HospitalInspections.org

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Based on document review, medical record review and interview, in one (1) of seven (7) medical records reviewed, it was determined that the facility failed to:

a) Protect patients at risk for sexual assault by implementing appropriate measures to ensure the patient's safety.

b) Ensure that a patient complaint of sexual assault was thoroughly investigated, document an outcome, develop, and implement a corrective action plan.

These failures place patients at risk for sexual abuse.

Findings include:

See tag A-0145.

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Based on medical record review, document review and interview, in one (1) of seven (7) medical records (MR) reviewed, the facility failed to conduct a thorough investigation and document the findings of a sexual assault complaint investigation, establish, and implement a policy and procedure for sexual assault investigation (Patient #2).

These failures may place patients at risk for sexual abuse.

Findings include:

The medical record of Patient #2 revealed a 46-year-old female with a history of Type 2 Diabetes, pneumonia due to COVID 19 Virus (2021), drug use (Opium, Cocaine, and Heroin) disorder, and alcohol use. The patient was brought to the Emergency Department on 02/28/2023 at 3:17 PM for drug and alcohol assessment after she was found hitting her head on a wall. There was no loss of consciousness. The patient also had bilateral healing frost bite wounds on her hands. The patient was admitted to the Medical Surgical Unit on 2/28/23 at 3:29 PM with a diagnosis of cellulitis and abscess of the hand. The patient remained in the ED until she was transferred to the inpatient Medical Surgical Unit on 03/01/23 at 7:53 PM.

On 03/02/23 at 9:10 PM, Registered Nurse (RN) documented that the patient told her not to say anything and that the nurse who did her electrocardiogram (EKG) "touched me." The patient was asked by the RN "touch me how?" She then told the RN "he put his fingers in my vagina." RN also documented that the Charge Nurse and Physician were notified.

The patient left the facility against medical advise on 03/06/23 at 12:12 PM.

Review of the investigative report revealed that the facility interviewed the patient on 03/02/23 after she reported the incident. Staff L, Patient Care Technician who performed the EKG was interviewed and suspended on 03/02/23 pending completion of the investigation.

The investigation report did not indicate an outcome for the sexual abuse investigation.

There was no documented evidence that the patient was offered or received a sexual assault examination.

On 03/03/23 at 1:07 PM, the patient was seen by Staff N, Medical Resident. The patient was evaluated but there was no documentation of a sexual assault examination or a refusal of an exam by the patient.

During interview on 7/28/23 at 3:10 PM, Staff O, Chief Nursing Executive, Senior VP/Chief Nursing Officer stated that the investigation was unsubstantiated on 03/03/2023 and Staff L was asked to return to work on the same inpatient unit.

Review of facility policy titled "Abuse and Neglect Assessment Procedures" effective 02/21/22, page 4 states:
C. Adult Abuse ...
3. Document the following in the patient's record:
a. The patient's complaints and symptoms as well as the results of the observations and assessment (use the patient's own words whenever possible).
b. The patients complete medical and trauma history and relevant social history.
c. A detailed description of any injuries, including type, number, size, location, resolution, possible areas of injury. Document description of all injuries ...

There was no documented evidence of the patient's symptoms as well as the results of observation including a detailed description of the patient's injury.

When the policy on the process of investigating an allegation of sexual assault was requested, Staff P redirected surveyor back to page 4 of the policy titled "Abuse and Neglect Assessment Procedures" effective 02/21/22.

The policy did not provide a procedure to follow for the investigation of a sexual abuse allegation.

On 07/28/2020 at approximately 3:00 PM, these findings were shared with Staff O, Chief Nursing Executive and Staff P, Senior Director of Quality and Performance Improvement.