HospitalInspections.org

Based on interview and document review, the facility failed to follow their policy regarding allegations of abuse from a staff member, resulting in the potential for harm to any of the 98 patients receiving treatment at the facility. Findings include:

On 12/13/22 at approximately 0945, interview with Hospital Director Staff A, revealed that she had been investigating an allegation of abuse of patient #1. Staff A was queried about the disposition of the alleged sexual abuser and she stated that he was currently on administrative leave, and that immediately following the incident, he was reassigned to a different part of the building from where patient (Pt.) #1 was located. Staff A also stated that the state police had been called and had interviewed the patient and were performing their own investigation. Additionally, the Office of Recipient Rights (ORR) and the State Hospital Administration (SHA) was also investigating. Staff A was asked to expand on what it means to be 're-assigned'. Staff A stated that re-assignment is preferably out of the building, sometimes the reassignment is to a different part of the building (north vs. south), with the explicit verbal directions to not have any contact with the patient of concern. If the allegation is considered 'Abuse 1', then they are suspended. She then stated that sexual abuse can be considered Abuse 1 level. Staff A was next queried who determines the level of abuse. Staff A stated that facility policy determines the level of Abuse 1 or Abuse 2. The policy was requested and Staff A was next queried who decides if the employee is placed on administrative leave. Staff A stated that HR (Human Resources), in consult with Staff A, and that she has the autonomy to suspend/place employees on administrative leave. Staff A stated that the employee of concern (Staff C) was currently on administrative leave for delaying the reporting of a sexual assault, and that he would be off the schedule until the ORR completed its investigation. Staff A was next asked if this particular incident would be level 1? Staff A stated, "Yes, it would be because of the sexual nature."

On 12/13/22 at approximately 1100, during review of documents 'Suspension and Reassignment Log' revealed that Staff C was suspended on 11/30/22 for "allegation of rape, failure to report."

On 12/13/22 at approximately 1115, during review of untitled document referred to as 'Staff C's work schedule', provided by Staff A, it was revealed that Staff C was re-assigned to the same building on the day following the incident (11/23/22), however, he was assigned to 27 south (instead of 27 north). The schedule indicated that Staff C worked six shifts following the alleged incident, before being placed on suspension/administrative leave on 11/30/22, when the Office of Recipient Rights began its investigation. It should be noted that the alleged incident occurred on 11/22/22, at the end of Staff C's shift. Staff C returned to work on 11/23 through 11/27. "A" is listed on the schedule for 11/24/22 and 11/25/22, and represents 'Annual Leave' usage, as Staff C presented to work on those days but was allowed to go home after working one hour, due to overstaffing.

On 12/13/22 at approximately 1030, an interview was conducted with Staff C. Staff C was queried if he had been reassigned. Staff C stated, "I have never been reassigned. I was assigned to a different building, but I am 'relief', which is like a 'float' person, who goes wherever there is need. Staff C was questioned when he was suspended. Staff C stated, "the 30th (11/30/22) is was officially on paid leave, pending the investigation. It had never happened to me before in 19 years, but I had assumed I'd be off, I didn't know."

On 12/14/22, during review of standard operating procedure (SOP) titled "Employee Assignment Pending Investigation", #3.86, issued 09/2021, page 3 of 3, paragraph 1 states, "For allegations of Abuse 1 or 2, or Neglect 1 or 2, the employee will be removed from patient care immediately and suspended pending investigation."

On 12/14/22, during review of policy "APF 132 Definitions and Reporting of Abuse and Neglect", dated 10/01/2015, it was revealed on p.1 of 17, that Abuse Class (level) 1 is defined as 'a non-accidental act, or provocation of another to act, by an employee, volunteer or agent of MDHHS which caused or contributed to the death or sexual abuse of or serious physical serious harm to a recipient."

On 12/14/22 at 1330, during interview with Hospital Director Staff A, Staff A was queried if Staff C should have been suspended immediately, according to SOP #3.86? Staff A replied, "Yes, you're right."