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Based on observation, interview and record review, the hospital failed to have a system in place to protect and promote each patient's rights when:

1. Patient (Pt) 1's grievance alleging sexual misconduct by the physician who examined her in the Emergency Department was not prioritized and the grievance process did not include hospital staff contacting Patient 1 to include her side of the story. The hospital did not follow their own grievance policy and procedure in handling the allegations of sexual misconduct. Patient 1 was one of 30 patients sampled in the survey. (Refer to A-0123);

2. Six of 30 Pt's (Pt 1, 5, 6, 8, 29 and 30) were not provided basic patient rights such as chaperones during procedures, privacy curtains, or the protection of confidential health information while being treated in the Emergency Department of the hospital. (Refer to A-0143).

The cumulative effects of these systemic problems resulted in the inability of the facility to ensure the provision of quality health care and patient rights for Pts 1, 5, 6, 8, 29 and 30 .

Based on interview and record review the hospital failed to communicate, verbally and in writing, after Patient (Pt) 1 reported a sexual misconduct grievance against Doctor (Dr) 1 after being examined by Dr 1 in the hospital Emergency Department (ED) on 2/25/19. The hospital did not prioritize the grievance in accordance with their grievance policy and did not conduct an investigation that included interviewing Pt 1. The hospital did not communicate the steps the hospital took on behalf of Pt 1 to investigate the grievance.

This failure resulted in Pt 1 suffering anxiety, feelings of emotional distress, and the sense that her concerns were not worthy of the hospital's efforts to investigate and had the potential to have the same results for all patients filing a grievance at the facility

Findings:

During an interview on 6/17/19 at 8:20 a.m., Pt 1 stated she came to the ED by ambulance for abdominal pain on 2/24/19. Pt 1 stated on 2/25/19, Dr 1 informed her in order to determine what was wrong he needed to perform a rectal (area connecting anus to the end of the large intestine) exam to rule out a bowel obstruction. Pt 1 stated Dr 1 inserted two fingers into her vagina. Pt 1 stated she is a medical professional and was trained to do a rectal exam and only one finger is used. Pt 1 stated "I was on my side, watched him [Dr 1] lube [apply lubricant] two fingers ... he was in my vagina for quite a while. I thought this was weird ...rubbing around the front of my vagina." Pt 1 stated Dr 1 "... went in the wrong hole." Pt 1 stated she thought "... Did he slip? Was it an accident? Oh my God he was playing in there ..." Pt 1 stated she informed Dr 1 after he completed the exam, that he examined her vagina and not her rectum. Pt 1 stated Dr 1 then performed a rectal exam. Pt 1 stated Dr 1 examined her in the hallway of the ED. Pt 1 stated an overhead security camera was visible from her gurney. Pt 1 stated she was upset about "... cameras watching me get a vaginal (exam) ..." Pt 1 stated there was no hospital staff to witness the examination. Pt 1 stated she talked to her nurse and a nursing supervisor the morning of 2/26/19 and told them that Dr 1, "went into the wrong hole". Pt 1 stated a security guard from the hospital took her formal complaint on the evening of 2/26/19 regarding sexual misconduct by Dr 1. Pt 1 stated she contacted the hospital on 3/11/19 when she had not heard back from the hospital. Pt 1 stated she called to inquire about her grievance and received a return call the following day, 3/12/19, informing her that the grievance went to peer review and the hospital could not give her any more information. Pt 1 stated she felt like she never wanted to go to a hospital again. Pt 1 stated she felt "sexually abused, emotionally abused and physically abused". Pt 1 stated she "wanted it [the experience] to go away ...when my husband touches me I see him [Dr 1]." A request was made for the video Pt 1 mentioned; the hospital denied the video existed.

During an interview with Risk Manager (RM), on 6/17/19 at 1:40 p.m., she stated Pt 1 reported her complaint about sexual misconduct on 2/26/19. RM stated the hospital reported the allegations of sexual misconduct to the police department on 2/26/19. RM stated the hospital practice was to not conduct internal investigations once a report is made to the police. RM was unable to provide a hospital policy to support this practice. The police department was contacted and stated this case is still under investigation.

During an interview with the Department Chief (DC), on 6/17/19 at 4:00 p.m., the DC stated she had a conversation with Dr 1 regarding the exam of Pt 1. The DC stated her conclusion was it was an "oopsie" because he was doing a "blind entry". The DC stated at the time of the exam the lighting was poor and the blanket covering Pt 1 interfered with the visualization of the rectal exam. The DC stated she did not review the chart prior to making her determination that the vaginal exam was accidental. The DC stated she did not speak to Pt 1 prior to making her conclusion.

During an interview on 6/24/19 at 12:07 p.m., with the Manager of Risk Management (MORM), she stated for allegations of inappropriate touching we notify security, they notify the police department and the police department investigates. The MORM stated no one witnessed this event so it was not reportable. The MORM stated during peer review it was concluded that it was "a simple mistake." The MORM stated the clinical supervisor took the complaint from Pt 1 and no other interviews were conducted because they were waiting to hear back from the police.

During an interview with Clinical Supervisor (CS) 1 on 8/28/19 at 10:30 a.m., she stated she was requested to meet with Pt 1 when Pt 1 conveyed concerns about an "inappropriate rectal exam" to Pt 1's bedside nurse. CS 1 stated Pt 1 had "heightened emotions." CS 1 stated Pt 1 was tearful and very emotional. CS 1 stated she contacted security, filled out a hospital incident report and documented the encounter in Pt 1's clinical record.

During an interview with Pt 1 on 8/29/19 at 12:45 p.m., she stated "... he [Dr 1] went into my vagina, flicking around, front, back and swirls with his fingers." Pt 1 stated there was no chaperone present during the examination of her vagina or rectum. Pt 1 stated this exam occurred in the hallway of the ED. Pt 1 stated she felt vulnerable and waited to get home to call the hospital risk manager. Pt 1 stated she used the words "sexual battery" and "sexual abuse" when speaking to the hospital staff. Pt 1 stated the hospital never initiated communication with her after she filed her grievance on 2/26/19. Pt 1 stated she initiated a call to the hospital on 3/11/19 to get an update, 13 days after filing the grievance. Pt 1 stated she did not receive any written communication from the hospital. Pt 1 stated she felt "vulnerable ...I did everything in my power to stop him from touching another patient ...I shared it all, it wasn't right, I feel like he molested me". Pt 1 validated the hospital had her accurate home address.

During an interview with the MORM on 8/29/19 at 10:45 a.m., The MORM stated she was aware of Pt 1's grievance the day she filed it [2/26/19]. The MORM stated this grievance was assigned to the Risk Manager. The MORM validated that RM returned Pt 1's call on 3/12/19, 13 days after the initial grievance. The MORM stated a letter dated March 22, 2019 was sent to Pt 1's listed address from hospital records. Pt 1 denied receiving the letter and the hospital could not provide evidence that it was sent.

During an interview with the MORM and RM on 8/29/19 at 1:55 p.m., the MORM validated a letter was sent and the hospital's practice is that grievance follow up letters are not sent certified receipt. The MORM stated no one from risk management ever spoke to Pt 1 to get her side of the story. The MORM was unsure if the staff involved in the peer review spoke to Pt 1. The MORM stated in hindsight the hospital did not do their due diligence to investigate this grievance.

During an interview on 8/29/19 at 3:01 p.m., the Chief Medical Officer (CMO) stated he was made aware of Pt 1's allegation in February. The CMO stated, "We did not contact the patient afterward because we felt that we had enough information to make a determination based on the information that was obtained immediately after the incident. We took it through our process of peer review and it was presented to the risk management committee. We did not contact the patient after discharge to follow up on the complaint as the matter was turned over to the police department. We did not have feedback from the patient on her well-being after the event and post discharge. Peer review had recommendations for Physician 1 to examine patients in a private procedure room and to always use a chaperone during the examination."

During an interview with the CMO on 9/3/19 at 11:05 a.m., he stated after a discussion with the survey team he identified a missed opportunity for a clinical staff member to interview Pt 1. The CMO stated he conducted this interview himself on 8/30/19.

During a concurrent interview with the Director of Informatics (DI), and record review for Pt 1, on 9/3/19 at 2:10 p.m., the DI validated there was no documentation in Pt 1's clinical record about her concerns by RN 1, CS 1, and CM 2.

On 8/29/19, a review of a document titled, "[Hospital] Security Department" dated 2/26/19, indicated "...on 2/26/19 at approximately 1805 hours, I [security guard] was contacted by... Clinical Supervisor [CS 1] regarding a report of sexual misconduct against a patient by a hospital staff member." This document indicated a police report was made.

A review of the hospital policy and procedure titled "Patient and Patient's Family Complaint & Grievance," dated 1/16/17, indicated "... I. Purpose ... C. To establish a mechanism to receive, investigate, evaluate, and respond to written or verbal complaints or grievances concerning patient care or hospital practice ... III. Policy ... A. Additional issues that qualify as grievances include: 1. Complaints that involve allegations of abuse or neglect ... D. The Point of Service (POS) leadership or designee will contact the complainant within seven business days to acknowledge receipt of the complaint. A written response will be sent within thirty business days of the date [hospital] received the written or verbal grievance ... E. Grievance about situations that endanger the patient or have the potential to endanger the patient, such as neglect or abuse should be reviewed immediately given the seriousness of the allegation and the potential for harm to the patient(s). V. Procedure ... B. Grievances received will be responded to as follows: ... a. Investigation and resolution ... b. POS leadership or designee contact the patient or the patient's representative within seven business days to acknowledge the grievance and inform them that our written response shall be mailed within thirty business days ..."

Based on interview and record review the facility failed to obtain the Conditions of Admission (COA, form for consent for treatment in hospital) on admission for one of 30 sampled patients (Pt) 15.

This failure resulted in Pt 15 receiving care and treatment without consent.

Findings:

During a concurrent interview and record review on 8/29/19 at 9 a.m., Pt 15's "Patient Demographic" indicated Pt 15 was admitted on 7/31/19. Registered Nurse (RN) 4 validated that the COA was not completed and not in the medical record, 29 days after admission.

A review of the facility policy and procedure titled, "Consents" dated 6/21/17, indicated, "... All patients, or their legal representatives, must sign a Conditions of Admission form on admission to the hospital or as soon as possible thereafter. This is normally done during the admitting process ..."

Based on observation, interview and record review the facility failed to ensure privacy, respect and dignity was provided when;

1. One of 30 sampled Patient's (Pt) 1 did not have a chaperone during a rectal and vaginal exam;

2. Two of 30 sampled Pt's, Pt 29 and 30 stationed in hallway beds were not provided privacy screens and call bells;

3. One of 30 sampled Pt's (Pt 5) was not provided privacy screens and was not provided the protection of confidential health information, and;

4. Two of 30 sampled Pt's, Pts 7 and 8 stationed in hallway beds were not provided privacy screens during procedures.

These deficient practices of violating the right of privacy for Pts 1,5,6,8,29, and 30 had the potential to cause unnecessary exposure of body parts, potential for embarrassment, and private information to be exposed to staff, visitors, and other patients.

Findings:

1. During an interview with Pt 1, on 6/17/19 at 8:20 a.m., Pt 1 stated Doctor (Dr.) 1 performed a rectal exam by inserting two fingers into her vagina. Pt 1 stated Dr. 1 "... went in the wrong hole." Pt 1 stated she had to inform Dr. 1 that his fingers were in her vagina. Pt 1 stated Dr. 1 then performed a rectal exam. Pt 1 stated these examinations occurred in the hallway of the Emergency Department (ED). Pt 1 stated an overhead security camera was visible from her gurney and expressed concern the procedure was recorded. Pt 1 stated there was no chaperone to witness the examination.

During an interview with Registered Nurse (RN) 1 on 6/17/19 at 3:30 p.m., RN 1 stated she was the nurse for Pt 1. RN 1 stated when a patient in a hallway bed requires a vaginal or rectal exam, the patient is moved to a procedure room to protect her privacy. RN 1 stated moving patients to a procedure room for privacy "... happens all the time" RN 1 stated the chaperone policy requires a staff to be a chaparone during sensitive exams. Chaperone policy was requested and not received.

During an interview with RN 2 on 6/17/19 at 3:35 p.m., RN 2 stated for sensitive examinations and procedures the expectation is for staff to take the patient into a private room and have a chaperone present. RN 2 stated he is not aware of sensitive exams taking place in a hallway bed. RN 2 stated per the chaparone policy, a second staff person present when performing rectal and vaginal exams. Chaparone policy was requested and not received.

During an interview with RN 3 on 6/17/19 at 3:45 p.m., RN 3 described the process for a rectal exam. RN 3 stated the first step is to provide privacy with a chaperone present. RN 3 stated the chaperone policy indicates the chaparone should be hospital employee. Chaparone policy was requested and not received.

During an interview with Dr. 2 on 6/17/19 at 4 p.m., Dr. 2 stated we never do rectal exams in the hallway, even if we used privacy screens. Dr. 2 stated a rectal exam would never be performed with a security camera overhead. Dr. 2 validated a chaperone would be used for vaginal and rectal exams.

During an interview with Risk Manager (RM) 1 and RM 2 on 6/24/19 at 12:15 p.m., a chaperone policy was requested and not received.

During an interview with the Clinical Manager (CM) 2 on 8/28/19 at 10:55 a.m., CM 2 stated he believed hospital policy required a female present for sensitive exams. Chaperone policy was requested and not received.

During an interview with the Director of Security (DOS) on 8/28/19 at 2:15 p.m., the DOS stated the ED had ceiling mounted hallway cameras. The DOS validated one of the cameras in the ED could see past privacy screens.

2. During an observation on 8/28/19 at 10:45 a.m., in the ED Pod A, Pts 29 and 30 didn't have privacy screens or call bells available for use. Pts 29 and 30 were both given hallway beds due to high occupancy of the ED.

During an interview with RN 5, on 8/28/19 at 10:50 a.m., RN 5 stated privacy screens are to be provided to all patients in the hallway beds and every patient should have a call bell.

During an interview with Pt 29, on 8/28/19, at 10:55 a.m., Pt 29 stated he had been admitted to the hospital and had been waiting in the ED hallway for a room to become available for two days. Pt 29 stated privacy screens had not been offered. Pt 29 stated, "It would be nice to have a privacy screen."

During an interview with Pt 30, on 8/28/19, at 11:05 a.m., Pt 30 stated he had been in a hallway bed for one day and had not been offered privacy screens during procedures or call bells to inform staff when he was in need of assistance.

3. During a concurrent tour of the ED and interview with the Director of Nursing Administration (DNA) on 8/29/19 at 8:36 a.m., every room in the ED was occupied by a patient. The ED was divided into three "pods": Pod A, Pod B, and Pod C. The hallways in all three pods were lined with gurneys occupied by patients.

During an interview on 8/29/19 at 9:10 a.m., Pt 5 stated he arrived to the ED on 8/26/19 at approximately 1 p.m. Pt 5 stated he was sent for Computerized Tomography (CT scan, a way to create pictures of the inside of the body using medical imaging technology) at approximately 4:30 p.m. Pt 5 stated when he returned to the ED after the CT scan at approximately 5 p.m., he was placed in a chair in a "side hallway" (small hallway at the end of the nurses' station) and remained in that chair until 8/27/19 at 4:30 a.m. Pt 5 stated there were patients on either side of him while he was in the chair in the "side hallway" and he could hear their personal and medical information being discussed. Pt 5 also stated other patients could hear his information being discussed and he was not provided with privacy when they started his intravenous line (IV-directly into the vein). Pt 5 stated when he was moved from the chair, he was placed on a gurney in the hallway (in Pod A). Pt 5 stated once on the gurney, no privacy screens were provided.

4. During an observation on 9/3/19 at 11:44 a.m., in the triage area, the Phlebotomist (PH) 1 was drawing blood from Pt 8 with no privacy screens in place. The procedure was visible to other staff, patients and visitors in the hallway.

During a concurrent observation and interview on 9/3/19 at 11:54 a.m., in the ED, Pt 7 was stationed in hallway A bed (A-HA) 6 and RN 3 was performing the procedure of inserting an IV. RN 3 did not use the privacy screen while performing the IV insertion. Privacy screens were available for use on the head of the bed and the foot of the bed of Pt 7. The procedure was visible to other staff, patients and visitors. The CM 1 stated the privacy screens should be used and quickly pulled the privacy screens around Pt 7 and RN 3. CM 1 stated her expectation of RN 3 was to use the privacy screens when starting an IV.

During an interview on 9/3/19 at 12:16 p.m., PH 1 stated she did not provide Pt 8 with privacy screens during the lab draw. PH 1 stated the importance of privacy screens is to protect the patient's private information.

A review of the hospital policy and procedure titled, "Patient rights and responsibilities" dated 5/18, indicated "... To receive full consideration of privacy concerning their medical care. Case discussion, consultation, examination and treatment are confidential and should be conducted discreetly."

A review of the hospital policy and procedure titled, "Full Capacity/Full Capability Protocol for Acute Care Units..." dated 6/18, indicated "... Purpose: To provide safe and appropriate patient care during events where patient admissions exceed available inpatient bed capacity of [hospital name]. To facilitate efficient admission, bed assignment, and discharge of patients during inpatient surge events ...j. Provide bells for overflow beds/chairs and privacy screens as needed ..."

A review of the hospital document titled, "Your Patient Guide" dated 3/18, indicated " ...Adult Patient Right: You have the right to ... 11. Have personal privacy respected. Case discussion, consultation, examination and treatment are confidential and should be conducted discreetly. You have the right to be told the reason for the presence of any individual. You have the right to have visitors leave prior to an examination and when treatment issues are being discussed. Privacy screens should be used in semiprivate rooms ..."