HospitalInspections.org

Based on observation, staff interviews, and review of documents, the hospital:

- failed to write policies and procedures regarding all forms of abuse (including sexual misconduct), neglect, and harassment pertinent to both children and adults in a manner that clearly described actions to be taken by hospital staff regarding the identification of such instances in a proactive manner, train staff to identify and report suspected instances as soon as an instance is observed or suspected, immediately protect the patient during investigation of any allegation, objectively investigate timely and thoroughly, and report to appropriate hospital staff and state agencies as required for a mandatory reporter; and
- failed to train staff regarding hospital policies and procedures so they are consistently followed for children as well as adults who are also treated at this children's hospital.

The hospital system failed to protect an adult patient with profound mental limitations and the inability to talk - a vulnerable adult without the ability to knowingly consent - to be kissed, caressed, fondled, and sexually aroused by a female relative caregiver for at least a one-week period. Throughout this period, multiple nursing staff and social workers, each considered a mandatory reporter who work throughout the hospital, failed to document relevant observations and report concerns timely to hospital leadership and State officials. (A mandatory reporter is an individual held responsible by state laws to report suspected instances of abuse and neglect.) Hospital staff then failed to protect the vulnerable patient when verbally informed to do so by a representative of the Missouri State Adult Protection agency until written documentation was provided one day later, but then hospital staff planned to have another family members or visitor rather than facility staff be responsible for protecting the patient while State officials sought guardianship and conservatorship for this vulnerable adult. This systematic failure placed one vulnerable adult at continued risk and in immediate jeopardy to the patient's health and safety.

The cumulative result of these findings resulted in noncompliance with the Condition of Participation for Patient's Rights. At the time of the exit conference at 4:00 p.m. on 4/29/10, hospital staff had been unable to implement actions to abate this immediate jeopardy situation.

Based on observations; review of hospital policies and procedures, state statute, and records; and interviews, the facility:

- failed to write policies and procedures regarding all forms of abuse (including sexual misconduct), neglect, and harassment pertinent to both children and adults in a manner that clearly described actions to be taken by hospital staff regarding the identification of such instances in a proactive manner, train staff to identify and report suspected instances as soon as an instance is observed or suspected, immediately protect the patient during investigation of any allegation, objectively investigate timely and thoroughly, and report to appropriate hospital staff and state agencies as required for a mandatory reporter; and
- failed to train staff regarding hospital policies and procedures so they are consistently followed for children as well as adults treated at this children's hospital.

These failures resulted in the hospital's inability to protect an adult patient with severe mental retardation and inability to talk - a vulnerable adult without the ability to knowingly consent - to be kissed, caressed, fondled, and sexually aroused by a female relative caregiver for at least a one-week period before staff intervention.

The facility census was 248.

Findings included:

1. Review of the facility policy "Abuse, Neglect and Intimate Partner Violence Screening and Evaluation (Combined Suspected Child Abuse and Neglect Policy)", last revised 11/09, shows the purpose is to provide guidelines for screening and reporting suspected cases of abuse, neglect and intimate partner violence within the hospital and to appropriate state agencies.

- Policy section A. shows Children ' s Mercy Hospital staff and Medical Staff who are mandated reporters of suspected abuse include: physicians, medical examiners, coroners, dentists, chiropractors, optometrists, podiatrists, residents, interns, nurses, hospital or clinic personnel, and any other health practitioner, psychologist, mental health professional, social worker, or minster.
- Policy section B shows it is the responsibility of any staff member to identify through observation the possible abuse of any child. The policy shows: It is the responsibility of all hospital patient care staff and Medical Staff members to identify any child, regardless of socioeconomic status, race, ethnicity, or gender, for whom there is reasonable cause to suspect that the child has been or may be subjected to abuse or neglect or observes a child being subjected to conditions or circumstances which would reasonably result in abuse or neglect.
- Policy section D shows staff will consult with Social Work for an at risk patient. The policy shows: If a patient or a family member at risk for abuse, neglect or intimate partner violence is identified through the screening process, the patient care staff will consult Social Work.
- Policy section E shows hospital and Medical Staff will receive education on child abuse, child neglect and intimate partner violence screening based on current literature, provider needs (knowledge and skills), applicable law and regulations.

- Procedure section A Screening shows all patient care staff, in conjunction with the responsible Medical Staff members(s), shall be responsible for screening patients and their families, initially and on an ongoing basis, for the following hallmark indicators related to child abuse: history does not match the injury; unexplained bruises, marks or injuries; inappropriate delays in seeking or providing emotional/medical/physical care, including basic needs; and/or disclosure of child abuse by self or others.
- Procedure section B shows all patient care staff, in conjunction with the respective Medical Staff member(s), shall be responsible for screening patients, and their families, initially and on an ongoing basis, for the following indicators related to child neglect: failure to provide adequate or timely healthcare; purposeful noncompliance with healthcare recommendations; failure to provide a safe living environment; failure to provide adequate clothing, shelter and nutrition; failure to provide appropriate emotional support; and/or disclosure of child neglect by self or others.

- The evaluation section of the policy shows the health care team will decide if there is sufficient information to suspect abuse and this will be based on observed interactions and other findings. The policy shows: A conclusion as to whether or not there is sufficient information to suspect abuse, neglect or intimate partner violence will be determined by the health care team. Identification may be based on: physical findings, statements of patients/family, observed interactions, and other circumstances raising a suspicion of abuse, neglect or intimate partner violence. Any minor child who is assessed or treated at Children's Mercy Hospital [CMH] by staff, where child abuse or neglect is suspected, will be assessed with a pertinent history and physical exam by a physician/advanced practice nurse at one of the CMH service sites to determine the extent of any injury. Consultation with social work is required. In cases of suspected abuse/neglect, responsible staff shall obtain the history as soon as practical. The hospital social worker will have primary responsibility to obtain the abuse/neglect related history unless there is a medical concern requiring urgent evaluation and treatment.

- The reporting section of the policy shows staff should notify the physician prior to making a report to state agencies and any mandated reporter can initiate a report. The policy shows: If there is a determination of suspected abuse/neglect, a report must be made to the appropriate state agency(ies). If the provider has not been involved in the evaluation, staff should notify the provider prior to making the report. Any mandated reporter may initiate a report to the state agency(ies) but coordinated team efforts will generally designate the assigned social worker as the actual reporter.


2. Review of facility policy "Disruptive and Dangerous Patients/Families/Visitors", last revised 4/06, shows the purpose is that the maintenance of a safe, orderly environment for delivery of patient care is an essential component of the Hospital's mission to patients and staff. Each staff member has a responsibility to prevent, identify and work to correct situations in which a patient or family/visitors jeopardizes the safety of the patient care environment.

The policy documents hospital staff will be alert to situations which may place patients and staff at risk and will notify the appropriate person (i.e., nurse manager, nursing supervisor and security). The nurse manager/nursing supervisor will collaborate with the attending physician and others as appropriate in an attempt to manage the behavior of the patient, visitor or family in question. If informal collaboration is ineffective, an ad hoc patient conduct committee may be formed to create and implement a plan to resolve a specific situation. The committee will review alternatives for managing dangerous/disruptive visitors or family members. This could include: restricted visitation; prohibited visitation; supervision by outside agency; etc.


3. Review of Missouri Revised Statutes chapter 208, "Old Age Assistance, Aid to Dependent Children and General Relief" shows in section 208.912: When ...hospital and clinic personnel engaged in examination, care, or treatment of persons...medical resident or intern; mental health professional; minister; nurse; nurse practitioner...other health practitioner...pharmacist; physical therapist; physician; physician's assistant...psychologist; vendor as defined in section 208.900; personal care attendant; or social worker has reasonable cause to believe that a consumer has been abused or neglected as defined in section 660.250RSMo, as a result of the delivery of or failure to deliver personal care assistance services, he or she shall immediately report or cause a report to be made to the department.

Any person required in subsection 1 of this section to report or cause a report to be made to the department who fails to do so within a reasonable time after the act of abuse or neglect is guilty of a class A misdemeanor.


4. Review of Missouri Revised Statues chapter 660 shows abuse is defined as the infliction of physical, sexual, or emotional injury or harm including financial exploitation by any person, firm or corporation. The statue shows the definition of eligible adult to be a person sixty years of age or older who is unable to protect his or her own interests or adequately perform or obtain services which are necessary to meet his or her essential human needs or an adult with a disability, as defined in section 660.053 (a mental or physical impairment that substantially limits one or more major life activities, whether the impairment is congenital or acquired by accident, injury or disease, where such impairment is verified by medical finding), between the ages of eighteen and fifty-nine who is unable to protect his or her own interests or adequately perform or obtain services which are necessary to meet his or her essential human needs.

5. Open record review showed Patient #1 entered the facility on 4/08/10 for treatment of pneumonia. Review of the admitting history and physical, dated 4/08/10, showed the patient is a 19-year-old male with severe developmental delay and a diagnosis of Allan-Herndon-Dudley Syndrome who presented to this facility after an episode of dyspnea (difficult or labored breathing) at school. Allan-Herndon-Dudley Syndrome is a genetic disorder which typically results in marked speech defects, muscle atrophy and severe mental retardation of the individual.

During an interview 4/27/10 at 3:55 p.m., Licensed Clinical Social Worker (LCSW) Staff F said nursing staff reported to Social Worker Staff E on Monday morning (4/26/10) that a night shift nurse working the weekend reported the patient's close female relative/caregiver was being sexually inappropriate with Patient #1.

During an interview on 4/27/10 at 4:00 p.m. Social Worker Staff E said he/she talked with a representative (Representative Q) from the Adult Protective and Community Services the previous day (4/26/10) when the representative visited the hospital and interviewed Patient #1's female relative/caregiver. On 4/26/10, Staff E said Representative Q said the facility needed to start the paperwork so guardianship of the patient can be determined, and that a third person had to be in the room at all times when the female relative/caregiver visits the patient. Staff E said he/she then told the female relative/caregiver that another family member had to be present in the room when she visits, that the facility could not provide a staff member to be present during her visits, and gave the female relative/caregiver a copy of the letter from the Adult Protective Services representative.

During telephone interview on 5/03/10 at 9:51 a.m., Social Worker Staff E said he/she received a voice mail dated 4/26/10, timed around 5:00 p.m., that he/she had a faxed letter from Adult Protective Services Representative Q, but he/she did not have the letter in his/her hands until after lunch on Tuesday, 4/27/10. Staff E did not implement visitor restrictions until approximately 4:00 p.m. on 4/27/10. (Note: this was after the surveyor informed facility staff that it was the hospital ' s responsibility to protect the patient.) Staff E said he/she did not implement visitation restrictions until that time because he/she was waiting to talk with the Adult Protective Services representative for clarification.

During an interview on 4/27/10 at 4:10 p.m., Staff A (the Senior Director of Quality Improvement and Safety); Staff B (the Senior Director of Allied Health and Support Services), Staff C (the Critical Care Director) and Staff D (the Director of Social Work Services) reported that none of them were aware of the situation between Patient #1 and his close female relative/caregiver until this date.


Interviews that provide further information include the following:

- During an interview on 4/28/10 at 9:30 a.m., LCSW Staff G said on Saturday, 4/24/10, a day shift nurse Staff R reported that night shift nurse Staff M passed on in report ("report" is made when one shift of nursing staff is leaving and another shift of nurses is beginning to care for patients) that he/she observed the female relative/caregiver of Patient #1 being inappropriate with the patient. LCSW Staff G told nurse Staff R to pass on to the night nurse, Staff M, to page the social worker when next on duty since the night nurse needed to document the observed incident. LCSW Staff G stated he/she went to Patient #1's room and observed the female relative/caregiver sleeping. Staff G's shift ended at noon on Saturday, but prior to leaving the facility returned to the patient's room and observed the female relative/caregiver changing the patient's diaper. The female relative/caregiver told LCSW Staff G she preferred to change the patient's diaper. LCSW Staff G reported the staff concerns to the female relative/caregiver, including that she was kissing the patient on the face, arms and stomach, and blowing raspberries on the patient's stomach. The female relative/caregiver denied touching the patient's groin except to clean the patient during a diaper change. The female relative/caregiver said that sometimes when she cleans the patient's penis, the patient gets an erection, but she will clean the penis and then pinch the penis to make the erection go away. Staff G said to the surveyor, "I don't feel pinching of the penis is inappropriate behavior by the [female relative/caregiver]. She is uncomfortable with [the patient] having an erection." Staff G said staff has had concerns since the patient's admission (i.e., 4/8/10 - a two-week period). LCSW staff G said he/she did not contact night nurse Staff M directly concerning the observations because his/her shift was about to end for the day, he/she didn't know how to call the nurse, and didn't know if he/she could call the nurse. Staff G said that based on the information he/she had from nursing, he/she implemented the best he/she could by passing along the message that staff needs to document their observations. LCSW staff G said, "We can't require visitation restrictions without an order from child protective services." Staff G said night nurse Staff M again witnessed inappropriate behavior by the female relative/caregiver and then the facility took additional steps.

(During an interview on 4/29/10 at 9:15 a.m. the facility director of social work, Staff D said there is no policy that a social worker cannot make a hotline call if they don't have the information directly from the person who observed the questionable behavior. Director D said the social work staff may feel making a hotline call is futile due to their past experience with reporting.)

- During an interview on 4/28/10 at 10:25 a.m. LCSW Staff H said on Saturday (4/24/10) he/she was a float social worker (meaning that he/she would " float " to different areas of the hospital where patients were treated) and was covering the Pediatric Intensive Care Unit (PICU) unit. Staff H got a call from night nurse Staff M that he/she had received a message to call social work about Patient #1. LCSW Staff H said he/she knew the social worker on the morning shift, Staff G, talked with someone during the day to document any concerns, but LCSW Staff H told the surveyor that he/she thought the issue had been taken care of during the day. Staff H said the social worker covering the morning shift told him/her there had been concerns about the Patient #1's female relative/caregiver inappropriately touching the patient. LCSW Staff H said he/she did not ask night nurse Staff M what he/she had a concern about, because he/she wasn't sure who the nurse was that the morning social worker had talked to. LCSW staff H said, "I didn't feel a need to get involved in the middle." The social worker said, "I don't think we handled this case any differently than a child abuse case. The patient was in a safe place." LCSW Staff H said that from what Staff G said, it sounds like the patient's female relative/caregiver was blowing raspberries on the patient's stomach and that is appropriate for a close female relative/caregiver to do to a child. The social worker confirmed the patient is 19-years-old and said the facility doesn't want to make a report to state agencies too lightly. He/she said nurses didn't document their concerns. Social worker Staff H said, "I don't feel comfortable not having first-hand information. I did not ask [Staff M] about his/her concerns."

- During a telephone interview on 4/28/10 at 4:05 p.m., Registered Nurse (RN) Staff M said he/she worked the night shift last Friday night until Saturday morning (4/23/10 - 4/24/10). Staff M went into Patient #1's room and the female relative/caregiver was lying across the patient's body kissing the patient's abdomen. Staff M said the patient's adult diaper was up around his/her belly button and the female relative/caregiver rolled it down low on the groin and started kissing the patient ' s low groin area. Staff M said the female relative/caregiver's head was pointed toward the patient's feet and the female relative/caregiver was rubbing the inside of the patient's upper thigh. Staff M said during report on Saturday morning, he/she reported the behavior of the female relative/caregiver to the on-coming shift of nurses and to the charge nurse. Staff M said a day shift nurse, Staff R, said he/she would contact the day shift social worker and report the female relative/caregiver 's behavior. Staff M said when he/she returned to work on Saturday evening, the charge nurse instructed him/her to call the social work department. Staff M said he/she spoke over the phone to Social Worker Staff H who told her/him to document his/her observations in the computer system. Staff M said she told the social worker his/her name and the situation he/she had observed between the female relative/caregiver and the patient. Staff M said he/she did not report his/her observations to the social worker during the Friday/Saturday shift because it was close to the time he/she was going off duty. Staff M said when he/she observed the female relative/caregiver's behavior, the patient did not seem uncomfortable. Staff M said when he/she returned to duty on Saturday night, there were no instructions from anyone about monitoring the female relative/caregiver ' s visits and Social Worker Staff H did not discuss any restrictions staff should impose on the female relative/caregiver.

Other interviews regarding observations of care provided by the female relative/caregiver and Patient #1 include the following:

- During an interview on 4/28/10 at 2:35 p.m. Registered Nurse Staff I said he/she cared for the patient Monday (4/26/10). Staff I said he/she heard from another nurse on a different shift that the female relative/caregiver was kissing the patient on the mouth, chest and groin. Staff I said it was passed on in report that the female relative/caregiver was not to do a diaper change by herself because staff had witnessed the female relative/caregiver doing a diaper change and cleaning the patient's penis and scrubbing the perineal area (the penis, scrotum, and genital area between the scrotum and anus in a man) until the patient got an erection. Staff I said he/she observed from the doorway of the patient's room the female relative/caregiver kissing the patient. When the female relative/caregiver saw him/her watching, she moved to block the view of nursing staff, but Staff I observed the female relative/caregiver kissing the patient on the mouth for what Staff I felt was eight to ten seconds.

Staff I said on Monday 4/26/10 around 9:20 a.m. he/she saw a representative from the Adult Protective Services at the patient's bedside. Staff I said the Social Worker Staff E mentioned the visit from the Adult Protective Services, but did not say there were any restrictions on the female relative/caregiver visiting. Staff I said he/she did not know of visitation restrictions until today (4/28/10 - two days later). Staff I said he/she did not report any of his/her observations or concerns about the behavior of the female relative/caregiver toward the patient, nor did he/she document any concerns or observations in the patient ' s medical record. Staff I said nursing staff already knew of the inappropriate behavior by the female relative/caregiver, so he/she thought the behavior had been reported.

- During an interview on 4/28/10 at 3:00 p.m., Registered Nurse (RN) Staff J said he/she heard sometime last week that the patient's female relative/caregiver was kissing the patient inappropriately. Staff J said the other nurse said while kissing the patient, the female relative/caregiver was telling the patient he was sexy. Staff J said he/she did not report this conversation with the other nurse because he/she didn't directly observe the behavior.

- During an interview on 4/28/10 at 3:25 p.m., RN Staff K said he/she did not observe inappropriate behavior by the female relative/caregiver toward the patient but the female relative/caregiver made some unusual comments. The female relative/caregiver complained to Staff K that nurses did not know how to care properly for the patient, complained that a "Barbie Doll" nurse was taking care of the patient and the nurse was too beautiful. The female relative/caregiver kept telling Staff K that she is a very affectionate close female relative/caregiver and very affectionate toward the patient.

- During an interview on 4/29/10 at 11:05 a.m., RN Staff O said he/she cared for Patient #1 on Thursday and Friday (4/22/10 and 4/23/10). Staff O said the close female relative/caregiver is very affectionate toward the patient and kissed the patient on his chest a lot. Staff O said he/she and the female relative/caregiver were giving perineal care to the patient; the female relative/caregiver was very slow and concise with washing the patient's penis. Staff O said, "Usually you just clean the patient making sure the patient is clean, but you don't continually keep washing the perineal area like the [female relative/caregiver] did." Staff O said the female relative/caregiver is the patient's caregiver at home. Staff O said he/she did not talk to anyone regarding his/her concerns about the way the female relative/caregiver was cleaning the patient. Staff O said, "Maybe I should have. Maybe it was a red flag." Staff O said it is confusing that the patient is 19-years-old, but mentally is a baby. Staff O said if the primary care giver is a male and the patient is a 19-year-old female, "I would view that differently, the behavior [by a male] would be inappropriate."

- During an interview 4/29/10 at 11:30 a.m., RN Staff P said he/she cared for the patient on Sunday 4/25/10. Staff P said he/she saw the female relative/caregiver being inappropriate several times on that shift. The female relative/caregiver was kissing the patient's abdominal area and kissing the patient's feet. Staff P said, "When she kissed the patient, she was very passionate, it seemed sexual, it was like she was making out with the patient's feet." Staff P said another situation he/she thought was inappropriate was the female relative/caregiver reported to him/her that the patient had a pimple on the penis. Staff P said the pimple was so small he/she could hardly see it, but the female relative/caregiver kept pointing it out. Staff P said the patient had a bowel movement in the adult diaper and he/she and the female relative/caregiver were going to clean the patient. Staff P said he/she wanted to check the linen under the patient to see if the sheet was wet and the female relative/caregiver put her face next to the patient's diapered scrotum and placed her cheek on the wet linen to smell it. Staff P said he/she verbally reported the female relative/caregiver ' s behavior to the next shift of nursing staff, but could not remember who he/she reported it to. Staff P said he/she did not document any of his/her observations or concerns. Staff P said he thought at the time if the female relative/caregiver behaves this way toward the patient while the patient is here in the hospital, " I wonder what goes on at home " (since the female relative/caregiver and Patient #1 reside together).


Review of records revealed:

- Open record review for Patient #1 showed a case management note dated 4/24/10 at 9:29 a.m. by Social Worker Staff G. The note documents, "SW [social worker] received a page from PICU requesting SW assistance to speak with [female relative/caregiver] about inappropriate behavior and hygiene. SW read previous SW notes then went to PICU to speak with nurse and [female relative/caregiver]. When SW presented to PICU, [nurse, Staff R] informed SW that [female relative/caregiver] is sleeping. [Nurse R] reports his/her main concern is that [female relative/caregiver] has been seen by nursing staff since admission 'rolling down patient ' s diaper and kissing on his/her groin area, stomach and face' inappropriately. [Nurse R] reports those actions have not been documented by any staff nor addressed with [female relative/caregiver] once witnessed. SW expressed concern with lack of documentation and intervention. SW informed [Staff R] that if [patient] is being inappropriately touched by [female relative/caregiver] that is sexual abuse and a referral to Adult Protective Services (APS) will need to be completed. SW informed [Nurse R] to page SW once [female relative/caregiver] awakes so SW can assess the situation appropriateness for APS referral."

- Review of case management note dated 4/24/10 at 11:45 a.m. by Social Worker Staff G showed, "SW paged by PICU [Staff nurse R] reporting [female relative/caregiver] is awake. SW presented to PICU to talk with [female relative/caregiver]. Upon entering the room [female relative/caregiver] was cleaning [patient's] penis as she was in the process of changing the diaper. SW introduced self and asked [female relative/caregiver] if she typically changes the patient's diapers or if the nurses do. [The female relative/caregiver] reported she does not like how the nurses care for the patient and she prefers to care for the patient herself. SW asked nurse [Staff R] to enter the room so [female relative/caregiver] could explain how she prefers patient to be care for. SW then spoke with [female relative/caregiver] alone in a conference room explaining SW is here to talk with [female relative/caregiver] about behaviors nurses have reported. [The female relative/caregiver] reports she does not kiss [patient] on his groin area. She reports she kisses the patient on the face and stomach and will blow raspberries on the patient's stomach. She denies kissing or touching the patient's groin area. [The female relative/caregiver] reports at times when she changes the diaper the patient will get erect which makes it easier for her to clean the patient. SW discussed appropriate and inappropriate touching with [female relative/caregiver]. SW informed [Nurse R] that staff needs to document inappropriate behavior. SW further informed him/her that following PICU rules states that blinds and curtain needs to remain open and that staff needs to follow those rules. SW informed [Nurse R] that since documentation was not done, the nurse that observed the concerning behavior (kissing and rubbing the patient's groin area) needs to contact SW directly that SW cannot report based on second hand information."

- Review of case management note dated 4/25/10 at 5:15 a.m. by Social Worker Staff H shows on 4/25/10 at approximately 4:58 a.m., "SW received page to call PICU nurse [Staff M]. [Staff M] advised that [he/she] had been asked to contact SW re. concern for patient. SW reviewed patient notes and requested that [Staff H] document any concerns for follow up by SW. [Staff M] agreed to document as a nursing note in the electronic medical record (EMR). "

- Review of Psychosocial Nurse note entered into the medical record on 4/25/10 at 5:25 a.m. (a late entry for observations on 4/24/10 at 8:00 p.m.) by RN Staff M showed the female relative/caregiver at patient's bedside, inappropriate behavior observed, female relative/caregiver laying across patient's abdomen and kissing all around patient's abdomen, observed female relative/caregiver tucking down the top portion of patient's diaper to the pelvic area and female relative/caregiver kissing on upper portion of patient's pelvic area that she had just exposed. Also noted that female relative/caregiver was stroking patient's upper inner thigh while kissing patient. Informed charge nurse and on-coming nurse of behavior and the inappropriateness of it. Social worker to be consulted.

- Review of case management note, dated 4/26/10 at 8:14 a.m., by Social Worker Staff G shows in part that the social worker received the chart and noticed documentation from RN Staff M reporting continued inappropriate behavior by female relative/caregiver. Social worker then contacted APS (Adult Protective Services) and stressed that Children ' s Mercy Hospital does not do investigations and looks to APS for recommendations of a safety plan.

Social worker staff E provided this surveyor with a letter faxed from Missouri Adult Protective and Community worker, Representative Q. Review of this letter dated 4/26/10 showed the State agency had a concern regarding the relationship between this patient and his female relative/caregiver. The letter states in part that the concern alleges sexual abuse and misconduct. The letter states employees in the social work department and the nursing staff at the hospital are concerned about some of the physical aspects between the patient and his female relative/caregiver and a hotline report was made. Based on the information given, it is believed that in the best interest of the patient, that the patient's female relative/caregiver only be granted visitation rights to the patient while accompanied by another, third party person. This would be in the interest of protecting the patient from any potential abuse or advances made by his/her female relative/caregiver.

Further review of the letter showed in order to ensure the future safety of the patient; it is believed that a guardianship and/or conservatorship should be in place. The letter gave the facility guidelines the Jackson County Probate Court (the relevant Missouri legal authority) will be looking for.

During a telephone interview on 4/29/10 at 10:45 a.m. the Adult Protective and Community Representative Q said after seeing the patient and talking with the patient's female relative/caregiver on Monday 4/26/10, he/she informed Social Worker Staff E that someone, a third person, had to be in the patient's room whenever the female relative/caregiver is visiting. He/she said they talked about how to protect the patient and the third person in the room needed to be a staff member from the facility. Representative Q said Staff E told him/her the facility needed to put these concerns in writing to him/her and he/she could not put restrictions on the female relative/caregiver visiting until he/she receives a letter from the hospital. Representative Q said Staff E did not tell him/her that the facility could not assign a staff member to be the third party present during the female relative/caregiver ' s visits.

In a subsequent telephone interview on 5/03/10 at 9:15 a.m., Representative Q said he/she faxed the letter to the facility around 2:30 p.m. Monday 4/26/10 and he/she called and spoke with Social Worker Staff E to inform Staff E the letter was faxed.

Nevertheless, observation of the PICU on 4/27/10 at 3:50 p.m. found Patient #1 lying in bed with his female relative/caregiver at the bedside. No staff member or other third party individual was observed in the room.

During an interview on 4/27/10 at 4:15 p.m., Staff C (the Critical Care Director) said hospital staff has not notified the patient's physician and he/she C would notify Patient #1's physician now of the situation with the patient's female relative/caregiver.

Review of case management note dated 4/27/10 at 5:14 p.m. by Social Worker Staff E showed the social worker provided Patient #1's female relative/caregiver a copy of the letter to the facility from Adult Protective Services, informed her that the facility would not be able to supervise visitation, and she