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Based on document review, staff interviews and record review it was determined the hospital failed to ensure care was provided in accordance with hospital policy and procedure which caused a delay of treatment for patient #1 following an alleged sexual assault. This failure has the potential to negatively impact all patients receiving care at this hospital. (See tag A 0142, A 0144 and A 0145).

Based on record review, hospital policy and staff interviews it was determined the hospital failed to follow its own policy titled Sexual Abuse/Assault of Patients. The hospital's failure to follow its own policy delayed in patient #1 receiving the treatment in the appropriate time frame to collect evidence in an alleged sexual assault. This failure has the potential to impede the treatment and investigation of any patient that alleges sexual abuse/assault.

Findings include:

1. A review of the facility document titled Sexual Abuse/Assault of Patients, last revised 9/21/17, states: "Nursing staff will follow the procedures outlined in this policy upon receiving a report or discovery of a sexual assault."

2. In an interview with Patient Advocate #1 on 2/4/19 at approximately 12:50 p.m., it was determined on 1/18/19 she received a complaint from patient #1 that alleged health service worker (HSW) #1 had inappropriately touched her in a sexual nature. Patient #1 further stated she had informed another female staff member within the past week. Patient Advocate #1 stated during the investigation she found out that HSW #2 had been notified on 1/16/19 of the alleged abuse. She was notified by patient #1 of the alleged abuse.

3. In an interview with HSW #2 on 2/5/19 at approximately 3:50 p.m., it was determined that she thought it was a Tuesday evening when patient #1 came to her and said: "Just wanted to let you know HSW #1 was coming in my room and doing things to me." HSW #2 stated the patient told her he was saying sexually inappropriate things to her. She informed the patient she knew she had to tell the Registered Nurse (RN). HSW #2 stated: "I told the RN and he said I needed to fill out an incident report and I told him I was getting ready to leave and we would do it in the morning because I had never done one before."

4. In an interview with the RN on 2/6/19 at approximately 7:55 a.m., it was determined that HSW #2 did come to him and say that patient #1 was making accusations against HSW #1 from the other night. The RN stated he couldn't remember the exact date and time. He stated: "I told her its always been my understanding whoever the accusation was reported to should be the one filling out the report" and she said: "I'm getting ready to leave and we will talk to the Nurse Manager when we come back in the morning." He stated: "The next morning HSW #2 said that she had already spoke to the Nurse Manager. It's fine, go ahead and go. So I left. She never told me anything about sexual inappropriateness." When questioned about what the policy is related to sexual abuse he stated: "I immediately notify the supervisor to get an APS report pack, fill out an incident report and make sure the person being accused is not in contact with the patient."

5. A review of the investigation by Patient Advocate #1 revealed that patient #1 notified HSW #2 on 1/16/19. The RN was notified of patient #1 making accusations against HSW #1 and the Nurse Manager was notified the next morning. An Adult Protective Services (APS) reporting form was not sent in to APS until Patient Advocate #1 was notified by patient #1 of the alleged abuse. No incident report was completed by the hospital until 1/22/19, the Nurse Practitioner was not notified of the alleged incident until 1/22/19, the patient guardian was not notified by the hospital until 1/22/19 and the patient was not sent out for a sexual assault exam until 1/22/19. Patient Advocate #1 did notify the guardian on 1/18/19 of the alleged abuse.

6. A review of the hospital policy titled Incident Reporting and Review, effective date 1/15/15, states: "An employee that witnesses a potential/actual injury to a patient must complete and sign an Incident Report form, as soon as possible."

7. A review of the hospital policy titled Handling of Patient Complaint/Grievances, effective date 5/1/18, states: "If the staff person receives the complaint, the staff person receiving the complaint shall make every reasonable attempt to immediately resolve the patient's concern. If the complaint cannot be resolved, the staff member shall promptly assist the patient with initiating a "Patient Grievance," file it on their behalf or contact Legal Aid Patient Advocate."

8. During the entrance conference with the Chief Executive Officer (CEO) on 2/4/19 at approximately 10:45 a.m., it was determined that his expectation is if any employee was accused of physical or sexual abuse they were automatically suspended pending the investigation.

9. A review of an email sent from Patient Advocate #1 dated 1/18/19 at 10:50 a.m. revealed that the CEO, Assistant CEO, Chief Nursing Executive (CNE), Nurse Manager for unit A-3, Director of Quality and Director of Safety were notified an APS report and grievance would be filed on behalf of patient #1. Patient Advocate #1 asked for the video to be secured at this time. A reply was sent to Patient Advocate #1 at 10:53 a.m. from the CEO asking for the video to be secured.

10. A statement received from Patient Advocate #2 dated 2/1/19 states that on 1/18/19 at approximately 1530 (3:30 p.m.) "I received a call from the Clinical Nursing Director asking if I could attend a video review for an investigation Patient Advocate #1 was assigned."

11. A review of the staffing schedule for unit A-3 revealed HSW #1 was on the unit after HSW #2 and the RN was notified of the alleged abuse of the patient.

12. In an interview with the Director of Quality and Assistant CEO on 2/6/19 at approximately 10:05 a.m., they concurred the hospital did not follow its policy related to sexual assault/abuse of a patient.

2019-3-007

Based on document review, staff interviews and record review it was determined the hospital failed to follow its own policies and procedures. This resulted in health service worker (HSW) #1 being allowed to have continued contact with patient #1 after HSW #2 was notified of allegations of alleged sexual abuse by the patient. This failure has the potential to negatively impact all patients receiving care at this hospital.

Findings include:

1. A review of the facility document titled Sexual Abuse/Assault of Patients, last revised 9/21/17, states: "Nursing staff will follow the procedures outlined in this policy upon receiving a report or discovery of a sexual assault."

2. In an interview with Patient Advocate #1 on 2/4/19 at approximately 12:50 p.m., it was determined on 1/18/19 she received a complaint from patient #1 that alleged HSW #1 had inappropriately touched her in a sexual nature. Patient #1 further stated she had informed another female staff member within the past week. Patient Advocate #1 stated during the investigation that she found out HSW #2 had been notified on 1/16/19 of the alleged abuse. She was notified by patient #1 of the alleged abuse.

3. In an interview with HSW #2 on 2/5/19 at approximately 3:50 p.m., it was determined that she thought it was a Tuesday evening when patient #1 came to her and said: "Just wanted to let you know HSW #1 was coming in my room and doing things to me." HSW #2 stated the patient told her he was saying sexually inappropriate things to her. She informed the patient she knew she had to tell the Registered Nurse (RN). The HSW #2 stated: "I told the RN and he said I needed to fill out an incident report and I told him I was getting ready to leave and we would do it in the morning because I had never done one before."

4. In an interview with the RN on 2/6/19 at approximately 7:55 a.m., it was determined that HSW #2 did come to him and say that patient #1 was making accusations against HSW #1 from the other night. The RN stated he couldn't remember the exact date and time. He stated: "I told her its always been my understanding whoever the accusation was reported to should be the one filling out the report and she said: "I'm getting ready to leave and we will talk to the Nurse Manager when we come back in the morning." He stated: "The next morning HSW #2 said that she had already spoke to the Nurse Manager. It's fine, go ahead and go. So I left. She never told me anything about sexual inappropriateness." When questioned about what the policy is related to sexual abuse he stated: "I immediately notify the supervisor to get an APS report pack, fill out an incident report and make sure the person being accused is not in contact with the patient."

5. A review of the investigation by Patient Advocate #1 revealed that patient #1 notified HSW #2 on 1/16/19. The RN was notified of patient #1 making accusations against HSW #1 and the Nurse Manager was notified the next morning. An Adult Protective Services (APS) reporting form was not sent in to APS until Patient Advocate #1 was notified by patient #1 of the alleged abuse. No incident report was completed by the hospital until 1/22/19, the Nurse Practitioner was not notified of the alleged incident until 1/22/19, the patient guardian was not notified by the hospital until 1/22/19 and the patient was not sent out for a sexual assault exam until 1/22/19. Patient Advocate #1 did notify the guardian on 1/18/19 of the alleged abuse.

6. A review of the hospital policy titled Incident Reporting and Review, effective date 1/15/15, states: "An employee that witnesses a potential/actual injury to a patient must complete and sign an Incident Report form, as soon as possible."

7. A review of the hospital policy titled Handling of Patient Complaint/Grievances, effective date 5/1/18, states: "If the staff person receives the complaint, the staff person receiving the complaint shall make every reasonable attempt to immediately resolve the patient's concern. If the complaint cannot be resolved, the staff member shall promptly assist the patient with initiating a "Patient Grievance," file it on their behalf or contact Legal Aid Patient Advocate."

8. During the entrance conference with the Chief Executive Officer (CEO) on 2/4/19 at approximately 10:45 a.m., it was determined that his expectation is if any employee was accused of physical or sexual abuse they were automatically suspended pending the investigation.

9. A review of an email sent from Patient Advocate #1 dated 1/18/19 at 10:50 a.m. revealed that the CEO, Assistant CEO, Chief Nursing Executive (CNE), Nurse Manager for unit A-3, Director of Quality and Director of Safety were notified an APS report and grievance would be filed on behalf of patient #1. Patient Advocate #1 asked for the video to be secured at this time. A reply was sent to Patient Advocate #1 at 10:53 a.m. from the CEO asking for the video to be secured.

10. A statement received from Patient Advocate #2 dated 2/1/19 states that on 1/18/19 at approximately 1530 (3:30 p.m.) "I received a call from the Clinical Nursing Director asking if I could attend a video review for an investigation Patient Advocate #1 was assigned."

11. A review of the staffing schedule for unit A-3 revealed HSW #1 was on the unit after HSW #2 and the RN was notified of the alleged abuse of the patient.

12. In an interview with the Director of Human Resources on 2/5/19 at approximately 4:20 p.m., it was determined that HSW #1 was suspended on 1/22/19 by phone. She stated that she would have sent the suspension letter out on 1/23/19 and in that letter it does state that he is to return his badge and keys to the Human Resources (HR) department immediately.

13. In an interview with HSW #1 on 2/5/19 at approximately 11:10 a.m., it was revealed that he did not return his badge and keys until 1/28/19. He stated he gave the badge and keys to the secretary in HR.

14. In an interview with the Human Resources Assistant on 2/6/19 at approximately 9:50 a.m. she stated: "In reference to where HSW #1's badge and keys were, the CNO brought them to me yesterday morning saying they had been laying in Nursing Administration." She did state as soon as she was notified of the suspension of HSW #1 she did deactivate his badge.

15. In an interview with the Director of Quality and Assistant CEO on 2/6/19 at approximately 10:05 a.m. they concurred the hospital did not follow its policy related to sexual assault/abuse of a patient.




38861

2019-3-011

Based on document review, video review and staff interviews it revealed the hospital failed to provide care in a safe setting. This failure was identified in two (2) of five (5) medical records reviewed. This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed an order for Close Intermittent Observation (CIO). The order stated "CIO from 0700-2300 (7:00 a.m.-11:00 p.m.) 1q30 from 2300-0700 (11:00 p.m.-7:00 a.m.)." A second order stated "Patient to be turned/assisted to turn and reposition every 1 hour dur q 2 hours at night and as needed."

2. A review of the medical record for patient #2 revealed an order for CIO. The order stated "CIO male/female 7a to 11p (7:00 a.m.-11:00 p.m.) and 1Q15 mins 11p to 7a (11:00 p.m.-7:00 a.m.) x 24h."

3. A review of the video for Unit A5 for 1/23/19, 2/5/19 and 2/6/19 was conducted on 2/7/19 at 8:00 a.m. The Director of Safety and Security accompanied the surveyors during the review of the videos. The video revealed fifteen (15) minute checks were not completed as per hospital policy. The video for 1/23/19 revealed fifteen (15) minute checks were not completed at 11:00 p.m., 11:15 p.m. and 11:45 p.m. The video for 2/5/19 revealed fifteen (15) minute checks were not completed at 11:00 p.m. and 11:45 p.m. The video for 2/6/19 revealed fifteen (15) minute checks were not completed at 12:15 a.m. and 1:15 a.m. The Director of Safety and Security concurred fifteen (15) minute checks were not being completed.

4. An interview was conducted with the Nurse Practitioner (NP) on 2/7/19 at 10:20 a.m. She stated patient #1 currently has no skin breakdown and is very fragile. She stated patient #1 has a high level of care and is nursing home appropriate but they are unable to find a nursing home who will accept her. She stated they do a head to toe assessment every three (3) to six (6) months. She stated patient #1 and #2 are ordered CIO for the day shift and level one (1) checks at night due to they are sleeping. She stated patient #1 is to be turned every two (2) hours at night and every hour in the day. She stated she feels they do a fabulous job taking care of the patients.

5. A review of the Turn Reposition Log for patient #1 revealed nursing staff failed to turn patient #1 as ordered. There was no repositioning noted on 2/7/19 for 6:00 a.m. and 7:00 a.m., no repositioning on 2/6/19 for 1:00 a.m. to 6:00 p.m., no repositioning on 2/5/19 for 9:00 p.m., no repositioning on 2/4/19 for 7:30 a.m., no repositioning on 2/3/19 for 8:00 a.m., 10:00 a.m. and 1:00 p.m. to 6:00 p.m., no repositioning on 2/2/19 for 1:00 p.m., no repositioning on 2/1/19 for 4:00 a.m. to 8:00 a.m. and 12:00 p.m., no repositioning on 1/31/19 for 4:00 p.m., no repositioning on 1/30/19 for 11:00 p.m., no repositioning on 1/29/19 for 9:00 a.m. to 11:55 a.m., 5:00 p.m. and 8:00 p.m. and multiple occasions patient #1 was not turned in January 2019.

6. A review of the CIO Observation Record for at risk patients revealed no observation record for 7:00 a.m. on 1/26/19 and no CIO observation noted for 11:00 p.m. on 1/29/19 for patient #1.

7. A review of the Face Check Log Sheets revealed on 1/23/19 documentation was noted of a fifteen (15) minute face check completed at 11:00 p.m., 11:15 p.m. and 11:45 p.m. but video shows no fifteen (15) minute face checks were completed at this time. On 2/5/19 documentation was noted of fifteen (15) minute face checks completed at 11:00 p.m. and 11:45 p.m. but video shows no fifteen (15) minute face checks were completed at this time. On 2/6/19 documentation was noted of fifteen (15) minute face checks completed at 12:15 a.m. and 1:15 a.m. but video shows no fifteen (15) minute face checks were completed at this time.

8. A review of the policy titled Observation Of At Risk Patients, revision date 2/02/16, stated in part: "When a patient is placed on CIO, a staff member will be doing fifteen (15) minute checks on the assigned patient(s)."

9. A review of the policy titled Unit Face Checks/Security Checks, revision date 7/24/17, revealed in part: "Face Checks will be done every fifteen (15) minutes on all shifts unless otherwise ordered."

10. A interview was conducted with the Assistant CEO on 2/7/19 at appropriately 11:30 a.m. She concurred the nursing staff was not following policies and physicians orders.

Based on record review, hospital policy and staff interviews it was determined the hospital failed to follow its own policy titled Sexual Abuse/Assault of Patients. The hospital's failure to follow its own policy delayed in patient #1 receiving the treatment in the appropriate time frame to collect evidence in an alleged sexual assault. This failure has the potential to impede the treatment and investigation of any patient that alleges sexual abuse/assault.

Findings include:

1. A review of the facility document titled Sexual Abuse/Assault of Patients, last revised 9/21/17, states: "Nursing staff will follow the procedures outlined in this policy upon receiving a report or discovery of a sexual assault."

2. In an interview with Patient Advocate #1 on 2/4/19 at approximately 12:50 p.m., it was determined on 1/18/19 she received a complaint from patient #1 that alleged health service worker (HSW) #1 had inappropriately touched her in a sexual nature. Patient #1 further stated she had informed another female staff member within the past week. Patient Advocate #1 stated during the investigation she found out that HSW #2 had been notified on 1/16/19 of the alleged abuse. She was notified by patient #1 of the alleged abuse.

3. In an interview with HSW #2 on 2/5/19 at approximately 3:50 p.m., it was determined that she thought it was a Tuesday evening when patient #1 came to her and said: "Just wanted to let you know HSW #1 was coming in my room and doing things to me." HSW #2 stated the patient told her he was saying sexually inappropriate things to her. She informed the patient she knew she had to tell the Registered Nurse (RN). HSW #2 stated: "I told the RN and he said I needed to fill out an incident report and I told him I was getting ready to leave and we would do it in the morning because I had never done one before."

4. In an interview with the RN on 2/6/19 at approximately 7:55 a.m., it was determined that HSW #2 did come to him and say that patient #1 was making accusations against HSW #1 from the other night. The RN stated he couldn't remember the exact date and time. He stated: "I told her its always been my understanding whoever the accusation was reported to should be the one filling out the report and she said: "I'm getting ready to leave and we will talk to the Nurse Manager when we come back in the morning." He stated: "The next morning HSW #2 said that she had already spoke to the Nurse Manager. It's fine, go ahead and go. So I left. She never told me anything about sexual inappropriateness." When questioned about what the policy is related to sexual abuse he stated: "I immediately notify the supervisor to get an APS report pack, fill out an incident report and make sure the person being accused is not in contact with the patient."

5. A review of the investigation by Patient Advocate #1 revealed that patient #1 notified HSW #2 on 1/16/19. The RN was notified of patient #1 making accusations against HSW #1 and the Nurse Manager was notified the next morning. An Adult Protective Services (APS) reporting form was not sent in to the APS until Patient Advocate #1 was notified by patient #1 of the alleged abuse. No incident report was completed by the hospital until 1/22/19, the Nurse Practitioner was not notified of the alleged incident until 1/22/19, the patient guardian was not notified by the hospital until 1/22/19 and the patient was not sent out for a sexual assault exam until 1/22/19. Patient Advocate #1 did notify the guardian on 1/18/19 of the alleged abuse.

6. A review of the hospital policy titled Incident Reporting and Review, effective date 1/15/15, states: "An employee that witnesses a potential/actual injury to a patient must complete and sign an Incident Report form, as soon as possible."

7. A review of the hospital policy titled Handling of Patient Complaint/Grievances, effective date 5/1/18, states: "If the staff person receives the complaint, the staff person receiving the complaint shall make every reasonable attempt to immediately resolve the patient's concern. If the complaint cannot be resolved, the staff member shall promptly assist the patient with initiating a "Patient Grievance," file it on their behalf or contact Legal Aid Patient Advocate."

8. During the entrance conference with the Chief Executive Officer (CEO) on 2/4/19 at approximately 10:45 a.m., it was determined that his expectation is if any employee was accused of physical or sexual abuse they were automatically suspended pending the investigation.

9. A review of an email sent from Patient Advocate #1 dated 1/18/19 at 10:50 a.m. revealed that the CEO, Assistant CEO, Chief Nursing Executive (CNE), Nurse Manager for Unit A-3, Director of Quality and Director of Safety were notified an APS report and grievance would be filed on behalf of patient #1. Patient Advocate #1 asked for the video to be secured at this time. A reply was sent to Patient Advocate #1 at 10:53 a.m. from the CEO asking for the video to be secured.

10. A statement received from Patient Advocate #2 dated 2/1/19 states that on 1/18/19 at approximately 1530 (3:30 p.m.) "I received a call from the Clinical Nursing Director asking if I could attend a video review for an investigation Patient Advocate #1 was assigned."

11. A review of the staffing schedule for Unit A-3 revealed HSW #1 was on the unit after HSW #2 and the RN was notified of the alleged abuse of the patient.

12. In an interview with the Director of Quality and Assistant CEO on 2/6/19 at approximately 10:05 a.m. they concurred the hospital did not follow its policy related to sexual assault/abuse of a patient.

Based on document review, video review and staff interviews it revealed the nursing staff failed to provide patient care as ordered by the medical staff. The nursing staff failed to follow their own policy for patient monitoring regarding fifteen (15) minute checks and Close Intermittent Observation (CIO). This failure was identified in two (2) of five (5) medical records reviewed. This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed an order for CIO. The order stated "CIO from 0700-2300 (7:00 a.m.-11:00 p.m.) 1q30 from 2300-0700 (11:00 p.m.-7:00 a.m.)." A second order stated "Patient to be turned/ assisted to turn and reposition every 1 hour dur q 2 hours at night and as needed."

2. A review of the medical record for patient #2 revealed an order for CIO. The order stated "CIO male/female 7a to 11p (7:00 a.m.-11:00 p.m.) and 1Q15 mins 11p to 7a (11:00 p.m.-7:00 a.m.) x 24h."

3. A review of the video for Unit A5 on 1/23/19, 2/5/19 and 2/6/19 was conducted on 2/7/19 at 8:00 a.m. The Director of Safety and Security accompanied the surveyors during the review of the videos. The video revealed fifteen (15) minute checks were not completed as per hospital policy. The video for 1/23/19 revealed fifteen (15) minute checks were not completed at 11:00 p.m., 11:15 p.m. and 11:45 p.m. The video for 2/5/19 revealed fifteen (15) minute checks were not completed at 11:00 p.m. and 11:45 p.m. The video for 2/6/19 revealed fifteen (15) minute checks were not completed at 12:15 a.m. and 1:15 a.m. The Director of Safety and Security concurred fifteen (15) minute checks were not being completed.

4. An interview was conducted with the Nurse Practitioner (NP) on 2/7/19 at 10:20 a.m. She stated patient #1 currently has no skin breakdown and is very fragile. She stated patient #1 has a high level of care and is nursing home appropriate but they are unable to find a nursing home who will accept her. She stated they do a head to toe assessment every three (3) to six (6) months. She stated patient #1 and #2 are ordered CIO for the day shift and level one (1) checks at night due to they are sleeping. She stated patient #1 is to be turned every two (2) hours at night and every hour in the day. She stated she feels they do a fabulous job taking care of the patients.

5. A review of the Turn Reposition Log for patient #1 revealed nursing staff failed to turn patient #1 as ordered. There was no repositioning noted on 2/7/19 for 6:00 a.m. and 7:00 a.m., no repositioning on 2/6/19 for 1:00 a.m. to 6:00 p.m., no repositioning on 2/5/19 for 9:00 p.m., no repositioning on 2/4/19 for 7:30 a.m., no repositioning on 2/3/19 for 8:00 a.m., 10:00 a.m. and 1:00 p.m. to 6:00 p.m., no repositioning on 2/2/19 for 1:00 p.m., no repositioning on 2/1/19 for 4:00 a.m. to 8:00 a.m. and 12:00 p.m., no repositioning on 1/31/19 for 4:00 p.m., no repositioning on 1/30/19 for 11:00 p.m., no repositioning on 1/29/19 for 9:00 a.m. to 11:55 a.m., 5:00 p.m. and 8:00 p.m. and multiple occasions patient #1 was not turned in January 2019.

6. A review of the CIO Observation Record for at risk patients revealed no observation record for 7:00 a.m. on 1/26/19 and no CIO observation noted for 11:00 p.m. on 1/29/19 for patient #1.

7. A review of the Face Check Log sheets revealed on 1/23/19 documentation was noted of fifteen (15) minute face check completed at 11:00 p.m., 11:15 p.m. and 11:45 p.m. but video shows no fifteen (15) minute face checks were completed at this time. On 2/5/19 documentation was noted of fifteen (15) minute face checks completed at 11:00 p.m. and 11:45 p.m. but video shows no fifteen (15) minute face checks were completed at this time. On 2/6/19 documentation was noted of fifteen (15) minute face checks completed at 12:15 a.m. and 1:15 a.m. but video shows no fifteen (15) minute face checks were completed at this time.

8. A review of the policy titled Observation Of At Risk Patients, revision date 2/02/16, stated in part: "When a patient is placed on CIO, a staff member will be doing fifteen (15) minute checks on the assigned patient(s)."

9. A review of the policy titled Unit Face Checks/Security Checks, revision date 7/24/17, revealed in part: "Face Checks will be done every fifteen (15) minutes on all shifts unless otherwise ordered."

10. A interview was conducted with the Assistant CEO on 2/7/19 at appropriately 11:30 a.m. She concurred the nursing staff was not following policies and physicians orders.

Based on document review, staff interviews and record review it was determined the Chief Nursing Executive (CNE) failed to ensure the nursing staff followed hospital policy and procedure. This failure has the potential to negatively impact any patient receiving care at this hospital.

Findings include:

1. A review of the facility document titled Sexual Abuse/Assault of Patients, last revised 9/21/17, states: "Nursing staff will follow the procedures outlined in this policy upon receiving a report or discovery of a sexual assault."

2. In an interview with Patient Advocate #1 on 2/4/19 at approximately 12:50 p.m., it was determined on 1/18/19 she received a complaint from patient #1 that alleged health service worker (HSW) #1 had inappropriately touched her in a sexual nature. Patient #1 further stated she had informed another female staff member within the past week. Patient Advocate #1 stated during the investigation she found out that HSW #2 had been notified on 1/16/19 of the alleged abuse. She was notified by patient #1 of the alleged abuse.

3. In an interview with HSW #2 on 2/5/19 at approximately 3:50 p.m., it was determined that she thought it was a Tuesday evening when patient #1 came to her and said: "Just wanted to let you know HSW #1 was coming in my room and doing things to me." HSW #2 stated the patient told her he was saying sexually inappropriate things to her. She informed the patient she knew she had to tell the Registered Nurse (RN). The HSW stated: "I told the RN and he said I needed to fill out an incident report and I told him I was getting ready to leave and we would do it in the morning because I had never done one before."

4. In an interview with the RN on 2/6/19 at approximately 7:55 a.m. it was determined that HSW #2 did come to him and say that patient #1 was making accusations against HSW #1 from the other night. The RN stated he couldn't remember the exact date and time. He stated: "I told her its always been my understanding whoever the accusation was reported to should be the one filling out the report and she said: "I'm getting ready to leave and we will talk to the Nurse Manager when we come back in the morning." He stated: "The next morning HSW #2 said that she had already spoke to the Nurse Manager. I'ts fine, go ahead and go. So I left. She never told me anything about sexual inappropriateness." When questioned about what the policy is related to sexual abuse he stated: "I immediately notify the supervisor to get an APS report pack, fill out an incident report and make sure the person being accused is not in contact with the patient."

5. A statement received from Patient Advocate #2 dated 2/1/19 stated that on 1/18/19 at approximately 1530 (3:30 p.m.) "I received a call from the Clinical Nursing Director asking if I could attend a video review for an investigation Patient Advocate #1 was assigned."

6. In an interview with the Chief Nursing Executive on 2/6/19 at approximately 11:15 a.m. she stated she was unable to explain why patient #1 was not sent out for a rape exam or why an incident report was not filled out by staff after Patient Advocate #1 notified administration on 1/18/19 of the alleged sexual abuse.

7. In an interview with the Director of Quality and Assistant CEO on 2/6/19 at approximately 10:05 a.m., they concurred the hospital did not follow its policy related to sexual assault/abuse of a patient.