HospitalInspections.org

The Condition of Participation for Governing Body has not been met.

Based on hospital documentation and staff interview, the Governing Body failed to ensure abuse allegations were handled according to hospital policy to ensure the safety of all patients. The finding includes:

The hospital had two (2) Immediate Jeopardy surveys for abuse on 3/2/22 and 5/4/22. Review of governing body meeting minutes dated 6/8/22 identified staff were educated to the hospital's abuse policies and procedures following the Immediate Jeopardy's, different scenarios related to abuse were discussed during unit huddles, and audits were initiated. The governing body minutes during the period of 7/13/22 through 7/26/23 failed to identify compliance was reviewed and/or discussed regarding abuse.

Review of email correspondence dated 7/16/23 at 11:43 PM from PCT #1 to the Director of Behavioral Health noted PCT #1 reported an allegation of sexual abuse indicating RN #5 was having intimate relations with patients both while admitted at the hospital and after discharge. The hospital failed to follow their abuse policy by removing the alleged employee from patient care and failed to conduct a comprehensive investigation in accordance with hospital polices. The alleged employee continued to work from 7/16/23 until surveyor inquiry on 10/11/23.

Interview with the Chief Quality and Safety Officer on 10/19/23 at 2:00PM identified QAPI minutes are reviewed at each advisory board meeting which are shared with the Governing Body; however, audits had concluded when the hospital determined goals were met.

The hospital failed to ensure sustained compliance with the submitted plans to correct the deficient practice placing patients at risk for further abuse.



Please cross reference A - 0145, Immediate Jeopardy under Patient Rights.

The Conditions of Participation for CFR 482.13 Patient Rights was not met.

The hospital failed to conduct a comprehensive investigation when notified on 7/16/23 that an employee had inappropriate interactions between him/herself and patients. The hospital failed to remove the alleged employee from patient care areas in accordance with hospital policy. The alleged employee continued to work (7/16/23 to 10/11/23) resulting in Immediate Jeopardy.

Please see A-145

Based on a review of facility documentation, hospital email and text correspondence, staff interviews, and policy review, for 1 of 3 sampled patients reviewed for abuse, the hospital failed to implement their abuse policy by removing a staff member from patient care when an allegation of abuse was made known to several staff members and failed to conduct a comprehensive investigation into the allegations in accordance with hospital policy. The employee continued to work for several months resulting in Immediate Jeopardy. The finding includes:


Patient #11 was admitted to the behavioral health unit on 4/25/23 for psychotic symptoms, paranoia, aggressive behaviors, and anxiety. Patient #11 was discharged from the behavioral unit on 5/2/23.

Text message correspondence dated 5/5/23 at 4:00 PM from RN #5 to PCT #1 noted RN #5 was going to see Patient #11.

Text message correspondence dated 5/6/23 at 8:15 PM noted a picture of Patient #11 and RN #5 in an embrace with a caption of "alive and well".

Text message correspondence dated 6/7/23 at 3:54 PM noted Patient #11 requested $30.00 from RN #5 through a cash application.

Review of email correspondence dated 7/16/23 at 11:43 PM from PCT #1 to the Director of Behavioral Health noted PCT #1 reported an allegation of sexual abuse indicating RN #5 was having intimate relations with patients both while admitted at the hospital and after discharge.

Text message correspondence between PCT #1 and RN #8 (nurse manager) dated 7/25/23 at 1:04 AM noted a picture of RN #5 with Patient #11 cheek to cheek.

Text message correspondence between PCT #1 and the Director of Behavioral Health dated 7/25/23 at 1:07 AM noted a screen shot from RN #5's phone stating she was driving out to see Patient #11 the next day and was nervous. Additionally, 5 pictures were sent of Patient #11 and RN #5 together.

Email correspondence dated 7/26/23 at 11:59 PM from PCT #1 to RN #6 noted PCT #1 reported an allegation of sexual abuse identifying RN #5 has had intimate relations with patients, was sending money to former patients, and inappropriate relations in patient rooms.

Email correspondence dated 8/24/23 at 8:02 AM from RN #6 noted "this is something I cannot be involved in, please reach out to the union or HR for further assistance."

Interview with PCT #1 on 10/11/23 at 10:18 AM stated that she reported to the HR staff and the Director of Behavioral Health on 7/16/23 that RN #5 was having inappropriate relations with Patient #11 both while the patient was in house and after discharge. PCT #1 stated that when she reported this to HR and the Director, she was told that she was only saying this out of retaliation because she was suspended. PCT #1 stated that she emailed or sent a text messages (including pictures of RN #5 and Patient #11) regarding RN #5 having inappropriate relations with Patient #11 to the Director of Behavioral Health, the RN Supervisor, HR and the nurse manager, but was never asked/ interviewed regarding the text or emails.

Interview with the Senior Lead Human Resource Business Partner on 10/11/23 at 1:50 PM stated that an email was forwarded to him by PCT #1 regarding allegations that RN #5 was having inappropriate relations with patients and staff. The Senior Lead stated that he had no part in the investigation because it was not his department. The HR lead stated that when an allegation is made it is to be "arced up to" Leadership, HR would become involved, and the staff person involved would be placed on administrative leave pending the investigation. The Senior lead stated that the person who did the investigation was unavailable, but he looked for any documentation regarding the allegation and could not find anything. He further stated that RN #5 was not placed on administrative leave when PCT #1 reported the allegations.

Interview with the Director of Behavioral Health on 10/11/23 at 2:20 PM stated he did receive an email from PCT #1 stating that RN #5 was having inappropriate interactions with patients and staff. The Director stated that he called RN #5 and asked if there was any truth to what was said, and RN#5 stated no. The Director stated that he reviewed video in the hallways and common areas and saw nothing inappropriate and at that point felt the RN didn't do anything inappropriate, so he closed the investigation. The Director stated that although the abuse policy identified a thorough investigation will be conducted, staff will be removed from patient care and the Chief Nursing Officer told him to place RN #5 on administrative leave, he felt because the nurse had called in sick, he could have the investigation completed before she returned to work, and RN #5 was not placed on leave. The Director further stated that due to the cyber-attack on the hospital all his documentation/ notes of what he looked at was not available.

Interview with RN #8 (nurse manager) on 10/11/23 at 2:40 PM stated that she received a text message/picture from PCT #1 on 7/25/23 with RN #5 and a male "cheek to cheek" and stated RN #5 was having relations with patients in patient rooms. RN #8 stated that she did not know who the other person in the picture was, so she went to the Director who advised her to go to HR. RN #8 stated that she contacted HR and discussed the allegations regarding RN #5 having inappropriate relations with a patient and was told that an investigation would be started.

Interview with RN #5 on 10/16/23 at 10:30 AM stated that the picture in the text messages that was sent to the Director of Behavioral Health, the nurse manager, and nursing supervisor was of herself with Patient #11. RN #5 stated that she did send money to the patient and met up with the patient one time after the patient was discharged but denied any intimate relations. RN #5 stated that she thought she could not have a relationship with a current patient but if they were discharged it was ok. RN #5 stated that she was unaware of the expected boundaries of the staff/patient relationship policy.

Interview with the Senior Lead HR Business Partner on 10/16/23 at 10:50 AM stated that he met with RN #5 who reported that when Patient #11 was being discharged, PCT #1 gave the patient money and talked about meeting up sometime. The Senior lead stated that RN #5 told him that the patient was flirty on the unit, she admitted to meeting up with Patient #11 but denied any sexual relations with the patient.

Interview with the Director of Behavioral Health on 10/16/23 at 12:08 PM stated that he deleted the text messages PCT #1 sent him. The Director stated that during the investigation one staff member stated they had heard of pictures being taken of staff and former patients and that there were text messages.

Interview with PCT #2 on 10/16/23 at 1:30 PM stated that she was aware of RN #5 going into Patient #11's room and kissing and touching the patient's private area. PCT #2 stated that RN #5 told her about it the night it occurred and would speak about it in general at the nursing station. PCT #2 stated that she didn't report it because she didn't make much of it and didn't think of it as abuse.

Interview with the DON on 10/17/23 at 11:35 AM stated that when the allegation of abuse was identified, she directed the Director of Behavioral Health to take the lead, follow the abuse policy, and complete the investigation. The DON stated that she was unaware of any email, texts or statements made by PCT #1 involving RN #5 and a previous patient about personal relationships until 10/11/23. The DON stated that when staff received the emails, texts or statements, the allegations should have been investigated and the RN should have been placed on administrative leave at that time. The DON further stated that RN #5 was placed on administrative leave on 10/11/23.

Review of the hospital Policy, Expected Boundaries of the Staff/Patient Relationship, identified staff is not to engage in the following behaviors with current or former patients, such as: sharing personal information, using personal phone while on duty including sharing of photos, personal texts, emails etc., meeting or corresponding with patients outside the work setting, intentionally touching the patient, including back rubs, holding hands or any other inappropriate physical behaviors.

Review of the hospital policy, Safe patient environment, free from abuse, neglect or harassment, identified any form of suspected abuse or harassment allegations regarding a patient will immediately be reported to a manager, supervisor, or director and as soon as the allegation is known in order to ensure the safety and well-being of those involved. The employee will be removed from patient care and patient care areas. This will remain in place until the investigation is complete. All allegations will be thoroughly and timely investigated.