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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.11 Compliance with Federal, State, and Local Laws was out of compliance.

A-0021 - The hospital must be in compliance with applicable Federal laws related to the health and safety of patients. Based on document review and interviews, the facility failed to report occurrences to the Department and law enforcement as required by state statute. Specifically, the facility failed to report occurrences of physical abuse and sexual abuse.

Based on document review and interviews, the facility failed to report occurrences to the Department and law enforcement as required by state statute. Specifically, the facility failed to report occurrences of physical abuse and sexual abuse.

Findings include:

Facility policy:

The Occurrence/Critical Incident Reporting to External Agencies policy read, a critical incident is any significant event or condition that must be reported within twenty-four (24) hours to the Department that is of public concern and/or has jeopardized the health, safety and/or welfare of individuals.

Reference:

The Health Facilities and Emergency Medical Services Division (HFEMSD) Occurrence Reporting Manual (2018), retrieved from https://drive.google.com/file/d/14h1U8zVP59HM9pusTeN08hjhRCGJsb63/view read, any occurrence involving physical abuse of a patient or resident, as described in Section 18-3-202, 18-3-203, and 18-3-204...C.R.S., by another patient or resident, an employee of the facility, or a visitor to the facility." Section 25-1-124(2)(d), C.R.S. Two elements needed: Intent, or, knowingly or recklessly, and, bodily injury and/or serious bodily injury, and/or unreasonable confinement or restraint.

Any occurrence involving sexual abuse of a patient or resident, as described in section...18-3-402, 18-3-403, 18-3-404, or 18-3-405 C.R.S., by another patient or resident, an employee of the facility, or a visitor to the facility." Section 25-1-124 (2)(d) C.R.S. Three elements needed: Knowingly, and, consent not given, and sexual intrusion or penetration or, touching intimate parts or the clothing covering the intimate parts or, examiners or treats resident/patient for other than bona fide medical purposes or, observes or photographs another person's intimate parts or, physical force/threat.

In addition to the report to the department for an occurrence described in paragraph (d) of subsection (2) of this section, the occurrence shall be reported to a law enforcement agency. Section 25-1-124 (8) C.R.S.

It is the allegation of the event, not the outcome of the provider's investigation, which makes it reportable.

1. The facility failed to ensure occurrences were reported to the Department and law enforcement as required by state statute or regulation.

a. Review of the adverse event log revealed occurrences of physical and sexual abuse. Examples included:

i. Review of the adverse event log revealed on 10/12/24 at 4:10 p.m., a patient suddenly pushed a peer to the ground as they passed by one another.

ii. Review of the adverse event log revealed on 10/30/24 at 9:20 p.m., a patient kicked a peer in the groin which caused the peer to groan.

iii. Review of the adverse event log revealed on 11/24/24 at 3:40 p.m., a patient reported a peer touched them on the leg which made them uncomfortable. The peer also attempted to touch the peer's chest without contact.

iv. Review of the adverse event log revealed on 11/25/24 at an unspecified time, a patient slapped a peer on the buttocks.

b. Review of the state agency's occurrence reporting database on 1/13/25 revealed no occurrences were reported for the events of 10/30/24, 11/24/24 and 11/25/24. When requested, the facility was unable to provide evidence of law enforcement notification for the event which occurred on 10/12/24.

This was in contrast to the HFEMSD Occurrence Reporting Manual which read any occurrence involving physical abuse of a patient by another patient should have been reported if two elements were met: Intent, or, knowingly or recklessly, and, bodily injury and/or serious bodily injury, and/or unreasonable confinement or restraint had occurred.

Any occurrence involving sexual abuse of a patient by another patient should have been reported if three elements were met: Knowingly, and, consent not given, and sexual intrusion or penetration or, touching intimate parts or the clothing covering the intimate parts.

c. On 1/15/25 at 2:37 p.m., an interview was conducted with behavioral health technician (BHT) #2. BHT #2 stated the registered nurses or the manager reported occurrences to the police. BHT #2 stated they followed patient precautions and helped reinforce boundaries the patients needed to ensure safety on the unit.

d. On 1/15/25 at 10:43 a.m., an interview was conducted with milieu manager (Manager) #1. Manager #1 stated they reported any physical or sexual assault to the police, regardless of whether it actually happened.

e. On 1/16/25 at 9:02 a.m., an interview was conducted with director of risk management (Director) #3. Director #3 stated alleged sexual, physical, or verbal abuse as well as neglect constituted a reportable critical incident. Director #3 stated staff notified them when incidents happened and ensured law enforcement received the report immediately and the state agency received the report within 24 hours.

Director #3 stated they were unsure why the incident on 10/12/24 at 4:10 p.m. was not reported to law enforcement as required by state statute. Director #4 stated they reported the incident on 10/30/24 to law enforcement, but not to the Department because their investigation revealed the patients did not have malicious or sexual intent, despite the kicked patient who moaned in pain. Director #3 stated they reported the incident on 11/24/24 to law enforcement, but not to the Department because the peer touched the patient just above the knee, despite the patient complaining the touch (and the attempted touch of their breast) made them feel uncomfortable. Director #3 stated they reported the incident on 11/25/24 to law enforcement, but not to the Department because their investigation revealed there was no intent to sexually assault the patient.

This was in contrast to the Occurrence/Critical Incident Reporting to External Agencies policy which read, a critical incident was any significant event or condition that must be reported within twenty-four (24) hours to the Department that was of public concern and/or jeopardized the health, safety and/or welfare of individuals.

Additionally, this was in contrast to the guidance of the HFEMSD Occurrence Reporting Manual (2018) which read, it was the allegation of the event, not the outcome of the provider's investigation which made it reportable.