HospitalInspections.org

Based on document review, Medical Record (MR) review and interview the facility did not comply with the Condition of Participation for Governing Body.
This was evident by the Governing Body's failure to investigate allegations of abuse, mistreatment and neglect. The Governing Body failed to assume responsibility for ensuring that the facility's Risk Management department conducted thorough and timely implementation of their Policies to investigate all allegations of sexual abuse and provide a review of these investigations.

As a result, patients were placed at risk for harm.

Findings include:

During an Allegation Survey on 02/07, 02/11, 02/12, 02/13/ 02/14 and 02/18/2020, an IJ situation was identified for the facility's failure to protect multiple patients who alleged staff members of abuse, including sexual abuse, over a twelve-month period.

Patient #1 alleged sexual assault in January 2019 which was not thoroughly investigated by the facility's Risk Management department and subsequently two additional patient complaints (Patient #27 and #28) of staff abuse were not investigated as per the facility's implementation of the "Patient Abuse, Mistreatment, Neglect," "Survivors of Sexual Assault who are under the supervision of the hospital (inpatients)," "Reporting Occurrence," and "Incident Management Program" Policies last revised April 2019.

Risk Management failed to review the care and responses rendered to these patients. As a result, problems in these reports were not identified and appropriate corrective measures were not implemented therefore placing patients at risk.

During the survey, the findings identified non-compliance with the Condition of Participation for Patient Rights. (See Tag A 115)

The Governing Body failed to ensure that an immediate and thorough investigation was conducted regarding allegations of abuse and to ensure that Risk Management assessed, analyzed, identified areas for improvement and then implemented corrective actions to prevent a recurrence which placed all patients at risk for physical and psychological harm. (See Tags A 145)

Based on Medical Record (MR) review, document review and interview, in 3 (three) of 3 (three) cases reviewed, the facility failed to protect patients from potential abuse and neglect. (Patients #1, #27 and #28).
This was evident in the facility's failure to: (1) separate alleged perpetrators from patients and conduct an immediate, thorough investigation of allegations of abuse when patients complained and (2) Report, analyze, review, and monitor incidents of alleged abuse to identify possible patterns and trends.

These failures placed patients at risk for harm.

Findings pertinent to 1:

Review of Patient #1's MR identified the following: On 1/18/19 the patient reported a possible allegation of sexual assault to the facility staff (Nurses and Physician). The facility staff failed to interview the patient, other patients, all staff identified on duty the night of the alleged allegation, and to separate potential staff from patient care responsibilities then conduct an immediate and thorough investigation.

Review of the investigative documentation and staff schedules revealed, potential staff members and patients were not interviewed or removed from patient contact, and an immediate comprehensive investigation was not completed.

Per interviews of Staff H (Associate Director of Risk and Quality Improvement -Psychiatry) and Staff I (Assistant Director of Risk Management- Psychiatry) on 2/13/20 at 1:32PM, they both confirmed that the first interviews of the nursing staff involved in the patient's care wasn't conducted until 3/23/19, three months after the patient alleged she was possibly sexually assaulted. They also confirmed that the staff on tour during the alleged period was never removed from patient care responsibilities and that the patient, other patients and staff were never interviewed regarding the allegation.


On 5/23/19, Patient #28 a 37-year-old male admitted on 5/20/19, reported via voicemail, an allegation of sexual assault to the Sexual Assault Victims Intervention (SAVI) line. He stated that while he was in the facility's Emergency Department, a cleaning staff member grabbed his genital area.

Review of the MR and Occurrence Reporting form revealed a nursing supervisor reported the allegation to a physician who saw the patient on 5/24/19. There is no documented evidence the facility interviewed all potential staff or removed potential staff from patient contact or conducted a thorough investigation of this allegation.

Per interview of Staff K (Associate Executive Director of Risk Management) on 2/13/20 at 11:06AM, the staff member confirmed that the process for investigation of sexual assault was not followed for this patient.


On 10/30/19 at 9:30AM, Patient #27 an 81-year-old woman, reported to the facility's Patient Relations Department and alleged that on Tuesday 10/15/19, while in the Emergency Department's (ED) observation unit, room #2 (two), she "woke up to find a male nurse touching her breast nipple in a circular motion."

Review of the investigative report and staffing schedules on 2/13/20 at 3:00PM, noted that on 11/8/19, eight to nine days after the patient made the complaint, all staff members identified on duty the night of the alleged allegation were not interviewed by the administrative and risk management staff.

Review of the Staffing schedules revealed that Staff P and Staff Q, the two male nurses on duty on the night of the alleged assault, continued providing care to other patients without interruption.

Per interview of Staff J (Associate Executive Director of the ED), and Staff K (Associate Executive Director of Risk Management) on 2/13/20 at 3:22 PM. They both confirmed that the staff members were never removed from providing care to other patients before a conclusion was reached.

The facility policy and procedure (P&P) titled "Survivors of sexual assault who are under the supervision of the hospital (inpatients)," last revised April 2019, contained the following statements: "Reports of sexual assault will be given priority status, investigated thoroughly and promptly, and if warranted, receive services from the hospital's Sexual Assault Response Team."

The facility policy and procedure (P&P) titled "Patient Abuse, Mistreatment, Neglect," last revised March 2019, stated that "It is the responsibility of the Hospital to document, investigate and follow-up on all reported allegations of patient physical abuse, mistreatment or neglect."

Both policies however, lacked guidance for the separation and the removal of alleged staff from patient care responsibilities until a thorough investigation is completed

Findings pertinent to 2:

On 1/18/19, Patient #1 reported to the facility's staff (Nurses and Physician), that she believed somebody sexually assaulted her and requested to be examined and evaluated for sexual assault.

Per review of the Patient Safety Committee Meeting minutes, dated January 2019 to February 2020, there was no documented evidence that this allegation was reported to the facility's hospital wide patient safety committee for analysis or review and there was no monitoring of the data to identify possible patterns and trends with incidences related to sexual assault.

Similar findings of failure to report, analyze, review and monitor allegations of sexual assault were identified for patient #'s 27 and 28.

The facility policy and procedure (P&P) titled "Reporting Occurrence," last revised February 2018, stated that "The Risk Manager will review all occurrences, request additional investigational reports of appropriate staff, where necessary, interview witnesses if needed, and enter the report follow up in the Occurrence Reporting Database."

The facility policy and procedure (P&P) titled "Incident Management Program," last revised February 2019, contained the following statements: " this policy is to ensure an integrated and comprehensive strategy for identifying, documenting, reporting and investigating individual incidents on a timely basis; reviewing individual incidents to identify appropriate preventive or corrective actions, identifying incident patterns and trends through the compilation and analysis of incident data; reviewing incident patterns and trends to identify appropriate preventive or corrective actions and implementing preventive and corrective action plans; monitoring incident management practices."

Based on Medical Record (MR) review, document review and interview, in 3 (three) of 3 (three) cases reviewed, the facility failed to protect patients from potential abuse and neglect and effectively implement the facility's " Patient Abuse, Mistreatment, Neglect" Policy to by investigating allegations of abuse and neglect. This was evident when patients complained of being abused by staff and the staff failed to implement the required procedures including: (1) separation of alleged perpetrators from patients and (2) Report, analyze, review, and monitor incidents of alleged abuse.

These failures potentially place patients at risk of harm.

Findings pertinent to (1)

Review of MR for Patient #1 dated 1/18/19 at 1:43 AM, a physician noted Patient #1 was yelling, disruptive unable to verbally calm down by staff and required the use of medication.
At 2:04 AM and 4:28 AM, Staff N (Registered Nurse) documented the patient woke up very upset threatening staff and reported that someone was in her room.
Staff O (Registered Nurse), at 6:24 AM on 1/18/19, documented that the patient was observed "talking to self and asking staff about rape kit."

There was no documented evidence that the patient was interviewed or that these complaints were escalated or reported to oncoming staff.

On 1/18/19 at 1:20 PM, seven hours after the patient asked staff about a rape kit, Staff V (Resident Physician) noted the patient self-reported that she "believes somebody sexually assaulted her and requested to be examined and evaluated for sexual assault."

Review of the investigative documentation and staff schedules revealed, potential staff members and patients were not interviewed or removed from patient contact, and an immediate comprehensive investigation was not completed.

Although staff (Registered Nurses) were aware of the allegations at the time of occurrence, the investigation and escalation to Leadership were not implemented as per the Policy until seven hours after the patient complained and asked staff about a rape kit. There is no documented evidence that the allegations were investigated at the time of the occurrence.

A review of the investigative report, staffing schedules and interviews of Staff H and Staff I, on 2/13/20 at 1:32 PM revealed the facility's Psychiatry Risk Management and Quality team failed to interview the patient involved in the allegation, potential staff members, and other patients present at the facility around the date and time the alleged incident occurred.

During interview of Staff H and Staff I, on 2/13/20 at 1:32 PM, they both confirmed the first interviews of the nursing staff involved in the patient's care wasn't conducted until 3/23/19, three months after alleged sexually assault occurred. They acknowledged that a thorough investigation should have been conducted sooner.

On 5/23/19, Patient #28 a 37-year-old male admitted on 5/20/19, reported via voicemail, an allegation of sexual assault to the Sexual Assault Victims Intervention (SAVI) line. He stated that while he was in the facility's Emergency Department, a cleaning staff member grabbed his genital area.

Review of the MR and investigative documents revealed a nursing supervisor reported the allegation to a physician who saw the patient on 5/24/19. There is no documented evidence the facility interviewed all potential staff, removed potential staff from patient contact or conducted a thorough investigation of this allegation.

Per interview of Staff K (Associate Executive Director of Risk Management) on 2/13/20 at 11:06 AM, the staff member confirmed that the process for investigation of sexual assault was not followed for this patient.


On 10/30/19 at 9:30AM, Patient #27 an 81-year-old woman, reported to the facility's Patient Relations Department and alleged that on Tuesday 10/15/19, while in the Emergency Department's (ED) observation unit, room #2 (two), she "woke up to find a male nurse touching her breast nipple in a circular motion."

Review of the investigative report and staffing schedules on 2/13/20 at 3:00 PM, noted on 11/8/19, nine days after the patient made the complaint, Staff P, (a male Registered Nurse) assigned to the patient, and Staff R (a female Nurse Practitioner) were the only staff members interviewed by the facility's Administrative staff and Risk Management.

The facility failed to interview Staff Q, (the other male nurse on duty that night) and Staff S (the other female Nurse Practitioner) assigned to the unit the night of the alleged assault.

Review of the Staffing schedules revealed that Staff P and Staff Q, the two male nurses on duty on the night of the alleged assault, continued providing care to other patients without interruption.

Per interview of Staff J (Associate Executive Director of the ED), and Staff K (Associate Executive Director of Risk Management) on 2/13/20 at 3:22 PM. They both confirmed that the staff members were never removed from providing care to other patients before a conclusion was reached.

The facility policy and procedure (P&P) titled "Survivors of sexual assault who are under the supervision of the hospital (inpatients)," last revised April 2019, contained the following statements: "Reports of sexual assault will be given priority status, investigated thoroughly and promptly, and if warranted, receive services from the hospital's Sexual Assault Response Team."

The facility policy and procedure (P&P) titled "Patient Abuse, Mistreatment, Neglect," last revised March 2019, stated that "It is the responsibility of the Hospital to document, investigate and follow-up on all reported allegations of patient physical abuse, mistreatment or neglect."

However, both policies lacked guidance for the separation of alleged persons, and the removal of alleged staff from patient care responsibilities until a thorough investigation is completed.

Findings pertinent to (2)

On 1/18/19 At 1:20 PM, Patient #1 reported to Staff V, that she "believes somebody sexually assaulted her and requested to be examined and evaluated for sexual assault."

Per review of the Patient Safety Committee Meeting minutes January 2019 to February 2020, there was no documented evidence that this allegation was reported to the facility's hospital wide patient safety committee for analysis, review and monitoring of the data to identify possible patterns and trends with incidences related to sexual assault.

Similar findings of failure to report, analyze, monitor and identify possible patterns and trends with incidences related to sexual assault were noted for patient # 27 and # 28.


The facility policy and procedure (P&P) titled "Reporting Occurrence," last revised February 2018, stated that "The Risk Manager will review all occurrences, request additional investigational reports of appropriate staff, where necessary, interview witnesses if needed, and enter the report follow up in the Occurrence Reporting Database."

The facility policy and procedure (P&P) titled "Incident Management Program," last revised February 2019, contained the following statements: " this policy is to ensure an integrated and comprehensive strategy for identifying, documenting, reporting and investigating individual incidents on a timely basis; reviewing individual incidents to identify appropriate preventive or corrective actions, identifying incident patterns and trends through the compilation and analysis of incident data; reviewing incident patterns and trends to identify appropriate preventive or corrective actions and implementing preventive and corrective action plans; monitoring incident management practices."