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Based on interview and document review, the facility failed to develop and implement a policy that protected patients from an alleged hosital staff abuser resulting in the potential for unsatisfactory outcomes for all patients served by the facility. Findings include:

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A-0145 Failure to ensure a method was in placed to ensure that patients are free from all forms of abuse, neglect, or harassment

Based on interview and document review, the facility failed to develop and implement policies to ensure the prevention and protection of patients from an alleged hospital staff abuser resulting in the potential for unsatisfactory patient outcomes for all patients served by the facility. Findings include:

Review of the medical record on 8/2/2021 at 1606 revealed Patient #1 was a 45-year old female with a past medical history of psychiatric issues, heart issues, diabetes, and a right AKA (above the knee amputation). She was well known to the hospital and had been admitted from 6/9/2021 to 6/17/2021 for anasarca (swelling all over the body) and hepatic encephalopathy (a change in mentation because a damaged liver cannot eliminate the blood of toxins). On 6/14/2021 at 2330 during rounding, the primary nurse noted a decrease in mentation and the REACH (Rapid Evaluation at [facility name] Hospital-commonly known as a rapid response) team was activated. Patient #1 was insistent that she needed to void; however, because of the decreasing mentation and the patient falling asleep during conversation, it was deemed unsafe to allow the patient to get out of bed, even to a bedside commode. Despite the offering of alternative options to assist with voiding, Patient #1 was "throwing herself around the bed and refusing a bedpan." A CODE GREEN (assistance needed with a situational disturbance) was called. Security officers arrived and helped position the patient properly in bed. Patient #1 had bilateral wrist restraints applied at 0130. The physician was notified of the above events and ordered an indwelling catheter for the patient. The catheter was placed at 0200.

When interviewed on 8/3/2021 at 1315, Patient Safety Officer Staff B confirmed that the facility had been unaware of the alleged sexual assault of Patient #1 on 6/15/2021 by an unknown male staff member until a sheriff's deputy had appeared on the nursing unit on 6/22/2021 requesting to speak with the nurse manager. Staff B stated an immediate investigation ensued and all staff members, both male and female, that had cared for the patient during the early morning hours of 6/15/2021 including primary caregivers and those that had responded to the REACH activation and the CODE GREEN had been interviewed. Staff B further stated the facility had been unable to substantiate any allegations of sexual assault.

On 8/3/2021 at 0840, review of the Complaint/Grievance Log from 11/2020-present revealed there were no entries regarding Patient #1 and no entries from any other patient regarding sexual assault by a staff member.

Policies regarding procedure to take when a hospital staff member was accused of an assault and/or sexual assault were requested. Policies #138, revised March 2020 titled "Mandatory Reporting of Victims of Abuse/Neglect, Sexual Assault, or Domestic Violence", #126, revised June 2019, titled "Evidence Collection and Preservation" and #AP920, revised June 2019, titled "Violence in the Workplace" were reviewed. None of the above listed policies addressed the procedure of what should occur if a hospital employee/contracted employee was accused of assault and/or sexual assault including removal of the alleged perpetrator from all patient care until the investigation was complete.