HospitalInspections.org

Based on the surveyor's review of records and staff interviews, the facility failed to follow its "Abuse and Neglect. . ." policy and conduct a thorough investigation of all allegations claiming abuse, neglect, and mistreatment, resulting in the inability of the facility to ensure staff took the appropriate corrective and remedial actions. The findings include:

On the afternoon of 4/19/2022, Staff #4 reported to hospital leadership an outcry from patient #1, that alleged a peer [patient #2] had pressured her to enter his room and coerced her into participating in inappropriate sexual acts.

The facility's "Abuse, Neglect, Exploitation, or Assault, Reporting, Investigation, and Response" policy reads [in part] as follows:

a. The patient has the right to make a police report, if the patient is 16 years of age or older. If the patient is 15 years of age or younger, the parents or Legally Authorized Representative (LAR) will be notified if the minor desires to file a police report. If the event involves a criminal act (e.9., sexual assault, battery), under the direction of the CEO, Law Enforcement shall be notified by the supervisory staff on the scene. . . If the allegation is within 96 hours of the alleged event, the patient (victim) will be encouraged not to change clothes, shower, or bathe in anticipation of a SANE (Sexual Abuse Nurse Examiner) examination.

Staff #2 was the hospital's delegatee, responsible for investigating such allegations. Issues with staff #2's investigation are listed as follows:

a. In a personal interview conducted in the facility's conference room on the morning of 6/8/2022, staff # 2 stated, "I interviewed patient #1 [the female]. It was difficult to understand her because of her IDD [intellectual development disability]. I found the allegation unfounded. I based my investigation findings on the patient interviews and the review of camera footage. I watched the footage for Saturday [4/16/22] from 8 am to 6 pm. I did not see her enter his room. I had to deal with my staff labeling the male patient before the investigation was performed. The police were not called either. The female was not offered a sexual assault exam. We [the facility] only call the police if the internal investigation is substantiated. I found the allegation unfounded. Yes, I should have reviewed the camera footage from Saturday, Sunday, and Monday. I didn't speak with the female's parents. I typically send both parents a letter notifying them of my findings. I did not send the female's parents a letter. "

b. In the investigative report dated 4/20/2022, staff #2 documented that patient #1 stated, "It [the sexual contact] happened this weekend [4/16-4/17] or maybe Monday [4/18]. "

c. When asked why he did not review the entirety of the footage for Saturday, Sunday, and Monday [4/16 - 4/18], staff #2 stated, "I just looked at Saturday because that's when she [patient #1] said the incident occurred."

During a telephone interview on the morning of 6/8/2022, patient #1's mother stated, "Someone, I think it was a nurse, called me to tell me. With her [patient #1], it is very difficult to assess what is real because of her intellectual disability. I was told that an investigation was going to be conducted, the video surveillance footage would be reviewed, and I would be informed of what was found. Her [patient #1] CPS [child protective services] case worker and I were going to discuss pressing charges once we knew the investigation results. I never heard from them [the facility] again. I don't know the status of the investigation."

Patient #1's medical record lacked documentation of legal guardian notification, response to the event, and notification of outcome. Surveyor could not locate a record or person that could attest to notifying patient #1's guardian.

Findings were validated during the exit conference on the afternoon of 6/8/2022; the facility's staff was notified that the facility's "Abuse" policy did not indicate the decision to file charges, notify the police, or offer a SANE examination was at the discretion of the risk manager. Staff #1 stated, "Yes, this policy [Abuse, Neglect policy] is out of date. It doesn't reflect our current practice. We will be updating it."