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Based on interviews, observations, and review of facility policy and medical records, the hospital failed to fully investigate a grievance of alleged sexual abuse for one (Patient #1) of one patient sampled for abuse; and (Refer to A0119) No other Patient abuse or neglect grievances were noted.

The facility failed to promote the safety and well-being of Patient #1 after allegations of sexual assault were made on 1/21/2022. (Refer to A0145).

Patient #1 made a sexual assault allegation on 01/21/2022 at approximately 5:00 PM to the physical therapist. The Chief Nursing Officer talked to Patient #1 on 01/21/2022 between 5:00 PM and 6:00 PM and proceeded to give her a business card in case she needed anything over the weekend.

Patient #1 remained in the room adjacent to the alleged perpetrator for 4 days. No rape exam was conducted for Patient #1 for 7 days. The alleged perpetrator was not placed on any additional monitoring. The facility failed to thoroughly investigate the allegation of sexual abuse allegation which could result in the hospital failure to take actions to prevent abuse from occurring again. Sexual abuse/ assault has serious psychological emotional and physical effects on survivors.

The systemic failures constitute an immediate jeopardy situation.

The Immediate Jeopardy was removed on 03/18/2022 at 3:15 PM after verification of implementation of removal actions.

Based on facility staffing sheets, staff interviews, facility policy review, and job description the facility failed to ensure precautions in place to prevent possible sexual abuse to the other 19 patients on the unit. The facility became aware of the allegation of sexual abuse on 01/21/2022 approximately 5:00 PM regarding a male patient on the West unit. The facility created a potential harm for the 20 patients on the West Unit.

Refer to tag A 0386, refer to Tag A 0392

The system failure constitutes an immediate jeopardy situation.

The facility failed to provide standard nursing services to protect patients safety and well-being after reports of sexual abuse allegations. On 03/17/2022 at 6:38 PM the Director of Quality/ Risk Manager, Chief Nursing Officer, Nurse Manager, Regional Director of Quality/ Risk Manager and via phone the Chief Executive Officer was informed of the Immediate Jeopardy which began on 01/21/2022. The facility implemented an immediate action plan on 3/18/2022. The Immediate Jeopardy was removed on 03/18/2022 at 3:15 PM after verification of implementation of removal actions.

Based on interviews, observations, and review of facility policy and medical records, the hospital failed to fully investigate a grievance of alleged sexual abuse in one (Patient #1) of one patient sampled for abuse.

Findings included:

Review of the facility policy and procedures titled, "Patient and Customer Complaint or Grievance", #8, reviewed 08/16/2021 ...Page 3 ... Grievances involving situations that potentially endanger the patient such as neglect, or abuse should be reviewed immediately. Upon notification, the patient will be immediately removed from any situation that may endanger the patient.

On 03/14/2022 at 12:20 PM, a tour was conducted of the West unit, which is a locked unit, accessible with employees' badges. Upon entering the unit, the nursing station is to the left. Down a hallway to the right, rooms located on the left-side of hall were: Patient # 1's semi-private room, Patients #2 and #3's room, and a third room. The doors to the Patient #1's room and Patients #2 and #3's room are directly adjacent to each other.

On 03/14/2022 at 2:07 PM, an interview with Chief Nursing Officer (CNO) revealed that she was aware of an allegation of sexual assault on Friday (01/21/2022) and spoke to Patient #1 and she described a man with a black hat and tattoos (which fit Patient #2 per the CNO). CNO left a business card with her in case she needed anything over the weekend.

On 03/15/2022 at 8:58 AM an interview conducted with Director of Quality/ Risk Manager (DQR) revealed that Largo Police Officer interviewed Patient #1 and she described to that the patient was wearing red shorts Bermuda length with a faded white T-Shirt that says "Lets Roll" with a tear under the right shoulder (described Patient #3). Review of the Largo Police report completed 01/25/2022 at 2:33 PM states the report documents the sexual battery allegations between a bed ridden victim in the Encompass health facility. The suspect (Patient #3) named. There was insufficient probable cause to arrest Patient #3 based on allegations alone.

On 03/15/2022 at 2:25 PM, an interview conducted with Staff F, Physical Therapist, revealed that on 01/21/2022 at approximately 5:00 PM, Patient #1 informed her that a man came into her room and exposed his genitals to her. Staff F went to the nursing suite and informed the Chief Executive Officer (CEO), Chief Nursing Officer (CNO) and the Nurse Manager on 01/21/2022 approximately 5:00 PM.

An interview was conducted on 03/16/2022 at 10:15 AM with Patient #1 regarding the alleged sexual assault that occurred on 01/21/2022. Patient #1 stated she was terrified all weekend because her (patient #1) room is in an isolated location at the end of the hall and the man who sexually assaulted her room was just next door. Patient #1 said she was not safe where she was and asked an unknown staff member on Sunday, 01/23/2022 to move her room and the staff member told me that we will on Monday 01/24/2022.

On 03/16/2022 at 12:00 PM, a second interview with Staff D revealed that Patient #1's room was moved on Monday (01/24/2022) per Patient #1's request because she did not feel safe.

Review of Patient #1's nursing progress note dated 01/25/2022 4:30 PM revealed that the patient reported allegations of sexual assault to a psychologist. Director of Quality met with patient and investigation initiated. There was no evidence the allegations of sexual assault that took place on 01/21/2022 were documented in the medical record prior to this note, four days later.

Review of Patient #1's Emergency Room (ER) visit from 01/28/2022 at 9:52 PM note revealed Patient #1 presented with pelvic pain. She states she was sexually assaulted while at the rehab by another patient (#2) there last Friday (01/21/2022). She states with all the confusion, a police officer did not come until Tuesday (01/25/2022). She states that she did not have any examination to her pelvic area and is concerned that she has a sexually transmitted disease (STD). She has an indwelling Foley catheter in place. She states she could not get him (the alleged perpetrator) off of her because she was so weak. She states she has not had a shower since the incident and has not even washed under her nails in case of any evidence. Genitourinary exam revealed a urinary catheter in place. Patient has a 3mm laceration in the 7:00 position in the entry of the vagina. This in incisional (the free dictionary defines incisional as a cut, gash, notch, or incisiveness). In the 6:00 position there is evidence of increased tension to the vaginal wall at the entry of the vagina.

On 03/16/2022 at 2:40 PM, interview with Staff A revealed the facility did not conduct a Root Cause Analysis for the event that occurred 01/21/2022.

Based on observation, staff interviews, patient interview, and review of facility policy and medical records, the facility failed to promote the safety and well-being of Patient #1 after reporting allegations of sexual assault.

Findings included:

Review of Facility Policy and Procedure title, "Allegations of Abuse/ Neglect", # 688, reviewed 05/12/2021 revealed: Purpose: To make every effort to protect patient from abuse or neglect while a patient in the hospital and properly investigate reports of abuse/ neglect occurring in the hospital ... Hospital staff will take necessary steps to ensure that patient are kept safe from abuse/ neglect and that allegations of abuse/ neglect ... are investigated promptly, thoroughly, and reported to the proper authorities ... Unwitnessed report of Abuse 1. Take immediate action to protect the patient from harm 2. Unit staff must contact their supervisor and or a supervisor on duty immediately upon notifications of allegations/ findings of any form of abuse/neglect. 3. The patient must be: A. Examined immediately for injury B. treated, if necessary, C. Secure from harm by taking any additional necessary actions to ensure the patient safety and welfare, including but not limited to i. moving patient to another unit ... Documentation: a. allegations of abuse/ neglect are pertinent to assessment/ treatment decision and should be reflected as reported in the medical record.

On 03/14/2022 at 12:20 PM, a tour was conducted of the West unit, which is a locked unit, accessible with employees' badges. Upon entering the unit, the nursing station is to the left. Down a hallway to the right, rooms located on the left-side of hall were: Patient # 1's semi-private room, Patients #2 and #3's room, and a third room. The doors to the Patient #1's room and Patients #2 & #3's room are directly adjacent to each other.

03/14/2022 at 12:33 PM, an interview was conducted with Staff B regarding the sexual abuse allegations. Staff B stated that another staff member informed her that Patient #1 said that male patient exposed his genitals to her and tried to get into bed with her. Staff B stated she took it upon herself to sit where she could keep an eye on both rooms and stated that Patient #2 attempted to go into Patient #1's room and Staff B stopped him.

On 03/14/2022 at 12:50 PM, an interview was conducted with Staff C regarding the sexual abuse allegations and Staff C said she tried to post herself outside of the patient room (Patient #2) but could not stay there because she had other patients to take care of.

On 03/14/2022 at 2:07 PM, an interview was conducted with the Chief Nursing Officer (CNO) regarding the sexual assault that occurred on 01/21/2022. The CNO said it was a Friday between 5:00 PM and 6:00 PM on 01/21/2022 when Staff F (Physical Therapist) informed Nursing administration that Patient #1 made an allegation. The CNO then recalled that she went into speak to Patient #1 and gave Patient #1 her business card in case she needed anything over the weekend. The CNO stated that after she left Patient #1 room, she verbally informed the nursing staff to make sure that Patient #2 does not enter Patient #1's room, and to pass on the information to the oncoming shift and have increased surveillance at the end of the hall. The CNO informed the surveyors that Patient #2 was not with a one-to one sitter nor was patient #1 moved at that time.

On 03/15/2022 at 2:25 PM, an interview conducted with Staff F, Physical Therapist (PT), revealed that on 01/21/2022 at approximately 5:00 PM, Patient #1 informed her that a man came into her room and exposed his genitals to her. Staff F went to the nursing suite and informed the Chief Executive Officer (CEO), Chief Nursing Officer (CNO) and the Nurse Manager on 01/21/2022 approximately 5:00 PM.

On 03/16/2022 at 3:33 PM, an interview conducted with Psychologist revealed she spoke to patient #1 on 01/25/2022 and Patient #1 informed her that Patient #2 had entered her room on 01/21/2022 and said something "Crude" and exposed his genitals to her. Patient #2 crawled on top of her as she tried to fight him off. Staff N described the patient as "fragile and crying and sobbing." Staff N reported the discussion she had with Patient #1 to Nursing administration. Staff N spoke to Patient #1 again on 01/26/2022 and Patient #1 was concerned about the possibility of a sexually transmitted disease (STD).

On 03/16/2022 at 9:53 AM, and interview conducted with Patient #4's family revealed that she was told on 01/23/2022 by Patient #1 that a male patient came into her room and tried to get under the covers with her.

An interview conducted on 03/16/2022 at 10:15 AM with Patient #1 regarding the sexual assault that occurred on 01/21/2022. Patient #1 stated she was terrified all weekend because where her (patient #1) room is located, it is isolated at the end of the hall and the man (Patient #2) room in proximity, just next door. Patient #1 said she was not safe where she was and asked an unknown staff member on Sunday 01/23/2022 to move her room and the staff member told me that we will on Monday 01/24/2022.

On 03/14/2022 at 1:35 PM, an interview was conducted with Staff E regarding when Patient #1 was moved and was informed she was moved either Monday (01/24/2022) or Tuesday (01/25/2022).

Review of Patient #1's Emergency room visit from 01/28/2022 at 9:52 PM note revealed Patient #1 presented with pelvic pain. She states she was sexually assaulted while at the rehab by another patient last Friday (01/21/2022). She states with all the confusion, a police officer did not come until Tuesday (01/25/2022). She states that she did not have any examination to her pelvic area and is concerned that she has an STD. She has an indwelling Foley catheter in place. She states she could not get him off of her because she was so weak. She states she has not had a shower since the incident and has not even washed under her nails in case of any evidence. Genitourinary exam revealed a urinary catheter in place. Patient has a 3mm laceration in the 7:00 position in the entry of the vagina. This in incisional (the free dictionary defines incisional as a cut, gash, notch, or incisiveness). In the 6:00 position there is evidence of increased tension to the vaginal wall at the entry of the vagina.

Review of Patient #2's Medical record Physicians progress notes reveal that on the 01/19/2022 nightshift, patient was lying on the floor in front of another patient's bed.

Interview conducted on 03/21/2022 at 11:01 AM with Nurse Practitioner CC revealed that when Patient #2 was in room 126B his roommate and the roommate's wife were uncomfortable, scared and concerned about Patient #2. Nurse Practitioner CC revealed that on 01/19/2022 going into 01/20/2022 another female patient informed him that while she was on the bedside commode a man in a wheelchair came into her room and she yelled at him, and he left. This was relayed to the charge nurse. The patient that day was moved to the locked unit of the hospital room 128A.

Based on staff interviews, review of facility policy, facility staffing sheets, and job descriptions, the facility failed to monitor patient location and activity after allegations of sexual abuse brought against the male patient.

Findings included:

Review of Policy and Procedure title, "Nursing Staffing", #400, review 05/12/2021, ...Purpose to develop a nursing staffing plan that will support the provision of quality patient care in a safe, cost-effective manner using qualified, skilled personnel ...A registered Nurse will be immediately available to assist and supervise patient care as well as to respond to emergency situation ... Patient care assignment will be made by a Registered Nurse and take into consideration A. The training, experience, and capability of the person to whom the task is delegated. B. the degree and availability of supervision required for the staff member, including student nurses and staff orientation. C. The condition of the patients' identified needs, complexity of assessment and care required. D. Patient safety and infection control issues.

Review of the job description for Chief Nursing Officer (CNO) revealed ...The CNO holds full responsibility for the quality of nursing care provided ... Develop and implements the plan for providing nursing care, treatment, and services. Determines of the types and numbers of nursing personnel necessary to provide nursing care ...

On 01/21/2022 Patient #1 made an allegation of a male patient coming into her room and exposing himself to her. On 01/21/2022 to the CNO she described Patient #2. On 01/25/2022, she described Patient #3 to the Largo Police Officer.

On 03/14/2022 at 12:33 PM an interview was conducted with Rehab Nursing Technician (RNT) stated when she found out about the alleged sexual abuse on 01/21/2022 she sat near the room and noticed Patient #2 trying to go into Patient #1's room again.

On 03/14/2022 at 12:50 PM an interview was conducted with staff C regarding the allegation of sexual abuse. Staff C stated that they tried to post themselves outside of the room but had other patients to take care of and could not stay posted at the doorway.

On 03/16/2022 at 10:47 AM an interview was conducted with Staff K; inquired if there was a specific instruction regarding the allegation of sexual assault on 01/21/2022 and she stated she worked the weekend of 01/22/2022 and 01/23/2022. She keep an eye on Patient #3 because he wanders around and she has never seen Patient #2 wander around.

On 03/16/2022 at 11:29 AM, an interview with the Chief Nursing Officer in which she stated that there was an increase in staff on 01/21/2022 through 01/24/2022 for the West Unit. The West Unit is a locked unit, accessible with employees' badges.

Review of the facility staffing sheets from 01/21/2022 through 01/30/2022 revealed no increase in the staffing for the west unit and no decrease in patients noted during that time frame.

Based on staffing schedules reviewed, staff interviews, job descriptions and facility policies the facility failed to provide adequate staffing to ensure the safety and well-being of all the patients on the West Unit after an allegation of sexual abuse brought against a male patient on the unit.

Findings included:

Review of the Policy and procedure title, "Plan for the Provision of Patient Care", #100, reviewed 02/11/2022 .... Ensures a sufficient number of qualified, competent, professional and support personnel are available to meet the objectives of each service and the needs of the patient population ... The needs of each patient are assessed every shift and as needed, to determine the level of patient acuity and to plan or adjust staffing needs. The final determination is made through the experience and knowledge provided by the nurse executive in a daily assessment of the acuity needs of the patients ...

Review of the Policy and procedure title, "Allegations of Abuse/ Neglect", # 688, reviewed 05/12/2021, ... Hospital staff will take necessary steps to ensure that patient are kept safe from abuse/ neglect ... Secure from harm by taking any additional necessary actions to ensure the patient safety and welfare ...

Review of the job description for Chief Nursing Officer (CNO) revealed ...The CNO holds full responsibility for the quality of nursing care provided ... Develop and implements the plan for providing nursing care, treatment, and services. Determines of the types and numbers of nursing personnel necessary to provide nursing care ...

On 03/14/2022 at 2:07 PM with the Chief Nursing Officer the surveyor conducted an interview and inquired why the patient was not on a one-one sitter to protect every patient in the facility, the CNO stated that Patient #2 has not done anything like this, he had a brain injury and very forgetful but pleasant.

03/16/2022 at 11:29 AM, an interview with the Chief Nursing Officer in which she stated that there was an increase in staff on 01/21/2022 through 01/24/2022 for the West Unit. The West Unit is a locked unit, accessible with employees' badges.

Review of the facility staffing sheets from 01/21/2022 through 01/30/2022 revealed no increase in the staffing for the west unit and no decrease in patients noted during that time frame.