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Based on observation, interview, and document review, the hospital failed to develop and implement appropriate, adequate steps to ensure immediate patient protection after an allegation of potential abuse was witnessed and verbalized by 1 of 1 patient (P1) who reported being slapped and/or struck by an employee of the hospital. This resulted in the alleged perpetrator (AP) not being removed from direct patient care, or placed on supervised care, until several days after a witnessed incident which met the criteria of an allegation of physical assault. As a result, the hospital was found out of compliance with the Condition of Participation - Patient Rights at 42 CFR 482.13.

A condition-level deficiency was issued.

Findings include:

See A-0145; Based on observation, interview, and document review, the hospital failed to ensure appropriate and adequate steps were implemented to ensure patient protection after an allegation of potential abuse was witnessed and verbalized by 1 of 1 patient (P1) who reported being slapped and/or struck by an employee of the hospital. The alleged perpetrator (AP) was a hospital-employed registered nurse (RN-D) who was not removed from direct patient care, or placed on supervised care, until several days after a witnessed incident which met the criteria of an allegation of physical assault and/or abuse. This had potential to affect all patients receiving care in the campus' pediatric infusion center.

Based on observation, interview, and document review, the hospital failed to ensure appropriate and adequate steps were implemented to ensure immediate patient protection after a credible allegation of abuse was witnessed and verbalized by 1 of 1 patient (P1) who reported being slapped and/or struck by an employee of the hospital. The alleged perpetrator (AP) was a registered nurse (RN-D) who was not removed from direct patient care, or placed on any supervised care, until several days after a witnessed incident which met the criteria of an allegation of physical assault and/or abuse. This had potential to affect all patients receiving care in the campus' pediatric infusion center.

Findings include:

A received Child Protection Intake Summary, dated 10/24/22, identified the intake on-call person received a telephone call from Mayo Clinic Hospital which outlined, " ... on Saturday, 10/22/22 a nurse slapped [P1] across the face. The incident was witnessed by security officers."

P1's ED (Emergency Department) to Hosp (Hospital) record, dated 10/20/22 to 10/25/22, identified P1 as a minor child (less than 18 years old) who admitted to the hospital from the ED on 9/25/22. P1's medical diagnoses included suicidal ideation, post-traumatic stress disorder (PTSD), and oppositional disorder.

On 11/7/22 at 10:21 a.m., P1's county-appointed guardian (G)-A was interviewed, and she explained P1 was on a "parallel protection program" and her agency, in collaboration with the county, had decision-making authority for P1. G-A stated she was aware of an incident which happened on 10/22/22 and she recalled their agency received an email about the incident explaining the wording used in the communication was P1 had been "slapped or hit" during an altercation between P1 and a nurse. The incident had been witnessed by a security guard and the hospital reported to herself (G-A) the nurse "had physically made contact" with P1 using her hand adding, "It had happened." G-A stated the hospital reported they would be reviewing the incident and altercation using "their own processes," and G-A stated she requested the hospital no longer assigned the alleged nurse to work with P1; however, the hospital never explained or addressed how the nurse who potentially assaulted P1 would be handled or addressed (i.e., removed from patient care). Further, G-A stated she had since visited P1 following the altercation and P1 did not raise concerns about the incident or report feeling unsafe in the hospital.

P1's Nursing Note, dated 10/22/22 at 6:52 p.m. and authored by RN-D, outlined RN-D arrived in P1's room to assist after P1 had attempted to swallow their (the hospital) fall-risk bracelet. The note recorded de-escalation techniques were attempted but not successful which lead to an emergency behavioral response team (BERT; including security officers) being requested. RN-D attempted to administer oral medications to P1, however, P1 struck out at RN-D causing the medication (mixed with pudding) to land on RN-D's scrub top. P1 continued to escalate and was recorded as verbally saying, "If you touch me, I will [expletive] punch you, you fat [expletive]." P1 then started to remove and consumed small pieces of wallpaper and an order for intramuscular (IM) medication was obtained. P1 continued to consume pieces of wallpaper and the note identified, "This [RN-D] stood near them [P1] and was holding wall paper trying to prevent them from ripping any more small pieces off to eat. [P1] spit in this RN's face. In an attempt to block spit, this RN extended her left arm and palm forward. This RN's palm accidentally touched [P1] right cheek. They became upset they were touched." The note continued and outlined multiple doses of IM medication were then administered with the help of security and P1 was placed into restraints.

On 11/7/22 at 11:40 a.m., the Francis 2B unit was toured with RN-A present. RN-A explained the unit consisted of a long, single hallway which had a sensory room at the end with another adjacent corridor which had a "team lounge" present. RN-A stated pediatric patient rooms were on both sides of the long, single hallway and verified video monitoring was present in the corridor, however, not in any of the patient rooms on the unit. At 11:47 a.m., P1 was observed in her room on the unit with a personal care attendant (PCA)-A present in the room. RN-A stated P1 was one a "one to one [1:1; constant supervision]" due to her behavioral history, and explained the 1:1 had been present since her admission to the unit. P1 was interviewed at this time and stated she had been at the hospital "a month at least," however, then turned away from the surveyor. The surveyor questioned P1 if anyone from the hospital had ever abused, struck, or hit her to which P1 did not verbally respond and continued to look down at the floor. PCA-A then stated aloud to P1, "Is that a no or a yes?" P1 responded, "I don't want to talk." P1 had no visible bruising on her exposed skin at this time and the interview was ceased.

On 11/7/22 at 12:01 p.m., RN-B was interviewed. RN-B verified she was assigned direct care for P1 on 11/7/22, and explained P1 resided in the hospital due to awaiting placement in the community. P1 did not need much, if any, physical help with cares or activities of daily living (ADLs), however, did need supervision for safety concerns and her history of behavior. RN-B stated a BERT had to be contacted to help clam and de-escalate P1 multiple times over the course of her hospitalization which RN-B verified P1 was currently, and had been throughout her admission to the unit, on a 1:1 for these reasons. RN-B stated she was unaware and had not heard any information regarding P1 being potentially 'slapped' or physically abuse while residing at the hospital and added P1 did not have a history of false accusations towards staff or others to her knowledge. RN-B explained if a patient, including a minor child, began to spit then multiple approaches could be attempted including use of "droplet shields" or even just stepping back and away from the patient, however, the staff would never want to extend their hand to block the bodily fluids as it brings the staff closer to the point of aggression and could even harm the patient if physical contact was made. Further, RN-B stated if an allegation of abuse, such as a slap by a staff member, was observed or heard then she would report it immediately to her charge nurse and they were responsible to address it further.

On 11/7/22 at 12:10 p.m., Francis 2B unit manager RN-C was interviewed. RN-C verified she was aware of the incident between RN-D and P1 which happened on 10/22/22, and she explained one of the pediatric infusion center nurses, RN-D, had come to the floor to help the staff take their scheduled breaks. This was not uncommon and the nurses often worked across the inpatient unit and the outpatient infusion center care venues at different times. RN-D explained when the incident happened, P1 had been escalating and a behavioral response team was called for which included multiple security officers being present. P1 then began to spit at RN-D who reacted and put her hand up to shield herself from the spit, however, in doing so "made contact" with P1's face causing P1 to respond, "You [RN-D] [expletive] hit me you [expletive]." RN-C stated she had been involved in the investigation of the incident and her belief was RN-D's action was not intentional but rather an attempt to shield or deflect the spit.

RN-C then recalled the timeline of the events immediately following the incident. RN-C stated RN-D finished her shift shortly following the incident and left the campus. The "house supervisor" had then been notified of the incident and, the following day on 10/23/22, a campus "resource officer" was onsite and wanted to interview persons involved, including RN-D who was present and working. RN-C verified RN-D worked the following day after the incident, on an unsupervised basis, in the pediatric infusion center despite the altercation and subsequent allegation of abuse being voiced by P1 (i.e., you hit me). RN-C explained the infusion center was solely an outpatient basis and, while technically possible, the chance of RN-D have unsupervised access to a patient was minimal given family members were typically present with the minors. RN-D stated RN-D was allowed to return to work despite the allegation, and a corresponding investigation being underway, as no actual abuse had been substantiated against her at that point. However, in the days following 10/23/22, a decision was then made to place RN-D on paid leave so the investigation could be completed. RN-C explained if an allegation of abuse was voiced by a patient, the nursing administrator would be notified and, typically, the staff member is then placed on paid-leave while the investigation is completed. RN-C expressed the delay in placing RN-D on leave happened as they did not get all the relevant information, including the security guard(s) testimony, at "the unit level" until a few days following the incident. This resulted in it being unclear there was even an allegation to follow up on until those days following.

On 11/7/22 at 1:48 p.m., registered nurse house supervisor (RN)-E was interviewed. RN-E recalled the incident on 10/22/22, between P1 and RN-D and explained she had worked "the night shifts" over that weekend and learned about the altercation several hours after it happened. There would have been another house supervisor present when the altercation happened; however, RN-E stated she was unaware if they had been notified or not of the altercation, and subsequent allegation of abuse, between P1 and RN-D on 10/22/22, prior to herself learning of the event. RN-E explained she had been contacted around midnight on 10/23/22 about the incident from a security supervisor who had been reviewing his officers' report which outlined RN-D had "slapped a patient." RN-E stated the security officer (SO)-B who wrote the report which had the allegation listed was still on campus, so she visited with him. SO-B recalled the event and stated RN-D and P1 were in close quarters with each and P1 then spit on RN-D which caused RN-D to have "a reactionary response" and use her hands to push back from P1, and, in the moment, RN-D's hand did make contact with P1's face and caused P1 to react and make a remark about it. RN-E stated she was unsure who a security officer would report a witnessed allegation of abuse to, however, explained typically the unit manager would be the "front line person" who received and address any allegations to her understanding. RN-E stated the nurses often "trust in our security colleagues" to deal with abuse or behavioral situations, which is what lead to the Rochester Police Department getting involved and interviewing persons the following day as any physical allegation gets "treated as assault." When questioned on immediate protection steps completed after the incident on 10/22/22, RN-E stated she was aware RN-D would be returning the following day to work at the onsite infusion center. As a result, she reached out and contacted the Mayo Clinic legal department on what next steps should be taken. RN-E explained the legal department "felt strongly" that RN-D was able to return to work until a valid reason was provided demonstrating she could not, so as a result, RN-D returned to work on an unsupervised basis on 10/23/22 as no official police report had been filed or completed up to that point. RN-E acknowledged the investigation into the incident and subsequent allegation had not been completed or even officially started when RN-D returned to work and added, "I don't think we had enough information [to know that]."

A provided Incident Detail Report, dated 10/22/22 at 8:05 p.m., listed a physical assault incident for P1 had occurred with two officers responding, including SO-B. The report included two separate narrative fields to be completed by each of the responding officers with their version of events. SO-B's report identified the officers responded to P1's room and they helped RN-D administer medications due to escalating behaviors. The report then outlined P1 began tearing wallpaper from the wall which caused SO-B to return inside the room. P1 then spat in RN-D's face which caused RN-D to suddenly strike P1 in the mouth with an open hand. P1 responded and accused RN-D of hitting her, which caused RN-D to step back while verbalizing some profanity. The report concluded without any indication the observed physical allegation was being reported or acted upon as an allegation of potential abuse.

On 11/7/22 at 3:08 p.m., security officer (SO)-B was interviewed via telephone. SO-B recalled the incident involving P1 on 10/22/22, and explained a BERT had been called due to the patient having escalating behaviors. SO-B arrived and assisted RN-D with administering intramuscular (IM) medication and, during this attempt, P1 made several derogatory comments and called the nurse "a bitch." After the medication was given, SO-B and their colleague turned to leave the room. However, an audible tearing noise could be heard which caused him to turn back around. P1 was observed tearing wallpaper from the wall which caused himself and the other security officer to re-enter the room. SO-B explained it was himself, SO-A, RN-D, and P1 being in the room off to the side in a "little inlet" with P1 in the corner, and RN-D in-between himself and P1; however, SO-A verified he had a clear line of sight to P1. SO-A stated P1 then started to spit at RN-D which, in turn, caused RN-D to have "almost out of a knee-jerk reaction" and extend her left hand and strike P1 in the mouth area of her face. P1 then verbally reacted, "You [expletive] [expletive], you just hit me in the face!" RN-D then immediately backed away from P1 and said aloud, "Oh shit." SO-B explained P1 was eventually assisted to her bed and, ultimately, had to be placed in physical restraints to de-escalate the situation.

SO-A explained RN-D using her hand appeared as a slap as RN-D's hand was open when it made contact with P1, and he added it was "not a self-defense move [motion]" but rather appeared "like a mother smacking her kid in the mouth for swearing." SO-B stated using hands to slap, or even raising them to stop someone from spitting onto themselves, was not something the hospital taught staff to use. SO-B stated he felt RN-D saying, "oh shit," immediately following the contact with P1 affirmed "she knew she had just messed up." SO-B stated he was not sure of RN-D's motive when she made contact with P1's face using an open hand; however, he added, "I do not think she meant to strike the child in an aggressive, willful manner." Immediately following the incident, SO-A recalled a "time gap" happened as he believed the other officer who responded had addressed it in their reporting. When asking about it several hours later, SO-B stated he learned it had not been reported so he reported it to his supervisor who then contacted the house supervisor (RN-E) about the incident. SO-B stated if he witnessed an allegation of potential abuse, such as this incident, then "from the training we've had" he stated there was "not a firm policy on where to go [for reporting]" with the information to his knowledge.

On 11/8/22 at 9:01 a.m. RN-D was interviewed and explained she routinely worked on the pediatrics units (including Francis 2B) along with the onsite pediatric infusion center which was "where I am [working] today." RN-D recalled the incident between herself and P1 on 10/22/22, and stated she had come to the unit to help relieve other staff for their routine breaks. P1's "staff assist" light was activated and P1 was attempting to, or already had, eaten several non-food items before she started to bite herself. A BERT was activated and the physician, whom was present in the hallway, ordered medications to help de-escalate P1. RN-D attempted to give oral medications in pudding which P1 struck out and knock onto RN-D's uniform, so she excused herself to clean up. RN-D returned to P1's room and then accidentally used incorrect pronouns for P1 which escalated the situation and a decision was made to use IM medication. P1 proceeded to rip several pieces of wallpaper off the wall and security officers, including SO-B, arrived to assist. RN-D stated she was in P1's room immediately in front of P1 attempting to hold up a large piece of torn wallpaper with her left hand, and P1 then started spitting at her. This caused herself to release the wallpaper and extend her left hand outwards (like a stop motion) in effort to block the bodily fluids. However, her hand then made physical contact with P1's face. P1's then yelled, "You hit me you fat [expletive]!" RN-D and the present security officers then administered the IM medication to P1 and, ultimately, placed her in restraints with several people being needed to assist. RN-D explained she felt her hand making contact was "not a hit, it was not a slap" but rather just accidental due to her standing so close to P1. RN-D denied wanting to make contact with P1 when she extended her hand, however, verified P1 did allege "you hit me" when it occurred. RN-D stated the incident had several witnesses, including SO-B, and voiced the incident had been reported to the charge nurse and security was going to address it, too, so she entered her progress note (see above; dated 10/22/22) and left the campus as she "didn't want to stay" after the incident. RN-D verified she returned to work the following day, on 10/23/22, and worked in the pediatric infusion center on an unsupervised basis in between security and the police department wanting to visit with her. RN-D then had a few scheduled days off and, during those days, was contacted by the hospital and placed on leave. Then, several more days later, the hospital contacted her again and stated they were unable to substantiate any abuse findings as they felt her reaction was "self defense" and "not intentional." The hospital then discussed the incident with her and she would be completing AVADE training (an approach to preventing, avoiding, de-escalating, and mitigating violence and aggression in the workplace) soon thereafter. RN-D reiterated she did not act with intent to strike P1.

A provided Office of Risk Management (ORM) Investigative/Legal Discovery brief, dated 11/2/22, identified the hospital-completed investigation of the incident between P1 and RN-D on 10/22/22 and the corresponding timeline of when each investigative piece (i.e., interview) was conducted. A date of incident was listed as 10/22/22, with narrative text which outlined P1 had spit at RN-D which, in reaction, it was alleged RN-D slapped P1 on her mouth. A section was listed which outlined the various investigative allegations and plan(s) which started on 10/24/22 (two days after the incident) and including obtaining employee records and interviewing witnesses to the event. The completed interviews included testimony from SO-B, dated 10/27/22, which recorded his presence at the scene of the event and RN-D slapped P1 which he viewed as knee-jerk reaction to being spit on. The slap was described as across the mouth with an open hand palm and specifically listed the slap did not appear to be self-defense related as it was hard hitting and audible. P1 then alleged aloud RN-D had struck her and called her a derogatory name. The report included other testimony, including from RN-D, and concluded with a section for the conclusion of the investigation. The report determined ORM was unable to substantiate RN-D had intentionally slapped or struck P1 as it was RN-D reacted to being spit on and extending her arm which made the contact.

On 11/8/22 at 11:20 a.m., the hospital leadership team, including the director of accreditation (DOA)-A, patient safety manager (PSM), associate administrator of hospital operations (AAHO), vice chair of nursing practice (VCN), and nurse administrator for pediatrics (NAP) were interviewed. PSM explained the "patient safety reporting process" included events being received into a single data base. The incident on 10/22/22 was "discovered" on 10/23/22, as the team reviews all events from the previous day and weekend. Their team reviews each event and then starts to ensure the information gets routed to appropriate leadership departments and the organizational risk department depending on the event details. The hospital safety team and accreditation teams' were also typically notified. The incident on 10/22/22, PSM stated P1 was not physically harmed and they did not prior nor currently believe the incident or allegation was 'reportable' based on the events. However, through a review group they determined a closer investigation or review may be needed and, as a result, have a systems and process review for the incident scheduled in the coming weeks. AAHO explained the hospital leadership team has "multiple ways" it gets notified of events and allegations with many of the events coming directly to their email systems. AAHO stated they were out of state when the incident with RN-D and P1 occurred, however the process to determine a "need for follow-up" started timely regardless. However, AAHO stated the security events and reports provided can be multiple pages in length and unless a concern is highlighted or known, then things could get missed in the report. AAHO stated the accreditation team was typically good at picking up on items which needed to be reported as potential vulnerable adult or minor concerns, and if needed, the event is forwarded to the ORM who then performed a "full investigation." AAHO explained the leadership group had "a lot of discussion" about the incident on 10/22/22, and through first interviews which had been completed, they determined RN-D's actions were "in self defense" was the initial reaction until more reports came in with more details. A decision was then made to place RN-D on paid leave as they felt more review into the allegation and incident was needed. AAHO added they had "engaged what we felt was an appropriate approach" to the situation.

The interview continued and when questioned on actions taken to provide immediate and ongoing protection while the investigation was being completed, including why RN-D had been allowed to work unsupervised the following day after the incident, NAP stated she became aware of the incident on Sunday, 10/23/22, when the information had been passed down from security to the overnight supervisor (RN-E). NAP stated her initial instinct was to immediately place RN-D on administrative leave as the allegation caused her to be "very concerned." NAP then contacted VCN and discussed the incident as there was multiple staff members and leadership positions who needed to be involved to place a person on administrative leave. However, after some more information was obtained and the inconsistencies between the accounts made the incident sound more like RN-D was merely trying to deflect P1's spit and, in doing so, made accidental contact with P1; NAP reached back to VCN and they determined to allow RN-D to work on 10/23/22, despite the allegation and further need to investigate. The decision was ultimately made, in part too, after "recognizing the need of the unit." NAP verified RN-D returned to work on 10/23/22, despite the investigation being ongoing and the report outlining SO-B's version of events, on an unsupervised basis. NAP reiterated the decision was made based on inconsistencies from accounts and the information they had available to them in the moment. When more information became known, then the decision was made to place RN-D on leave for the investigation process as they felt it was "more appropriate" given the new information they received regarding the incident.

During the abbreviated survey, multiple requests were made for a policy or procedure which outlined the hospital's protocol or response to provide immediate protection for patients, both involved and not-involved, after an allegation of abuse is made. A provided Caregiver Misconduct Reporting Procedure policy, dated 1/2022, identified instructions on how to report and document suspected events of caregiver misconduct. A procedure was listed which directed an employee who witnesses such event should report it immediately to an immediate supervisor, division chair, house supervisor or the patient safety (group). Those group(s) would then notify Risk Management and Global Security, and work with those groups to obtain patient account of the event. The policy included, "Partner with Global Security, Nurse or Operations Administrator and Human Resources to determine whether the subject of the allegations should be placed on administrative leave during the pendency of the investigation." The policy lacked any other steps or guidance on how to ensure immediate protection would be provided until these groups were notified and could act on the concern. In addition, the policy lacked any separate direction for weekday versus weekend hours to ensure events, such as the 10/22/22 incident between P1 and RN-D, were acted upon timely if they occurred off-hours or during the weekend.

On 11/8/22 at approximately 2:00 p.m., DOA-A verified there were no additional specific policies they could locate and provide demonstrating a process or hospital protocol for immediate and ongoing patient protection once an allegation of potential abuse is witnessed or expressed.

A provided Abuse, Neglect or Exploitation of Vulnerable Adults and Minors Procedure, dated 6/2022, listed a section labeled, "Reporting Abuse, Neglect, or Exploitation of a Minor," which identified steps to take if a mandated reporter knows or has reason to believe child abuse or neglect has occurred. This included making a verbal report, a written report as soon as possible (but no later than 72 hours), and notifying social services for appropriate follow up (i.e., filing a SANC report). However, the policy lacked any direction or guidance on how immediate protection would be provided to a patient who voiced an allegation or had one against them witnessed.