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Based on interview and document review, the facility failed to develop and implement a policy that protected patients from an alleged abuser resulting in the potential for unsatisfactory outcomes for all patients served by the facility. Findings include:

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A-145 Failure to develop and implement policy protecting patients from an alleged abuser

Based on interview and record review, the facility failed to develop and implement a policy that protected patients from an alleged abuser while an investigation was in progress resulting in the potential for unsatisfactory outcomes for all patients served by the facility. Findings include:

On 4/13/2021 at 1130, review of incident reports log from 7/1/2019-10/1/2019 revealed two entries of alleged abuse dated 7/15/2019 and 7/18/2019 regarding the same incident. Patient #3 alleged Physician Staff H had kissed her following a bronchoscopy (a procedure which allows visualization of the lungs and airways) on 7/15/2019.

Review of Patient #3's medical record on 4/12/2021 at 1504 revealed she had adenocarcinoma (cancer) in her right lung for which she had received chemotherapy. A bronchoscopy was performed by Physician Staff H on 7/15/2019 to determine the efficacy of the treatment. The patient had received conscious sedation including a total of Versed (sedative) 3 mg (milligrams) and Fentanyl (pain medication) 50 mcg (micrograms).

On 4/13/2021 at approximately 1000 during an interview with Registered Nurse (RN) Staff L who was the nurse during Patient #3's bronchoscopy, she stated following the bronchoscopy, she had been sitting at the computer charting with her back to the patient. "(Physician Staff H) was talking with the patient and then I heard a kiss. (Staff L demonstrated a puckering of the lips and sucking in of air with a loud kissing type sound.) I immediately turned around and saw he was walking out of the room. When I looked at the patient, her eyes were very big and she asked me, 'Did you see that?' I said, 'No.' She said, 'He just kissed me on the lips.' I was speechless! I said, 'What?' The patient repeated it again, 'He just kissed me on the lips.' I didn't know what to say. I think I said, 'That was odd that he would do that.'. I was inclined to believe her because I had heard that kissing sound...After I had taken her back to her unit, I reported what she said to the coordinator (equivalent to an assistant manager). The unit was busy, and I didn't think about doing an incident report until after I was home, so I filled one out the next time I was at work."

Further review of the incident report dated 7/15/2019 revealed Patient #3 had told Oncology RN Staff Q, who was her primary nurse, that Physician Staff H had "kissed her and told her she wouldn't remember it" presumably because of the sedation medication she had received. Staff Q also reported this to his supervisor and immediately filed an incident report. Staff Q was unavailable for interview.

On 4/13/2021 at 1511, an interview was conducted with Human Resources Staff W who revealed the investigation was a collaborative effort between herself and the senior counsel chief (equivalent to a medical director) of the physician's group to which Physician Staff H belonged. Staff W stated the investigation began by interviewing staff reporting Patient #3's allegation and they spoke with Physician Staff H last, three days after the alleged incident on 7/18/2019. At that time, Physician Staff H admitted he had kissed the patient. He stated the treatment Patient #3 had was not successful and he had felt sorry for her because he felt she would die within six months. He was immediately placed on a "precautionary suspension" until completion of the investigation. Physician Staff H's employment was terminated on 7/26/2019.

Review of facility policy #8195952 titled "Management of Actual or Suspected Vulnerable Adult Abuse Policy with Procedure" effective 6/2020 states, "In compliance with Michigan law, (facility name) care givers will report any adult observed, in the course of their professional capacity or within the scope of their employment, whom they suspect to be a victim of abuse or neglect. This includes: 1. Developmentally disabled adults, 2. Dependent adults, 3. Elderly vulnerable adults, and 4. Victims of domestic violence...5. Victims of human trafficking...6. Victims of sexual assault...All patients who present with evidence of possible criminal mistreatment, whether the mistreatment is from a stranger or from family or a friend or a caregiver will 1. Receive care for his/her injuries. 2. Have the incident reported according to Michigan State Law to appropriate agencies....Steps to Take When Abuse is Indicated or Suspected...Report to the patient's attending physician the findings suggesting abuse, neglect, abandonment, and/or exploitation and the patient's verbal statements regarding his/her injuries." It was noted there was nothing within the policy outlining that a vulnerable adult could be someone that is sedated, what to do if it was a hospital caregiver that was the abuser, or what steps to take directly in protecting the patient and/or other patients from a caregiver abuser within the hospital.

Review of facility policy #9284578 titled "Medical Staff Professionalism Policy with Procedure" effective 2/2021 states, "Examples of Unprofessional Conduct...Inappropriate physical contact with another individual...Review of Reports of Identity-Based Harassment...Identity-based harassment is verbal or physical conduct that: (i) is unwelcome and offensive to an individual who is subjected to it or who witnesses it...examples of identity-based harassment include, but are not limited to...Unwanted physical contact, including touching...All reports of potential identity-based harassment will be reviewed by the Leadership Council in the same manner as outlined earlier in this Policy. In addition, while a Practitioner may be asked to voluntarily refrain from exercising clinical privileges, pending the review of any behavioral matter under this Policy, particular attention will be paid to determining if an agreement to voluntarily refrain is appropriate while an allegation of identity-based harassment is being reviewed...Because of the unique legal implications surrounding identity-based harassment, a single confirmed incident requires the actions set forth in this section. Two or more members of the Leadership Council shall personally meet with the Practitioner to discuss the incident. if the Practitioner acknowledges the seriousness of the matter and agrees that there will be no repeat of such conduct, the meeting shall be followed with a formal letter of admonition and warning to be placed in the Practitioner's confidential file..."

Review of Medical Staff Bylaws was conducted 4/14/2021 at 1000. Article 6, Section B states, "Investigations...(c) The person to whom the matter is referred shall conduct or arrange for an inquiry to determine whether the question raised has sufficient credibility to warrant further review and, if so, shall forward it in writing to the Executive Committee...When a question involving clinical competence or professional conduct is referred to, raised by, the Executive Committee, the Executive Committee shall review the matter and determine whether to conduct an investigation...An investigation shall begin only after a formal determination by the Executive Committee to do so...Whenever, in their sole discretion, failure to take such action may result in imminent danger to the health and/or safety of any individual, the Executive Committee, the Chief of Staff, the chair of a clinical department, the VPMA (vice president of medical affairs), or the President shall each have the authority to (1) afford an individual an opportunity to voluntarily refrain from exercising privileges pending an investigation; or (2) suspend or restrict all or any portion of an individual's clinical privileges as a precaution..."