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Based on interview, record review, and review of the Kentucky Revised Statue 209.030, it was determined the facility failed to report an allegation of sexual abuse by a facility employee towards a patient to state agencies. This effected one (1) of ten (10) sampled patients (Patient # 1) for closed medical records reviewed.

The findings include:

Review of the Kentucky Revised Statue (KRS) 209.030 (2) revealed the following: Any person, including but not limited to, physician, law enforcement officer, nurse, social worker, cabinet personnel, coroner, medical examiner, alternate care facility employee, or caretaker, having reasonable cause to suspect that an adult has suffered abuse, neglect, or exploitation, shall report or cause reports to be made in accordance with the provisions of this chapter.

Review of KRS 209.0303(3), revealed the following: An oral or written report shall be made immediately to the cabinet upon knowledge of suspected abuse, neglect, or exploitation of an adult.

Interview on 12/12/16 at 10:23 AM, with Patient #1, revealed he/she informed facility staff on 10/09/16, that earlier in the day a Respiratory Therapist (RT) had repeatedly touched him/her and made sexual suggestive comments in the course of providing care. Patient #1 revealed, following discharge from the facility he/she contacted the RT's licensing board to see if the incident had been reported for investigation. Patient #1 further revealed, upon the advice of the Kentucky Respiratory Therapist Board, Patient #1 filed a complaint with the Cabinet for Health and Family Services (CHFS).

However, review of the complaint information from CHFS and the Department for Community Based Services (DCBS), revealed no documented evidence the facility had reported Patient #1's sexual abuse allegation to the state agencies. In addition, review of the facility's "Accidents and Incidents Log" revealed no documented evidence the alleged incident was reported by Patient #1.

Interview conducted on 12/13/16 at 9:16 AM, with the facility's Risk Manager, revealed Patient #1 did report an allegation of sexual abuse to facility staff. Further interview revealed actions taken by facility personnel included contacting the local police department, interviewing staff that were on duty on the day of the alleged incident, terminating the alleged perpetrator and notifying the alleged perpetrator's licensing board of the alleged incident. Per interview, the Risk Manager acknowledged the allegation of sexual abuse was not reported to either CHFS or DCBS for investigation. The Risk Manager further revealed the facility had not developed a policy to direct facility staff to report allegations of staff abuse of patients. Further interview with the Risk Manager, verified Patient #1's complaint/allegation of abuse was not listed on the "Accident and Incidents Log". Per interview, the facility failed to list the complaint/allegation on the Log for follow up, and failed to report the abuse allegation to state agencies for investigation. The Risk Manager revealed, "I am not aware of any other allegations of staff to patient abuse ever occurring". The Risk Manager further stated, she had been in her position at the facility since "the early 1990's".

Interview on 12/13/16 at 9:42 AM, with the facility's Associate Chief Nursing Officer (ACNO) revealed the facility had contacted the RT's Licensing Board and notified them of the allegation because facility administration felt the RT's behavior was unprofessional. The ACNO further revealed facility administration did not realize they needed to report the allegation to CHFS or DCBS since the police had been contacted. The ACNO further acknowledged the facility should be following state and local laws regarding the reporting of suspected abuse allegations of facility staff to state agencies.