HospitalInspections.org

Based on record review, interview and policy review, the hospital failed to ensure care was provided in a safe setting when a staff member was not removed from patient care when an allegation of sexual assault was verbalized by one discharged patient (#30) of two abuse allegations reviewed.

This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation (CoP): Patient's Rights.

Please refer to A-0144.

Based on observation, interview and policy review, the hospital failed to ensure policy was followed when:
- Staff failed to insert a urinary catheter (a small flexible tube inserted into the bladder to provide continuous urinary drainage) with aseptic technique (process that is intended to minimize contamination from pathogens) for one patient (#15) of one current patient observed;
- Staff failed to ensure intravenous catheters (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) were cared for and maintained per policy for eight (#5, #11, #12, #13, #15, #16, #17 and #23) of 13 current patients observed;
- Staff failed to create clean barriers for six (#11, #14, #19, #24, #26 and #50) of 10 current patients observed;
- Staff failed to perform hand hygiene for 10 (#13, #14, #15, #17, #18, #19, #22, #25, #49 and #50) of 15 current patients observed;
- Staff failed to clean the workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand, that can be moved from patient to patient) when providing care to seven (#11, #12, #13, #14, #17, #18 and #19) of eight current patients observed; and
- Three patient care staff members had long gelled fingernails.

This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation (CoP): Nursing Services.

Please refer to A-0398.

Based on interview, record review and policy review, the hospital failed to ensure care was provided in a safe setting when a staff member was not removed from patient care when an allegation of sexual assault was verbalized by one discharged patient (#30) of two abuse allegations reviewed.

Review of the hospital's policy titled, "Caregiver Misconduct, Patient Abuse, Neglect, Misappropriation of Property and Harassment," reviewed 02/10/25, showed:
- For the protection of patients and involved personnel, patient care providers involved in patient abuse, neglect or harassment must be relieved of patient care responsibilities and removed from patient care areas of the hospital during the pendency of a prompt investigation.
- The Administrative Supervisor will conduct a preliminary investigation to gather pertinent information to understand the allegation further and determine escalation.
- The Administrative Supervisor will notify the Administrator on Call (AOC) to discuss the allegation and findings of the preliminary investigation.
- The AOC, in consultation with the Administrative Supervisor, will determine if the individual will be placed on administrative leave or suspension.
- Any employee, contractor, volunteer or other personnel working in the patient care site who is accused of abuse, neglect or harassment of a patient by any source will immediately be removed from all patient care responsibilities anywhere in the hospital or patient care site, until the determination of administrative leave is made.

Review of the hospital's document titled, "Event Report," dated 05/01/25, showed:
- Staff WW, RN, was accused of sexually harassing Patient #30.
- Staff WW stated that he needed to assess the patient's bottom wounds, the patient became upset and accused Staff WW of sexual assault.
- Patient #30 stated that Staff WW just wanted to touch him and look at his butt.
- Staff WW stated that he never put his hand on the patient.
- When the patient became upset Staff WW left the room and called Staff MM, House Supervisor.
- At 9:00 PM, the patient used his call light and asked to speak to a supervisor.
- When the supervisor responded Patient #30 was very upset, would not state why he was upset, and he did not want Staff WW in his room.
- At 9:15 PM, Staff MM arrived in the patient's room and the patient alleged he refused to have his wounds looked at and Staff WW tried to pull his pants down.

Review of the hospital's document titled, "Event Review PER427798," dated 05/02/25, showed:
- On 05/01/25, the allegation was called into the on-call risk pager in the evening.
- The involved staff was removed from caring for the patient and a buddy system was implemented.
- A preliminary review included witness statements from all involved staff and the patient.
- On 05/02/25, a meeting was held with Human Resources Partner, Nurse Manager, Administrative Supervisor, Department Director, Risk Management Manager and Operations Vice President to discuss the preliminary information and agreed the event did not meet the definition of abuse.
- The allegation was unsubstantiated the day following the event, the alleged perpetrator (AP) continued to provide patient care for the remainder of his scheduled shift.

Review of Patient #30's medical record showed on 04/20/25, he was admitted to the hospital with hypokalemia (low potassium level in the blood), anemia (low amounts of oxygen rich blood, causes paleness and weakness), hypoalbuminemia (a condition where you have less-than-normal amounts of the protein albumin in your blood), cystitis without hematuria (inflammation of the bladder, usually caused by infection without presence of blood), dehydration (a condition caused by excessive loss of water from the body), hypomagnesemia (low magnesium level in the blood), leukocytosis (an increased number of white blood cells in the blood, especially during an infection), microcytic hypochromic anemia (a condition that impairs the blood's ability to carry oxygen efficiently, which can lead to fatigue and weakness) and chronic (long term, on-going) buttock and tailbone wounds. He was a paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease).

During a telephone interview on 10/22/25 at 12:06 PM, Staff MM, House Supervisor, stated that the nurse accused of sexual harassment called for assistance with de-escalation of the patient. The patient had a "really bad bottom wound." The nurse needed to assess the wound, the patient refused, and the patient alleged the nurse tried to pull his pants down. She questioned the patient if the nurse had placed his hands on him and he replied yes. She then told the nurse to stay out of the patient's room. She attempted to call the AOC twice without a return phone call. She spoke with a Risk Management representative and was told "to do what she needed to do." The charge nurse interviewed other patients of the nurse and there were no concerns voiced; those interviews were not documented. She called the floor's Team Leader, and the decision was made to allow the nurse to continue to work and to remove him from that patient. She wanted to send the AP home, but the Team Leader said it was "okay" to let him work. She was not aware at the time that the expectation was for the AP to be removed from patient care. This was the first time she had an experience with a patient allegation of abuse.

During a telephone interview on 10/22/25 at 1:05 PM, Staff OO, Risk Manager, stated that she became involved with the sexual abuse allegation the day after the event. She was not aware that the AP was not removed from patient care at the time of the allegation. Failure to remove the AP did not meet the hospital's expectations. The hospital tried to remove staff from patient care by placing them in a non-patient care role if possible. If a non-patient care role was not available, the AP was placed on administrative leave. The complaint was unsubstantiated the following day.

During an interview on 10/22/25 at 3:05 PM, Staff VV, Chief Nursing Officer (CNO), stated that she believed the suspension of a staff member with an allegation of abuse was a "gray area." The decision was based on what happened with the preliminary investigation and if the investigation was to be on-going. During off hours the House Supervisor and Charge Nurse with the added support of the AOC and Risk Management made the decision for removal of the staff member. She expected interviews were conducted with the patient, AP and witnesses. During the preliminary investigation the AP was to "hang out, not caring for patients," to determine the results of the preliminary investigation. If the investigation required more time the staff member was then sent home.

Based on observation, interview and policy review, the hospital failed to ensure policy was followed when:
- Staff failed to insert a urinary catheter (a small flexible tube inserted into the bladder to provide continuous urinary drainage) with aseptic technique (process that is intended to minimize contamination from pathogens) for one patient (#15) of one current patient observed;
- Staff failed to ensure intravenous catheters (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) were cared for and maintained per policy for eight (#5, #11, #12, #13, #15, #16, #17 and #23) of 13 current patients observed;
- Staff failed to create clean barriers for six (#11, #14, #19, #24, #26 and #50) of 10 current patients observed;
- Staff failed to perform hand hygiene for 10 (#13, #14, #15, #17, #18, #19, #22, #25, #49 and #50) of 15 current patients observed;
- Staff failed to clean the workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand, that can be moved from patient to patient) when providing care to seven (#11, #12, #13, #14, #17, #18 and #19) of eight current patients observed; and
- Three patient care staff members had long gelled fingernails.

Findings included:

Review of the hospital's undated document titled, "Skills Urinary Catheter-Indwelling Insertion (Female)," showed:
- If contamination or a break in sterile technique (specific practices and procedures used to create and maintain an area free from any microorganisms or pathogens) occurs before or during catheter insertion, discard the supplies and restart the procedure with a new catheter insertion kit.
- Take extra precautions to cover the rectal area with a drape during the procedure to reduce the risk of cross-contamination.
- Open the sterile (completely clean and free from germs) inner package containing the catheter supplies, using sterile technique.
- Slide the sterile drape with the plastic (shiny) side down under the patient's buttocks.
- Place the fenestrated sterile drape (a drape with an opening) over the perineum (the area between the anus and the scrotum or vulva).

Observation on 10/20/25 at 2:00 PM, in the Labor and Delivery Unit, showed Staff Q, RN, touched the backside of the urinary catheter sterile package when opening the kit prior to insertion of the urinary catheter with the contaminated glove for Patient #15. Staff Q failed to cover the patient's rectal area, place a sterile drape under the patient or over the perineum.

Review of the hospital's policy titled, "IV Medications, Fluids and Tubing," revised 11/12/24, showed:
- IV tubing should be labeled with date and time upon initiation for all admitted patients.
- IV tubing is to be aseptically maintained when disconnected by placing a new sterile cap on the end when not in use.
- Immediately prior to each use, the injection port will be aseptically cleansed with a friction scrub of at least five seconds for a peripheral line.

Review of the Center for Disease Control and Prevention, "Guidelines for the Prevention of Intravascular Catheter-Related Infections," dated 02/28/24, showed staff were to maintain aseptic technique for the insertion and care of intravenous catheters (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream).

Observation on 10/20/25 at 2:00 PM, on the Third Floor, showed Patient #5's IV tubing was not labeled with the start time and date.

Observation on 10/20/25 at 12:50 PM, in the Intensive Care Unit (ICU, a unit where critically ill patients are cared for), showed Patient #11's IV tubing was not labeled with the start time and date.

Observation on 10/20/25 at 1:20 PM, in the Step-Down Unit, showed Patient #12's IV tubing was disconnected from the patient and plugged into itself. Three IV tubings were not labeled with the start time and date.

Observation on 10/20/25 at 1:25 PM, in the Step-Down Unit, showed Patient #13's IV tubing was not labeled with start time and date.

Observation on 10/20/25 at 2:00 PM, in the Labor and Delivery Unit, showed Patient #15's IV tubing was not labeled with the start time and date.

Observation on 10/20/25 at 2:35 PM, in the Emergency Department (ED), showed Staff T, Registered Nurse (RN), wiped her gloved hand with the sanitizing scrub prior to cleaning patient #16's skin for an IV insertion.

Observation on 10/21/25 at 9:00 AM, on the Fourth Floor, showed Staff U, LPN, failed to scrub the hub prior to administering IV fluids to Patient #17.

Observation on 10/21/25 at 11:20 AM, in the Endoscopy (a procedure to examine the interior of a hollow organ or cavity of the body with a lighted tube with a camera) Unit, showed Staff EE, RN, wiped her gloved hand with the sanitizing scrub prior to cleaning patient #23's skin for an IV insertion.

Review of the hospital's policy titled, "Equipment and Electronic Cleaning," revised 11/21/24, showed:
- Cleaning of all equipment shall be done in a safe manner consistent with the type and intended use of the equipment and utilizing infection prevention and control principles to prevent the spread of potentially infectious organisms.
- Equipment and items used for patient care will be cleaned and disinfected.
- Items that come in contact with intact skin and those exposed to blood or other potentially infectious material must be cleaned with a hospital disinfectant.

Observation on 10/20/25 at 12:50 PM, in the ICU showed Staff J, RN, failed to establish a clean barrier prior to placing medications on patient #11's WOW.

Observation on 10/20/25 at 1:45 PM, in the Two East Unit, showed Staff P, RN, failed to create a clean barrier when she placed blood tubing on the WOW keyboard while she administered blood to Patient #14.

Observation on 10/21/25 at 9:40 AM, on the Third Floor, showed Staff Y, RN, failed to create a clean barrier when she placed Patient #19's medication on the WOW and sink counter.

Observation on 10/21/25 at 11:30 AM, in the Endoscopy Unit, showed Staff FF, RN, failed to create a clean barrier when she placed Patient #24's uncapped saline lock (a thin flexible tube placed into a vein used for fluid or medication or nutrition administration) tubing on the patient's blankets prior to an IV insertion.

Observation on 10/21/25 at 11:50 AM, on the Second Floor, showed Staff II, Nurse Extern, failed to create a clean barrier prior to placing a lancet (a small, pointed instrument used to make small cut for a blood sample) on Patient #26's bed prior to assessing her blood glucose (sugar).

Observation on 10/22/25 at 9:20 AM, on the Second Floor, showed Staff DD, Wound Nurse, failed to create a clean barrier when she placed Patient #50's wound care supplies on the sink counter. The supplies were stored in the room within the splash zone of the sink.

Review of the hospital's policy titled, "Hand Hygiene (washing hands with soap and water or alcohol-based hand sanitizer)," revised 07/24/24, showed SSM Health follows the Centers for Disease Control and Prevention (CDC) and the World Health Organization's (WHO) "Five Moments for Hand Hygiene," which include:
- Immediately before touching the patient and upon arrival to patient care areas;
- Before a clean/aseptic procedure;
- After body fluid exposure risk;
- After touching a patient; and
- After touching patient surroundings.
- Contact with patient objects (linens, equipment, furniture, etc.) is associated with hand contamination, even without having touched the patient.
- Perform hand hygiene before putting on gloves and upon removal of gloves.

Observation on 10/20/25 at 1:25 PM, in the Step-Down Unit, showed Staff N, RN, failed to perform hand hygiene between glove changes when she provided care to Patient #13.

Observation on 10/20/25 at 1:45 PM, in the Two East Unit, showed Staff P, RN, failed to perform hand hygiene and glove changes when she retrieved and returned a phone from her pocket when she provided care to Patient #14.

Observation on 10/20/25 at 2:00 PM, in the Labor and Delivery Unit, showed Staff Q, RN, failed to perform hand hygiene between glove changes when she provided care to Patient #15.

Observation on 10/21/25 at 9:00 AM, on the Fourth Floor, showed Staff U, LPN, failed to perform hand hygiene prior to entering Patient #17's room.

Observation on 10/21/25 at 9:20 AM, on the Fourth Floor, showed Staff V, Food Service Aide, failed to perform hand hygiene prior to entering Patient #17's room.

Observation on 10/21/25 at 9:00 AM, on the Fourth Floor, showed Staff W, Tray Passer, failed to perform hand hygiene prior to entering Patient #17's room.

Observation on 10/21/25 at 9:25 AM, on the Fourth Floor, showed Staff D, RN, failed to perform hand hygiene and glove changes when she retrieved and returned a phone from her pocket and removed an alcohol wipe from her pocket prior to administering IV medications to Patient #18.

Observation on 10/21/25 at 9:40 AM, on the Third Floor, showed Staff Y, RN, failed to perform hand hygiene and glove changes when she retrieved and returned a phone from her pocket three times while administering medications to Patient #19.

Observation on 10/21/25 at 11:10 AM, on the Second Floor, showed Staff DD, Wound Nurse, failed to perform hand hygiene and glove changes when she borrowed and returned a pen from Staff K, Surgical Services Director, for labeling the wound dressing on Patient #22.

Observation on 10/21/25 at 11:40 AM, on the Second Floor, showed Staff GG, RN, failed to perform hand hygiene and glove changes when she retrieved and returned a phone from her pocket when she provided care to Patient #25.

Observation on 10/22/25 at 9:05 AM, on the Second Floor, showed Staff DD, Wound Nurse, failed to perform hand hygiene and clean her pen before returning the pen to her pocket after marking the wound dressing for Patient #49.

Observation on 10/22/25 at 9:20 AM, on the Second Floor, showed Staff DD, Wound Nurse, failed to perform hand hygiene and clean her pen before returning the pen to her pocket after marking the wound dressing for Patient #50.

Review of the hospital's policy titled, "Equipment and Electronic Cleaning," revised 11/21/24, showed computer and accessories are considered dirty until cleaned by staff prior to
patient care. If staff touch contaminated computer or accessories, hand hygiene must be
done prior to patient contact.

Observation on 10/20/25 at 12:50 PM, in the ICU, showed Staff J, RN, failed to clean the WOW before and after touching Patient #11 and the WOW, while she administered medications.

Observation on 10/20/25 at 1:20 PM, in the Step-Down Unit, showed Staff M, RN, failed to clean the WOW before and after touching Patient #12 and the WOW, while she administered medications.

Observation on 10/20/25 at 1:25 PM, in the Step-Down Unit, showed Staff N, RN, failed to clean the WOW before and after touching Patient #13 and the WOW, while she administered medications.

Observation on 10/20/25 at 1:45 PM, in the Two East Unit, showed Staff P, RN, failed to clean the WOW before and after touching Patient #14 and the WOW, while she administered blood.

Observation on 10/21/25 at 9:00 AM, on the Fourth Floor, showed Staff U, Licensed Practical Nurse (LPN), failed to clean the WOW before and after touching Patient #17 and the WOW, while she administered medications.

Observation on 10/21/25 at 9:25 AM, on the Fourth Floor, showed Staff D, RN, failed to clean the WOW before and after touching Patient #18 and the WOW, while she administered medications.

Observation on 10/21/25 at 9:25 AM, on the Third Floor, showed Staff Y, RN, failed to clean the WOW before and after touching Patient #19 and the WOW, while she administered medications.

Review of the hospital's policy titled, "Hand Hygiene," revised 07/24/24, showed Artificial nails/nail products will not be worn by individuals having patient contact.

Observation on 10/21/25 at 9:00 AM, on the Fourth Floor, showed Staff U, LPN had long gelled fingernails.

Observation on 10/21/25 at 9:15 AM, on the Fourth Floor, showed Staff V, Food Service Aide, had long gelled fingernails.

Observation on 10/21/25 at 9:10 AM, on the Fourth Floor, showed Staff X, Nurse Manager, had long gelled fingernails.

During an interview on 10/22/25 at 3:05 PM, Staff VV, Chief Nursing Officer (CNO), stated that she expected staff to follow all policies and procedures. She expected IV tubing to be labeled with the start date and time. She was not surprised by the failed tubing labels; it was difficult to expect 100% compliance. When asked about barrier expectations she stated that it was a "gray area," she expected items to be placed within their packages and not placed in areas with clutter. She did not expect items to be stored near splash zones if they were not contained within a bin, paper packages were not to be stored in splash zones. She expected staff to follow the five moments of hand hygiene. She expected a urinary catheter to be inserted with aseptic technique and draped according to the hospital's policy. She expected the WOWs to be cleaned according to policy.