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Based on interview, record review and review of facility policy, it was determined the facility failed to protect and promote patient rights for one (1) of ten (10) sampled patients (Patient #1). The facility failed to ensure an allegation of abuse for Patient #1 was investigated in a timely and effective manner, and failed to ensure protection of other patients from potential abuse while the investigation was in progress.

In addition, the facility's "Identification, Assessment and Reporting of Suspected/Alleged Victims of Abuse, Neglect or Exploitation Policy, revised 08/06, did not include a written procedure for investigating abuse
and neglect including methods to protect patients from abuse during investigations. Also, this policy did not comply with KRS 209.030 regarding reporting allegations immediately to the Cabinet.

Patient #1 was transferred from the facility to a Long Term Care (LTC)facility on 11/26/13 where he/she made an allegation that he/she was raped the night before while at the facility. On 11/27/13 this information was conveyed to the hospital by the LTC facility to which the patient was transferred on 11/26/13. The facility failed to interview the night shift staff who had been working on 11/25/13, the alleged date and time of the rape until 12/03/13, six (6) days later. In addition, the staff assigned to the patient on the morning of 11/26/13, the date of discharge, were not interviewed. There was no documented evidence of a timely and effective investigation in order to protect other patients in the facility.

The findings include:

Review of the facility's "Identification, Assessment and Reporting of Suspected/Alleged Victims of Abuse, Neglect or Exploitation Policy, revised 08/06, revealed no documented evidence of information related to investigating or protection after an allegation of abuse was made. Review of the policy section entitled "Reporting and Treatment Process-Sexual Assault", revealed in cases of rape a report to Adult Protective Services (APS) was not made and police assumed the responsibility for reporting to APS.

Review of Kentucky Revised Statutes (KRS) Chapter 209:030 revealed any person should immediately make an oral or written report to the Cabinet upon knowledge of suspected abuse, neglect or exploitation of an adult.

Review of Patient #1's medical record revealed the hospital admitted the patient on 10/29/13, with diagnoses which included Escherichia Coli (E-coli) Wound Infection, a Urinary Tract Infection, Status Post Open Reduction and Internal Rotation (ORIF) of a Right Hip Fracture, Decubitus Ulcer of the Sacrum, and Malnutrition. Review of the hospital Discharge Summary dated 11/26/13, revealed the patient was to be transferred to a Long Term Care (LTC) facility.

Review of the "Initial Report/Suspected Abuse" form completed by the LTC facility, to which the patient was transferred on 11/26/13, revealed on 11/27/13 at 12:12 PM, the LTC facility Administrator reported the patient's allegation of having been raped at the facility on 11/25/13. Review of the Form revealed the LTC Administrator notified the Clinical Care Supervisor (CCS) at the facility of this information.

Interview on 12/03/13 at 3:45 PM, with the Administrator of the LTC facility, revealed on 11/27/13, Patient #1 made an allegation of being raped the night of 11/25/13, while at the facility and prior to being transferred to the LTC facility.

Review of the facility's investigation revealed the Director of Nursing (DON) received a call on 11/27/13 from the facility's Clinical Care Supervisor (CCS). Continued review revealed the CCS notified the DON the LTC facility had phoned and reported to the CCS an allegation of alleged rape that that allegedly had occurred at the facility. Review revealed the CCS had verified there no males had worked the night in question, 11/25/13. According to the facility's investigation, the CCS had interviewed staff who worked the day shift on 11/27/13, the date of report, and staff were not aware of the alleged rape. Additionally, it was noted the DON notified the facility House Administrator, the facility Risk Manager, and the Chief Executive Officer (CEO) on 11/27/13; however, there was no documented evidence the facility notified the Cabinet of Patient #1's allegation of rape. Review revealed the DON called the LTC facility Administrator on 11/28/13, and was told Patient #1 was confused but made the allegation he/she was raped the night before the patient left the facility. Further review revealed the LTC facility was sending Patient #1 to the Emergency Room of another facility, for a rape test kit to be performed. Per the investigation, the DON had interviewed Registered Nurse (RN) #1, who was the charge nurse for the night for 11/25/13, on 12/02/13 regarding the alleged rape reported by the LTC facility. According to the investigation RN #2 and State Registered Nurse Aide (SRNA) #1, who had been assigned to Patient #1 on 11/25/13 on the night shift from 7:00 PM until 7:00 AM on 11/26/13, were not interviewed until 12/03/13, six (6) days after the facility became aware of the allegation of rape. In addition, there was no documented evidence the day shift staff, who had been assigned to Patient #1 on 11/26/13 on the day shift at the time of discharge, were interviewed.

Interview on 12/05/13 at 1:33 PM, with the CCS revealed she had called the DON to report the allegation on 11/27/13 after receiving the call from the LTC facility. She stated she only interviewed the staff who were working day shift on 11/27/13 and she had not performed a formal interview. She indicated she "pulled" the staff working on day shift on 11/27/13, to the nursing station and asked if Patient #1 had reported anything to them. Further interview with the CCS revealed she did not document the staff interviews she performed on 11/27/13.

Interview on 12/05/13 at 12:10 PM, with the House Administrator revealed she was informed of the allegation on 11/27/13 by the DON. She stated she and the CCS had called the day shift staff together on 11/27/13 and talked to them to see if they were aware of the allegation of rape. The House Administrator stated she did not interview any other staff; however, had gone in a few patient rooms and asked the patients if they needed anything. She stated she did not document the interviews performed with staff or other patients.

Interview with the DON and the CEO on 12/05/13 at 10:00 AM, revealed the DON received the notification of the allegation of rape on 11/27/13 which was a holiday and administrative staff were not in the facility. The DON stated she contacted staff by phone and talked with the CCS who had no concerns and reported no staff had reported anything suspicious. The DON indicated she did not interview the RN and SRNA, who were assigned to the patient on 11/25/13 from 7:00 PM until 7:00 AM, until 12/03/13. The DON stated she did not interview the staff who took care of Patient #1 on the morning of 11/26/13 when the patient was discharged. According to the DON, if Patient #1 had still been in the facility, or if there was anything suspicious had been reported, she would have talked to more staff. Continued interview with the DON, revealed she felt the facility's investigation could have been more thorough and felt this was an ongoing investigation.

Additionally during the interview on 12/05/13 at 10:00 AM, the CEO stated if there had been anything suspicious or any " red flags", she and the DON would have come into the facility to conduct interviews sooner. She stated however, there was no need to interview all staff immediately as there were no "red flags". The CEO stated she was not sure if the policy was correct in stating, in cases of rape, a report to APS was not made by the hospital, and the police assumed responsibility for reporting. The DON stated the current abuse policy was taken from the regulation; however there was no documented evidence it contained information regarding investigation and protection of patients after an allegation of abuse.

Further interview with the CEO on 12/05/13 at 12:45 PM revealed the facility conducted interviews for the investigation until they felt patients were safe. The DON, who was also present during this interview, stated she concluded staff would tell Administration if there was an allegation of abuse since they were trained to do so.

Interview on 12/05/13 at 2:42 PM with the Risk Manager, revealed if there had been a reasonable suspicion of abuse, the facility would have needed to interview staff and patients in a more timely manner; interview more staff, and speak to family members. However, she stated this was not a complete investigation; the investigation should have been conducted in a timely and effective manner; and, all the interviews with staff should have been documented.