HospitalInspections.org

Based on interview and document review, the facility failed to ensure filed grievances were investigated, resolved, and/or responded to, in a timely manner for 1 of 4 patients (P1) who filed grievances.

Findings include:

On 5/17/23 at 10:18 a.m., P1's family member (FM)-A was interviewed. FM-A stated on 5/6/23, at 1:31 p.m. P1 informed her someone tried to rape him the previous night and "stuck their fingers in his butt." FM-A explained she contacted staff on the unit at 1:39 p.m. and was informed staff were aware of the allegation; however, they felt the allegation was unsubstantiated and thus they were not going to investigate it any further. FM-A stated due to her frustration with the response, and lack of additional follow-up, FM-A hung up on this staff and contacted ER staff with her concerns and P1's allegation. The ER staff informed her they were unable to find information on the allegation; however, they would contact another staff for additional follow-up. Shortly after, a supervisor called her and informed her staff already knew about the allegation, the alleged perpetrator (AP) was moved off the unit, and unit video footage from the previous night was requested. Per a call on 5/7/23, FM-A was updated the video footage review identified no concerns. FM-A stated she expressed concerns related to the video footage. FM-A stated she filed a police report on 5/6/23, and on 5/7/23, she met police at the hospital to assist P1 in filing a police report. FM-A stated she was extremely frustrated by facility and police processes, as it took at least three hours from the time the police arrived at the hospital to the time it took for the "five-minute interview" with P1. FM-A stated a patient relations representative (PR)-A contacted her on 5/8/23, and she was updated there "would be no further communication [with FM-A] until the investigation was conducted" and FM-A "would get a letter." FM-A stated she did not have any further communication with PR-A, or other staff, after the 5/8/23 conversation, and had not yet received any letter(s). FM-A stated she expected staff would have contacted her right away once P1 alleged the sexual abuse because "I am his guardian." FM-A stated she did not trust the hospital, did not trust the unit video coverage, and was upset staff questioned P1 for decisions related to a SANE (sexual abuse nurse evaluator) exam and not her. FM-A explained P1's sexual abuse allegation was "not normal" as this was the first time P1 alleged sexual abuse. FM-A stated she felt this impacted P1 negatively based on P1's actions after the allegation in which P1's phone calls to her were significantly decreased since the allegation.

A facility Complaint Notification (typed document) dated 5/16/23, identified FM-A filed a grievance with the Patient Representative Office regarding concerns with how staff managed P1's 5/6/23 verbalized sexual assault allegation. The document indicated FM-A's descriptions of follow-up events, and FM-A remained "very upset" with the incident and included questions FM-A wanted answers for. FM-A's grievance concerns were consistent with the 5/17/23 interview. The document lacked the date FM-A initially filed the grievance with patient relations, or any follow-up steps (investigation) taken by the Patient Representative Office or a complaint investigator. The document lacked indication a letter was sent to FM-A within seven business days of the grievance to inform of a resolution, or the facility was continuing to work to resolve the grievance and required additional time.

Information on the facility's grievance follow-up investigation actions related to FM-A's grievance was requested, but was not provided.

On 5/18/23, at 11:37 a.m. PR-A was interviewed. PR-A explained the grievance process, based on policy and expectations, included the following steps: the grievance investigation immediately started after a grievance was received/discussed with the complainant to ensure internal processes and appropriate staff notification(s) were implemented, thus ensuring patient safety; the grievance was "typically" forwarded to a complaint investigator within 24 hours of a filed grievance in order to address concerns in a timely manner; and within seven business days a resolution letter, or a letter which updated the complainant additional time was required, was sent to the complainant. PR-A stated if a grievance was filed over a weekend, the grievance process steps would begin on the following Monday. PR-A stated they spoke at length to FM-A on 5/8/23, and on two other occasions "a bit further in that week." No documentation was available that reflected information on the two additional conversations. FM-A's grievance was forwarded to a complaint investigator on 5/16/23, and PR-A was unsure as to the reason for the grievance being forwarded eight days (versus the typical 24 hours) after the initial conversation with FM-A. PR-A denied the facility sent FM-A any letters in relation to a resolution or the need for additional time.

On 5/18/23, at 2:06 p.m. the vice president of safety and quality (VPSQ) was interviewed. The VPSQ stated she expected the patient representatives to ensure they understood a complainant's grievance to the best of their ability which thus may require additional back and forth conversations; however, she explained she expected staff to follow the seven business day time-frame based on "when the call comes in," or when patient relations "understood what the complaint was," for resolution or to follow the extension process when applicable. The extension process always required a call to the complainant and "something in writing" to say more time was required. In addition, she expected any delays/concerns with a grievance process to be documented. The VPSQ stated it was an "unusual" time frame for FM-A's complaint to be forwarded to the investigators, and she was unaware of any specifics on how long it took patient relations to understand FM-A's concerns. The VPSQ stated it was her understanding patient relations and FM-A spoke multiple times and staff investigated the allegation over the weekend and found the allegation unsubstantiated. The VPSQ stated, "We have to understand what the concern is before we act" as FM-A's "voice needed to be heard." The VPSQ stated the policy was meant to guide staff and when some thing was out of the norm, they tried to work to resolve it with leadership. The VPSQ stated she was not concerned about seven-day time frames as she was most concerned staff responded accurately to FM-A and the "spirit of patient rights."

The facility policy Patient Complaint/Grievance reviewed 11/16/22, identified a patient representative was expected to forward patient complaints/grievances to a complaint investigator within 24 hours of receipt during normal business hours and to ensure, for most cases, all complaints/grievances were responded to within seven business days. If the investigation was not completed in seven business days, the patient representative was to inform the complainant additional time was needed for the investigation and follow-up with a written response would be provided as soon as possible depending on the actions the hospital was required to take. In addition, the policy identified to expedite any complaints/grievances about situations that endanger the patient, such as abuse or neglect.

Based on interview and document review, the facility failed to report an allegation of patient-to-patient sexual abuse to the State Agency (SA) for 2 of 2 patients (P1, P7) reviewed for patient-to-patient abuse.

Findings include:

A report to the SA (by a complainant not affiliated with the hospital) dated 5/8/23, identified the complainant received an email from a different complainant on 5/6/23, which indicated P1 stated he was "raped last night" and digitally penetrated by another patient. The email stated the complainant informed staff of P1's allegation; however, the complainant was informed by staff P1's allegations were not investigated as the allegation did not happen, but due to P1's behaviors directed at the alleged perpetrator (P7) after the allegation, and staff moved P7 to another unit.

P1's medical record identified an admission date of 3/17/22, where he remained on an in-patient psychiatric unit. P1's main diagnoses were autism and schizophrenia in which P1 required a legal guardian. P1, based on communication and cognitive deficits was not interviewable.

P1's nursing and provider progress notes identified the following entries:
-On 5/6/23, entered at 10:06 a.m. P1 demonstrated increased agitation despite reassurance and offered coping items. He became fixated on P7. He watched P7 "with a slight grin on his face" earlier in the morning and made "punching gestures" at P7 while he "glared" at him. [At unknown time], P1 stated "f*ing pedophile comes here and thinks he can take over my unit," "he raped me in my sleep," and "I need to f* up the retard." After, P1 approached P7 from behind and "made punching motions." P1 and P7 were separated until P7 was transferred to another unit.
-On 5/6/23, entered at 2:27 p.m. staff were contacted by P1's family who stated P1 informed them he was "raped and penetrated by a peer overnight," at 12:36 in the night. P1 declined to provide additional information; however, he stated, 'I don't feel safe here.'
-On 5/6/23, entered at 2:30 p.m. P1 was informed about a HART (Hennepin Assault Response Team) exam, dependent on guardian consent, to which P1 responded, 'I will figure it out myself ...it did happen.'
-On 5/8/23, entered at 12:27 p.m. P1 repeated the word 'assault' when the provider questioned him on the abuse allegation.

P7's medical record identified and admission date of 4/24/23 where he remained on an in-patient psychiatric unit. P1's main diagnoses were autism and impulse control disorder with a recent history of masturbating and being sexually aggressive in public and was ordered assault precautions. P7, based on communication and cognitive deficits was not interviewable. P7's nursing and provider progress notes identify the following entries:
-On 5/4/23, entered at 5:48 p.m. P7 was transferred to P1's psychiatric unit.
-On 5/6/23, entered at 1:07 p.m. P7 "was targeted by a male peer who gestured to hit [P7] a couple of times. Will be transferred to [a different psychiatric unit] to maintain safety."
-On 5/6/23, at 1:30 p.m. P1 was transferred.

A Psychiatry Inpatient Event report, dated 5/6/23, identified a "Criminal Act" delineated from an alleged sexual assault. Contributing factors indicated "Patient to Patient" and "Lack of HCA for 1:1." The report indicated an entry dated 5/8/23, at 7:19 a.m. P1 reported to family he was raped with penetration by a male peer and P1 stated to staff 'it did happen.' Triage and leadership were notified, and proper protocol was followed. A second entry dated 5/8/23, at 10:30 a.m. indicated no security report was seen. A third entry dated 5/8/23, at 11:29 a.m. indicated the 15-minute rounding sheets for 5/5/23's evening and night shift were reviewed, P1 and P7 were separated, video monitoring feed was watched, P1's family was contacted, a police report was filed by P1's family, and the police interviewed P1 on 5/7/23. P1's family considered whether to request a HART exam. A fourth entry dated 5/16/23 (11 days later), at 4:07 p.m. indicated "Based on the detailed and thorough investigation conducted by department leadership, the allegation of assault was unsubstantiated. There is no reason to believe that the assault occurred. For this reason, a Vulnerable Adult (VA) report was not filed."

When interviewed on 5/17/23, at 10:18 a.m. P1's family member (FM)-A stated, on 5/6/23, at 1:31 p.m. P1 informed her someone tried to rape him the previous night and "stuck their fingers in his butt." FM-A explained she contacted staff on the unit at 1:39 p.m. and was informed staff were aware of the allegation; however, they felt the allegation was unsubstantiated and thus they were not going to investigate it any further. Due to her frustration with the response, and lack of additional follow-up, FM-A contacted ER staff with her concerns and P1's allegation. The ER staff informed her they were unable to find information on the allegation; however, they would contact another staff for additional follow-up. Shortly after, a supervisor called her and informed her staff already knew about the allegation, the alleged perpetrator (AP) was moved off the unit, and unit video footage from the previous night was requested. Per a call on 5/7/23, FM-A was updated the video footage review identified no concerns. FM-A filed a police report on 5/6/23, and on 5/7/23 met police at the hospital to assist P1 in filing a police report. FM-A explained P1's sexual abuse allegation was "not normal" as this was the first time P1 alleged sexual abuse and because of P1's continued statements the abuse occurred, even days after the initial allegation. FM-A stated she felt this impacted P1 negatively based on P1's actions after the allegation in which P1's phone calls to her were significantly decreased since the allegation.

During interview on 5/17/23, at 2:57 p.m. registered nurse (RN)-A stated he was the on-call supervisor that weekend. He explained, on 5/6/23, midmorning, he was updated P1 targeted P7 and a decision was made to move P7 to another unit, and then around 1:50 p.m. he was updated on P1's sexual allegation statements. RN-A initiated investigatory steps and contacted the triage nurse to provide further instructions. RN-A stated during conversations with P1's family, family stated P1's allegations were not his norm. In addition, RN-A stated P7 required sexual precautions due to his history. RN-A stated he did not file an alleged abuse VA report as it fell to the treatment team to determine if a VA report was required once they reviewed the information. He explained he was unsure of the policy and facility expectations for VA abuse reporting processes and timelines; however, identified it ultimately was the responsibility of the social worker(s) to file a VA report. On 5/7/23, RN-A updated the treatment team, primary provider, social worker, clinical coordinator, etc., via a messaging system; however, he denied verbal conversations with any of these staff over the weekend.

When interviewed on 5/17/23, at 3:31 p.m. RN-B stated the facility took abuse allegations "very seriously" and when a patient alleged abuse she was expected to notify the triage nurse; however, she stated she lacked knowledge related to policy and facility expectations for VA abuse reporting processes and timelines. RN-B explained, on 5/6/23, prior to a break she did not feel P1's initial allegations were serious in nature until after she returned from a break and the triage nurse approached her and stated P1 was "making a very clear allegation." After that, staff worked together to follow the proper protocols which included completion of an incident report, along with family, provider, security, and top leadership notifications. She explained her role in the process was to ensure patient safety and to fill out an incident report, which she completed at the end of her shift on 5/6/23. She explained the triage nurse was responsible for the rest of the follow-up steps and any VA reporting if applicable. RN-B was unsure if a VA report was filed. She identified P1's allegation was new for him, and she felt this was the first time P1 alleged abuse from a peer.

During interview on 5/17/23, at 3:54 p.m. RN-C stated he was the triage nurse that weekend. He explained during the earlier morning hours on 5/6/23 he was on the unit and staff reported P1 was becoming aggressive towards P7. When he returned to the unit during later morning hours, he was updated about P1's allegation. After, he contacted the on-call supervisor and was provided additional instructions, which he followed. RN-C stated for sexual abuse allegations they were required to follow their specified policy and protocols. Allegations were reported to the common entry point (CEP - S.A.) if staff felt "strongly" about the allegation or knew it happened. He denied he filed a VA report or instructed any other staff to complete because P1's allegation "was not a specific allegation" and it was only necessary to do an internal investigation. He identified he "did not feel strong enough about the allegation;" however, he "[could] not discount it." He explained his initial understanding of P1's allegation "in a sense ...was not like a real [complaint]. It was just a whole lot of anxious rambling." RN-C denied knowledge P1 had past incidents of sexual abuse allegations, and such an allegation was "out of [P1's] norm."

When interviewed on 5/17/23, at 4:23 p.m. the patient safety coordinator (PSC)-A stated if there was an allegation of sexual abuse, she expected staff to follow the policy and associated sexual abuse algorithm. In addition, when such an allegation was expressed, she expected staff to escalate the information to their leaders and involve patient safety as soon as possible so they assisted in the investigation. If an allegation was reported over a weekend, she expected staff to contact the on-call patient safety staff. PSC-A explained a very thorough investigation was required to obtain as many details as possible to determine if there was a "reason to believe" and/or "how likely did it happen." This drove the decision to submit a VA file with the S.A. and the facility conducted their own investigations prior to filing VA reports; however, "if a patient reports [an allegation] then we should submit a VA report as we are mandated reporters." PSC-A explained she felt strong enough staff in the patient safety role knew vulnerable adults and everyone who was admitted was vulnerable and thus the facility followed the "reason to believe" patient safety protocols. PSC-A stated she was updated on P1's allegation on 5/8/23 and staff did not contact patient safety over the weekend. She reviewed the allegation on 5/8/23 and it was determined by leadership on that day a thorough investigation was already completed over the weekend and the allegation would not be reported to the S.A. She explained the date of 5/16/23 on the incident report was a late entry. In addition, she stated staff were aware that 5/8/23 was greater than 24 hours from the initial allegation.

During interview on 5/18/23, at 10:36 a.m. P1's medical doctor (MD)-A stated all allegations of abuse were to be reported; however, as "nurses have their own policy" she was unsure who staff were expected to report abuse to or what the reporting time frames were. In addition, she was unsure if she expected P1's allegation to be reported to the S.A. as she understood staff watched video footage and determined the allegation was unsubstantiated.

When interviewed on 5/18/23, at 10:49 a.m. social worker (SW)-A stated allegations of abuse were to be reported immediately to the S.A. and all staff were mandated reporters. She indicated psychiatric unit social workers did not work weekends. She explained in the past social services performed most of the VA reports; however, currently the staff who were involved in the allegation firsthand filed the report. SW-A stated it was her understanding P1's allegation was filed and explained she expected it to be filed to protect the patients, to ensure patients were not blamed for things they did not do, to thoroughly investigate, and to ensure staff were doing their jobs as expected.

During interview on 5/18/23, at 2:06 p.m. the vice president of safety and quality stated the facility utilized a "reason to believe" process to determine when to report a VA to the S.A. A VA report was filed when the facility believed the allegation could have happened or they were unable to obtain enough information to decide. The vice president explained their abuse reporting policy is based off state information related to "reason to believe," and what other states defined for similar situations. She expected staff to follow policies and procedures and to walk through the algorithm and explained the algorithm needed "tweaking" to decrease unnecessary reporting; however, she would never instruct staff to not report concerns. The vice president stated P1's allegation investigation was "basically done by [5/8/23]" when patient safety followed up with the team: "All the pieces came together, and we do not believe we needed to report as they did not have reason to believe it happened."

A policy Vulnerable Adult, dated 4/26/21, identified the facility-oriented health care personnel to the VA policy and procedures and reporting requirements. In addition, the policy identified all facility employees were mandated reports and directed reports of suspected maltreatment of a VA was to be reported to the appropriate county agency within 24 hours from the time there was knowledge of the incident, which was especially important for those patients unable or unlikely to report maltreatment without assistance. The policy identified, for purposes of evaluating incidents of possible reportable maltreatment, the following incidents were not considered maltreatment under state law: accidents, therapeutic conduct, health care decisions, and consensual sexual conduct in certain situations. The policy lacked identification of "reason to believe" processes for determination of VA reporting decisions. The policy identified a supporting document Sexual assault allegation flowchart.

A Patient Sexual Assault Allegation Response Guideline flow sheet algorithm, undated, identified the typical process/steps if there were an allegation of sexual abuse. The flow sheet directed a mandated reporter submitted a VA report within 24-hours of the event report. In addition, the mandated reporter was directed to contact patient safety or social services for assistance in completing the report as needed and directed on the psychiatry units the social worker(s) completed the VA report.