HospitalInspections.org

Based on interview and document review, the facility failed to investigate an allegation, and protect patients, currently receiving care on 1 of 1 medical surgical units reviewed, from potential abuse following an allegation of abuse. The hospital did not meet the Condition of Participation of Patient Rights at 42 CFR 482.13. The cumulative effect of this system failure resulted in the hospital's inability to ensure patient rights were protected and promoted.

The findings include:

Based on interview and document review, the facility failed to thoroughly investigate 1 of 10 patient (P1) allegations of abuse; and failed to protect 40 patients currently receiving care on 1 of 1 medical surgical units from potential abuse following an allegation of abuse. Refer to A-0145.

Based on interview and document review, the facility failed to thoroughly investigate 1 of 10 patient (P1) allegations of abuse; and failed to protect 40 patients currently receiving care on 1 of 1 medical surgical units from potential abuse following an allegation of abuse.

Findings include:

Review of the facility investigation report identified they had received a complaint from P1 on 9/23/19, alleging nursing assistant (NA)-A sexually abused P1 the morning of 9/20/19. P1 had not reported the incident to staff until 9/23/19.

During an interview on 10/1/19, at 1:00 p.m. registered nurse (RN)-A stated she was made aware of the allegation of sexual abuse the afternoon of 9/23/19, via an email from RN-B, who worked on another unit in the hospital. RN-A stated she met with human resources (HR) some time that week to formulate questions, and identify key staff members to interview. RN-A was not able to identify the exact date of that meeting. After meeting with HR, RN-A stated she had notified NA-A on 9/27/19, that he had been placed on administrative leave until further notice, pending an investigation. RN-A stated she had only completed 8 of 12 interviews, and had not interviewed NA-A regarding the events surrounding the allegation. RN-A had no supporting documentation to identify the steps in her investigation, or how a determination was made as a result of her investigation. RN-A had no guidance or procedure to follow in completing an accurate and thorough investigation. RN-A was unsure how patients had been kept safe during the time of the allegation, prior to the suspension of NA-A. RN-A verified a lack of investigation and safety measures towards patients was a concern.

During interview on 10/2/19 at 10:50 a.m. RN-B stated she was notified of the allegation of sexual assault by an unknown staff member on 9/23/19, prior to a surgical procedure. RN-B met with P1, and P1 confirmed the allegation of sexual abuse. RN-B then sent an e-mail to RN-A who worked on the medical surgical floor, asking if alleged abuser, NA-A, worked on that unit. RN-B advised RN-A that P1 had made an allegation of sexual assault against NA-A from an incident on 9/20/19.

During interview on 10/2/19, at 1:00 p.m. human resources staff (HR)-A stated she was notified by RN-B regarding the alleged sexual abuse via e-mail on 9/24/19, at 9:15 a.m. Upon reading the e-mail, HR-A stated she spoke to other HR staff for recommendations on how to proceed. HR-A and other HR employees were unable to identify the correct procedure for an alleged abuse report. On 9/25/19, 2 days after the initial notification to staff, HR-A then notified the quality director (QD)-A. HR-A stated she notified the quality director of the allegation of sexual abuse on 9/25/19. On 9/26/19, 3 days after the allegation was identified by staff, HR-A and the QD-A decided to place NA-A on administrative leave until further notice. RN-A was notified of the decision on 9/26/19, and was responsible for notifying NA-A who was currently working.

During review of the unit schedules, NA-A worked 9/20/19, 9/21/19, 9/22/19, 9/24/19, 9/25/19, and 9/26/19.

During interview with a quality director (QD)-A on 10/2/19, at 11:45 a.m QD-A confirmed NA-A worked 9/24/19, 9/25/19, and 9/26/19, after HR and the unit manager received notification of the allegation of sexual abuse.

The facility policy Vulnerable Adult Maltreatment: Assessment and Reporting dated 7/17, lacked direction on how staff were to proceed with an investigation and protection of the vulnerable adult or other patients during an investigation of allegations of sexual abuse.