HospitalInspections.org

Based on observation, interview and policy review the hospital failed to:
- Follow their policy for the investigation of abuse and neglect and perform a timely and thorough investigation to accurately determine whether abuse had occurred for one current patient (#6) and one discharged patient (#12) of three allegations of abuse reviewed. (A-0145)
- Immediately remove two staff members from patient care after allegations of abuse were reported for one current patient (#6) and one discharged patient (#31) of three allegations of abuse reviewed. (A-0145)
- Ensure linen cabinets were locked and secure from patient access. (A-0144)
- Ensure all personal hygiene items were locked and secure from patient access. (A-0144)
- Ensure a metal door-jam frame lock was secured. (A-0144)
- Ensure a fire extinguisher was attached to the wall and secure from patient access. (A-0144)
- Ensure physician orders were followed for every five-minute rounding for one current patient (#24) of one patient reviewed. (A-0144)
- Ensure a unit specific orientation was completed for four staff members (M, N, BB and UU) of seven staff members reviewed. (A-0144)

These failed practices resulted in the noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights.
Please refer to A-0144 and A-0145

Based on observation, interview, record review and policy review, the hospital failed to:
- Ensure linen cabinets, that contained items of contraband (items that are illegal, forbidden, or that can be used to harm self or others), were locked and secure from patient access on three of three units observed.
- Ensure contraband items were monitored and accounted for on one unit of three units observed.
- Ensure a 10-pound fire extinguisher was secured from patient access, on one of three units observed.
- Ensure a metal door-jam frame lock was secured on one unit of three units observed.
- Ensure physician ordered, every five-minute checks were completed on one patient (#24) of five patients reviewed.
- Ensure unit specific orientation was completed for four staff members (M, N, BB and UU) of seven staff members reviewed.

Findings included:

Review of the hospital's policy titled, "Rights and Responsibilities of Individuals, Contraband," dated 04/2020, showed staff will consider any item deemed to be unsafe to be contraband.

Review of the hospital's document titled, "Adult Unit Guidelines," dated 02/2019, showed patients were informed: "personal hygiene-the locked cabinet with your belongings will be unlocked with staff supervision only. Personal hygiene, including showering, shampooing and cleaning teeth are expected to be completed at this time. Erasers or pencils with erasers are not allowed on the unit. The staff reserves the right to deny any item not on this list if it jeopardizes safety."

Review of the undated hospital document titled, "Contraband Guide," showed general items not allowed were items with strings or straps, any items with metal or glass, sharp objects, alcohol, drugs, medication or paraphernalia, plastic bags, or chemicals.

Review of the hospital's policy titled, "Provision of care, treatment and services: observations, patient," dated 04/2020, showed the following:
- To maintain patient health and safety, the hospital staff encourage patients to practice daily safety and documented routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the Registered Nurse (RN).
- Level of observation can be increased by the RN any time there was a concern but only a psychiatric (relating to mental illness) practitioner may decrease the level.
- The psychiatric practitioner will order one of three levels of observation at the time of admission and as the patient's condition warranted a change: Every 15-minute checks, every five-minute checks or one to one (1:1, continuous visual contact with close physical proximity).
- The psychiatric practitioner may also order a precaution level of observation for suicide (to cause one's own death).
- Every 15-minute checks: all patients are monitored at minimum once every 15-minute block of time.
- Every 5-minute checks: patients are placed on every 5-minute checks if their behavior was unpredictable and there was potential risk for harm to self or others, yet the behavior was not at the point requiring constant 1:1 observation.

Review of the hospital's policy titled, "Safety management, environmental risk assessment," dated 04/2018, showed it was the hospital's policy to conduct a risk assessment of the physical environment to evaluate hazards and develop protective measures associated with various tasks performed in each area within the hospital. The "pro-active risk assessment" was used to evaluate the risks in the environment of care and establish the appropriate controls or measures to limit the impact on the ability of the organization to perform clinical and business activities.

Review of the hospital document titled "Pro-Active risk assessment," dated 07/20/24 through 07/25/24, showed no documentation of locked cabinets, secured fire extinguishers, metal door-jam closures or personal hygiene items.

Review of the hospital document titled "Behavioral Health Assistant (BHA) environmental rounds," dated 04/08/24 through 04/16/24, showed no shift documentation of checks for locked cabinets, secured fire extinguishers, metal door-jam closures or personal hygiene items for all three units (adolescent, adult, and silver linings [geriatric unit]).

Review of the hospital's policy titled, "Suicide Precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm)," dated 04/2020, showed the psychiatric practitioner shall order observation and precautions consistent with the assessed level of risk. Suicide risk, level of observation and/or placement on SP will be communicated to all staff. SP may include removing items that are the focus of self-harm or plan for suicide, limit linens and belongings and increased contraband checks.

Review of the hospital's document titled, "Incident Report Form," dated 02/06/24, showed on 02/06/24 at 6:35 PM, Patient #20 reported to staff that she felt suicidal and swallowed two pencils.

Review of the hospital's document titled, "Incident Investigation Report," dated 02/08/24, showed:
- Patient #20 reported to staff she felt suicidal and swallowed two pencils. The patient obtained them when she used a pencil to fill out menus for the kitchen. She was transferred to Hospital B for evaluation and treatment.
- Patient #20's history included multiple hospitalizations for ingestion of foreign bodies and pica (compulsive eating of material that may or may not be food).
- During a previous admission to Centerpointe Hospital of Columbia she swallowed a battery and was sent to an outside hospital for treatment.
- At Hospital B an esophagogastroduodenoscopy (EGD, procedure in which a thin scope with a light and camera at its tip is used to look inside the organs of the upper digestive tract) was completed and six pencils were removed from the patient.
- Corrective action included continuation of re-iterating the importance of the patient form when presenting patients to physicians discussed with the intake department.

Review of Patient #20's medical record dated 02/05/24 through 02/06/24, showed:
- She was a 29-year-old female, transferred from an outside medical facility on 02/05/24 at 1:04 PM, for depression and suicidal ideation (SI).
- She had a past medical history of several abdominal surgeries due to foreign body ingestion.
- Safety precautions included every 5-minute checks throughout her hospitalization.
- Physician documentation on 02/06/24, showed Patient #20 was transferred by ambulance to a medical facility after she swallowed two pencils.

Observation on 04/17/24 at 10:30 AM, on the Adult 2 Unit, showed Patient #27 was in the hallway with one pencil in his possession. Patient #13 was in the hallway, standing on his hands, with his feet propped against a door and two pencils in his possession.

Observation with concurrent interview on 04/17/24 at 10:25 AM, on the Adult 2 Unit, showed no pencils were signed out for use by patients on 04/17/24. Staff OO, BHA, stated that staff were to make sure patients given a pencil were written on the sign out sheet daily. When the pencils were returned their names were to be marked on the list. The sheet was used to track the pencils so staff could ensure all were accounted for.

Review of Patient #13's medical record showed:
- He was a 28-year-old male, admitted on 03/23/24 for hearing voices and seeing things that were not there.
- Upon his admission he reported hearing voices that told him to rape, molest and hurt others.
- On 04/17/24 safety precautions included every 15-minute checks.

Review of Patient #27's medical record showed:
- He was a 62-year-old male, admitted on 03/31/24 for increased confusion and aggression.
- At his residential facility he made several threats to harm staff and had been aggressive toward other patients and staff. During his transfer he made homicidal (thoughts or attempts to cause another's death) threats towards transport staff.
- On 04/17/24 safety precautions included every 5-minute checks and assault precautions (AP, measures to alert staff of a patient's potential to become violent with others).

Observation with concurrent interview on 04/15/24 at 2:20 PM, on the Adolescent Inpatient Unit, showed one unlocked cabinet containing multiple items of contraband that included two full sized bottles of shampoo and conditioner, five towels and paper cups with liquid in them. Staff C, Unit Manager, stated that the cabinet containing contraband items should have been locked and not accessible to patients.

Observation on 04/15/24 at 2:20 PM, on the Adult 1 Unit, showed an unlocked cabinet contained two small shampoo bottles, two small lotion bottles, four hand towels, and two personal clothing items.

Observation on 04/15/24 at 2:25 PM, on the Adult 2 Unit, showed an unlocked, patient hallway cabinet, that contained six small bottles of hair conditioner, four small bottles of shampoo, two small bottles of mouth wash, one toothbrush, one small tube of toothpaste, one container of deodorant, four wash cloths, and four towels.

Observation on 04/16/24 at 9:00 AM, on the Adult 2 Unit hallway, showed an unlocked patient cabinet by patient room 407, that contained one pillow, towels, sheets, and an unsecured fire extinguisher.

Observation on 04/16/24 at 9:03 AM, on the Adult 2 Unit, showed the door-jam frame lock was not secured for patient room 400. The frame lock could be pulled down, leaving a three-inch-long by two-inch-wide piece of metal exposed.

Observation on 04/16/24 at 9:13 AM, on the Adult 2 Unit, showed on the bathroom counter in patient room 305, a container of deodorant, a small bottle of mouth wash, a small bottle of hair conditioner and a small bottle of shampoo.

During an interview on 04/15/24 at 2:20 PM, Staff H, RN, stated that cabinet doors were to stay locked at all times.

During an interview on 04/15/24 at 2:27 PM, Staff I, RN Nurse Manager, stated that all hallway cabinets were to be locked. They were unlocked for shower time only and were not to be left open.

During an interview on 04/16/24 at 9:02 AM, Staff I, stated that she did not know how long the patient hallway cabinet had been unlocked. The cabinets were checked the previous week and they were locked at that time.

Review of Patient #24's medical record from 04/12/24 through 04/16/24 showed:
- He was a 52-year-old male, alert and oriented times four (A&O x 4, a person is oriented to person, place, time and situation), admitted on 04/12/24 with SI and a plan to jump off of a bridge.
- He had a history of depression (extreme sadness that doesn't go away).
- His Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self-inflicted harm and desire to end one's life), dated 04/12/24 showed, he had current suicidal thoughts with a specific plan and was determined to be a high suicidal risk.
- Physician orders, dated 04/12/24, showed the patient was placed on SP, and every five-minute checks through 04/16/24, when he was placed on every 15-minute checks.
- Patient observation report documentation dated 04/12/24 through 04/16/24, showed the patient was on every five-minute checks from 04/12/24 at 6:55 PM through 04/13/24 at 11:44 AM. There was no every five-minute documentation for two days, 11 hours, and 45 minutes before the physician order changed from every five-minute checks to every 15-minute checks.

During an interview on 04/16/24 at 1:33 PM and 04/18/24 at 8:35 AM, Staff B, Director of Quality Management (DQM), stated that there were no physician orders for Patient #24 to be changed from every five-minute checks to every 15 minute checks and the patient should have stayed on every five minute checks until an order to change was received. The hallway cabinets were always to be locked. Patients should not have access to the fire extinguisher. The fire extinguisher should be secured and locked unless needed. The fire extinguisher was considered a security risk. Personal hygiene items should not be left in patient rooms. Room checks were completed every shift. She expected the door-jam frame lock to always be secured, as it was a ligature risk. If a patient had an order for every five-minute checks, the patient remained on every five-minute checks until an order was received for every 15-minute checks. A high-risk suicide patient on the floor with unlocked cabinets and an unsecured fire extinguisher placed patients at risk of harm.

During an interview on 04/16/24 at 4:11 PM, Staff QQ, BHA, stated that when a patient was on five-minute checks, they were to stay on five-minute checks until an order was received to change to every 15-minute checks. The hallway cabinets were to be locked at all times. If personal hygiene items were found in a patient room, they were to be taken out and locked up. Room checks were done every shift.

During an interview on 04/16/24 at 4:34 PM, Staff RR, RN, stated that when a patient was on five-minute checks, they should have stayed on five-minute checks until an order was received to change to every 15-minute checks. If a high suicide patient was on every five-minute checks, they should have stayed on every five-minute checks until an order to change was received. The hallway cabinets were to be locked at all times. Linens were not to be in the cabinet with the fire extinguisher. She expected the fire extinguisher cabinet and the linens cabinet to be locked at all times. She expected the metal door-jam frame to be secured. The fire extinguisher and the metal door-jam frame lock could have been used as a weapon.

During an interview on 04/16/24 at 4:45 PM, Staff SS, RN, stated that when a patient was on five-minute checks, they were to stay on five-minute checks until an order was received to change to every 15-minute checks. If a high suicide patient was on every five-minute checks, they were to stay on every five-minute checks until an order to change it was received. The hallway cabinets were to always be locked. Linens were not supposed to be in the cabinet with the fire extinguisher. She expected the fire extinguisher cabinet, and the linens cabinet were to always be locked. She expected the metal door-jam frame to always be secured. The fire extinguisher and the metal door-jam frame lock could have been used as a weapon.

During an interview on 04/17/24 at 4:11 PM, Staff TT, BHA, stated that when a patient was on five-minute checks, they were to stay on five-minute checks until an order was received to change to every 15-minute checks. The hallway cabinets were to always be locked. If personal hygiene items were found in a patient room, they were to be taken out and locked up. Room checks were done every shift.

Review of Staff BB's, Agency RN, personnel file, showed a hire date of 01/30/24 and a termination date of 03/22/24. There was no unit specific orientation completed.

Review of Staff M's, BHA, personnel file showed a hire date of 01/30/23 with no documentation of a unit specific orientation.

Review of Staff N's, BHA, personnel file showed a hire date of 12/11/23 with no documentation of a unit specific orientation.

Review of Staff UU's, BHA, personnel file showed a hire date of 12/11/23 and a termination date of 04/11/23. There was no unit specific orientation completed.

During an interview on 04/17/24 at 10:20 AM, 11:20 AM and 04/18/24 at 10:15 AM and 12:05 PM, Staff GG, CNO, stated that all staff were expected to complete a unit specific orientation. She was unaware Staff BB, did not complete a unit specific orientation.


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Based on interview, record review and policy review, the hospital failed to follow their internal policy for investigation of abuse and neglect and perform a timely and thorough investigation to accurately determine whether abuse had occurred for one current patient (#6) and one discharged patient (#12) of three allegations of abuse reviewed. The hospital failed to immediately remove two staff members from patient care after allegations of abuse were reported for one current patient (#6) and one discharged patient (#31) of three allegations of abuse reviewed. These failed practices placed all patients admitted to the hospital at increased risk for their safety.

Findings included:

Review of the hospital's policy titled, "Abuse and Neglect," dated 04/2020 showed:
- Staff who witness or suspect the patient has been abused either physical or verbally will immediately report such abuse to the Administrator on Call (AOC), Nursing Supervisor, Director of Risk Management and the Chief Nursing Officer (CNO).
- The staff member shall be notified of the allegation and suspended from duty, pending results of the investigation.
- If the staff member is working at the time of the allegation of abuse, the department head will assign replacement staff as necessary to complete the shift.

Review of the hospital's undated document titled, "Incident MO00233351," showed:
- On 03/17/24 at 11:00 AM, Staff CC, Licensed Practical Nurse (LPN), notified Staff DD, House Supervisor, of the abuse allegation against Staff BB, Agency Registered Nurse (RN), from Patient #6.
- At 10:00 PM, 11 hours later, the abuse allegation was escalated to the Quality Management Director, Chief Executive Officer (CEO), Unit Manager and AOC.
- On 03/18/24 at 10:50 AM, 23 hours and 50 minutes later, Patient #6 was interviewed.
- Staff DD, House Supervisor, erroneously believed the investigation process could not proceed until an incident report was filed. Due to this, Staff BB, was not immediately sent home and the notification process was not immediately begun.

Review of the hospital's document titled, "Witness Statement," dated 03/17/24 showed:
- Staff CC, LPN, stated that Patient #6 was in the seclusion room, (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) standing by the door.
- Staff BB, Agency RN, was trying to redirect the patient. The patient was tearful and yelling.
- Staff BB was closing the seclusion room door and pushed Patient #6 from the doorway hard enough for her to hit the wall and fall to the ground, approximately four feet.
- The patient was not physically aggressive at the time.

Review of the hospitals document titled "Timesheet," dated 03/17/24 through 03/18/24, showed on 03/17/24, Staff BB, Agency RN, worked from 6:55 AM through 7:39 PM.

Review of Patient #6's medical record showed on 02/13/24, she was a 19-year-old female on a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) for physical aggression. Her psychiatric (relating to mental illness) diagnosis was bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows) with psychotic features (characterized by defective or lost contact with reality), rule out paranoid schizophrenia (a mental illness that involves mistaken beliefs that one or more people are plotting against them or their loved ones), rule out attention deficit/hyperactive disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors) and rule out Impulse Control disorder (failure to resist an urge or temptation).

During an interview on 04/17/24 at 8:35 AM, Staff B, Quality Management Director, stated that she expected Staff DD, House Supervisor, was aware of the requirement to immediately remove staff and collect witness statements. The investigation for Patient #6's allegation of abuse began approximately 24 hours after the alleged abuse was reported.

During a telephone interview on 04/16/24 at 3:43 PM, Staff DD, House Supervisor, stated that she was notified of the abuse allegation by Staff CC, LPN. Staff DD did not communicate the event to leadership, she did not remove Staff BB from patient care and she did not initiate an investigation.

During an interview on 04/17/24 at 3:05 PM, Staff I, Nurse Manager, stated that she was surprised and unaware that Staff BB was not immediately removed from care and the allegation was not immediately escalated.

During a telephone interview on 04/17/24 at 11:00 AM, Staff HH, Physician, stated that pushing a patient was abuse and the staff member was immediately removed from patient care.

Review of the hospital's undated document titled, "Incident MO00233321," showed on 03/15/24 at 10:30 AM, Staff YY, Behavioral Health Aide (BHA), notified Staff ZZ, House Supervisor of an abuse allegation against Staff UU, BHA, for Patient #31. Staff UU, was not immediately removed from the schedule pending investigation. He finished his shift on 03/15/24 and part of a shift on 03/16/24 before relieved of duty pending an investigation of alleged abuse.

Review of the hospitals undated, untitled document showed:
- On 3/15/24, 10:00 AM, Patient #31 slammed her door and attempted to lock herself in by standing behind the door.
- Staff UU, BHA, and Staff YY, BHA, wedged the door open to explain the door was not allowed closed.
- The patient continued to try and close the door.
- She stopped trying to close the door and she was yelling "get out."
- She attempted one more time to close the door and Staff UU gave her a five second warning to move or he would forcibly move her.
- The patient did not move, Staff UU picked her up off the floor and proceeded to throw/toss her on the bed.
- Afterwards, Staff UU stated, "That was aggressive, but I don't care."

Review of the hospitals document titled "Timesheet," dated 03/15/24 through 03/17/24, showed on 03/15/24, Staff UU, BHA, worked from 7:04 AM through 7:31 PM. On 03/16/24 Staff UU, began work at 7:08 AM.

Review of Patient #31's medical record showed on 03/02/24, she was a 25-year-old female with a history of bipolar disorder and Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring because of injury or severe psychological shock).

During an interview on 04/17/24 at 3:05 PM, Staff I, Nurse Manager, stated that "Quality made the decision not to send Staff, UU, BHA, home" after the allegation of abuse against Patient #31.

During an interview on 04/17/24 at 8:35 AM, Staff B, Quality Management Director, stated that she did not send Staff UU, BHA, home and was "on the wrong side of safety." She did not want to create "staffing holes." Staff A, CEO, corrected the situation and sent Staff UU home the following day. On 03/16/24 during the afternoon, Staff DD, House Supervisor, walked Staff UU out of the hospital pending completion of the investigation.

Review of the hospital's document titled, "Interview," dated 04/02/24, showed:
- On 04/02/24, a nursing supervisor reported a sexual assault allegation by Patient #12 to Staff Q, Patient Advocate, and Staff WW, Risk Management Director.
- Patient #12 reported Patient #18 was present during the incident.
- Patient #12 reported she did not know who assaulted her but there was spit on her vagina when she wiped and she asked a nurse for a rape kit.

Review of the hospital's document titled, "Interview," dated 04/03/24, showed:
- Staff N, BHA, was sitting in another hall for a one to one (1:1, continuous visual contact with close physical proximity) patient when Patient #12 yelled out she had been raped and needed a rape kit.
- He stated that Patient #12 said a gentleman had gone into her room and touched her, but she did not know who.
- When asked if the incident was reported to other staff or a RN, he stated that he was unsure; and he asked Staff WW, Risk Management Director, who he should report incidents like this to overnight. He was told all staff were responsible to report any incident to their supervisor.

Review of the hospital's document titled, "Interview," dated 04/02/24, showed:
- Staff VV, BHA, stated that Patient #12 reported someone touched her while she was sleeping and it smelled.
- She did not see anyone go into Patient #12's room.
- She stated Patient #12 requested a rape kit from the nurse.
- After Patient #12 reported the incident, she and Staff PP, BHA, reported the incident to the patient's nurse.

Review of the hospital's document titled, "Interview," dated 04/03/24, showed
Staff PP, BHA, stated Patient #12 insisted someone had raped her and accused Staff N, BHA. She then reported the incident to the nurse and stated that Patient #12 had requested a rape kit.

Review of the hospital's undated document titled, "Incident Report," showed:
- On 03/30/24, Patient #12 reported to Staff PP, BHA, someone entered her room, she smelled a "man's breath," someone "came" on her and she alleged Staff N, BHA, raped her.
- Staff PP, BHA, reported the alleged sexual assault to Staff P, RN.
- Staff P, RN, reported the sexual assault allegation to Staff HH, Physician.
- On 04/02/24, Patient #12 requested to speak with Staff Q, Patient Advocate, to report the inappropriate sexual contact.
- Staff WW, Risk Management Director, notified Staff GG, CNO and Staff B, Quality Management Director, of the allegation.
- On 04/02/24 Staff Z, Physician, offered to transfer Patient #12 to Facility B for a sexual assault forensic exam (SANE, a RN or nurse practitioner who has completed specialized training to assist sexual assault victims and collect all forensic evidence and perform exams), she accepted.
- Patient #12, Patient #18, Staff N, BHA, and Staff PP, BHA, were interviewed, but Staff P, RN, could not be reached to interview.
- Patient #12 could not directly specify who allegedly assaulted her when interviewed by Staff WW, Risk Management Director.
- The allegation was ruled unsubstantiated.
- Opportunities for improvement were identified as an extended lapse in time of report to Staff WW, Risk Management Director, after the initial allegation was made to the Physician and House Supervisor.

Review of Patient #12's medical record showed:
- On 03/15/24, she was a 29-year-old female with schizophrenia, non-adherent to medication, had delusions (false ideas about what is taking place or who one is) she was poisoned. She exhibited flight of ideas (jumping from one topic to the next, common with mania [a period of time when a person cannot sleep for days, feels elevated and is easily distracted]), pressured speech (rapid, compulsive talking, a classic symptom of bipolar disorder) on examination, paranoia (excessive suspiciousness without adequate cause) and reported auditory hallucination (hearing things that are not heard by others, imaginary).
- On 03/30/24 at 6:56 AM, Patient #12 requested a rape kit and stated she had been raped. Staff P, RN, called Staff HH, Physician, and notified Staff AA, House Supervisor.
- At 4:30 PM, staff reported to Staff HH Patient #12 alleged that someone raped her, nursing was noted to be investigating.

During a telephone interview on 04/16/24 at 5:00 PM, Staff HH, Physician, stated that on 03/30/24 during rounds he was informed by the nursing staff that Patient #12 had reported an allegation of sexual assault, and it appeared to be a dream or delusion. He spoke with Patient #12 in the presence of a nurse to investigate the alleged abuse. Patient #12 would not elaborate about the claim and was apprehensive. He directed nursing staff to call the medical treatment team for a recommendation. He expected nursing staff to inform him of allegations of abuse and sexual assault. He was expected to speak with patients who alleged abuse and referred to medical for guidance on needed exams.

During an interview on 04/18/24 at 10:12 AM, Staff WW, Director of Risk Management, stated that on 04/02/24, she was made aware of Patient #12's sexual assault allegation after she was asked to file a grievance. The investigation into the sexual assault allegation began on 04/02/24, three days after the abuse allegation was reported. She spoke to Staff Z, Physician, who offered a SANE on 04/02/24, but she was not aware he had also been informed of Patient #12's sexual assault allegation on 03/30/24. She felt the investigation was a "mess" and the information she provided was "conflicting, confusing and insufficient."

During an interview on 04/16/24 at 12:28 PM, Staff Z, Physician, stated that on 03/30/24 he was consulted by a nurse about Patient #12's allegation of sexual assault. He expected to be notified each time there was an allegation of sexual assault.

During an interview on 04/18/24 at 9:49 AM, Staff XX, Physician's Assistant (PA, a type of mid-level health care provider that can diagnose illnesses, develop and manage treatment plans, prescribe medications, and may serve as a principal healthcare provider), stated that on 03/30/24, Patient #12 reported that someone had gone into her room the night prior and inappropriately touched her. She reported this to nursing staff immediately. She offered Patient #12 a SANE, but she declined. She expected staff to inform her when a patient reported sexual assault.

During a telephone interview on 04/16/24 at 1:27 PM, Staff AA, House Supervisor, stated that she did not receive a report from nursing staff that Patient #12 alleged sexual assault, only that she had been delusional and paranoid. She expected notification by staff immediately if a patient reported sexual assault.

During a telephone interview on 04/16/24 at 9:14 AM, Staff P, RN, stated that she notified Staff AA, House Supervisor, and Staff HH, Physician, about Patient #12's sexual assault allegation. If a patient reported abuse or neglect, the expectation was to notify the House Supervisor and Physician.

During an interview on 04/17/24 at 10:20 AM and 11:20 AM, Staff GG, CNO, stated that she expected staff members accused of abuse were immediately sent home. She expected an investigation to begin immediately upon the report of abuse. The House Supervisor would begin interviews. She agreed the investigation of Patient #12's sexual assault allegation was not thorough and was poorly done. She expected the House Supervisor to report the incident to herself and the Risk Manager.

During an interview on 04/17/24 at 8:35 AM, Staff B, Quality Management Director, stated that she expected an allegation of abuse was immediately reported to the AOC, Quality Manager, Risk Manager and CEO. A staff member with an allegation of abuse were to be sent home immediately. She would have done more to investigate Patient #12's allegation. She agreed that immediate education for supervisors was necessary.

During an interview on 04/17/24 at 3:05 PM, Staff I, Nurse Manager, stated that staff members accused of abuse were to be immediately removed from patient care until an investigation was completed.