HospitalInspections.org

Based on document review and staff interviews, the acute care hospital's administrative staff failed to report 1 of 1 incidents of possible dependent adult abuse (Patient #1) in a timely manner. Failure to report an incident of possible dependent adult abuse in a timely manner to the applicable local and state agency may result in the administrative staff allowing the alleged abuse to continue with dependent adults after the staff member committed possible acts of sexual abuse. The hospital's administrative staff identified a census of 8 inpatients on the adult behavioral health unit on entrance.


Findings include:


1. Review of policy, "SEIRMC-FM/WB Suspected Dependent Adult Abuse" dated effective 10/2021, revealed in part, "...staff engaged ...in the care or treatment of adults...identify suspected cases of dependent adult abuse should be aware of the laws, the reporting responsibilities ...when and how to contact the appropriate authorities ... ...Mandatory reporters shall report and cooperate with the Iowa Department of Human Services in the reporting and in the investigation of dependent adult abuse ...For a suspected case of dependent adult abuse a Mandatory Reporter shall immediately make an oral report to the Iowa Department of Human Services ... "

The policy contained inaccurate information for reporting all allegations of dependent adult abuse within 24 hours to the Iowa Department of Inspections and Appeals and lacked a clearly defined procedure that addressed reporting, investigation, patient safety concerns, and follow up process to address investigation identified concerns.

2. Review of grievance report event ID 31801, report dated 12/12/22, revealed in part, "...Date of Event: 12/5/22, Details: Quality, Legal Services, and Nursing Executive was made aware on 12/6/2022 that this patient had voiced allegations of being raped while an inpatient on the Behavioral Health Unit ...Event Type: Alleged Abuse/Neglect ..."

The Department of Inspection and Appeals was notified 6 days after leadership became aware of the allegation of rape.

3. Review of Patient #1's medical record revealed on 11/2/22 at 2:43 PM, Psychiatrist A documented in part, " ...[Patient #1] whispered to me that someone has been sneaking into [their] bed at night and having sex with [them] ...fears ...being anally penetrated ..." and on 11/8/2022 at 4:48 PM Psychiatrist A documented in part " ... {Patient #1] fears [they] got pregnant last night when [they] had sex with a peer ..."

4. During an interview on 2/8/22 at 8:15 AM, Psychiatrist A, reported they did not think for a moment that the allegation was credible. Patient #1 was psychotic and periodically experienced delusions. Patient #1 also reported having had sex with current spouse and past spouses while hospitalized on the unit. Patient #1 had no visitors. Psychiatrist A reported patients are watched very closely. Staff know where patients are at all times and do every 15-minute checks, in addition the unit is small and patient activity is easily viewed. Psychiatrist A verbalized Psychiatrist A reported the allegation when instructed by hospital leadership. The hospital had been notified that Patient #1 reported the alleged rape to a social worker at the facility where Patient #1 now resided and the social worker reported Patient #1's allegation of rape while hospitalized in the behavioral health unit.

5. During an interview on 2/7/22 at 4:30 PM, RN B reported Patient #1 verbalized someone had come into their room last night and had sex. RN B reported there was no way that could have happened due to the close supervision that is provide, every 15-minute checks, and Patient #1's room was located directly across from the nurses' station. The patient (Patient #2) that Patient #1 identified did this, didn't even have any interactions with Patient #1. Patient #1 had not acted disturbed when they made the allegation, showed no emotion, it was just another statement. Patient #1 frequently made many statements that were clearly untrue. It was just part of Patient #1's illness. RN B acknowledged RN B did not report the allegation of abuse to their supervisor or other hospital leadership.

6. During an interview on 2/7/2023 at 3:49 PM, Social Worker (SW) C reported Patient #1 verbalized to SW C that someone had been in Patient #1's room and had sex with them. SW C didn't recall what day this had been. SW C reported Patient #1 had been delusional and made delusional statements on a regular basis. SW C reported staff watched patients very closely, the unit was a small 8 bed unit with clear and easy visualization from the nurses' station. SW C reported staff knew where patients were at all times so SW C did not consider this a credible allegation, but was part of Patient #1's illness. SW C reported that Social Worker C had been contacted by the SW at the facility Patient #1 resided, Patient #1 made and allegation of rape that had taken place in the Behavioral Health Unit and that they would be reporting the allegation per their policy. Social Worker C acknowledged Social Worker C did not report the allegation of abuse to hospital leadership.


7. During an interview on 2/9/2023 at 10:00 AM, the CNO, Director of Compliance, Director of Accreditation, and the Director of Quality acknowledged the hospital's dependent adult abuse policy contained inaccurate information and lacked clear guidance to staff on reporting of dependent adult abuse and the steps to follow once an allegation had been made to assure patient safety and meet all regulatory reporting requirements. The Director of Compliance and the CNO acknowledged the hospital did not report the allegation of rape within 24 hours of notification and had asked Psychiatrist A to report the allegation 6 days after leadership had been notified of the allegation.