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Based on interview and document review, the hospital failed to ensure appropriate measures were implemented to ensure patient protection after an allegation of staff to patient sexual abuse was verbalized by 1 of 1 patient (P1) who reported sexual abuse by staff during the provision of care. The facility failed to implement a thorough investigation into the allegation and the alleged perpetrator continued to provide unsupervised patient care.

As a result, the hospital was found out of compliance with the Condition of Participation Patient Rights at 42 CFR 482.13.

An immediate jeopardy was issued at A-0145. See A-0145 for additional information.

Based on interview and document review, the hospital failed to ensure appropriate measures were implemented to ensure patient protection after an allegation of staff to patient sexual abuse was verbalized by 1 of 1 patient (P1) who reported sexual abuse by staff during the provision of care. The facility failed to implement a thorough investigation into the allegation and the alleged perpetrator continued to provide unsupervised patient care. This had the potential to affect all patients receiving care within the hospital.

The immediate jeopardy began on 8/18/25, when P1 reported to her day shift registered nurse (RN) that a nurse had touched her vagina overnight, the hospital failed to protect patients after the allegation was made. The incident was not thoroughly investigated and the alleged staff member continued working on the unit without supervision, placing other patients at risk for sexual abuse. The Regulatory and Accreditation Officer, Inpatient Nursing Practice Director, and Saint Cloud Hospital President were informed of the immediate jeopardy on 9/4/25 at 4:15 p.m. The immediate jeopardy was removed on 9/9/25 at 2:43 p.m. but the hospital remained out of compliance with the COP of Patient's Rights at 42 CFR 483.13.

Findings include:

P1's admission record dated 8/15/25, indicated P1's diagnoses included acute spontaneous subarachnoid, intracranial hemorrhage due to cerebral aneurysm (HCC), and cerebral artery vasospasm. P1 was treated, stabilized, and was discharged home on 8/30/25.

On 8/15/25, P1's medical record indicated P1 arrived at the emergency department (ED) via emergency medical services (EMS) and was subsequently transferred to intensive care unit (ICU) for further evaluation.

During an interview on 9/2/25 at 2:38 p.m. P1 stated she was sexually abused by the male night nurse, on the night of 8/17/25 into 8/18/25. P1 recalled AP coming into her room, started asking "weird" questions and wanted to rub her back. AP then put his thumb/finger inside her vagina. P1 indicated she did not say anything to AP because she did not know what to do. P1 described the alleged perpetrator (AP) as an African American. P1 explained it was dark in the room so she could not provide any further description of the AP and was not aware of the exact time of occurrence because she had not looked at the clock. P1 reported the incident to the registered nurse (RN)-A on the morning of 8/18/25. P1 explained after a couple of days the incident still bothered her so she talked to another nurse (not identified) who would try and find more information. The nurse came back and reported no one knew anything about her report of sexual assault, so P1 called the police. P1 stated no one offered her a SANE (sexual assault nurse examination) after she had reported. The police officer told her the exam needed to be done within 12 hours, so she declined the exam when offered days later. P1 stated no one from the hospital interviewed her after RN-AC nor after she reported to the police.

P1's Flowsheet dated 8/18/25 included (but not limited to) at 12:00 a.m. indicated R1 was repositioned in bed. At 2:00 a.m. indicated R1 was in bed, foley catheter had 150 ml (milliliters) of urine. At 4:00 a.m. indicated R1 was alert and orientated, had mild/moderate pain, R1 was repositioned, room was darkened, wet to cold cloth to head; and "Back rub". Additional documentation at 4:00 a.m. included foley catheter was in place draining clear/yellow/straw colored urine- Urinary containment device;Absorbent chux in place;Limit use of briefs; Linens clean dry, wrinkle free; Stabilize tubes;Skin folds clean and dry was documented.

During an interview on 9/3/25 at 11:30 a.m. RN-A stated on 8/18/25 P1 reported to her she was sexually abused by the male night nurse. P1 reported AP rubbed her back first then put his finger into her vagina. RN-A stated she reported the incident to her charge nurse, RN-B, immediately and did not report to the State Agency or law enforcement.

During an interview on 9/3/25 at 9:33 a.m., RN-B stated RN-A reported P1's sexual abuse allegation to her on 8/18/25. On the same day RN-B then followed-up with P1 who reported the same allegations, however, RN-B did not remove the AP who she described as "Middle Eastern" from the schedule that evening and reassigned the AP to care for different patients on the same unit but restricted the AP from providing care to P1. RN-B explained when P1 required personal hygiene, staff were to use the "buddy system" after the allegation was made. RN-B stated on 8/19/25, the following day, she reported the allegation to RN-C the director of the ICU. RN-B did not report it to the State Agency on 8/18/25 nor call the police to file a criminal report.

During an interview on 9/3/25 at 11:58 a.m. RN-C stated RN-B told her on 8/19/25 about P1's sexual abuse allegation. RN-C stated she attempted to talk to P1 on 8/19/25 and 8/20/25 but she was sleeping on both occasions. On 8/21/25, 3 days after the allegation, she was able to talk to P1 who stated the male night nurse, who P1 described as an African American, had sexually assaulted her on 8/18/25 by rubbing her back and putting his thumb into her vagina. RN-C updated P1's care plan to reflect two staff at all times during cares. RN-C did not file a report to the State Agency on 8/21/25. Further explaining during an interdisciplinary meeting on 8/25/25, the team realized the incident should have been reported to the State Agency, so RN-C directed RN-B to make the report. RN-C stated the AP was not suspended; he was still working in the ICU but not caring for P1 anymore. RN-C reported no education was provided to the staff pertaining to timely reporting nor was there education provided for protocols on immediately implementing patient protections after an allegation of abuse was made.

P1's Patient Protection Event Summary that was entered on 8/22/25 included an event identified as staff to patient "sexual criminal" with no detectable harm. The description of the event indicated on 8/22/25 the writer became aware that St. Cloud Police were on site to take a report from P1 who was reporting a sexual assault that she states occurred while admitted to the ICU. This incident reportedly occurred this past weekend (8/16/25-8/1725). Because an exact date and time are not known, the date and time are approximate. P1 reports that either a nurse or doctor assaulted her. Further identified the writer reached out to the on-duty nursing supervisor and asked her if she could ensure that the patient is offered a SANE examination. She stated that she would reach out to ETC define ETC to facilitate this. Additionally indicated the writer was not a licensed staff member so a vulnerable adult report was not submitted.

During an interview on 9/4/25 at 3:24 p.m. a security officer (SO)-A stated a police officer came to the hospital on 8/22/25 per P1's request to investigate P1's alleged sexual assault by a staff member in the ICU. SO-A stated he went to the unit to make sure the charge nurse was aware of the allegation and to see if P1 had received an examination which the charge nurse did not know. SO-A stated he requested VA to be filed and it was not filed until 8/25/25.

P1's Patient Protection Event Summary Follow-Up Actions dated 8/25/25 included, ""pt reported "a male nurse "put a finger in her vagina". Pt added that she already reported the incident to ICU staff. Pt unable to recall when the incident occurred and name of staff involved. Pt stated that she feels uncomfortable sleeping in a different room by herself and would like for her partner/boyfriend to stay with her." Further identifying P1 had a history of hallucinations. The follow-up also included interviews from the nurses that P1 had reported the allegations to. The actions identified the team reviewed the facts of case which included: discussed allegation, timeline of events, no clinical management, no video footage needed due to no specific timeframe, determined no additional staff/pt interview needs, and male nurses removed from care team.

A Vulnerable Adult Maltreatment Report dated 8/26/25 received by the state agency from the hospital indicated on 8/18/25, P1 reported to staff member she was sexually assaulted by the male night nurse. The probable AP was removed from caring for P1. However, the AP remained providing patient care to others in the unit.

During an interview on 9/3/25 at 12:52 p.m. AP stated he provided care to P1 the night of 8/17/25. AP explained on 8/17/25 when he had administered P1 pain medication, P1 had told him that rubbing her back would help too, so he rubbed her back as requested. AP stated rubbing patient's back was part of nursing practices to alleviate pain and was a nonpharmacological intervention. Further explaining P1 had a Foley catheter and could not recall providing peri care to P1. AP stated he did not put his finger into her vagina. AP was reassigned to care for different patients on 8/18/25 in ICU. RN-B was the only person who talked to him on 8/18/25 about the allegation. AP confirmed he was not suspended but continued to work in the ICU on 8/18/25, 8/19/25, 8/20/25 and was off and came back on 8/26/25. AP stated he had not received any education since the allegation was made.

During an interview on 9/4/25 at 10:58 a.m. director of risk management (RM)-A stated she was made aware of the allegation on 8/25/25 after police came onsite to talk to P1. RM-A's team initiated the internal investigation and had determined P1's description of African American male did not fit the description of any staff who worked on the night shift that evening. RM-A stated AP was the only mail nurse assigned to care for P1 on 8/17/25, but there was not enough information to suspend any staff based on P1's description (African American), however, no attempt was made to re-interview P1 to obtain additional information about the AP (such as skin tone, defining characteristic, height, weight). RM-A stated the allegation was unsubstantiated because there was no AP that matched the description of "African America". RM-A stated there were some learning opportunities for ICU staff pertaining to reporting an allegation on time and ensuring education was provided however this has not been completed.

On 9/4/25 at 3:35 p.m. a voicemail was left for the lead investigating law enforcement officer requesting a return call; however the call was not returned.

Hospital's Vulnerable Adult (VA) Maltreatment policy dated 2/2025 indicated the responsibility of CentraCare to report suspected or actual abuse, neglect, misappropriation of property/financial exploitation and injuries of unknown origin, suspicious in nature, of vulnerable adults immediately but no longer than 2 hours from the time initial knowledge that the incident occurred has been received and thoroughly investigated as mandated by law.

Hospitals Rights and Responsibilities of Patients policy dated 11/2022, indicated patients shall be free from maltreatment as defined in the Vulnerable Adult Protection Act. "Maltreatment" means conduct described in Section 626.5572, Subdivision 15, or the intentional and nontherapeutic infliction of physical pain or injury, or any persistent course of conduct intended to produce mental or emotional distress.

The immediate jeopardy that began on 8/18/25, was removed on 9/9/25, when it was verified by interview, and document review the hospital completed review of the Vulnerable Adult policy by adding a clear definition of "allegation" and "alleged perpetrator", adding the hospital allegation workflow for team members and leadership to reference when an allegation is made as well as providing the allegation resource guide for leaders to aid in conducting thorough investigations. Also, the hospital provided educational handouts to be reviewed and signed off by nursing and security staff within a tracking log before their next scheduled shift. Practice changes include Vulnerable Adult (VA) & Child Maltreatment reports of abuse need to be filed immediately following the event or within 24 hours. Staff to initiate immediate protection measures such as ensuring immediate safety of the patient, suspending suspected team member, interviewing and assessing the patient (consider SANE). Also, staff have to file VA or Child Maltreatment, notify team members and/or patient representative if needed, and reassess all patients in contact with suspected team member.