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Based on document reviews and interviews, the hospital failed to provide a written response that contained the steps taken during the investigation, failed to send a written response within seven (7) days of the grievance and failed to provide a verbal report when unable to respond within an average of seven (7) days for two (2) of five (5) patients who were involved in grievances filed (Patient 1G and 3G).

Findings:

The hospital's "Patient and Customer Complaint or Grievance" policy, last reviewed 8/23/2022, states, in part, "A written communication must be sent to the patient (or patient's legal representative), even if other methods of communication are used (such as a family meeting). On average, the written response should be complete within 7 calendar days of receipt of grievance. When a patient communicates a grievance to the hospital via email or requests a response via email the hospital may provide its response in a manually encrypted email. In its resolution of the grievance, the hospital must provide the patient with: · the steps taken on behalf of the patient to investigate the grievance ... If hospital CEO or designee determines the investigation is not or will not be completed within 7 calendar days, he/she must provide patient/family with a verbal progress report. Hospital CEO or designee must maintain ongoing communication and complete written response within 30 days. The initial contact must include: · statement acknowledging receipt of the grievance · specific time frame when the patient/legal representative can expect a conclusion/resolution to their expressed grievance".

On 7/11/2023 at 3:04 PM, five (5) grievances were reviewed and revealed the following:

1. On 10/22/2022, the hospital received a grievance involving Patient 1G.

The written response, dated 11/1/2022, did not contain the steps taken to investigate the complaint.

2. On 3/12/2023, the hospital received a grievance involving Patient 3G.

- The written response, dated 3/31/2023, did not meet the policy expectation for a seven (7) day response; and
- No verbal report was provided to Patient 3G after receiving the grievance, when hospital leadership determined they could not meet the seven (7) day requirement.

On 7/11/2023 at 3:28 PM, the Director of Quality and Risk Management confirmed the above findings.

Based on document reviews and interviews, the hospital failed to notify the patient's primary care physician of his/her admission to the hospital for eight (8) of ten (10) patients reviewed (Patient #1, #2, and #4 - #9).

Findings:

On 7/11/2023, a policy related to federal requirement for notification of the primary care physician of admission was requested. As of 7/11/2023 at 4:00 PM, at the exit conference, no policy related to this requirement was provided by hospital leadership.

On 7/10/2023 at 1:30 PM, ten (10) patient records were reviewed and there was no documented evidence that the patient's primary care physician was notified promptly of their admission in eight (8) of the ten (10) patient records.

On 7/11/2023 at 1:35 PM, the Director of Therapy confirmed that they could not provide evidence that the primary care physician for eight (8) out of ten (10) patients were notified of their admission.

Based on document reviews and interviews, the hospital failed to ensure that patients were free from abuse and that allegations of abuse were thoroughly investigated for one (1) of ten (10) patients that alleged sexual abuse (Patient #1).

Findings:

On 10/26/2022 at 12:02 PM, the Division of Licensing and Certification ("DLC") received an entity reported complaint with the following information: Patient #1 reported on 10/22/2022 at approximately 5:30 AM, that he/she was wakened by a Certified Nursing Assistant ("CNA") at which time he lifted his/her hospital gown and "kept trying to feel me up". "I think he wanted to rape me, thank God I have this Foley catheter in me so he didn't know what to do. He kept fooling with it. It was very uncomfortable". The patient reported pain, as well as being uneasy.

On 7/10/2023, an investigation was initiated by the DLC into the reported incident.

The hospital's "Allegations of Abuse/Neglect" policy, last reviewed 06/30/2023, states in part, "Un-witnessed Report of Abuse 1. Take immediate action to protect the patient from harm. 3. The patient must be: A. examined immediately for injury B. treated, if necessary C. secured from harm by taking any additional necessary actions to ensure the patient's safety and welfare, including, but not limited to i. moving the patient to another unit ii. reassigning staff and/or suspending accused staff pending investigation iii. restricting visits from alleged abusers 4. The supervisor must immediately notify the hospital CEO/CNO/designee who will promptly contact Home Office Risk Management. 5. In the event that staff can confirm abuse has occurred, local law enforcement should be notified immediately and the appropriate state and licensure agencies should be notified after consultation with Home Office Risk Management and Home Office Human Resources. 6. In the event that staff cannot confirm abuse has occurred, notification to the appropriate law enforcement, state and licensure agencies will be determined on a case by case basis after consultation with Home Office Risk Management. For all acts of abuse/alleged acts of abuse/neglect, the hospital CEO/CNO/designee must contact the following people, as soon as possible after receiving notification: 1. The hospital Risk Manager and Human Resources Director (when allegations involve an employee). 2. The attending physician to discuss options relative to physical examination. 3. Home Office Risk Management (If not already notified) and Home Office Human Resources (when allegations involve an employee). The investigation should proceed according to the Checklist for Investigation and Evaluation of Reports of Abuse/Neglect Occurring Within the Hospital Setting. Physical assessment findings by nursing staff and the physician should be documented in the medical record.

The hospital's "Checklist for Investigation and Evaluation Of Reports of Abuse/Neglect Occurring Within The Hospital Setting", last revised 6/20/2018, states in part, "Stage I Immediately upon identification of patient concern:
- Confirm completion of event report (Safety/Security Form in RL)
- Attending MD notified by Employee/supervisor/manager
- Patient concern and MD notification and exam documented. Documentation should be objective, factual language of what is observed/said by the patient/others. Consider photographs of bruising, etc. by Supervisor/Manager/MD
- Home Office Risk contact notified by CEO/CNO/Risk Manager/designee
- Evaluate need to place employee on administrative leave by HRD/Home Office HR
- Develop investigation strategy - Consider: - potential witnesses - witness interview sequence - medical record review - CCTV tape review if available (secure copies) - Nurse call system tracking if pertinent by CEO/CNO/Risk Manager (Home Office Risk can assist)
- Investigation continues as needed by CEO/CNO/Risk Manager

Stage II First 24-48 hours:
- All written reports should be forwarded to Home Office Risk Management by CEO/CNO/Risk Manager Designee
- Review statutory reporting requirements

Stage III Time frame variable:
- Conference to discuss results of investigation. In general the investigation is complete when: It becomes apparent that the allegation does not have any factual basis.
If no evidence was found to indicate that an allegation could or could not be confirmed and further investigation is unlikely to uncover any additional evidence by CEO/CNO/Risk Manager/HRD/Home Office Risk /Home Office HR".

The failure to identify and thoroughly investigate a grievance and report of suspected abuse in accordance with hospital policy resulted in the following:

On 10/22/2022 at 6:40 AM, Patient #1 reported an alleged rape to Registered Nurse ("RN") #1. On 7/11/2023 at 12:01 PM, RN #1 was interviewed in relation to the allegation. She stated the following:
- I was Patient #1's nurse that morning;
- I went in at 6:30 AM and apologized for being later than usual with medications and Patient #1 said thank God you're here, I was raped by the CNA;
- I told my supervisor and he went right in and talked to Patient #1;
- The CNA was spoken to about the allegation by RN #2 and was removed from caring for Patient #1;
- The CNA had no fewer than nine (9) patients but not more than eleven (11) as we were very busy that morning;
- The CNA continued caring for other patients on the unit; and
- The CNA was allowed to care for female patients until the end of the shift.

On 7/11/2023 at 12:25 PM, RN #2, the Nurse Supervisor at the time, was interviewed in relation to the allegation. He stated the following:
- RN #1 said Patient #1 was accusing the CNA of rape;
- I notified [the Administrator on Duty];
- I believe I called the attending but did not document it;
- No physician examined Patient #1; and
- I allowed the CNA to continue working with both male and female patients.

When asked if it is standard practice to have an employee accused of rape and continue to work and just not take care of the patient making the allegation, he stated, "Initially, yes".

On 7/11/2023, the CNA's time card and assignment sheet were reviewed and revealed the following:
- The CNA worked on 10/21/2022 from 6:58 PM to 7:37 AM on 10/22/2022;
- RN #1 and RN #2 confirmed that the CNA continued to care for male and female patients after being accused of rape, until the end of the shift;
- It was reported to RN #1 at 6:40 AM;
- The CNA left at 7:37 AM, which is a duration of fifty seven (57) minutes;
- The CNA was assigned Room 201 A - 209 A during that time; and
- His assignment included six (6) females.

On 7/11/2023 at 9:58 AM, the Administrator on Duty ("AoD") at the time of the alleged event was interviewed in relation to the allegation. She stated the following:
- I am familiar with the incident;
- I was the AoD, and I was called by [RN #2] on 10/22/2022 between 7:30 AM and 8:30 AM;
- RN #2 said Patient #1 had been touched inappropriately, allegedly;
- I came in and I wasn't quite sure how to handle it so I talked with [the Chief Nursing Officer];
- It was my first or second time being AoD and I didn't know what to do;
- I did not interview Patient #1 or the CNA;
- I am not familiar with the checklist;
- I was not contacted immediately;
- I did not report the event to Home Office Risk; and
- I did not notify the physician.

On 7/11/2023 at 10:30 AM, Patient #1's Attending Physician was interviewed in relation to the allegation. He stated the following:
- I was off that weekend and I learned of the incident on 10/24/2022 at 11:17 AM, after rounding that morning; and
- I did not exam Patient #1, as there was no indication during rounds.

On 7/11/2023 at 12:37 PM, the Director of Quality and Risk Management ("DQRM") and the Chief Nursing Officer ("CNO") were interviewed in relation to the allegation of rape. They stated the following:
- No evidence was found that showed Patient #1's Attending Physician was notified until 10/24/2022;
- No evidence was found that showed a physician conducted a medical exam;
- Patient #1's medical record was not reviewed until 10/24/2022;
- We don't know who we would contact at the Home Office after hours or on a weekend;
- The CNA's work was completed at that time and did not care for other patients;
- The DQRM stated, "I had a conversation with Home Office on Monday";
- The DQRM could not confirm if the Event Report was completed immediately and sent to the Home Office;
- All written reports were not sent to the Home Office by 10/24/2022;
- The Human Resource Director ("HRD") or Home Office HR were not contacted immediately to determine if the CNA needed to be placed on administrative leave, as they are not available on the weekends or after hours;
- The CNO stated, "I can't recall", if Patient #1 received a medical exam by a physician;
- Patient #1 was sent on 10/24/2022 at approximately 6:00 PM to another medical facility due to discomfort in the peri area and needed to be evaluated by a physician to rule out sexual abuse;
- The medical record from the hospital visit was requested, but the DQRM stated that the hospital didn't want to release it due to the "sensitive nature" of the visit and no further requests were made until surveyors were onsite [a duration of eight (8) months and sixteen (16) days];
- The CNO stated, "Yes", I would want to know if one of my patients were sexually abused;
- The CNO stated, "No, I never saw the report from [the other medical facility] to determine if there were indications of sexual abuse and have no confirmation one way or another";
- No other patient interviews were conducted to determine if other patients had concerns around the care provided; and
- The DQRM stated that the investigation was completed on 10/25/2022, with a closure letter on 11/1/2022 to Patient #1, stating that " ... their investigation did not find evidence of inappropriate behavior ... " without the medical information needed from the other medical facility confirming or ruling out sexual abuse.

On 7/11/2023 at approximately 1:00 PM, the DQRM was asked about a statement in her investigation notes stating, "Week Prior (October 15th) - same time". She stated the following:
- While interviewing the patient on 10/24/2022 at 4:00 PM, Patient #1 stated that she had been sexually assaulted by a caregiver;
- Patient #1 is quoted saying, "He came in to check and started to play with my [genitalia] ... where my pee comes out. He was studying it ... He moved it up and down ...";
- Patient #1 continued to discuss the encounter in detail with the DQRM; and
- As of 7/11/2023, there was no documented evidence of an investigation completed by leadership staff related to this new allegation of abuse on 10/24/2022.

On 7/11/2023 at 1:54 PM, the Chief Executive Officer was interviewed. He was asked how people could follow the abuse and neglect policy after hours and weekends, as the DQRM stated that no one is available after hours or on weekends. "I haven't experienced that here, but to me we don't work in vacuums and we follow the policy. Staff can call a 1-800 number after hours or on the weekends".