HospitalInspections.org

Based on record review and staff interview the facility failed to protect and promote the rights of each patient.

The findings include:

1. Record review and staff interview revealed the facility failed to protect and promote the rights of each patient for 1 of 3 sampled patients (#1) by not ensuring that the patient was safe from abuse by not thoroughly investigating previous allegations of abuse by the same employee. The employee continued to work in the facility, having contact with patients, after multiple allegations of inappropriate conduct.


Record review and staff interview revealed the facility failed to ensure the safety of patients by not completely and thoroughly investigating allegations of abuse by five patients who were in the care of Employee #1.
See A0144 for more specific information.


2. Record review and staff interview revealed the facility failed to ensure that patients were free from all forms of abuse as evidenced by investigations of allegations of abuse by five patients who were in the care of Employee #1.
See A0145 for more specific information.

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The facility must provide an environment that promotes safety to patients. Based on record review and staff interview the facility failed to ensure the safety of patients by not completely and thoroughly investigating allegations of abuse by five patients who were in the care of Employee #1. Employee #1 continued to work in the facility and have contact with patients after multiple allegations of inappropirate conduct.

The findings include:

1. On 6/10/11 at 2:50PM during an interview with the compliance officer and the director of performance improvement, the compliance officer recalled sexual abuse allegations by Patient #1 which were reported to a staff nurse on 10/13/10 at 3PM. The incident was described as inappropriate touching by a male staff member which occurred on 10/13/10. The summary of the incident provided by the compliance officer stated the, "writer came on shift at 3PM and told me, she (patient) was scared because a male staff member just "touched her" inappropriately. She stated the tech put his hand on her stomach like a doctor would touch her, was taking vital signs and then put his hand in her underwear and asked if it hurts or tickles. The patient described the tech and pointed him out to the nurse and the house supervisor. The risk manager (compliance officer) and administrative staff were made aware. The compliance officer reported having administrative authority as the on call administrator and was able to receive complaints of this nature when on call.

The compliance officer stated she did not report prior allegations of sexually or physically inappropriate behavior regarding Employee #1 which were reported in August 2010, May 2010, and March 2010 to any state agency since they were not substantiated after investigations by the facility staff were completed. The compliance officer stated she works closely with the human resources director to thoroughly investigate complaints of abuse or neglect.

The September 2009 report to the state agency was reported to have been mailed to the state agency; however, there was no evidence to corroborate that at this time. The compliance officer provided evidence of requesting a state agency password to electronically file complaints of adverse incidents dated 6/10/11.



2. On 7/6/11 at 10:30AM, a review of the facility investigative documentation provided by the compliance officer revealed the following:


Employee #1 was the named in 5 separate abuse allegations from September 2009 to October 2010.

The documentation on incident #1 revealed that on 9/9/09 a female patient reported the employee had been sexually inappropriate with her when she was "drugged up" and putting clothes in the dryer. Police were called and the facility documentation revealed the patient could not recall the date or time when the alleged incident had occurred and the employee was suspended. Investigative interviews by the human resources director revealed interviews with Employee #1 and another mental health tech who both denied knowledge of the incident. Employee #1 was reinstated to work with pay on 9/10/09. The investigative documentation listed no name of the female patient who reported the incident and the compliance officer was unable to obtain any information to identify the patient. The employee performance improvement plan included a report of the employee suspension. The facility investigation included no evidence of an interview with the patient, had vague general statements from the two employees and did not include specific information regarding the incident.

The documentation on incident #2 revealed a report of sexual inappropriateness between Employee #1 and an adolescent female patient which was alleged to have occurred on 2/27/10. The incident was reported by the patient's therapist on 3/1/10 and involved sexual touching. The employee was alleged to have allowed the female to call her boyfriend on his personal cell phone then asked her to pull down her pants and he touched her. He left the area and called her down to the kitchen, pulled down the blinds and another incident of sexual inappropriateness occurred. The investigation involved patient statements, the therapist's report, and review of the patient record with another patient relating that the patient claiming sexual inappropriateness was always lying and attention seeking. The interviews of the patient related similar details of the alleged incident and facility investigative notes revealed the details relayed by the patient with the patient stating, "I know I'm lying in the past, but not this time." The therapist stated that she had "accused this" in the past, has past history of sexual tendencies and interviews with two others were different than what was originally reported. The investigation did not describe any further investigative protocols such as a check of Employee #1's cell phone records for improper use of the cell phone by patients or an interview of the patient's boyfriend to corroborate the patient's statement. The compliance officer confirmed that police were not contacted to report the alleged incident.

Review of the performance improvement plan stated that the employee was verbally counseled on 3/10 after an adolescent female alleged that the employee had inappropriate sexual dealings with her. Although the allegation was determined unfounded the employee was counseled not to enter patient rooms alone and to remain in the hallway in camera view.

The documentation on incident #3 revealed a report on 5/17/10 of two incidents reported by the patient to her physician involving an allegation of sexual abuse by Employee #1 and another patient. The patient advocate completed the report which had few specific details or documentation of further questioning regarding the incident with the patient stating, "these things that happened are no big deal-I'm a past rape victim, I don't want (Employee #1) to lose his job or the other patient to get in trouble. The hand written note on 5/27/10 by the human resources director revealed discussion with the nurse manager about the incident with no statements or interviews obtained. The note also indicated that the Director of Nursing (DON) would counsel the employee about this. The compliance officer confirmed that police were not contacted to report the alleged incident.


The documentation on incident #4 revealed a report on 8/16/10 that Employee #1 was called to the adolescent unit to diffuse the behavior of two agitated male patients. The staff reported the employee had returned to the unit later and entered each of the patient rooms and had closed the door. Upon entering the second patient room the employee closed the door, loud noises were heard, the door moved as if being bumped by someone several times and the door handle jiggled. The behavioral analyst tried to open the door and initially could not. The door opened and the patient was observed to be very distraught and upset. The employee left quickly. The patient alleged he was grabbed by the collar by Employee #1, with no evidence noted by staff of the patient having been struck. The employee performance plan revealed evidence of a final warning and a one day suspension for the employee. The employee was found to have had inappropriate dealings with a patient, violated the policies including "rude, discourteous behavior or language that is disruptive to the hospital or patients", and "committed breach of health and safety rules."

A performance improvement plan for Employee #1 showed that performance expectations included:
Employee not allowed to enter or to work on the adolescent unit at any time for any reason.
He should never be alone in a patient's room.
He should never close the door to a patient's room unless there was another staff member in the room.
Training revisit to the "therapeutic boundaries" video with post test.
Any further performance issues, policy infractions, or violations outlined will result in immediate termination.

The investigation of incident #5 revealed documentation of an alleged inappropriate sexual touching by Employee #1 involving a female patient (Patient #1) on 10/13/10. The female reported the allegation to staff who initiated the investigation. The patient reported the employee stated he was checking her for bed bugs, and taking her vital signs while alone in her room. Her roommate was asked to leave by Employee #1 for a phone call for 30 minutes duration in which the employee began to palpate her abdomen and then touched her vaginal area. The MD was on the unit and requested the administrator on call, and the police were to be called.

The charge nurse and the supervisor then provided for patient safety and completed the appropriate incident documentation. The record of the police visit included a booklet with number of the incident. The booklet which confirmed the police visit was not present on any of the other investigative documents provided by the facility.


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Based on record review and staff interview the facility failed to ensure that patients were free from all forms of abuse as evidenced by investigations of allegations of abuse by five patients who were in the care of Employee #1. Employee #1 continued to work in the facility and have contact with patients after multiple allegations of inappropirate conduct.

The findings include:

1. Review of facility documentation regarding Employee #1 in 5 separate abuse allegations from September 2009 to October 2010, revealed that although female patients had alleged inappropriate sexual touching on 9/9/09, 2/27/10 (not reported until March) and 5/17/10, and another incident occurred in August 2010 in a closed room with a male patient alleging that he was grabbed by the collar by Employee #1, the employee continued to work at the facility until October of 2010 when there was another allegation of inappropriate sexual touching involving Patient #1.

Review of the investigations from the reported incidents did not show that there was a thorough investigation. The compliance officer stated she did not report subsequent allegations of sexually or physically inappropriate behavior which were reported August 2010, May 2010, March 2010 and September 2009 to any state agency since they were not substantiated after investigations by the facility staff were completed. The facility was unable to provide documentation that reports to the police, or any adult/child protective agency were made. Facility staff indicated that a report was made to the state agency in September 2009, but were unable to provide documentation to show this.


2. Review of the performance improvement plan stated that the employee was verbally counseled on 3/10 after an adolescent female alleged that the employee had inappropriate sexual dealings with her. Although the allegation was determined unfounded the employee was counseled not to enter patient rooms alone and to remain in the hallway in camera view.

After the incident in August of 2010, other performance expectations included:
Employee not allowed to enter or to work on the adolescent unit at any time for any reason.
He should never be alone in a patient's room.
He should never close the door to a patient's room unless there is another staff member in the room.
Training revisit to the "therapeutic boundaries" video with post test.
Any further performance issues, policy infractions, or violations outlined will result in immediate termination.

Despite the performance improvement plan that Employee #1 was not to be in a patient's room alone with a patient, and the fact that there had been previous allegations of inappropriate sexual activity with female patients, the facility did not ensure that the employee followed the plan, and in October of 2010, another allegation of inappropriate sexual touching was made by a female patient (#1).

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The facility must provide an environment that promotes safety to patients. Based on record review and staff interview the facility failed to ensure the safety of patients by not completely and thoroughly investigating allegations of abuse by five patients who were in the care of Employee #1. Employee #1 continued to work in the facility and have contact with patients after multiple allegations of inappropirate conduct.

The findings include:

1. On 6/10/11 at 2:50PM during an interview with the compliance officer and the director of performance improvement, the compliance officer recalled sexual abuse allegations by Patient #1 which were reported to a staff nurse on 10/13/10 at 3PM. The incident was described as inappropriate touching by a male staff member which occurred on 10/13/10. The summary of the incident provided by the compliance officer stated the, "writer came on shift at 3PM and told me, she (patient) was scared because a male staff member just "touched her" inappropriately. She stated the tech put his hand on her stomach like a doctor would touch her, was taking vital signs and then put his hand in her underwear and asked if it hurts or tickles. The patient described the tech and pointed him out to the nurse and the house supervisor. The risk manager (compliance officer) and administrative staff were made aware. The compliance officer reported having administrative authority as the on call administrator and was able to receive complaints of this nature when on call.

The compliance officer stated she did not report prior allegations of sexually or physically inappropriate behavior regarding Employee #1 which were reported in August 2010, May 2010, and March 2010 to any state agency since they were not substantiated after investigations by the facility staff were completed. The compliance officer stated she works closely with the human resources director to thoroughly investigate complaints of abuse or neglect.

The September 2009 report to the state agency was reported to have been mailed to the state agency; however, there was no evidence to corroborate that at this time. The compliance officer provided evidence of requesting a state agency password to electronically file complaints of adverse incidents dated 6/10/11.



2. On 7/6/11 at 10:30AM, a review of the facility investigative documentation provided by the compliance officer revealed the following:


Employee #1 was the named in 5 separate abuse allegations from September 2009 to October 2010.

The documentation on incident #1 revealed that on 9/9/09 a female patient reported the employee had been sexually inappropriate with her when she was "drugged up" and putting clothes in the dryer. Police were called and the facility documentation revealed the patient could not recall the date or time when the alleged incident had occurred and the employee was suspended. Investigative interviews by the human resources director revealed interviews with Employee #1 and another mental health tech who both denied knowledge of the incident. Employee #1 was reinstated to work with pay on 9/10/09. The investigative documentation listed no name of the female patient who reported the incident and the compliance officer was unable to obtain any information to identify the patient. The employee performance improvement plan included a report of the employee suspension. The facility investigation included no evidence of an interview with the patient, had vague general statements from the two employees and did not include specific information regarding the incident.

The documentation on incident #2 revealed a report of sexual inappropriateness between Employee #1 and an adolescent female patient which was alleged to have occurred on 2/27/10. The incident was reported by the patient's therapist on 3/1/10 and involved sexual touching. The employee was alleged to have allowed the female to call her boyfriend on his personal cell phone then asked her to pull down her pants and he touched her. He left the area and called her down to the kitchen, pulled down the blinds and another incident of sexual inappropriateness occurred. The investigation involved patient statements, the therapist's report, and review of the patient record with another patient relating that the patient claiming sexual inappropriateness was always lying and attention seeking. The interviews of the patient related similar details of the alleged incident and facility investigative notes revealed the details relayed by the patient with the patient stating, "I know I'm lying in the past, but not this time." The therapist stated that she had "accused this" in the past, has past history of sexual tendencies and interviews with two others were different than what was originally reported. The investigation did not describe any further investigative protocols such as a check of Employee #1's cell phone records for improper use of the cell phone by patients or an interview of the patient's boyfriend to corroborate the patient's statement. The compliance officer confirmed that police were not contacted to report the alleged incident.

Review of the performance improvement plan stated that the employee was verbally counseled on 3/10 after an adolescent female alleged that the employee had inappropriate sexual dealings with her. Although the allegation was determined unfounded the employee was counseled not to enter patient rooms alone and to remain in the hallway in camera view.

The documentation on incident #3 revealed a report on 5/17/10 of two incidents reported by the patient to her physician involving an allegation of sexual abuse by Employee #1 and another patient. The patient advocate completed the report which had few specific details or documentation of further questioning regarding the incident with the patient stating, "these things that happened are no big deal-I'm a past rape victim, I don't want (Employee #1) to lose his job or the other patient to get in trouble. The hand written note on 5/27/10 by the human resources director revealed discussion with the nurse manager about the incident with no statements or interviews obtained. The note also indicated that the Director of Nursing (DON) would counsel the employee about this. The compliance officer confirmed that police were not contacted to report the alleged incident.


The documentation on incident #4 revealed a report on 8/16/10 that Employee #1 was called to the adolescent unit to diffuse the behavior of two agitated male patients. The staff reported the employee had returned to the unit later and entered each of the patient rooms and had closed the door. Upon entering the second patient room the employee closed the door, loud noises were heard, the door moved as if being bumped by someone several times and the door handle jiggled. The behavioral analyst tried to open the door and initially could not. The door opened and the patient was observed to be very distraught and upset. The employee left quickly. The patient alleged he was grabbed by the collar by Employee #1, with no evidence noted by staff of the patient having been struck. The employee performance plan revealed evidence of a final warning and a one day suspension for the employee. The employee was found to have had inappropriate dealings with a patient, violated the policies including "rude, discourteous behavior or language that is disruptive to the hospital or patients", and "committed breach of health and safety rules."

A performance improvement plan for Employee #1 showed that performance expectations included:
Employee not allowed to enter or to work on the adolescent unit at any time for any reason.
He should never be alone in a patient's room.
He should never close the door to a patient's room unless there was another staff member in the room.
Training revisit to the "therapeutic boundaries" video with post test.
Any further performance issues, policy infractions, or violations outlined will result in immediate termination.

The investigation of incident #5 revealed documentation of an alleged inappropriate sexual touching by Em