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Based on interview and document review, the facility failed to develop and implement a policy that protected patients from an alleged abuser while an investigation was in progress, resulting in the potential for unsatisfactory outcomes for any of the 108 patients residing in the facility. Findings include:

See specific tag A-0145.

Based on interview and document review, the facility failed to develop and implement a policy that protected patients from an alleged abuser while an investigation was in progress, resulting in the potential for unsatisfactory outcomes for any of the 108 patients residing in the facility. Findings include:

On 08/16/21 at approximately 1210, review of investigation documentation revealed a recipient rights complaint form dated 07/26/21 that indicated, on 07/25/21 Patient (Pt) #7 reported being raped by Resident Care Aide (RCA) D while RCA D was inside Pt #7's bedroom during a specific time frame.

On 08/16/21 at approximately 1020 during an interview, Assistant Director of Nursing (ADON) E indicated an investigation was still in progress regarding an allegation of sexual abuse reported by Pt #7 toward Resident Care Aide (RCA) D. ADON E said RCA D was alleged to have sexually abused Pt #7 during specific dates and times inside Pt #7's room. ADON E said RCA D remained working at the facility during the investigation, however he was reassigned to a different work area away from Pt #7 as their policy was not automatic suspension. ADON E said nursing management usually made the immediate decision to reassign staff once the abuse allegation was known. ADON E said the facility had no clear policy to address the protection of patients from alleged abusers however, the general practice was to reassign the alleged staff to a different work area away from the accuser. ADON E indicated the immediate suspension of staff accused of abuse was uncommon.

On 08/16/21 at approximately 1030 during an interview, Director A indicated the facility usually reassigned staff accused of abuse to work within other areas of the facility away from the patient involved. Director A indicated abuse investigations were a collaborative process usually involving multiple departments including nursing, recipient rights, human resources, and bargaining units.

On 08/16/21 at approximately 1035 during an interview, Assistant Director of Nursing (ADON) C said the sexual abuse investigation involving Pt #7 and RCA D was "still open" and RCA D remained working at the facility although he was assigned to work on other units away from Pt #7. ADON C indicated the green colored checklist in the investigation files was a tool used to organize the investigation process to ensure proper notification and other processes were followed.

On 08/16/21 at approximately 1210, review of investigation documentation revealed a folder containing a green colored checklist form titled, "Investigation Process" that indicated RCA D was reassigned. Note the words "Staff Reassigned" were pre-printed on the sticker with a blank line allowing the name of the reassigned staff to be filled in. Also note, this green checklist did not contain any other option for staff disposition during the investigation other than "Staff Reassigned".

On 08/16/21 at approximately 1425 during a phone interview, Behavioral Analyst H indicated Pt #7's legal guardian requested that Pt #7 not be interviewed by surveyors regarding the ongoing abuse investigation. Based on this request from the legal guardian, the surveyor did not interview Pt #7.

On 08/17/21 at approximately 1030, review of Pt #7's medical record revealed Pt #7 was a 37 year-old female with a long history of institutionalization since adolescence with brief breaks living at group homes and with her parents. The record indicated Pt #7 had an history of being abused and traumatized by her biological father. Pt #7 had received services within the facilities ABT (applied behavioral treatment) unit that specializes in treating intellectual, developmentally disabled, and autism spectrum patients. The most recent psychiatric evaluation dated 09/17/20 indicated diagnostic formulation and differential diagnoses including Post-Traumatic Stress Disorder, Obsessive-Compulsive Disorder, Mild Intellectual Disability, as well as rule out Autism Spectrum Disorder, rule out Major depressive Disorder, and rule out Borderline Personality Disorder.

On 08/16/21 at 1505 during an interview, the Attending Psychiatrist P revealed that he was made aware of patient #7's sexual abuse allegation however he was unsure if the abuse actually occurred or not. When queried of patient #7's mental status he stated, Pt #7 was "not well psychologically".

On 08/17/21 at approximately 1145, a review of facility policies and procedures pertaining to abuse and neglect was completed. Policies and procedures reviewed including those titled, "Definitions And Reporting Of Abuse And Neglect" approved 04/15/21, "Patient Grievances" implemented 08/02/19, "Incident Reporting" implemented June 2021, as well as administrative policies and procedures titled "Complaint Investigation, Reports And Remediation" dated 03/01/16, and "Department Of Health And Human Services Work Rules" effective 02/01/16. The policy titled, "Definitions And Reporting Of Abuse And Neglect" approved 04/15/21 indicated under "Standards" section 2, "b. Safeguard patients from abuse and/or neglect and act to obtain treatment for observed injuries and prevent additional harm.". These policies and procedures as written and implemented did not protect the patient or other patients from abuse when an alleged perpetrator was allowed to continue to work in the hospital, having access to other patients, while the full investigation was not complete.