HospitalInspections.org

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Based on interview, document review, and review of hospital policy and procedures, the hospital failed to protect each patient's right to remain free from all forms of abuse.

Failure to protect from abuse places patients at risk for physical and psychological harm, serious injury, or death.

Findings included:

1. Failure to recognize and file grievances regarding allegations of assault.

Cross-reference: A0118

2. Failure to protect patients from sexual assault while on hospital property.

Cross-reference: A0145

Due to the scope of the deficiencies cited under 42 CFR 482.13, the Condition of Participation for Patient's Rights was NOT MET.
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Based on interview and document review, the hospital failed to implement its policy and procedure regarding the prompt resolution of patient grievances in 1 of 5 patient (Patient #1401) grievances reviewed.

Failure to promptly resolve patient grievances violates the patients' right to a timely and consistent internal grievance process and puts patients at risk for harm or abuse from unresolved concerns.

Findings included:

1. Document review of the hospital's policy titled, "Patient Care Grievances and Complaints Administration," revised 11/22/21, showed that formal or informal written or verbal complaints are categorized as "patient grievances" when the complaints are regarding abuse or neglect.

2. Review of hospital documentation showed that on 04/16/22, hospital staff reported that Patient #1401 requested to file a hospital complaint and a police report regarding an alleged sexual assault by an emergency department physician (Physician #1401). Patient #1401 reported her concerns to her nurse, charge nurse, and the house supervisor. The staff asked that the patient stay to talk with the police, and she agreed. However, Physician #1401 went back into Patient #1401's room after the allegation occurred. The patient told Physician #1401 to leave the room and he complied. Patient #1401 then left the hospital against medical advice, stating that she did not feel safe.

3. On 06/01/22 at 3:00 PM, Investigator #14 interviewed the Patient Satisfaction Coordinator (Staff #1403). Staff #1403 stated that the complaint was not a grievance because she tried to call the patient 6 times and never received a call back. When asked about providing a written response to the patient, Staff #1403 stated that she did not provide a written response because it was not a grievance. Staff #1403 also confirmed that there was no grievance in their internal system related to Patient #1401's complaint.

4. On 06/01/22 at 4:15 PM, Investigator #14 interviewed the Chief of Human Resources (Staff #1402) regarding the sexual assault complaint not being treated as a grievance. Staff #1402 stated that it was not a grievance because they couldn't get ahold of the patient by phone to receive her complaint. Investigator #14 then asked about the grievance policy that specified that an allegation of abuse was a grievance. Staff #1402 stated that they had not been able to confirm the allegation with the patient because she didn't answer her phone.
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Based on interview and document review, the hospital failed to develop and implement an effective system to ensure a safe environment that prevented sexual assault in 3 of 3 allegations reviewed (Patients #1401, #1402, & #1403) (1) and failed to report the allegations of sexual assault to authorities (2).

Failure to protect patients from sexual assault by implementing interventions to prevent sexual assault and reporting allegations of sexual assault to authorities violates patients' rights to be free from abuse and receive care in a safe environment.

Findings included:

ITEM #1 - Free from abuse

1. Document review of the hospital's policy titled, "Patient Care Rights and Responsibilities Administration," revised 11/22/21, showed that patients have the right to be free from abuse and receive care that ensures the assessment and management of their safety.

2. Document review of the hospital's policy titled, "Conduct- Medical Staff," revised 12/13/21, showed that sexual comments or inappropriate touching are examples of prohibited conduct.

During review of hospital medical records and documents, Investigator #14 noted the following:

Patient #1401

3. Medical record review showed that Patient #1401 was a 25-year-old female who presented to the Emergency Department for medical care on 04/16/22.

On 04/16/22, hospital staff reported that Patient #1401 requested to file a hospital complaint and a police report regarding an alleged sexual assault by an emergency department physician (Physician #1401). Patient #1401 reported her concerns to her nurse, charge nurse, and the house supervisor.

Patient #1401 reported to the hospital staff that Physician #1401 told her that she "has nice boobs" and then started feeling both of her breasts for a prolonged period of time.

The staff asked the patient to stay and talk with the police. Staff told the patient that the Physician #1401 was off duty, so she was safe, and the patient agreed. However, Physician #1401 went back into Patient #1401's room after the allegation occurred. The patient told Physician #1401 to leave the room and he complied. Patient #1401 then left the hospital against medical advice, stating that she did not feel safe.

a. Physician #1401 was removed from the schedule from 04/21/22-04/25/22 pending internal investigation. The internal investigation was determined to be inconclusive, and the physician was placed back on the schedule without restrictions beginning on 04/26/22.

b. On 05/06/22, the hospital was issued a search warrant and affidavit by law enforcement requesting information regarding 2 alleged sexual assaults involving Physician #1401. Patient #1401 and a second patient (Patient #1402) both alleged that they were sexually assaulted by Physician #1401 while seeking medical care in the emergency department (ED).

c. Hospital documentation showed that Physician #1401 continued to work his shifts in the ED after additional evidence was provided regarding Patient #1401's allegation and learning of Patient #1402's similar allegation. Physician #1401 worked until 05/11/22 when he was placed on leave for the second time pending investigation.

d. On 05/25/22 at 11:15 AM, Investigator #14 interviewed the Chief of HR (Staff #1402) regarding the Physician being allowed to work after a second allegation was presented by law enforcement. Staff #1402 stated that the threshold for a trend of allegations was 3 and they had 2. Physician #1401 was removed from the schedule following the hospital's notification of a third allegation. When asked about protecting patients from abuse, Staff #1402 stated that Physician #1401 was accused and not convicted.

Patient #1402

4. Medical record and video documentation review showed that Patient #1402 was a 43-year-old female who presented to the ED for medical care following a motor vehicle accident on 02/23/22 at 12:17 PM. Physician #1401 evaluated the patient at 12:25 PM. Physician #1401 determined that the patient had several trauma-related injuries including a pneumothorax (air leaking from the lung into the area between lung and the chest wall creating pressure so the lung cannot expand. A trauma-related pneumothorax typically requires a chest tube placement to release the air and allow the lung to re-inflate). The patient was given pain medication at 3:50 PM and a chest tube was inserted by Physician #1401. At 4:24 PM, Physician #1401 ordered the patient to be admitted to the hospital to receive further care for her injuries. At 5:43 PM, care for Patient #1402 was handed over to a general surgeon (Physician #1407) for management of the chest tube and trauma-related injuries. Physician #1401 relinquished care.

At 6:27 PM, Physician #1401 entered orders for additional pain medication, muscle relaxer, and an antianxiety agent called Midazolam (typically used to cause drowsiness, decrease anxiety, decrease a patient's memory of a medical procedure, and increase patient compliance with a medical procedure). The medications were given by the ED nurse at 6:38 PM. The patient was transferred to the inpatient medical-surgical unit at 6:50 PM.

At 8:00 PM, the Medical Surgical unit, where Patient #1402 was transferred to, becomes a locked unit (no visitors allowed, and doors are locked except for limited badge entry for staff). A locked unit is a common hospital policy to increase the safety and security of patients.

At 8:34 PM, video surveillance and badge access records showed Physician #1401 went upstairs and entered Patient #1402's room. At 8:39 PM, staff entered the room to check on the patient. At 8:40 PM, staff leave the room and keep the door ajar. At 8:42 PM, the motion-censored hallway camera showed the door to the patient's room completely shut. Physician #1401 leaves Patient #1402's room at 9:47 PM, an hour and 13 minutes after entering the room. The patient was discharged from the hospital on 02/25/22.

a. On 04/27/22, Patient #1402 filed a police report regarding her alleged sexual assault. On 04/28/22, Patient #1402 was interviewed by law enforcement. Patient #1402 reported to law enforcement that she was admitted to the hospital after a car accident on 02/23/22. After receiving care in the ED, she was transferred to the Medical Surgical unit so they could monitor her condition. The patient reported that she was in and out of consciousness after receiving several medications in the ED. Patient #1402 was sleeping in her room on the Medical Surgical unit when she woke up to Physician #1401 massaging her breasts and buttocks and then she went back unconscious. The patient regained consciousness again when the physician pulled her body to her left side and tried to put his penis in her hand. The patient reported that her chest tube and broken ribs were located on her left side and laying on her left side caused her significant pain. The patient then asked the physician a question and she said that he appeared surprised that she had woken up again. The patient fell back asleep and then woke up to Physician #1401's penis in her mouth and he ejaculated. He left her room shortly after.

b. Investigator #14 reviewed the hospital investigation conducted by human resources (HR). The hospital investigation showed the following:

i. On 04/28/22, the hospital was notified of Patient #1402's allegations of sexual assault.

ii. The hospital HR staff interviewed witnesses, reviewed security video, and reviewed the patient's medical record.

iii. On 05/12/22, an agency nurse (Staff #1402), assigned to Patient #1402 at the time of the alleged sexual assault, was interviewed. Staff #1402 stated that the doctor in the patient's room was sitting very close to the patient and not talking. Just awkward silence. At one point the patient was turned over towards the doctor. The doctor was there for a long time.

iv. On 05/12/22 and 05/20/22, the charge nurse (Staff #1409) on the medical surgical unit the night of the alleged assault was interviewed. Staff #1409 stated that he accompanied Physician #1401 to Patient #1402's room to evaluate the chest tube placement. Staff #1409 stated that Physician #1401 adjusted the wall suction setting. Staff #1409 thought it was unusual for an Emergency Department (ED) provider to be on the 2nd floor since the patients aren't assigned to the ED providers.

c. On 06/16/22, Investigator #14 reviewed Physician #1401's electronic medical record remote access. The remote access audit showed that Physician #1401 accessed Patient #1402's medical record remotely on 05/28/22 from 3:28 PM to 5:53 PM.

d. On 07/01/22, Investigator #14 interviewed the Director of Security (Staff #1406) regarding Physician #1401 accessing medical records while on leave pending an investigation of sexual assault. Staff #1406 confirmed that the Physician had accessed the patient's record without clinical need while on leave.

e. On 07/07/22 at 3:00 PM, Investigator #14 interviewed the Chief of Human Resources (Staff #1402) regarding Physician #1401's medical record remote access. Staff #1402 stated that the physician still had remote access to patient medical records because he was not terminated. The hospital terminated the physician's medical record access on 06/06/22, the day the hospital became aware of the alleged victim's chart being accessed. Staff #1402 confirmed that Physician #1401 had unrestricted access to the alleged victim's chart from the initial allegation on 04/16/22 to the day of discovery of medical record misconduct on 06/06/22.

Patient #1403

5. Medical record review showed that Patient #1403 was a 38-year-old female who presented to the ED for medical care on 01/20/22. The patient complained of an abscess on her buttock and intermittent light-headedness. Physician #1401 was assigned to provide care to Patient #1403. Physician #1401's initial physical exam documentation included a bedside ultrasound of the buttock and an additional bedside ultrasound of the heart.

a. On 03/16/22 and 03/22/22, Patient #1403 mentioned to law enforcement that Physician #1401 sexually assaulted her but was unable to provide further details due to her medical condition at the time.

b. On 05/11/22, the hospital was notified of Patient #1403's allegation of sexual assault against Physician #1401.

c. On 06/07/22, Patient #1403's medical condition had resolved, and law enforcement conducted an interview. In the interview, Patient #1403 stated that on 01/20/22, Patient #1403 was seen in the ED for an abscess on her buttock. Physician #1401 performed an ultrasound on the patient's buttock and then did one on her chest as well. After the ultrasound on her chest, the physician made a comment about the appearance of her breast and began fondling both of her breasts in a cupping and squeezing motion for a prolonged period of time. The physician then asked the patient about breast implants and asked if she wanted to go out sometime. He then gave her his phone number. About a week later, Physician #1401 called the patient on her phone and asked her to come back in for a check-up, for which she declined.

d. Review of the hospital video documents showed the following:

i. On 01/20/22 at 9:12 PM, Physician #1401 entered Patient #1403's room alone. The physician conducts an ultrasound of the abscess on the patient's buttocks. The physician then unclasped the patient's bra and uses the ultrasound between the patient's breasts for approximately 50 seconds. The physician is then observed massaging the patient's breasts for approximately 3 minutes.

ii. At 10:23 PM, Physician #1401 writes something on a paper towel and hands it to the patient.

iii. At 11:40 PM, Physician #1401 reaches under the patient's gown and appears to unclasp her bra again. He then proceeds to squeeze and knead the patient's breasts for approximately 3 minutes. The patient is discharged home shortly afterwards.

6. In summary, the hospital put additional patients at risk of being sexually assaulted by allowing Physician #1401 to continue to practice. Hospital leadership gained knowledge of law enforcement's active criminal investigations with at least 2 separate allegations but allowed Physician #1401 to practice medicine unrestricted at the hospital. Once removed from the schedule, the hospital did not remove Physician #1401's remote medical record access. Subsequently, the physician accessed alleged victims' medical records without merit while on leave pending investigation.

ITEM #2 - Mandatory Reporting to Outside Agencies

1. Document review of the hospital's policy titled, "Patient Care Recognizing and Reporting Abuse Administration," revised 12/06/21, showed that an accusation of sexual assault occurring on hospital property should be reported within 48 hours or immediately as needed.

2. Document review of the hospital's policy titled, "Conduct- Medical Staff," revised 12/13/21, showed that sexual comments or inappropriate touching are examples of prohibited conduct. The policy also showed that a physician placed on leave pending an investigation shall have their license reported to the Washington Department of Health within 15 days.

3. On 05/25/22 at 9:30 AM, Investigator #14 interviewed the Chief of Human Resources (Staff #1402). Staff #1402 reported that the allegation occurred on a Saturday, and she called law enforcement on the following Monday to confirm that they were aware of the allegation.

a. On 06/02/22 at 4:00 PM, Investigator #14 interviewed the lead detective (Detective #1405) regarding Patient #1401's allegation. Detective #1405 could find no record of a call from the hospital to report a sexual allegation. The detective also reviewed case report narratives for a statement from hospital leadership but no statement was found.

4. On 06/01/22 at 12:56 PM, Investigator #14 interviewed the Director of Quality (Staff #1404). Staff #1404 confirmed that the physician's license was not reported within 15 days of him being placed on leave on 04/26/22 or 05/11/22, pending investigation.
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Based on interview, document review, and review of hospital policies and procedures, the hospital failed to ensure that patient safety incidents were reported into the incident reporting system for 2 of 3 events reviewed (1) and failed to include incidents that were reported in the incident reporting system in performance improvement activities (2).

Failure to ensure timely reporting of patient safety events limits the hospital's ability to implement measures that prevent or mitigate future patient harm.

Findings included:

Item #1- Internal Incident Reporting

1. Document review of the hospital's policy titled, "Safety Event Management System Administration," revised 12/06/21, showed the following:

a. The Safety Event Management (SEM) System is a comprehensive strategy and collection of online event reporting and tracking tools used to reach zero harm.

b. Alleged sexual assault is a reportable event.

2. Document review of the hospital's policy titled, "Patient Care Grievances and Complaints Administration," revised 11/22/21, showed that if a concern cannot be resolved within the department, the employee or supervisor should report it by submitting the information through the SRM (Safety Risk Management) system.

3. On 05/25/22, Investigator #14 and Investigator #2 requested and received hospital incident reports from 01/01/22 to 05/25/22. The document was labeled "Surveyor Log" and included 18 incidents filed between 01/01/22 and 05/25/22. The Patient #1401's complaint that was filed on 04/16/22 was not found in the list of incident reports provided by the hospital. The additional 2 alleged sexual assaults were also not listed in the 18 incidents provided.

4. On 05/25/22 at 9:50 AM, Investigator #14 and Investigator #2 interviewed the Chief of Human Resources (HR) (Staff #1402). Staff #1402 stated that there was only 1 allegation of sexual assault, and it was communicated by email, not in the incident reporting system. Staff #1402 provided the email of incident to the investigators for review.

5. On 05/26/22 at 1:25 PM, Investigator #14 interviewed local law enforcement (Detective #1405) regarding sexual allegations occurring at the hospital. Detective #1405 stated that there were 3 separate sexual assault allegations against Physician #1401. Detective #1405 provided copies of search warrants regarding 2 of these incidents served to the hospital on 04/18/22, 05/06/22, and 05/11/22. Detective #1405 also reported that they obtained additional information regarding Patient #1403 on 05/10/22 and verbally reported it to the hospital.

6. On 06/02/22 at 9:15 AM, Investigator #14 and Investigator #2 interviewed the Director of Security (Staff #1406). Staff #1406 confirmed that the hospital had received 2 reports of sexual assault by 05/06/22 and received a verbal report and name of the 3rd patient by 05/10/22.

7. On 06/02/22, Investigator #14 and Investigator #2 were shown an additional list of incident reports from 01/01/22 to present. This additional list included a separate incident report category referred to as Disruptive Providers and Patient #1401's complaint was found on this list.

8. On 06/02/22 at 11:52 AM, Investigator #14 and Investigator #2 interviewed the Chief of HR (Staff #1402). Staff #1402 confirmed that Patient #1401's incident was entered into the incident reporting system on the day of the event and then moved to the Disruptive Provider's subsection. Staff #1402 also confirmed that the other 2 patients were not in the incident reporting system or disruptive provider subsection.

9. On 06/02/22 at 11:30 AM, Investigator #14 and Investigator #2 interviewed the Patient Satisfaction Coordinator (Staff #1403). Staff #1403 was asked why the other 2 patients weren't in the incident reporting system. Staff #1403 stated that the other 2 patients had not complained directly to the hospital and that she had not received any complaints filed by staff or leadership regarding the additional cases.

Item #2- Incident Categorization

1. Document review of the hospital's policy titled, "Safety Event Management System Administration," revised 12/06/21, showed the following:

a. Safety events will be reviewed, categorized, and assigned for follow-up.

b. The safety event system provides information to assist with proactive processes to prevent reoccurrences.

c. The safety event system prevents future harm by identifying the parts of the organizational culture that contributed to the event.

d. Aggregate review of serious safety events (SEM reports) promotes safety through identification of trends

e. The Serious Safety Events Committee reviews individual reports related to patient safety as well as trends monthly to monitor progress.

2. On 06/02/22, Investigator #14 and Investigator #2 were shown an additional list of incident reports from 01/01/22 to present. This additional list included a separate incident report category referred to as Disruptive Providers and Patient #1401's complaint was found on this list.

3. On 06/02/22 at 11:52 AM, Investigator #14 and Investigator #2 interviewed the Chief of HR (Staff #1402). Staff #1402 confirmed that Patient #1401's incident was entered into the incident reporting system on the day of the event and then moved to the Disruptive Provider's subsection.

4. On 06/01/22 at 1:40 PM, Investigator #14 and Investigator #2 interviewed the Director of Quality (Staff #1404). Staff #1404 confirmed that reports in the safety event system regarding physician misconduct are reclassified as disruptive provider events and excluded from the quality program.
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Based on record review, interview, and document review, the hospital failed to ensure that the medical staff rules and regulations were followed.

Failure to follow medical staff conduct requirements regarding sexual assault puts patients at risk for violations of their right to be free from abuse.

Findings included:

1. Document review of the hospital document titled, "Professional Emergency Department Services and Medical Director Agreement," signed 06/2019, showed that all contracted emergency deparetment (ED) providers will abide by the Medical Staff Bylaws, policies, rules, and regulations and all district policies.

2. Document review of the hospital document titled, "Olympic Medical Center, Bylaws- Medical Staff," revised 01/19/22, showed the following:

a. Hospital leadership has the authority to suspend all or any portion of a provider's clinical privileges when the reported behaviors are warranted as defined in the Medical Staff Conduct policy.

b. A provider suspension pending investigation is referred to as a precautionary suspension and does not imply responsibility for the allegation but is a step in the professional review process.

c. The Medical Executive Committee shall review the matter that resulted in a precautionary suspension within 14 days, unless there are unusual circumstances, to determine if a recommendation is warranted or if the investigative process should continue.

3. Document review of the hospital document titled, "Olympic Medical Center, Conduct - Medical Staff," revised 12/13/21, showed the following:

a. Prohibited behavior includes sexual comments or innuendo and inappropriate sexual touching.

b. Perceived incidents of disruptive behavior should be reported in the hospital's event reporting system.

c. The perceived disruptive behavior will be forwarded to Human Resources (HR).

d. Medical staff will adhere to the hospital's Code of Conduct, Sexual Harassment, and Progressive Discipline polices.

4. Document review of the hospital policy titled, "Progressive Discipline," policy number 7.05, reviewed 05/29/20, showed the following:

a. A critical offense includes an act of sexual harassment such as sexual abuse of a patient or assault anywhere on the hospital property.

b. A first offense at the critical level includes suspension, investigation, and/or discharge.

c. A suspension may be used while awaiting the outcome of an external matter such as a pending action by a court. This type of suspension might be for a considerable amount of time pending the outcome of the external matter.

Hospital documentation showed the following:

5. On 04/16/22, the hospital received a patient complaint alleging that she was sexually assaulted by Physician #1401 while seeking medical care.

a. Physician #1401 was placed on an unspecified type of leave and asked not to work his shifts on 04/21/22 through 04/25/22, pending the conclusion of the HR investigation.

b. The HR investigation was completed on 04/25/22 and reported as inconclusive. Physician #1401 was placed back on the schedule on 04/26/22.

c. On 05/06/22, a search warrant and accompanied affidavit were served to the hospital by law enforcement regarding 2 allegations of sexual assault involving Physician #1401.

d. Hospital documentation showed that Physician #1401 worked his shifts in the ED on 05/08/22-05/10/22.

c. Hospital documentation showed that Physician #1401 was placed back on an unidentified type of leave on 05/11/22 pending investigation.

6. On 05/25/22 at 1:10 PM, Investigator #14 and Investigator #2 interviewed the Medical Staff Specialist (Staff #1415). Staff #1415 reported that the investigation regarding Physician #1401's conduct remained in HR and that the Medical Staff Bylaws process had not yet been initiated but would be when they received the investigative report from HR.

7. On 06/01/22 at 2:36 PM, Investigator #14 and Investigator #2 interviewed the Chief Medical Officer (CMO) (Physician #1416) in regard to the Medical Staff Bylaws review process not being initiated within 14 days of the allegation of sexual assault. Physician #1416 confirmed that The Medical Staff Bylaws review process had not been initiated. Physician #1416 stated that the Medical Executive Committee only reviewed allegations that HR had proven. When further questioned regarding the Bylaws specifying that the Medical Executive Committee determined whether there's sufficient evidence or if the investigation should continue, Physician #1416 reiterated that the allegations had not been proven.
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