HospitalInspections.org

Based on interview and document review, the facility failed to follow their grievance policy and procedure including investigation and providing a written response to a patient in response to a grievance and report a grievance of suspected maltreatment immediately to the State Agency for 1 of 10 patients (P6) who voiced a grievance to the facility of abuse.

Findings include:

Review of P6's 12/19/23 at 6:06 p.m., emergency record identified she was brought to the Emergency Department (ED) due to increased concern for safety at home with suicidal ideation with a plan for self-harm. She was assessed and placed on a 72 hour hold to facilitate acute psychiatric placement. Psychiatry was consulted on 12/21/23 and petitioned for Civil Commitment with the County. P6 had diagnosis of Bipolar I depressed, anxiety disorder, obsessive compulsive disorder, borderline personality disorder, self-injurious behaviors, post-traumatic stress disorder and major depressive disorder. The ED record documented attempts for acute care placement which were unsuccessful and P6 was housed in the ED pending placement.

Review of the timeline provided by registered nurse (RN)-A identified the sequence of the reported events on:
1) 12/29/23: During rounds of the ED department was notified by the charge nurse of an alleged abuse by an (unidentified) male technician against P6 during the overnight hours of December 28, 2023. Law enforcement had not been notified prior to the report and interviewed P6 on the morning of December 29, 2023. Immediate changes to P6's Behavioral Safety Plan included: 2 staff members in attendance during interactions and placed on video camera monitoring.
2) 12/31/23, an email was sent to RN-A (nurse manager) informing that P6 alleged a Behavioral health nurse, "patted her inappropriately" while assisting with a shower and drying her off.
3) 1/2/24, RN-A received email dated as sent December 31, 2023, that P6 alleged that she was "patted inappropriately" when assisted with drying following a shower. RN-A reached out to the compliance department for assistance on next steps to take regarding the allegations.
4) 1/3/24, Mayo Clinic Health System Clinical Coordination Council approved Immediate Response to Allegations of Abuse of a Patient by Mayo Clinic personnel Procedure-Mayo Health System.
5) 1/4/24, the incident was reported to Office of Risk Management (ORM) for investigation.

Interview on 1/4/24 at 2:38 p.m., with the licensed social worker (LSW) reported she had performed the initial social assessment when P6 came to the ED on 12/19/23. P6's admission was due to a mental health issues and suicidal ideation. On 1/3/24 she had spoken with P6 who informed her she had "Rights", she wanted to speak with the Ombudsman and that she had contacted law enforcement because an unidentified ED staff member had "sexually assaulted" her. P6 was not able to identify when the incident had occurred or who the staff member was. The LSW followed up with the nurse supervisor who was going to speak with P6. Immediately following the reported incident P6's plan of care was revised for two staff members in attendance for all personal care, and security was stationed outside the room, as a precaution. The LSW was unaware of any additional information about the alleged incident but stated P6's room was located across from the nursing station to allow for staff to monitor her.

Interview on 1/4/23 at 3:07 p.m., with physician (MD)-A reported P6 was housed in the main ED due to her need for oxygen. She was non-compliant and voiced multiple complaints that staff were not taking care of her. P6 would have behaviors of yelling and screaming for assistance when the ED was very busy, and staff could not immediately respond to her requests. He recalled one incident when the ED was very busy and P6 was in the doorway of her room yelling that she saw someone (several male technicians were across the hall), through the glass of her room, and claimed one of them had assaulted her. She did not know who the alleged person was and was not able to identify anyone. MD-A identified he was not able to recall the date of the incident, but reported P6 was not able to identify anyone or when the alleged assault had taken place. He stated he had been very busy with activity in the ED and had not responded to the allegation, but thought administration was aware and looking into the incident.

Attempted interview on 1/4/24 at 3:55 p.m. with P6 who voiced multiple complaints of mistreatment by the facility. She referenced incidents that had occurred from August 2022 and October 2023, and the reason she had been brought to the hospital, due to not wanting to live anymore. She stated while she had been in the ED she had been "sexually assaulted", and that she had been "patted" inappropriately when being assisted with a shower. P6 was not able to identify the alleged staff or the date/time the incident took place. She questioned who was calling and from where, then voiced she wished she had realized who she was talking to as she thought this surveyors agency (State Agency) was the agency that had put her in the hospital in the first place and hung up the phone.

Interview on 1/4/23 at 4:42 p.m., with registered nurse (RN)-A identified when she was notified on 12/29/23 of P6's alleged sexual assault she ensured safety measures were in place. Law enforcement had been notified of the allegation, however, she was unsure if the State Agency had been. She identified that security was also present outside P6's room when staff were in attendance and her room was across from the nurse's station and within the line of sight. RN-A denied knowledge of the Grievance and abuse policies and no reports were completed since P6 was not able to identify anyone. Following receipt of the email alleging the second incident she had thought the nurse was just helping P6 dry off but had reached out to Compliance for direction. RN-A confirmed she had not received any further direction, and no additional documentation or reporting was completed.

Interview on 1/4/24 at 4:50 a.m. with the Accreditation Specialist identified she was not certain of a policy in place, but reported the organization was currently working on a policy/procedure and it was currently in committee approval. She confirmed the alleged incident had not been reported tot he State Agency, and no further investigation had taken place. After the survey, and email was received identifying the facility had an Abuse and the Grievance policy. The incident had been referred to The Office of Risk Management for further investigation and their recommendations would be followed according to facility policy.

Review of the 12/27/23, patient Complaint and Grievance Procedure identified an application was available to all personnel who received a concern or complaint involving the Mayo Clinic or it's personnel. Prompt service was to be provided and if the issue is not able to be resolved, the patient was to be provided contact information for the Office of Patient Experience. If a concern or grievance was not able to be promptly resolved by staff present, it was to become a Grievance subject to The Joint Commission (TJC) and the Centers of Medicare and Medicaid Services (CMS) Conditions of Participation (CoP's). A Grievance was defined as any concern expressed by a patient regarding care provided, allegations of abuse, neglect, patient harm, or breach of restricted information or the hospital's compliance or a concern that was not promptly resolved by the department staff.

Review of the July 3, 2023, Mandated Reporting of Abuse, Neglect, or Exploitation of Vulnerable Adult Policy identified the purpose to ensure appropriate handling and reporting of suspected cases of abuse, neglect, or exploitation of vulnerable adults in accordance with state law. All personnel must report the suspected maltreatment to the State Agency as outlined in the policy. Information of an alleged incident involving a Mayo clinic associated person must be communicated immediately to the appropriate Unit/Department Manager/House Supervisor and Administrator of the department in addition to the legal department. The Legal department reviews the information/allegation and provides guidance on investigation and reporting requirements.