HospitalInspections.org

Based on document review and interview, it was determined that the Hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights.

Findings include:

1. The Hospital failed to have a written procedure or a system in place for investigation; protection; and interventions, following a sexual abuse allegation. (See A-145)

Based on document review and interview, it was determined that for 1 of 1 clinical record (Pt #1) reviewed for abuse, the Hospital failed to have a written procedure or a system in place for investigation; protection; and interventions, following a sexual abuse allegation.

Findings include:

1. The Hospital's policy/protocol on abuse allegations, was requested. On 10/19/2023 at 11:30 AM, the Director of Clinical Licensure and Accreditation (E #2) stated that the Hospital does not have a specific "Abuse" policy. E #2 stated that the Hospital categorizes abuse allegations as grievances. E #2, stated therefore, they reference and use the Grievance policy when handling abuse allegations. E #2 stated that the abuse allegations are handled on a "case-by-case" basis.

2. The Hospital's policy titled, "Patient/Patient Representative Grievance, and Section 504, Management Process" (dated 11/2022), was reviewed, and required, " ...A verbal or written complaint ...that is made to [Hospital] by a patient, or the patient's representative as defined by CMS Hospital Conditions of Participation, and which may regard the following: Allegations of harm, abuse or neglect ...G. Grievances are managed utilizing the following steps:1. Staff will address/escalate grievances that can be identified as a serious safety issue, that may harm the patient or others, and allegations of abuse and neglect. Staff will complete a file in the Event Reporting Application (ERA) utilizing the Feedback category/module ...Appropriate Quality Safety and Risk Manager is notified of a grievance related to patient injury, harm, or potential liability ..." The Grievance policy lacked steps/process on the reporting time frame of an abuse allegation; the process of what happens when the staff is accused an allegation; how the patients are protected following an abuse allegation; or the process involving a sexual abuse allegation (including informing the police or offering a sexual assault kit).

3. The Hospital's policy titled, "Corrective Action" (dated 10/2013), was reviewed, and required, "It is the policy of [Hospital] to use corrective action to address ...personal conduct issues ...The rules and regulations listed in this policy are not all inclusive but are intended to serve as a supervisory guide to corrective action ... Suspensions are generally used to allow for a thorough investigation of possible violations of [Hospital] policies, rules, regulation, or performance issues ...Suspensions will be for a time frame sufficient enough to thoroughly investigate the infarctions(s) or performance issue(s) ..." The policy did not definitively specify if or when an employee is suspended pending an abuse allegation.

4. P #1's clinical record was reviewed on 10/19/2023. Pt #1 had a scheduled orthopedic surgery on 10/12/2023. Pt #1 was subsequently admitted to the inpatient orthopedic unit (5 East/West).

-Pt #1's occupational therapy note, dated 10/17/2023 at 2:18 PM, included, " ...Pt was tearful during this session. 'What is happening to me?'. Appeared to have some sort of trauma response. Discussed with or secure chatted [direct messaging thread in the electronic medical record that can be shared amongst the care team] ...Based on observation during this session, pt's cognition appears to be impaired ...Interdisciplinary Handoff: Incident pt brought up from night before ..." The "Secure Chat" messaging thread indicated that the Unit Manager (E #10) was not on the thread until 10/17/2023 at 6:20 PM (approximately 4 hours after the allegation was received). E #4 received a sexual abuse allegation at this time from Pt #1, indicating a PCT (E #1), as the alleged.

-The physician's note (dated 10/17/2023 at 9:04 PM) documented by the Hospitalist (MD #1), included, "Called by nurse manager and nursing staff with concerns for possible SA [sexual assault] during hospitalization for shoulder surgery ...States she is in utter disbelief and feels violated. States she awoke with male figure standing above her, 'playing with himself'. States she feels like the right side of her labia feels tender and swollen with some dysuria [painful urination] ...She states feels scared and anxious-especially with regards to explaining to family...External exam without overt signs of trauma but with tenderness ..."

-A nursing note (dated 10/18/2023 at 4:45 PM), documented by the RN (E #6) included, "SANE (Sexual Assault Nurse Examiner) coordinator at bedside. The clinical record lacked documentation of the sexual assault kit being offered immediately following the sexual abuse allegation. The sexual assault kit was performed the following day (10/18/2023), after the patient requested a kit.

5. The Hospital's investigative report, dated 10/17/2023, included, "Event type: Patient Abuse: Patient [Pt #1] stated, 'She woke up around midnight [10/17/2023] and PCT [patient care technician/E #1] was standing in front of her by her bed grabbing [private area].' She said, 'E #1 scared/startled her, and she said he was sweating profusely and had a horrible stench and that her vagina hurt.' She said she does not know if he did anything to her, but her vagina hurt when she woke up." The investigation report did not include details of investigation or corrective actions. However, E #1 was suspended on 10/17/2023 pending investigation, after the allegation was reported (verified through review of schedule/assignments).

6. The Hospital's abuse training was reviewed on 10/23/2023 and entails a "Preventing and Reporting Abuse &Neglect" power point. The abuse training is provided to the staff upon hire and annually. The training power point included training on physical abuse; child abuse; elder abuse; long-term resident abuse; and domestic violence act. However, the training did not cover the process regarding a sexual abuse allegation.

7. On 10/19/2023 at 11:00 AM, an interview was conducted with Pt #1. Pt #1 stated that on last Saturday evening (10/14/2023) before midnight, "I heard a PCT (E #1) saying my name. When I opened my eyes, I saw [E #1] standing over me. [E #1] was standing on my left side. [E #1] had his arm across me and was holding the call light. [E #1] touched my breasts." Pt #1 stated that her vagina hurt after the incident. Pt #1 stated, "It has been horrible. [E #1] had his other hand was in his pants over his penis. [E #1] stated "Hi, I'm [name of E #1]. I yelled at [E #1] to get out of my room and get the nurse. The nurse came into my room and said, "Oh don't worry, [E #1] wouldn't hurt you. The nurse stated that [E #1] would not come in my room anymore." Pt #1 stated that E #1 came into her room multiple times that night after the incident. Pt #1 was crying at the end of the interview.

8. On 10/19/2023 at 1:40 PM, an interview was conducted with the Occupational Therapist (E #4). E #4 stated that E #4 is now aware that the Unit Manager, the OT Manager, or someone higher up should have been notified immediately of the abuse allegation.

9. On 10/23/2023 at 11:10 AM, an interview was conducted with the Orthopedic Manager (E #10). E #10 stated that the expectation is that staff notify management immediately of an abuse allegation. E #10 stated that the staff can notify management through the voice system or by notifying E #10 directly. E #10 stated that "chain-of command" should have been followed in Pt #1's instance. E #10 stated that "Secure Chat" is not the process for notifying management of an abuse allegation since E #10 is not always in front of the computer.

10. On 10/23/2023 at 8:45 AM, an interview was conducted with the RN (E #5/assigned to Pt #1 on 10/16/23 at 7:00 PM). E#5 stated that the night of 10/16/2023, the PCT (E #1) was assigned to Pt #1. E #5 stated that E #5 saw E #1 enter Pt #1's room. E #5 stated that Pt #1's room was located directly across from the nurse's station and the patient kept the door open since she had anxiety. E #5 stated that when E #5 entered Pt #1's room later that night, the patient asked if there was a male PCT on duty. E #5 stated that Pt #1 said, "Oh my God, he [E #1] woke me up and scared me. E #5 stated that Pt #1 did not express any abuse allegation at that time, but the husband called and stated that she was scared and that she did not want any males in her room anymore. E #5 stated that the following night, on 10/17 around 8 PM, the patient was complaining of burning sensation with urination and requested to speak with someone so that she could have a rape kit. E #5 stated that E #5 was not made aware of this allegation from the day shift, as this was the first time of her hearing of this.