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Based on interviews with staff, record review (RR), and review of the hospital's policy and procedure, the facility failed to ensure a family member's (FM)1 verbal allegations of sexual abuse (SA) was addressed as a grievance for the purposes of these requirements. FM1's reported an allegation of sexual abuse to the Hospital Operation Nursing Supervisor (HONS) on 05/16/21. The Nurse Manager (NM)1, NM2, Chief Nursing Executive (CNE), Director of Nursing (DON), Assistance Director of Nursing (ADON), Social Work Services Manager (SWM), Patient Relation Coordinator (PR), Director of Risk Management (DRM), and Senior Director of Quality/Patient Safety/Performance Improvement (QPI) were all aware of FM1's reported allegation of SA on 05/17/21 which was subsequently investigated, but not listed on the grievance log. The facility's process failed to identify a verbal allegation of SA as a grievance. As a result of this deficiency, patient's rights are not promoted or protected.

Findings include:

P8 was admitted to the hospital on 05/12/21 and discharged on 05/15/21 with diagnoses including pancreatic cancer, generalized weakness, acute renal failure, moderate dehydration, hypokalemia, hypomagnesemia, and severe protein calorie malnutrition. The week prior to admission, P8 was started on chemotherapy treatment. As a result of the Chemotherapy treatment, P8's appetite had significantly decreased contributing to the patient's generalized weakness. P8 was incontinent of bowel and bladder requiring the use of a peri-wand, intermittent bladder scans, and intermittent catherization for urinary retention.

On 05/16/231 at 05:05 PM, FM1 and FM2 called the hospital and reported an allegation of SA to HONS. The family reported after P8 was discharged, P8 informed them that Registered Nurse (RN)5 digitally penetrated the patient during a procedure. At 06:04 PM, hospital staff (HS)1 entered a comment into "MHS Unusual Occurrence Report", confirming HONS had spoken to FM1 regarding the allegation. HONS then informed NM1, ADON, and the Chief Nursing Executive (CNE), via email at 06:23 PM of the allegation. NM1 conducted an investigation regarding the allegation on 05/17/21 to 5/18/21 and reported the findings to the Advisory Core Team on 05/19/21. The investigation concluded the allegation of SA was unsubstantiated. NM1 called P8's family members were notified the allegation was unsubstantiated on 5/18/21.

Review of the hospital's "Patient Complaints, Grievances, and Appeals" policy and procedure documented "4.4.4 All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are considered grievances." and "4.4.5 Complaints made by a patient or patient representative via telephone:...b. Alleging abuse or neglect" is considered a grievance. Additionally, under the provisions/procedure portion of the policy, all complaints submitted by a patient or patient representative regarding possible abuse or neglect will be referred to Quality Management and Risk Management to investigate, follow-up, and report the event in accordance with medical center licensing requirements."

On 06/08/21 at 12:40 PM, surveyors reviewed the hospital's grievance log which did not contain the allegation of SA reported by FM1 and FM2 to HONS on 05/16/21 at 05:05 PM. On 03/08/21 at 01:55 PM. t06/09/21 the DON and the Compliance Officer (CO) confirmed the grievance log received and reviewed by this surveyor was the most current to date and did contain all grievances reported from February 2021 to date.

On 06/08/21 at 12:55 PM, reviewed the Unusual Event Report (UER) which the DON stated was a record of events which are not grievances. The UER is used to document events which are not identified as or rise to the level of a grievance. Reviewed the UER for events reported on 05/16/21, which documented an event that correlated with P8's medical record number. The description of the event type was labelled "COMM-Other". Inquired with the DON and CO for a more detailed description of "COMM-Other". On 06/09/21 at 09:00 AM, received details of the event which documentation "5/16/21 6:04 PM .... I received a phone call this afternoon (5/16/21 @1705) from pt family claiming that their family member...was abused by a staff..".

On 06/09/21 at 09:30 AM, conducted an interview with FM2. FM2 stated on 05/14/21 at approximately 12:40 PM, P8 stated after P8 was discharged, P8 reported to FM2 he/she was in fear for his/her safety due to RN5 threatening him/her and had penetrated P8 with his/her fingers. FM2 stated P8 reported he/she refused when RN5 straight catharized him/her, but RN5 continued with the procedure and penetrated P8 with his/her fingers during the procedure. FM2 reported the allegation to FM1 who then called and reported it to the hospital. FM2 stated the family received a phone call from the hospital on 5/18/21 and was informed the allegation was not substantiated. FM2 expressed to the hospital staff that the family was not satisfied a thorough investigation was conducted and stated the family did report the allegation of SA to Adult Protective Services (APS) and local authorities.

On 06/09/21 at 10:21 AM, conducted a group interview which included the CO, DON, PR, and QPI. They confirmed the telephone call from FM1 and FM2 on 5/16/21 at 5:05 PM was received from P8's family members and the investigation report was generated though the risk management report. The CO, DON, PR, and QPI confirmed the allegation should have been reported on the grievance log but was not. Inquired who was responsible to update the grievance log. The QPI stated PR was responsible for adding the event to the grievance log, however, the PR confirmed maintaining and updating the grievance log was not PR's responsible for adding events to the grievance log, it was the responsibility of the DRM and QPI. According to the hospital's policy and procedure, Quality Management and Risk Management are responsible to investigate, follow-up, and report the event appropriately. QPI stated the DRM manages the database of investigations and letters for grievances.

Based on interviews with staff, record review (RR), and review of the hospital's policy and procedure, the hospital failed to ensure a written notice of its decision, in resolution of a grievance, was provided to the patient representative. The written notice of the decision must contain the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the result of the grievance process, and the date of completion, and a grievance is considered resolved when the patient representative is satisfied with the actions taken on their behalf for the purposes of these requirements. Patient (P)8's patient representative (FM)1 and FM2 reported an allegation of sexual abuse (SA) to the hospital via telephone on 05/16/21. On 05/18/21, FM1 and FM2 received a phone call from Nurse Manager (NM)1 informing them of the results of the investigation and did not provide a written notification of the results of the grievance. FM1 was not satisfied a thorough investigation was conducted and informed NM1 the family intended on seeking legal action, which the hospital did not identified as an appeal by FM1.

Findings include:

On 05/16/21 at 5:05 PM, P8's family members contacted the hospital, via telephone, and reported the allegation of (SA) to HONS. Review of the "MHS Unusual Occurrence Report" documented an entry by hospital staff (HS)1 confirming on 5/16/21 at 05:05 PM, a call was transferred to HONS and reported P8 alleges RN5 had sexually abused P8 on 5/13/21 (Thursday) night. At 06:23 PM, HONS notified, via email, Nurse Manager (NM)1, Director of Nursing (DON)2, and the Chief Nursing Executive (CNE) informing them FM1 and FM2 had reported P8 claimed RN5 had sexually assaulted the patient, by digitally penetrating the patient.

Review of the hospital's Patient Complaint, Grievances, and Appeals policy and procedure, Patient Relations Coordinator (PR) will coordinate a response. A written response should be sent out within seven business days, if the grievance cannot be resolved within 7 days, an anticipated timeline in which the patient or patient representative can expect a written response.

On 06/09/21 at 09:30 AM, conducted an interview with FM2. FM2 confirmed, both FM1 and FM2, has not received any written communication from the hospital regarding the reported allegation of SA to date (06/09/21). FM2 stated the only communication they have had with the hospital was over the telephone. FM2 stated the family does not feel a thorough investigation was completed and did report the allegation of SA to the Adult protective Services (APS).

On 06/09/21 at 10:21 AM, conducted a group interview with the Compliance Officer (CO), Director of Nursing (DON), Patient Relations Coordinator (PR), and Senior Director of Quality/Patient Safety/Performance Improvement (QPI). The QPI stated the Director of Risk Management (DRM) has a database which tracks investigations and letters to the patients and patient representatives. Inquired with PR, CO, PR, and the DON if a letter was sent to the family. Requested a copy of the letter sent to the family. The QPI later confirmed a letter was not sent out to the family.

Review of the Advisory Core Team (ACT) Meeting minutes documented FM1 and FM2 were notified of the investigation results via telephone by NM1.

Based on interviews with staff members and record review, the hospital failed to ensure the patient's right to be free from abuse. The hospital must protect patients from abuse during an investigation of any allegation of abuse, conduct a thorough investigation, and report the findings of an investigation in accordance with state and federal laws for the purposes of these requirements. On 05/16/21, Patient (P)8's patient representative (FM)1 and FM2 called and reported an allegation of sexual abuse (SA) to the Hospital Operations Nursing Supervisor (HONS). The family members alleged P8 informed them, Registered Nurse (RN)5 digitally penetrated the patient while performing a procedure. On 05/17/21 Registered Nurse (RN)5 worked, unencumbered and directly with multiple patients, despite an active investigation into the allegation of SA reported on 05/16/21. Review of the investigative process and investigation reports document a thorough investigation was not conducted prior to determining the results of the investigation. As a result of this deficiency, patients are at a potential increased risk of sexual abuse and psychosocial harm.

Findings include:

1. On 05/16/21 at 5:05 PM, FM1 and FM2 contacted the hospital, via telephone, and reported the allegation of (SA) to HONS. Review of the "MHS Unusual Occurrence Report" documented an entry by hospital staff (HS)1 confirming on 5/16/21 at 05:05 PM, a call was transferred to HONS and reported P8 alleges RN5 had sexually abused P8 on 5/13/21 (Thursday) night. At 06:23 PM, HONS notified, via email, Nurse Manager (NM)1, Director of Nursing (DON)2, and the Chief Nursing Executive (CNE) informing them FM1 and FM2 had reported P8 claimed RN5 had sexually assaulted the patient, by digitally penetrating the patient.

On 06/08/21 at 01:41 PM, conducted an interview with the Director of Human Resources (DHR) and Human Resources staff (HRS) regarding the allegation of SA. DHR reported he/she was not informed of the allegation of SA made by P8's family member on 05/16/21. Reviewed the MHS Unusual Occurrence Report with DHR. DHR confirmed RN5 should not have worked or had contact with patients while an active investigation into the allegations of SA was being conducted. DHR stated RN5 should have been placed on leave until the investigation was completed and the results of the investigation did not substantiate the allegations of SA.

On 06/09/21 at 02:40 PM, conducted a telephone interview with RN5 regarding the allegation of SA. RN5 stated he/she received a phone call on the morning of 05/18/21 (after working on 05/17/21 from 7:00 PM to 7:00 AM) from NM2 during which he/she was informed of the allegation of SA. RN5 recalled asking NM2 if he/she would be placed on leave until the conclusion of the investigation. RN5 was informed by NM2, he/she would not be placed on leave and was required to report to his/her next scheduled shift later that evening. RN5 recalled being upset, could not sleep and did not feel comfortable working until the investigation was completed. Subsequently, RN5 took sick leave and did not work as scheduled on 05/18/21. Review of RN5's schedule confirmed RN5 did work on 05/17/21 and did not work on 05/18/21.

On 06/09/21 at 04:15 PM, conducted a review of the Advisory Core Team (ACT) Meeting minutes (05/19/21 at 11:30 AM- 12:00 PM) which documented the discussion, results of the investigation, communication with P8's family members for the investigation and allegations of SA. The ACT meeting minutes documented NM1 was still investigating/gathering facts on 05/17/21-05/18/21 and had not yet received RN5's statement at the time of the meeting. This confirmed RN5 worked unencumbered and provide direct care to multiple patients while the investigation into allegations of SA of P8 was still being conducted.

2. P8 was admitted to the hospital on 05/12/21 and discharged on 05/15/21 with diagnoses including pancreatic cancer, generalized weakness, acute renal failure, moderate dehydration, hypokalemia, hypomagnesemia, and severe protein calorie malnutrition. The week prior to admission, P8 was started on chemotherapy treatment. As a result of the Chemotherapy treatment, P8's appetite had significantly decreased contributing to the patient's generalized weakness. P8 was incontinent of bowel and bladder requiring the use of a peri-wand, intermittent bladder scans, and intermittent catherization for urinary retention.

On 05/16/231 at 05:05 PM, FM1 and FM2 called the hospital and reported an allegation of SA to HONS. The family reported after P8 was discharged, P8 informed them that Registered Nurse (RN)5 digitally penetrated the patient during a procedure. At 06:04 PM, hospital staff (HS)1 entered a comment into "MHS Unusual Occurrence Report", confirming HONS had spoken to FM1 regarding the allegation. HONS then informed NM1, ADON, and the Chief Nursing Executive (CNE), via email at 06:23 PM of the allegation. NM1 conducted an investigation regarding the allegation on 05/17/21 to 5/18/21 and reported the findings to the Advisory Core Team on 05/19/21. The investigation concluded the allegation of SA was unsubstantiated. NM1 called P8's family members were notified the allegation was unsubstantiated on 5/18/21.

Review of the hospital's "Patient Complaints, Grievances, and Appeals" policy and procedure documented "4.4.4 All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are considered grievances." and "4.4.5 Complaints made by a patient or patient representative via telephone:...b. Alleging abuse or neglect" is considered a grievance. Additionally, under the provisions/procedure portion of the policy, all complaints submitted by a patient or patient representative regarding possible abuse or neglect will be referred to Quality Management and Risk Management to investigate, follow-up, and report the event in accordance with medical center licensing requirements."

On 06/09/21 at 10:21 AM, conducted a group interview which included the CO, DON, PR, and QPI. Inquire regarding the investigative process, report, and results of the allegation of SA reported on 05/16/21. The QPI stated the HONS reported the allegation appropriately and NM1 conducted investigation which included obtaining witness statements, following up with NM2, and reporting the findings to the Advisory Core Team (ACT). The QPI, NM1, Social Work Services (SWS), and DRM attended the ACT meeting on 05/19/21, NM1's verbally presented the evidence of the investigation. Staff in attendance of the ACT meeting concluded the allegation of SA was unsubstantiated. Inquired if the allegations were investigated by risk management or quality management and if human resources were made aware of the allegations. QPI confirmed NM1 conducted the investigation and HR was not a part of the ACT meeting on 05/19/21.

On 06/09/21 at 01:05 PM, conducted an interview with NM1 regarding the allegation. NM1 confirmed responsibility of conducting and collecting information for the investigation. NM1 stated the evidence was verbally reported at the ACTs Meeting and the allegation was unsubstantiated. NM1 stated RN5 was not alone in the room with P8 while performing a straight catherization procedure. NM1 reported RN9 and RN10 were in the room during the procedure.

On 06/09/21 at 4:00 PM, conducted a review of all witness statements provided. Review of all witness statements did not document evidence any hospital staff was present in P8's room for the entire time RN5 performed the straight catheter procedure on P8. Review of RN9's witness statement documented initially, RN9 was in the room and assisted RN5 with the procedure. However, after RN5 had successfully inserted the straight catheter, RN9 offered additional help, RN5 declined and RN9 left the room while RN5 finished catharizing P8. Review of RN10's statement documented RN10 was aware RN5 was going to straight catheter P8 and RN9 offered to assist RN5. RN10 attested only to seeing RN9 and RN5 enter P8's room with the straight catheter kit. In an interview with RN10 on 06/10/21 at 07:45 AM, RN10 confirmed he/she was not in the room for the procedure. RN9 was no longer employed by the hospital and was not available to be interviewed.

On 06/10/21 at 11:00 AM, conducted an interview with Social Work Services (SWS). Quired SWS regarding P8's allegation of SA, the decision-making process during the ACTs Meeting, and how the decision to substantiate or unsubstantiate was reached. SWS reported becoming aware of the allegation through an email, the Unusual Occurrence Report, and spoke to the DRM regarding any further actions needed. NM1 presented a verbal summary of the investigation and finding at the ACTS meeting. NM1stated RN5 was not alone in the room with P8 during the procedure. After hearing RN5 was not alone in the room with P8 during the procedure, there was no need to follow-up and further investigate the allegations. If there was a need to follow-up the DRM would further investigate. Inquired if the attendees of the ACTs Meeting were provided a copy of the witness statements to independently review. SWS confirmed copies of the witness statements were not provided, received, or independently reviewed prior to unsubstantiating P8's allegations. SWS went on to say FM1 was not happy with the outcome of the investigation and threatened to report the incident to Adult Protective Services (APS) but APS hasn't showed up. SWS also stated DRM would have followed up if there was a question with the information provided.

Review of the ACTs Meeting minutes documented NM1 conducted the investigation on 05/17/21 and 05/18/21. At the time of the ACTs Meeting, RN5 did not submit a statement. The investigation/facts documented Incontinence care; bladder scan x2, purewick placed in presence and with help of at least one other staff member. This contradicted RN9's witness statement which confirmed RN9 left P8's room prior to the completion of RN5 performing the straight catheter, and RN10's statement and interview attesting RN10 was not in P8's room for the procedure.

During an interview with RN5 on 06/09/21 at 02:40 PM, RN5 stated RN9 was in the room for the entire procedure. RN5 reported P8 did not refuse the straight catheter but did stated he/she felt uncomfortable with the procedure. However, P8 needed to be straight catheter the hospital protocol. RN5 confirmed a statement was not provided to the hospital until 5/21/21 via email, which was after the ACT meeting that concluded the allegation was unsubstantiated.

3. The State Agency, the Office of Health Care Assurance (OHCA) became aware of the allegation of SA through a report from APS reported by P8's family members.

On 06/10/21 at 11:45 AM, inquired with QPI if the hospital notified APS or the SA regarding P8's allegation of SA. The QPI stated the allegation of SA was not reported to OHCA because the allegation was not substantiated and only needs to be reported if an allegation is substantiated. However, in accordance with Title 11 Chapter 93 for Broad Service Hospitals, suspected incidences of abuse should be reported to the Department of Health and to appropriate government agencies.