HospitalInspections.org

The Condition of Participation for Patient Rights has not been met.

Based on clinical record reviews, interviews and review of hospital documentation for two of ten patient's reviewed for care in a safe setting (Patients #2 and #3) the hospital failed to ensure that RN #1 did not have access to patients after two separate allegations of sexual assault.

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Based on clinical record reviews, interviews and review of hospital documentation for two of ten patient's reviewed for care in a safe setting (Patients #2 and #3) the hospital failed to ensure that RN #1 did not have access to patients after two separate allegations of sexual assault. The finding included:

a. Patient #1 arrived to the Emergency Department (ED) on 12/23/19 at 3:45 PM with complaints of alcohol withdrawal and tremors, started on high dose Valium protocol and was admitted to the medical floor on 12/23/19 at 10:00 PM for further evaluation and treatment for alcohol withdrawal.

Review of Patient #1's record identified that RN #1 assumed care of the patient on 12/24/19 at 7:00 AM. Review of the patient's record dated 12/24/19 at 8:25 AM identified documentation that RN #1 assessed Patient #1, which included, in part an assessment of the patient's respiratory system, with auscultation of breath sounds anterior and posterior with diminished breath sounds and a falls and mobility assessment with safety interventions that included, in part a bed alarm and provide standby assist to the bathroom. Review of the patient's record dated 12/24/19 at 2:30 PM, identified documentation that RN #1 conducted a urinary assessment of Patient #1 and identified that the patient's bladder was absent of distention.

Review of Patient #1's record identified that RN #1 conducted hourly safety checks on 12/24/19 from 7:00 AM to 7:00 PM. The record identified that RN #1 turned care of the patient over to RN #2 on 12/24/19 at 7:00 PM.

Review of a nurse's note dated 12/25/19 at 11:50 AM identified that Patient #1 verbalized upset feelings regarding an "incident from last night" however the record failed to identify the specific details of the patient's statement. The record identified that RN #3 identified that the patient was provided emotional support, including assurance that the patient would be kept safe.

Review of MD #1's progress note dated 12/26/19 at 9:05 AM identified that Patient #1 reported that "there was an episode of sexual assault" performed by a nurse on the evening of 12/24/19. MD #1's progress note identified that this incident had been reported to risk management and an investigation into the incident was occurring. MD #1's note identified that on 12/24/19 the patient had reported hallucinations and at that time was being treated with Valium. MD #1's note identified that the patient had no signs of physical trauma.

Review of a nurse's note dated 12/26/19 identified that the Chief Nursing Officer (CNO) was in to see Patient #1 after a report of sexual assault. The CNO identified that she spoke to the patient about completing a sexual assault kit as a means to collect evidence and the patient initially was unsure. The CNO provided the patient with further education and the option of utilizing a control number rather than his/her name. The patient agreed to the sexual assault kit and to see the counselor from the women's center but did not want the police notified. The CNO identified that the kit was completed on 12/26/19 at 3:00 PM and emotional support and reassurances were provided, and the patient met with the representative from the women's center.

Review of a sexual assault medical report completed by MD #1 dated 12/26/19 identified that the patient reported that he/she was sexually assaulted by a staff member on 12/24/19 at 9:45 PM. The patient identified that he/she was taken to the bathroom by the staff person (RN#1) and was forced to perform a sexual act.

Review of MD #1's report dated 12/26/19 identified that specimens were obtained from Patient #1 to be tested for sexually transmitted diseases, a sexual assault kit was performed, and a comprehensive exam was performed with no evidence of outward injuries. Additionally the report identified that the evidence collection was given to law-enforcement with a special ID number rather than the patient's name and the patient declined to have police notified of the incident.

Review of an authorization form signed by Patient #1 identified that the patient understood that he/she was not required to report the sexual assault to law-enforcement at the time of the collection, and if he/she did not report the assault immediately to law-enforcement, the evidence collected will be held for up to five years, during which time the evidence will be identified by a control number, not by name.

Review of the sexual assault checklist identified that no mandated report was made as it did not fall under "'Children Elderly or Adults with mental retardation".

Review of Patient #1's clinical record for the period of 12/26/19 to 12/29/19 identified that the patient was monitored for alcohol withdrawal, provided emotional support and was discharged with outpatient services on 12/29/19.

Interview with Nursing Supervisor (RN #2) on 8/4/20 at 8:00 AM identified that on the evening of 12/24/19 at approximately 9:00 PM, she was informed that Patient #1 wanted to speak to her regarding and incident that occurred earlier that day. RN #2 identified that she went directly to Patient #1's room and the patient informed her that he/she was upset because earlier the nurse touched him/her while listening to his/her lungs. RN #2 identified that she asked the patient for more details and the patient reported that the same nurse escorted him/her to the bathroom and forced him/her to perform a sexual act. RN #2 stated that she examined the patient and found no injuries and check the bathroom for any potential evidence however there was no evidence visible. RN #2 stated that she provided emotional support to the patient and reassured the patient that he/she would be safe. RN #2 stated that she identified the nurse who cared for P#1 during the time of the allegation (RN #1). RN #2 ensured that RN #1 was no longer on duty and then called the Nursing Director who directed her to ensure that two staff care for the patient.

Interview with the Nursing Director on 7/30/20 at 11:50 AM identified that she was informed of Patient #1's allegation and directed to ensure that a chaperone staff person accompanied caregivers during care of the patient. The Nursing Director identified that she established that RN #1 was not scheduled to work until 12/26/19. The Nursing Director stated that she did not contact RN #1 but directed that RN #1 would not be allowed to work on "that floor" and arranged for RN #1 to be scheduled in the ED when he returned to work on 12/26/19 at 7:00 AM.

Interview with the Chief Nursing Officer (CNO) on 7/30/20 at 11:08 AM identified that when the incident was reported to her on 12/26/19, she contacted the hospital and asked if RN #1 was working. The CNO stated that she was informed that RN #1 was not working on the inpatient unit but was working in the ED. The CNO identified that she called the ED and spoke to the Assistant ED Manager who confirmed that RN #1 was working the ED. The CNO stated that at approximately 9:00 AM she directed the ED manager to have RN #1 removed from the building (hospital). The CNO stated that she then went to speak with Patient #1 and encouraged the patient to allow her to collect for a sexual assault kit.

Interview with the Assistant ED Manager (RN#5) on 8/19/20 at 11:08 AM identified that on 12/26/19 he was the manager on duty in the ED. RN #5 identified that he arrived to the ED at approximately 9:00 AM and RN #1 was working in the ED. RN #5 stated that RN #1 arrived to work in the ED at 7:00 AM and was assigned (as a helper) to take vitals and helping as needed. RN #5 stated that he was not informed of any directive to keep RN #1 from caring for or assisting patients. RN #5 stated that as soon as he was informed to have RN #1 removed, he directed RN #1 to leave the hospital.

The hospital failed to ensure that RN #1 did not have access to patients after an allegation of sexual assault. RN #1 was identified as having unsupervised access to patients in the ED on 12/26/19 between 7:00 AM and 9:00 AM.

Subsequently, RN #1 was informed of Patient #1's allegation and was suspended. The CNO identified that RN #1 denied that this occurred and refused to cooperate with the hospital's investigation. RN #1 has not returned to work since 12/26/19. The CNO identified that since RN #1 would not cooperate with the investigation, he had been terminated.



b. Patient #2 was admitted to the hospital on 8/27/2018 for respiratory complaints. Review of the patient's record dated 8/29/18 identified that RN #1 cared for Patient #2 from 3:00 PM to 7:00 PM.

Review of hospital documentation and interview with the Nursing Director on 8/20/2020 at 1:00 PM identified that on 8/30/2018, she was asked to speak with Patient #2, who was about to be discharged from the hospital. Nursing Supervisor identified that Patient #2 informed her that the nurse who cared for him/her 8/29/18 "was a predator and should not be allowed to work in the hospital". The Nursing Director stated that the patient reported that the nurse (RN #1) tried to lift his/her Johnnie gown to listen to his/her lungs. Patient #2 reported that when he/she protested, RN #1 told him/ her that it was policy to have a stethoscope on the bare skin. Patient #2 stated that RN #1 then proceeded to listen to his/her lungs from the front and again placed the stethoscope on his/her bare chest and was looking down at his/her chest and made an inappropriate comment about his/her body. The Nursing Director stated that she verified that RN #1 was not on the unit and was not schedule for the next week as he was on vacation. The Nursing Director identified that she notified risk management of Patient #1's allegation and informed the risk manager that RN #1 was not scheduled to work for the next week.

Review of facility documentation dated 8/30/2018 at 4:51 PM identified the risk manager received an email informing her of Patient #2's allegation and the details of the incident. The email identified that the Human Resource department was notified with a plan to discuss the next steps to investigate the allegation.

Interview with the former Risk Manager on 8/20/20 at 12:00 PM identified that a plan to interview RN #1 upon his return to work on 9/5/18 was decided. For the period of 8/20/18 to 9/4/18 identified that RN #1 was not scheduled and did not work at the hospital. Review of payroll report identified that RN #1 clocked into work on 9/5/18 at 7:08 AM and reported to the inpatient unit.

Review of an email report from the Risk Manager to the Human Resource and Quality Departments dated 9/5/18 at 4:21 PM identified that an interview was held on 9/5/18 with RN #1, Risk Managers and Nursing Manager. The report identified that RN #1 was informed of the allegation and based on RN #1's explanation, employment history and specific details of the care provided to Patient #2, RN #1's interview was assessed to be credible and the allegation was not substantiated.

Interview with the former Risk Manager on 8/20/20 at 11:50 AM identified that she facilitated the meeting with RN #1 on 9/5/18. She was unable to provide additional documentation of the investigation, the time that the interview was conducted, and when the investigation concluded.

The hospital was unable to provide evidence that RN #1 did not have access to patients on 9/5/18 after an allegation of sexual assault. RN #1 was identified as having unsupervised access to patients on the inpatient unit for an unspecified amount of time, while an investigation was being conducted.


Review of the hospital's Patient Rights policy identified that care shall be provided in a manner that supports a patient's safety, dignity and individuality, and each patient has the right to be free from all forms of abuse and harassment.

The hospital did not have a policy in place to ensure that a staff member not have access to patients after an allegation of sexual assault.