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Based on the manner of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 484.13, PATIENT RIGHTS, was out of compliance.

A0145- Standard: Patient Rights: The patient has the right to be free from all forms of abuse or harassment. The facility failed to implement adequate measures to protect patients during the investigation of an alleged sexual assault on a patient. In addition, the facility did not thoroughly investigate the possibility an unidentified perpetrator posed a threat to other patients, and failed to ensure all employees were appropriately screened by conducting criminal background checks.

Based on observations, interviews, and document reviews, the facility failed to thoroughly investigate an allegation of sexual assault on a patient, and to implement appropriate procedures to ensure patient safety during the investigation. In addition, the facility failed to ensure employees were appropriately screened by conducting criminal background checks.

The failure exposed patients to potential harm from a possible sexual predator, or from employees with unidentified criminal histories.

POLICY

The facility policy, Investigating Serious & Sentinel Events, stated that promoting patient safety requires that every event be treated seriously and prompt action be taken to protect the patient as well as other patients who, without action, could also be at risk. The policy also stated that the facility should ensure communication and support among departments is coordinated. Allegations of sexual assault are categorized as a level 4, or sentinel event.

The facility policy, Safety and Security Management Plan, stated the facility provides a safe and secure environment for its patients by managing the identified risks associated with providing services for patients. Based on its processes, the facility reports and investigates incidents involving patients, staff, or others within its facility.

The facility policy, Patient Safety Program, stated that the program is to be integrated throughout the hospital.

The facility policy, Manager's Guide to Human Resources, stated criminal background checks must be performed for newly obtained employees in cases of acquisitions. Employees with a record of sexual crimes are not eligible for hire.

FINDINGS

1. The facility failed to thoroughly investigate an allegation of sexual assault on a patient.

a) A review of facility documents on 12/22/14 revealed that Patient #4 made an allegation to the facility on 12/15/14 that s/he had been sexually assaulted by an unknown perpetrator the night of 12/14/14.

b) Interviews with the facility's Director of Quality Management (DQM) on 12/22/14 at 4:10 p.m., and on 12/24/14 at 10:15 a.m., revealed s/he determined that Patient #4 was not a credible witness because the Patient's facial expression was not fearful, and the Patient did not provide sufficient details of the alleged event. S/he stated law enforcement and the Department had been notified because facility policy and regulations required it.

The DQM stated s/he interviewed Patient #4; Certified Nurse Aides #1, #9, #10; Registered Nurses #4, #8, #11, #12, #13, and other patients on the unit, and researched potential side effects of Patient #4's medications, as well as whether the patient's clinical condition could have caused a hallucination of the event. The DQM stated s/he did not investigate the possibility an unidentified perpetrator posed a continued risk to patients in the facility because s/he determined Patient #4's statements were not credible.

c) The Security Supervisor was interviewed on 12/23/14 at 11:21 a.m. The Supervisor stated s/he was not contacted by the DQM or anyone else at the facility about a possible sexual assault on a patient, and no one requested evidence such as visitor logs, security rounds logs, or videotape from security cameras. The Supervisor stated s/he learned of the allegation of sexual assault from other staff members through "hearsay" and that this interview was the first time anyone had formally spoken to him/her about an alleged sexual assault of a patient.

d) The facility's Resource Chief Executive Officer (CEO) was interviewed on 12/23/14. The CEO stated s/he received a phone call from the facility's DQM informing him/her of the allegation the morning of 12/15/14. S/he initiated a conference call with the Vice President of Clinical Operations and the Senior Director of Clinical Quality, who gave the facility guidance on how to proceed with the investigation and provide protection for patients during the investigation.

2. The facility failed to implement appropriate measures to protect patients after a patient alleged s/he had been sexually assaulted.

a) An interview with the DQM on 12/22/14 at 4:10 p.m. revealed the facility had implemented a change in staffing in response to the allegation, requiring that female staff care for female patients, and male staff members be accompanied by female staff members for contact with female patients. No other measures to protect patients from a possible sexual predator were taken.

b) The Resource CEO was interviewed on 12/23/14 at 3:31 p.m. The CEO stated s/he thought the change in staffing was adequate to protect patients because it would prevent male staff from being alone with female patients. S/he stated the staffing changes were to remain in place until law enforcement concluded their investigation, which was still on-going.

c) During the interview with the Security Supervisor on 12/23/14 at 11:21 a.m., s/he reported s/he was not asked to increase the security presence on the patient units or to increase the level of vigilance in the facility in response to the allegation.

d) On 12/23/14 at 1:37 p.m., the Chief Nursing Officer (CNO) was interviewed. S/he stated no formal communication took place with facility staff regarding the nature of the allegation, a need for increased vigilance, or protection of patients after the allegation was made. S/he reported the staff who were involved were instructed not to discuss the event.

3. The facility failed to ensure criminal background checks were conducted on all employees.

a) On 12/24/14, a review of facility documents revealed that 2 out of 8 employees had no criminal background checks on file.

b) The Human Resources (HR) Generalist was interviewed on 12/24/14 at 9:50 a.m. The HR Generalist stated 2 of 8 employees with no background checks on file had been employees of the previous entity before it was acquired by the facility, and that s/he could not answer the question of how the facility could ensure the acquired employees met the facility's hiring criteria. S/he suggested the Vice President of Human Resources (VP of HR) would have the answer to that question.

c) The VP of HR was interviewed on 12/24/14 at 10:00 a.m. The VP of HR stated she could not respond to the lack of criminal background checks for the acquired employees because s/he was not with the facility at the time of the acquisition.

The VP of HR stated the facility's organization runs Office of Inspector General reports monthly on all employees, but s/he did not know whether those reports showed criminal histories. The VP of HR stated an allegation of an arrest or a criminal conviction would trigger a repeat background check on an existing employee but that the facility would first ask the employee to voluntarily provide his or her criminal record information before conducting a background check.

d) The Human Resources (HR) Generalist was interviewed on 12/24/14 at 8:10 a.m. The HR Generalist stated a disciplinary action, a threat to a patient or visitor, or behaviors suggestive of drug use would trigger a repeat background check on current employees. S/he stated the Resource CEO would have to request such a repeat background check.

e) The Resource CEO was interviewed on 12/24/14 at 9:20. The CEO stated s/he had never personally requested a repeat background check on a current employee, but that s/he would send an employee for a drug screen if the employee's behavior was not normal. S/he stated that s/he relied on something to "pop up" during the license renewal process, as s/he believed an employee would have to be "clean" to renew his or her license. The CEO stated s/he or the HR Generalist would have to ask for a repeat background check to be done on non-licensed employees. The facility did not have a process for ongoing monitoring of non-licensed employees with regard to criminal histories.