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Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure patients received care in a safe setting for one (1) of ten (10) sampled patients, Patient #1.

A sexual abuse allegation was filed against Patient Care Assistant (PCA) #1 on 04/19/2021, and staff on the PCA's unit (3 E), were educated afterwards on provision of patient care to include bathing care and perineal care. PCA #1 was suspended at the time of the allegation; however, did not receive the training on provision of patient care, upon his return to work at the facility. The facility also failed to ensure PCA #1 received abuse training prior to allowing him to provide patient care when he returned to work. When PCA #1 returned to work, he was instructed by his supervisor to ensure another staff member was present with him when he provided perineal care or bathing care for patients. However, the facility failed to ensure PCA #1's supervisor's verbal instructions were documented and enforced after PCA #1 returned to work. Therefore, on 01/18/2022, another allegation of sexual abuse by PCA #1 was made by Patient #1 when he provided assistance without another staff member present. (See A 0395, RN Supervision of Nursing Care).

The findings include:

Review of the facility policy titled, "Alleged Abuse IN-FACILITY by Employees or Non-employees", revised 07/2021, revealed under the Investigation section the Identification, Investigation and Reporting information noted a final determination would be reached after the investigation. Further review revealed allegations would be substantiated, not substantiated (with corrective action), or not substantiated.

Review of the facility's investigation, regarding the 04/19/2021 allegation against PCA #1, revealed no documented evidence of a facility finding to substantiate or not substantiate (with or without corrective action), as per the policy.

Review of the facility's Action Plan and facility training for staff following the allegation of sexual abuse against PCA #1 on 04/19/2021, revealed training had been provided for staff working on unit 3 E (where PCA #1 had been working at the time of the allegation). Continued review revealed beginning on 04/25/2021, the unit 3 E staff were trained on the facility policy regarding Patient Care: Basic Care Needs (Bathing, Mouth Care, Perineal Care), effective date 08/2020. Further review revealed staff had been trained on procedural skills regarding bathing and perineal care for both male and female patients. Review of the Action Plan attachments and training documentation revealed the facility's sign-in sheets contained no notations indicating PCA #1 had received the education at that time.

Review of Patient #1's medical record revealed the patient had been admitted to the facility on 01/14/2022, from a sister facility as he/she had required a higher level of care after experiencing a transient ischemic attack, left hip fracture repair. Further review revealed Patient #1's diagnoses also included Diabetes Mellitus type II and severe protein-calorie Malnutrition.

Review of a facility self-reported incident dated 01/19/2022 and the five (5) day follow-up dated 01/24/2022, revealed Patient #1 alleged he/she had been touched inappropriately by PCA #1 after PCA #1 bathed him/her. Continued review revealed the facility suspended PCA #1 upon report of the allegation. Further review revealed the facility terminated PCA #1 immediately after receiving report of the incident. Review further revealed PCA #1 was terminated for failure to comply with the work restriction of requiring a second staff member to be present when he bathed a patient or when he provided perineal care for patients.

Review of the facility's employee file for PCA #1 revealed a Notice of Corrective Action, Termination document, dated 01/19/2022, which noted PCA #1's supervisor, the Director of Float Pool Nursing Operations (DFPNO), had informed the PCA, when he returned to work on 11/08/2021, to have a witness with him when completing bathing or peri-care for a patient. However, further review of the file revealed no documented evidence, of the restrictions noted on the Notice of Correction Action, Termination document, following PCA #1's return to work on 11/08/2021, after the suspension related to the 04/19/2021 allegation.

Review of PCA #1's work dates documentation provided by the DFPNO, as well as the PCA's Completed Training, revealed PCA #1 returned to work on 11/08/2021, and worked a total of thirteen (13) days prior to receiving abuse training from the facility on 12/06/2021. The facility did not provide documented evidence PCA #1 had received training/re-training on the facility's policy Patient Care: Basic Care Needs (Bathing, Mouth Care, Perineal Care), effective date 08/2020.

Interview on 02/02/2022 at 2:17 PM with the facility's Risk Manager revealed when Patient #1 made the allegation of sexual abuse against PCA #1, a "grievance" had been started. She revealed, although the facility's investigation of the allegation had been completed, as far as she was aware, there had been no finding indicating whether the abuse was substantiated or not substantiated.

Interview with the facility's Director of Quality and Patient Safety (DQPS) on 02/02/2022 at 2:20 PM, and additionally at 4:12 PM, revealed the facility closed its first investigation of the 04/19/2021 allegation of sexual abuse against PCA #1, as the State Agencies, had not substantiated abuse against the PCA, and the police also had cleared PCA #1. He revealed the facility did not have a formal finding of whether it had substantiated or not substantiated abuse against PCA #1 for the 04/19/2021. Continued interview revealed however, the facility had accepted the findings of the outside Stated Agencies and police, and had therefore allowed PCA #1 to return to work after completion of the State Agencies and police investigations. The DQPS stated following the 04/19/2021 abuse allegation against PCA #1, the facility's unit 3 E staff had been trained on basic patient care needs to include peri-care and bathing, as part of the facility's immediate response to the sexual abuse allegation. Further interview revealed as sexual abuse had not been substantiated against PCA #1 by the outside investigating agencies, the PCA had only completed the regularly scheduled pathway modules for abuse and neglect on 12/06/2021. The DQPS further revealed all facility policies were accessible to facility staff, and the expectation was for staff to follow those policies.

Interview with the facility's Director of Float Pool Nursing Operations (DFPNO) on 02/03/2022 at 4:06 PM, revealed PCA #1 had not had any special training related to patient care to include bathing and perineal care. The DFPNO stated although PCA #1 had previously been a nurse aide, and had received training during orientation when he started with the facility on 09/12/2016. She confirmed there had been no provision for staff to observe PCA #1 providing patient care, nor had staff been alerted of PCA #1's need to provide care with another staff member present. Interview revealed she had not alerted other staff as she didn't want PCA #1 to be treated like he was guilty of sexual abuse. Further interview revealed all staff had been trained on abuse identification and reporting after Patient #1 made the allegation of sexual abuse on 01/18/2021. She further revealed PCA #1 received abuse training from the facility within thirty (30) days of returning to work on 11/08/2021, which was the facility's policy.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure Registered Nurse (RN) supervision of nursing care was furnished for all patients for one (1) of ten (10) sampled patients, Patient #1.

Patient Care Aide (PCA) #1 was suspended from work following a 04/19/2021 allegation of sexual abuse by a patient. Upon returning to work, PCA #1 was instructed to have another staff member present when he was providing perineal care or bathing assistance for patients. On 01/18/2022, however, PCA #1 assisted Patient #1 with bathing with no other staff present, and afterwards the patient made an allegation of sexual abuse against him. The facility failed to ensure proper RN supervision of PCA #1 to ensure he followed the instructions given him to have another staff member present when he provided perineal care and bathing assistance. Additionally, the facility failed to ensure RN supervision of the PCA when he provided patient care, even though PCA #1 had previously had another patient make an allegation of sexual abuse against him.

The findings include:

Review of the facility policy titled, "Staff Assignments", last reviewed 06/2020, revealed an RN was assigned accountability for each patient receiving care in the facility. Further review of policy revealed when making assignments, the RN was responsible for ensuring the appropriate degree of supervision required by each staff member.

Review of Patient #1's medical record revealed he/she was admitted to the facility on 01/14/2022, following transfer from a sister facility due to requiring a higher level of care. Review revealed Patient #1 had experienced a transient ischemic attack, and was post-operative (post-op) repair of a left hip fracture. Further review revealed Patient #1 had diagnoses which included severe protein-calorie Malnutrition, and Diabetes Mellitus, Type II.

Review of a facility self-report incident report dated 01/19/2022, and review of the facility's five (5) day follow-up document dated 01/24/2022, revealed an allegation had been made by Patient #1 regarding having been touched inappropriately by PCA #1 after receiving bathing assistance from the PCA. Per review, the facility suspended PCA #1 from work upon receiving the allegation. Review revealed the facility later terminated PCA #1 for failure to comply with work restrictions given him by his supervisor upon return to work at the facility. Further review revealed PCA #1 was terminated for not complying with the requirement of having a second staff member present when he was bathing a patient or when he was providing perineal care for a patient.

Review of PCA #1's employee file revealed no evidence of any documented restrictions in the PCA's file following his return to work on 11/08/2021, following his suspension after the 04/19/2021 allegation of sexual abuse. Continued review revealed PCA #1's Notice of Corrective Action, Termination, dated 01/19/2022, which noted the PCA's supervisor had informed him upon his return to work on 11/08/2021, to have a witness with him when completing bathing or peri-care for patients.

Interview on 02/01/2022 at 10:21 AM, with the Director of Float Pool Nursing Operations (DFPNO), PCA #1's supervisor, revealed the PCA was a 3rd shift float PCA who worked all over the facility. The DFPNO revealed she had spoken with PCA #1 on 11/02/2021, prior to his return to work, and told him he would need to have a witness with him when giving baths or providing peri-care when he returned to work, in order to protect himself from any possible future accusations. Per interview, the DFPNO stated PCA #1 agreed to her instructions. Continued interview revealed there had been no system put in place to ensure PCA #1 adhered to her instructions for having a witness present. Interview revealed she had relied on PCA #1 ensuring he had the witness present during provision of patient baths or peri-care. She revealed other staff had not been informed of PCA #1's need for the restriction (instruction), for having another staff member present, in the interest of protecting PCA #1's reputation. Further interview revealed there had been no way for PCA #1 to document whether he had another staff member present with him, in the facility's electronic medical record system. She further revealed there had been no way for other staff to know of PCA #1's restrictions for ensuring a second person was present during baths and peri-care of patients, unless he told or asked another staff person to assist. In addition, the DFPNO revealed there had not been a system implemented to monitor PCA #1 after his return to work, and determine if he had been following the restriction.

Interview on 02/02/2022 at 2:46 PM, with the Market Vice President Human Resources Operations (MVPHRO) revealed when PCA #1 returned to work, following his suspension related to the 04/29/2021 allegation, his understanding was PCA #1's supervisor (the DFPNO), had instructed the PCA, for any contact with female patients he was supposed to have a witness. He revealed he was uncertain if there had been an audit plan implemented to ensure PCA followed the instructions, as that would have been the responsibility of PCA #1's supervisor. Further interview revealed in PCA #1's exit interview, after his termination, the PCA maintained his contact with Patient #1 had not been inappropriate. He further revealed however, PCA #1 had acknowledged he had not had any other staff present with him during his provision of care for Patient #1.

Interview with RN #6 on 02/03/2022 at 5:13 PM, revealed he had been the charge nurse who had created the schedule for 01/18/2022, the date of Patient #1's allegation. RN #6 stated he had not been aware of any restrictions for PCA #1 or for any of the other staff assigned to work on 01/18/2022. Further interview revealed usually if staff had any restrictions that information was passed in report by the previous shift's charge nurse.

Interview on 02/03/2022 at 9:57 AM, with PCA #1 revealed when he returned to work on 11/08/21, he had never been instructed by anyone of the need to have another staff member present with him when he was providing patients' baths or peri-care. Further interview revealed PCA #1 denied having done anything inappropriate while providing care for Patient #1.

Interview with RN #4 on 02/02/2022 at 4:16 PM, revealed he had been working on 01/18/2022, and Patient #1 reported to him PCA #1 had massaged his/her private area and legs after providing his/her peri-care and bath. RN #4 revealed he initiated the investigation process after Patient #1's allegation, and PCA #1 was sent home. RN #4 revealed he had worked with PCA #1 in the past, and had not been aware of the PCA ever requesting assistance when he was bathing a patient or providing a patient's peri-care.

Interview with RN #5 on 02/03/2022 at 8:30 AM, revealed she had been the charge nurse the night of 01/18/2022, when Patient #1 made the allegation against PCA #1. She stated RN #4 informed her of the patient's allegation, and had already initiated the investigation process. Further interview revealed she had not been aware of PCA #1 having any restrictions when providing peri-care or baths for patients. RN #5 further revealed however, she had observed him "cleaning up" patients by himself previously after his return to work.

Interview on 02/01/2022 at 10:55 AM, with RN #1, Charge Nurse on a unit where PCA #1 had worked before, revealed the PCA had worked on her unit on 11/23/2021. RN #1 revealed however, she had not been made aware of any restrictions the PCA had for providing patients' peri-care or for bathing them. The Charge Nurse stated the facility's staff did not always "communicate stuff to us" working in the float pool, and revealed information was "sometimes lost in the chaos" surrounding shift report. She revealed it had been possible PCA #1 had asked for assistance at times with bathing or peri-care when working on her unit. Further interview revealed she could not recall if PCA #1 had ever asked any other staff on the unit for assistance; however, could have asked someone she had not been aware of him asking.

Interview on 02/01/2022 at 11:12 AM, with RN #2, the Charge Nurse for the 4 Intensive Care (IC) unit, where PCA #1 worked on 01/10/2022, revealed no one had made her aware of any restrictions for PCA #1 regarding provision of patient care. Further interview revealed she did not recall if PCA #1 had requested assistance from her or other staff with any patient care while he had been working on that unit.

Interview on 02/01/2022 at 4:08 PM, with the Risk Manager revealed when she had initiated her investigation of the allegation of sexual abuse against PCA #1, she had not been aware of any restrictions the PCA had been placed on. She further revealed a restriction like had been placed on PCA #1, could have been put in place both to protect patients and also for the PCA's protection against further allegations as well.

Interview with the facility's Chief Nursing Officer (CNO) on 02/02/2022 at 3:24 PM, revealed he had heard about Patient #1's allegation against PCA #1, and the stipulation for the PCA to have another staff member present when bathing or providing peri-care for patients. Interview revealed regarding supervision and monitoring, the CNO stated nursing staff did rounding on patients. Per interview, nurse managers also routinely asked patients and families about any concerns or issues they might have with the care being provided, with no concerns. Further interview revealed the facility acted on any feedback received from patients and families. The CNO further stated, in the case of PCA #1 stipulation, it had been more about reminding him to ask for help in order to protect him from any additional allegations, than about having a specific tactic in place to monitor the PCA's care of patients.