuse incidents from 03/01/23 to 06/15/23. The Director of Quality (Staff #1) reported that the staff member who compiled that information was not available and no one else had access to the data. The list was later provided to the Investigator via email on 06/22/23. During the onsite investigation, Staff #1 provided the investigator with the UOR report for the previous 3 months, which included all patient grievances and incident reports. The Investigator's review of the reported incidents showed the following:

Patient #1

3. Patient #1 was a 24-year-old male admitted July of 2022 from Benton County Jail for competency restoration. On 04/24/23, Patient #1 submitted a patient grievance reporting that on 07/30/22, when he was on a different ward (1S1), a nurse forced him to touch her private area during a de-escalation. Review of the nursing progress notes in the Patient's medical record during the time of the reported incident (between 07/29/22 to 07/31/22) and during the time that the Patient submitted a patient grievance reporting the incident (between 04/23/23 to 04/25/23), found that nursing staff did not document the Patient's reported allegation of nursing staff requesting him to inappropriately touch them. Review of the medical and psychiatric provider's progress notes between 04/27/23 to 05/11/23 found that the providers failed to document the patient's reported abuse, or the determination if there was reasonable cause, as outlined in the hospital's policy. Review of the hospital's investigation documents found that the BHA Investigator was unable to verify that the assault occurred. Due to the lapse in time between the date of the incident, and the date reported, the investigator was unable to review any video. The BHA Investigator did not interview any staff that worked on the day of the incident.

4. On 06/15/23 at 1:00 PM, during an interview with the Investigator, Patient #1 stated that on 07/30/22, the nurse that tried to make me touch her "private parts" and stood in front of the camera to block the video feed. Patient #1 stated that he tried to report the assault to the Patient Advocate and the PREA (Prison Rape Elimination Act) Hotline, asking that the incident be reported to law enforcement. Patient #1 stated that he did not hear back from anyone regarding the reported incident.

Patient #3

5. Patient #3 was a 32-year-old female admitted on 03/15/23 from Benton County on a 45-day competency restoration. On 06/04/23, Patient #3 reported that on medication watch a male nurse displayed his groin to her. Review of the nursing and provider's progress notes between 05/15/23 to 06/14/23, found that staff failed to document the Patient's reported assault incident, or the determination if there was reasonable cause. Documents provided to this Investigator regarding the incident did not contain documentation of any staff interviews, or record reviews.

6. On 06/15/23 at 12:30 PM, during an interview with the Investigator, Staff #1 reported that it was discovered that the male nurse, who was with Patient #3 during medication watch, had spread his leg out widely while sitting in the chair. Staff #1 stated that it was not an intentional action by the staff member, and the staff member was later counseled. This information, and the resolution to the incident investigation, was not included in the incident/investigation documents provided to this Investigator.

Patient #4

7. Patient #4 was a 60-year-old male admitted on 08/15/22. The Patient's psychiatric diagnosis was Schizophrenia. Nursing staff initiated an UOR (incident report) on 04/04/23 to report that Patient #4 had reported that his former roommate "Monty" had accused him of raping him. Patient #4 stated that he had gotten on top of his roommate, but he had his clothes on. Review of the nursing, social work, and provider progress notes between 04/02/23 to 04/13/23, found that staff failed to document the Patient's reported assault incident in the medical record. Review of the hospital's investigation documents found that the BHA Investigator was unable to verify that the assault occurred. The investigation documents provided, including staff interviews, centered around the Patient's reported lost green bible.

8. On 06/15/23 at 4:05 PM, during an interview with the Investigator, the Deputy CEO (Staff #2) stated that they were unable to determine that an incident happened between Patient #4 and his roommate. Staff #2 provided this Investigator with an email that documented that the investigator was not able to determine who "Monty" was, or the connection with Patient #4. A staff member on the ward reported that "Monty" may have stolen the green bible. After determining if Patient #4 had ever had a roommate named "Monty," this Investigator was able to obtain the medical records for Patient #4's roommate for review. The two patients were roommates from 08/25/22 to 10/11/22. The investigator found that staff did not document any allegations of sexual assault between the roommates.

Staff #2 stated that the AOA Review Team was created to investigate allegations of abuse within the hospital The team consists of herself (Deputy CEO), the Director of Quality, the Chief Clinical Officer, the Chief Nursing Officer, the Director of Social Work, and the Patient Advocate. The team used to have an investigator on the team, but they don't any longer. When they need to have an investigator, they utilize the BHA investigator. If the incident is a criminal matter, such as a rape, the hospital reaches out to local law enforcement. They will take patient statements and conduct any investigation that is necessary. Additionally, Staff #2 stated that the AOA Review Team does not review/investigate any of the patient-to-patient incidents, the team only reviews staff to patient incidents. When the Investigator asked the Deputy CEO how the patient-to-patient incidents are investigated, Staff #2 stated that the treatment team does that. All the documentation regarding the investigation is documented in the treatment record.

9. On 06/15/23 at 5:00 PM, during an interview with the Investigator and Staff #1 and Staff #2, the Investigator asked the hospital leaders what policy or policies guide staff in the process to address patient-to-patient incidents or allegations of sexual assault. Staff #1 and Staff #2 verified that the hospital's policies do not provide clear written procedures to guide staff when investigating incidents of patient-to-patient assaults/allegations. Staff #1 and #2 stated that the hospital's policies and procedures also do not clearly outline how the hospital thoroughly investigates allegations of abuse. The policies do not define the process of the internal investigation, who is responsible for conducting the investigation, and what are the essential components of the investigation.

.