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Based on policy review, record review, document review, and interview, the Hospital failed to review an allegation of sexual assault immediately as required per policy for 1 (Patient 1) of 2 patients reviewed. This deficient practice has the potential to place patients or representatives at risk for unresolved grievances and complaints and systemic issues that could lead to harm and other adverse outcomes.

Findings Include:

Review of hospital policy titled, "117-ADM [Administration] Complaints and Grievances - RM [Risk Management] - [Above Named Hospital]," dated 03/28/18, showed, " ...Investigate and respond to patient and/or family/representative complaints and grievances, including but not limited to quality of care ...Patient Grievance - A grievance is defined as ANY of the following: ...A patient's rights complaint by a patient or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the CMS [Centers for Medicare and Medicaid Services] Hospital Conditions of Participation (CoP) ... Grievances about situations that endanger the patient such as abuse or neglect must be reviewed immediately ...The Patient Representative and/or designated person will send a letter of notification to the patient within 7 days of a received grievance ...The Facility Compliance Officer (FCO) will be responsible for addressing grievances involving potential corporate compliance violations or other regulatory violations ... All grievances will have a written response from the patient representative within thirty days of receipt of the grievance depending on the nature of the grievance ..."

Review of hospital policy titled, "200-ADM [Administration] Patient Rights and Responsibilities," dated 04/21/25, showed, " ...Patient Has The Right ...To personal security and privacy so that ...Patients are free from physical or mental abuse, neglect or harassment ... Patient Grievance Process: ... All formal written or verbal patient grievances will receive a written response from [Above Named Hospital] within 30 days of receipt of grievance ..."

Review of hospital policy titled, "158-IPCM [Inpatient Care Management] Abuse, Neglect and Exploitation," dated 02/21/24, showed, " ...To assist Health Center staff in identifying possible abuse/neglect/exploitation and outline appropriate actions for investigation and/or reporting ... Adult Abuse - An individual 18 years of age or older alleged to be unable to protect their own interests. Physical, psychological, or sexual acts that jeopardize an individual's medical care, health status, sense of personhood, right to self-determination, or personal property or income. Failure to provide a safe environment ... Reports of suspected abuse or neglect of residents of medical care facilities, including nursing homes, are to be reported to the Department of Health and Environment ..."

Patient 1

Review of Patient 1's medical record showed a 71-year-old was seen in the emergency department on 03/23/25 at 8:32 AM and admitted with a diagnosis of fecal impaction (hardened stool stuck in the rectum or lower colon due to constipation) and evidence of proctitis (an inflammation of the rectum's lining).

Review of a hospital document titled, "Event Log," dated 01/01/25 to 05/27/25, showed that Patient 1 filed a grievance with the hospital for alleged sexual abuse on 04/01/25. The document showed, " ...Report Date; 04/01/25 10:23 [10:23 AM]; Event Date 03/23/2025; [Patient 1] ...Category (s) associated with event or unsafe condition; Patient Security; Patient called grievance line yesterday (3/31/25). Pt [patient] states she was raped while in our ER [Emergency Room]. Pt [Patient] states she went to the ED [Emergency Department] on 3/23/25 to get an enema (a procedure that involves injecting fluid int the rectum to cleanse the colon or lower bowel) due to impaction ...she was raped (anal). Pt [Patient] stated that she screamed "stop" several times when the doctor began the exam, but he would not stop. States he pinned her down with his arm and continued to "jam his finger" into her anus (the opening of the rectum to the outside of the body) ..."

During an interview on 05/28/25 at 11:15 AM, Patient 1 stated that during an emergency room visit on 03/23/25 a doctor performed a painful rectal exam without clear consent, despite asking him to stop. Patient 1 stated the risk manager at the hospital was informed of the incident and was told the case would be resolved in 30 days. Patient 1 stated that no mail had been received from the hospital regarding the outcome as of date of interview.

During an interview on 05/29/25 at 10:58 AM, Staff H, Risk Manager, stated that policy does not specify a timeframe to report an allegation of sexual assault to the compliance officer. Staff H stated that the surgeon named in the grievance was not interviewed until May 20. Staff H stated that the case was initially handled as an "incident" instead of a grievance, and the patient was informed that a letter would be sent once the investigation was complete. Nearly 60 days passed without a formal letter being sent, including a 30-day extension letter that should have been sent earlier but was not.

During an interview on 05/29/25 at 3:38 PM, Staff C, Chief Executive Officer (CEO), stated, "When we receive an allegation of abuse, we follow policy. Any allegation of rape should be taken seriously and handled as a priority."

Based on policy review, record review, document review, and interview, the Hospital failed to provide a patient with a grievance of its written notification of decision, steps taken, and results of the grievance process as required for 1 (Patient 1) of 2 patients reviewed. This deficient practice has the potential to place patients or representatives at risk for unresolved grievances and complaints and systemic issues that could lead to harm and other adverse outcomes.

Findings Include:

Review of hospital policy titled, "117-ADM [Administration] Complaints and Grievances - RM [Risk Management] - [Above Named Hospital]," dated 03/28/18, showed, " ...Investigate and respond to patient and/or family/representative complaints and grievances, including but not limited to quality of care ...Patient Grievance - A grievance is defined as ANY of the following: ...A patient's rights complaint by a patient or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the CMS [Centers for Medicare and Medicaid Services] Hospital Conditions of Participation (CoP) ... Grievances about situations that endanger the patient such as abuse or neglect must be reviewed immediately ...The Patient Representative and/or designated person will send a letter of notification to the patient within 7 days of a received grievance ...The Facility Compliance Officer (FCO) will be responsible for addressing grievances involving potential corporate compliance violations or other regulatory violations ... All grievances will have a written response from the patient representative within thirty days of receipt of the grievance depending on the nature of the grievance. The final written response will include the following information: Name of hospital. Contact person. Steps taken on behalf of the patient to investigate the grievance ..."

Review of hospital policy titled, "200-ADM [Administration] Patient Rights and Responsibilities," dated 4/21/25, showed, " ...Patient Has The Right ...Patients are free from physical or mental abuse, neglect or harassment ... Patient Grievance Process: ... All formal written or verbal patient grievances will receive a written response from [Above Named Hospital] within 30 days of receipt of grievance ..."

Patient 1

Review of Patient 1's medical record showed a 71-year-old was seen in the emergency department on 03/23/25 at 8:32 AM and admitted with a diagnosis of fecal impaction (hardened stool that stuck in the rectum or lower colon due to constipation) and evidence of proctitis (an inflammation of the rectum's lining).

Review of hospital document titled "Event Log" dated 01/01/25 to 05/27/25, showed that Patient 1 filed a grievance with the hospital for alleged sexual abuse on 04/01/24. The document showed, " ...Report Date; 04/01/25 10:23 [10:23 AM]; Event Date 03/23/2025; [Patient 1] ...Category (s) associated with event or unsafe condition; Patient Security; Patient called grievance line yesterday (3/31/25). Pt [patient] states she was raped while in our ER [Emergency Room]. Pt [Patient] states she went to the ED [Emergency Department] on 3/23/25 to get an enema (a procedure that involves injecting fluid int the rectum to cleanse the colon or lower bowel) due to impaction ...she was raped (anal). Pt [Patient] stated that she screamed "stop" several times when the doctor began the exam, but he would not stop. States he pinned her down with his arm and continued to "jam his finger" into her anus (the opening of the rectum to the outside of the body) ..."

During an interview on 05/28/25 at 11:15 AM, Patient 1 stated that during an emergency room visit on 03/23/25 a doctor performed a painful rectal exam without clear consent, despite asking him to stop. Patient 1 stated the risk manager at the hospital was informed of the incident and was told the case would be resolved in 30 days. Patient 1 stated that no mail had been received from the hospital regarding the outcome as of date of interview.

During an interview on 05/29/25 at 10:58 AM Staff H, Risk Manager, stated that Patient 1's allegation of sexual assault was initially handled as an incident, and the patient was informed that a letter would be sent once the investigation was complete. Staff H stated that nearly 60 days passed without a formal letter being sent, including a 30-day extension letter that should have been sent earlier but was not.

Review of Patient 1's medical record or hospital documents failed to show that Patient 1 was provided with a written response from the patient representative within thirty days of receipt of the grievance with name of hospital, contact person and steps taken on behalf of the patient to investigate the grievance in accordance with hospital policy.