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Based on record review (medical record, hospital policy for Complaints/Grievances Resolution) the hospital failed to ensure systems were in place to ensure patient's written or verbal complaints of verbal/sexual abuse were identified as grievances and reviewed immediately upon receipt by the Patient Advocate, Director of Nursing or Nursing Supervisor for 3 of 3 Patients with allegations of abuse out of a total sample of 7 patients and one random patient. (Patient #2, Patient #5 and Patient #R1)
Findings:

Patient #2
The Medical Record for Patient #2 was reviewed. Review of the History and Physical Examination dated 10/27/09 revealed in part, "This is a 41-year old white female admitted for intravenous heroin dependency."

Documentation on the complaint resolution form, with a current date of 12/08/09, revealed in part, "Individual's Name: (Patient #2) Met with pt on B3, Nurse (Name of staff) asked pt if she had asked to see pt advocate. "No I've told all these people everything." Pt did ask this pt advocate how to file complaint with Name of Parish Sheriff's Office) Also asked this PA (Patient Advocate) if she had to meet with them, would I be present. Pt. Advocate returned later that afternoon to hand deliver # to patient." Further review of the Complaint Resolution Form, not completed and not signed, dated 12/05, revealed, "S6, Patient Advocate/Grievance Officer, met with Nsg. Supr. Re. incident on B5 with male staff member-alleges inappr sexual contact-gave supr her Journal notes. 12/7 10am-RM met with pt with (S18) RN present-pt stated she gave supr her journal-very confused re. how, when, if , what contact occurred-said didn't want to speak further & would contact RM if she wanted later-also given info re; Pt Advocate #, etc." Patient #2's Journal Notes alleging sexual abuse, dated 12/06/09, were attached to the complaint resolution form. Further review of the Complaint Resolution Form revealed no documented evidence the complaint was reviewed by Risk Management, the CEO or Administrative Representative. There was no documented evidence the complaint of alleged patient harm was handled as a grievance.

Review of the policy entitled Complaints/Grievances Resolution presented as the hospital's current policy revealed in part, "Complaint/Grievances that endanger the patient, such as neglect or abuse, will be reviewed immediately upon receipt by the Patient Advocate, Director of Nursing or Nursing Supervisor. On "off shifts" or weekends, the Nursing Supervisor will communicate with the Administrator On Call and the Chief Executive Officer to resolve any immediate potential for harm. Further investigations will occur after the immediate resolution to identify, investigate and resolve any deeper systemic problems. Please note that the contact numbers and addresses of the Louisiana Mental Health Advocacy, the Department of Health and Hospitals and the Joint Commission on Accreditation of Hospital are posted on all the units.

S3, PC was interviewed face to face on 01/05/10 at 2:15pm. S3 indicated she had been employed for 2 ? years and rotated shifts on DDU (Dual Diagnosis Unit), Detox, Building 5. S3 indicated she had cared for Patient #2 on the DDU and the Trauma Unit (Building 3) after she was transferred. Further S3 indicated Patient #2 had reported to her, when she worked on the Trauma unit, about S17, coming into her room and having an alleged sexual encounter while she was a Patient on the DDU about a month prior to her reporting. Further S3, indicated she told Patient #2 she would have to notify someone about the alleged event and she called the weekend House Supervisor, S10, and S7, HR Director on 12/05/09 to inform them of the alleged sexual abuse.

S10, RN weekend House Supervisor was interviewed per telephone on 01/06/10 at 10:30am. S10 indicated she worked 7p to 7a on 12/05/09 and was called by S3, PC regarding Patient #2's allegations of sexual abuse and she had gone over to Building 3 (Trauma Unit) to speak with her. Further Patient #2 did not want to talk about it because she was writing the events in a journal and just said she remembered she had been sexually assaulted while a patient in DDU. Further S10 took the journal notes to S22, DON's office and placed the notes under her door. Further there was no documented evidence the CEO, or attending physician was notified immediately of the alleged abuse. Further she indicated she assured Patient #2 the Administrator would follow up on her complaint of abuse.

S4, RN Manager DDU was interviewed per telephone on 01/22/10 at 3:20pm. S4 indicated complaints had to be handled within 24 hours and she did not know complaints of abuse were grievances.

Patient #5
The Medical Record for Patient #5 was reviewed. Review of the Psychiatric Discharge Summary dated 01/05/10 revealed, "Admitting Diagnosis Polysubstance Dependence, Substance Induced Mood Disorder. Patient's date of admission was 10/28/09 with a discharge date of 11/12/09. Review of the Physician Problem Oriented Progress Note dated 11/03/09 revealed in part, "Tearful-drooling-slurred speech states staff locked her in laundry room."

The hospital investigative report dated 11/09/09 was reviewed. Documentation revealed in part, "On 11/09/09 it was reported to HR that a patient in the DDU report improper behavior between (name of Staff S17) and herself via a note. Further documentation revealed, "On 11/04/09 S2, PC reported that (Patient #5) said that (S17) had locked her in the laundry room.

The hospital could not present documented evidence S23, PC had reported the allegation of sexual abuse immediately to the Nurse Manager and completed an Health Care Peer Review (HPR) document as per hospital policy on 11/02/09. There was no documented evidence the Nurse Manager immediately investigated Patients #5's complaint, 11/04/09 that (S17) had locked her in the laundry room. There was no documented evidence the complaint of alleged patient harm was handled as a grievance

S3, PC was interviewed face to face on 01/05/10 at 2:15pm. S3 indicated Patient #2 had come to her and stated Patient #5 had told her she had been locked in the laundry room by S17. Further S3 stated it was reported to S4, Nurse Manager.

S16, RN Weekend Supervisor was interviewed per telephone on 01/06/10 at 2:10pm. S16 indicated she worked 3p to 11pm on weekends. Further she indicated S3, PC had reported to her on 11/08/09 Patient #5's allegations of sexual abuse and she had talked to the patient. Further she had reported the incident to S22, DON.

S4, RN Unit Manager DDU was interviewed face to face on 01/05/10 at 2:40pm. She indicated it was reported to her by S3, PC S17 had locked Patient #5 in the laundry room but it didn't seem logical because the laundry door doesn't lock from the inside. Further there was suspicion Patient #5 had drugs on the unit and was offering money for sexual favors. Further the Patient's report of staff abuse was not documented or investigated at this time.

Patient #R1
The hospital investigative report dated 11/09/09 was reviewed. Documentation revealed in part, (Name of S3, PC) "Interview with HR on 11/09/09. The following is S3's recollection of the dates she worked during the time in question. 11/05/09-S3 approached S17 and asked if he knew of the allegations. He acknowledge that on Tuesday (Name of PC) had approached him about getting too friendly with patients and saying inappropriate statements. S17 also stated to S3 that he was waiting for (Name of S4 Nurse Manager) to approach him with the allegations because, the last time he had something similar happen, (Name of S4 Nurse Manager) instructed him that he had handled incorrectly (Name of Patient R1 incident). 11/08/09 S3 witnessed S17 making sexual implicit comments around staff. He has also made comments about other staff member in sexual manner."

S3, PC was interviewed per telephone on 01/21/10 at 10:20am. S3 indicated she had heard from other staff S17, PC had walked into the room on R1 while she was changing her clothes. Further she was told S17 had made an obscene gesture to R1 and said, "Don't worry I don't fool with trash." S3 indicated she had not reported what she had heard to the Nurse Manager and she not aware if the incident was reported and investigated. The CEO, Patient Advocate, Risk Management and Human Resource Director indicated, during this telephone conference, they were not aware of this incident S3 had just stated.

S4 Nurse Manager DDU was interviewed face to face on 01/22/10 at 10am. S4 indicated R1 had reported to her staff S17, PC had come into her room while she was taking a shower. R1 indicated the staff was S17, PC. S4 indicated she told S17 what the patient had said and S17 was upset. Further S17 left to go talk to Patient R1. She later learned S17 had told the patient while pointing to his wedding ring, "I look at my wife, I don't look at trash." Further she had not reported the incident to the CEO. Further the incident was not documented. There was no documented evidence the complaint was reviewed by Risk Management, the CEO or Administrative Representative. There was no documented evidence the complaint of alleged patient harm was handled as a grievance.

Review of the policy entitled Complaints/Grievances Resolution presented as the hospital's current policy revealed in part, "Complaint/Grievances that endanger the patient, such as neglect or abuse, will be reviewed immediately upon receipt by the Patient Advocate, Director of Nursing or Nursing Supervisor. On "off shifts" or weekends, the Nursing Supervisor will communicate with the Administrator On Call and the Chief Executive Officer to resolve any immediate potential for harm. Further investigations will occur after the immediate resolution to identify, investigate and resolve any deeper systemic problems. Please note that the contact numbers and addresses of the Louisiana Mental Health Advocacy, the Department of Health and Hospitals and the Joint Commission on Accreditation of Hospital are posted on all the units.
A patient complaint is an issue that can be resolved promptly, on the spot, by staff present.
A patient grievance is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient representative, when a patient issue cannot be resolved promptly by staff present, If a complaint cannot be resolved promptly by staff present or is referred to the patient advocate or hospital management, it is to considered a grievance." 7. If a prompt resolution is not possible, a written response will be forwarded to the person filing the grievance within seven days of receipt stating that issue is being investigated. A second /final response will be sent when the investigation is completed, indicating the Hospital's decision, the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion. This notice will be sent after the investigation is completed; i.e., within fourteen working days."

Based on record review (medical record, hospital policy and LA R.S.-Public Health and Safety) the hospital failed to ensure systems were in place to ensure patient's written or verbal complaints/grievances of abuse were investigated timely and thoroughly and reported timely to the Department of Health and Hospital, local law enforcement agency, CEO, attending physician, and medical director for 3 of 3 Patients with allegations of abuse out of a total sample of 7 patients and one random patient. (Patient #2, Patient #5 and Patient #R1) Findings:

Patient #2
The Medical Record for Patient #2 was reviewed. Review of the History and Physical Examination dated 10/27/09 revealed in part, "This is a 41-year old white female admitted for intravenous heroin dependency."
Review of the Psychiatric Discharge Summary revealed Patient #2 was admitted on 10/26/09 to the DDU and detoxed from opiates. The patient was transferred to the Trauma Unit on 11/24/09, 29 days after admit to the DDU (Dual Diagnosis Unit) for work with past sexual abuse at age 2O. Further review revealed in part, "Final Diagnosis: Posttraumatic stress disorder; Depression, Polysubstance Abuse."
Review of the Multidisciplinary Assessment dated 10/26/09 revealed in part, "Pt admitted in pt seeking safe detox from heroin and crack cocaine."
Documentation on 12/07/09, no time indicated, in the counseling progress notes revealed in part, "Pt. appeared in depressed and tearful mood. Pt stated she was struggling with feeling of guilt, shame and anger related to sexual abuse that patient stated occurred while she was on Bldg 5."
Documentation on the Psychiatric Progress Note dated 12/07/09 1445 (3:45pm) revealed in part, "Pt requesting sexually transmitted disease test due to reported sexual assault while hospitalized on DDU. Labs ordered. "Documentation on the Psychiatric Progress Note dated 12/09/09 1:15pm revealed in part, "I'm sorry I said anything." Pt alleged she was raped while on Building 5. Pt. admits to being under the influence while having a sexual encounter on Bld 5 Administrator and police notified."

Review of the Multidisciplinary Assessment Notes dated 12/08/09 revealed in part, "Pt. met with police and is accompanied by staff for support."

Documentation on the complaint resolution form, with a current date of 12/08/09, revealed in part, "Individual's Name: (Patient #2) Met with pt on B3, Nurse (Name of staff) asked pt if she had asked to see pt advocate. "No I've told all these people everything." Pt did ask this pt advocate how to file complaint with Name of Parish Sheriff's Office) Also asked this PA (Patient Advocate) if she had to meet with them, would I be present. Pt. Advocate returned later that afternoon to hand deliver # to patient." Further review of the Complaint Resolution Form, not completed and not signed, dated 12/05, revealed, "S6, Patient Advocate/Grievance Officer, met with Nsg. Supr. Re. incident on B5 with male staff member-alleges inappr sexual contact-gave supr her Journal notes. 12/7 10am-RM met with pt with (S18) RN present-pt stated she gave supr her journal-very confused re. how, when, if , what contact occurred-said didn't want to speak further & would contact RM if she wanted later-also given info re; Pt Advocate #, etc." Patient #2's Journal Notes alleging sexual abuse, dated 12/06/09, were attached to the complaint resolution form.

Review of the typed Investigative Notes, not signed or dated, presented to the surveyor by S2, Risk Management/Staff Development revealed, "12/08/09 RM (Risk Management, S2) met with patient with S18, at pt's request-patient stated that she gave Nsg. Supervisor (S10) her journaling and did not really want to discuss further-did say she remembered being in tub with hands on her, then blankets being brought to her room, and then showering with discharge present-then went back to saying that she did not want to talk further, but did give additional page of journaling to be added to her complaint-pt asked if police would be called-RM volunteered to call police with pt-asked if she had to be a part of report-told yes in that RM had second hand info and police would want first hand info-said she would think about-given RM and Pt. Advocate numbers for follow-up as she wished-said she would talk with B3/Trauma staff and therapist-no further contact from this pt to RM-reported this info to CEO, HR, DON and Patient Advocate-
RM also requested that pt's therapist notify the above if any info became clearer to patient.
12/8 and 12/9-RM spoke with B5/DDU staff re: allegations of sexual activity involving this pt and male staff member-no staff witnessed any inappropriate contact-they noted (name of Patient #2) had been verbal in telling staff things going on in unit and were shocked that if something happened to that she would not have reported it-especially that she didn't report for approx 5 weeks-staff also noted in the way the unit is situated and staff locations, it would be hard to not notice a staff member missing from his station unless other staff notified , i.e. break, to Cafe', etc-staff members involved in discussion S4, Nurse Manager DDU, S3, (Psychiatric Counselor) PC, S12, PC, S19, PC-they will discuss with other staff in assuring pt's being monitored correctly and notify NM, NSG Supr, DON, RM, Pt. Advocate, HR and/or CEO be notified when allegations arise to follow-up ASAP-also reminded to assure that MD notified when allegations arise to follow-p ASAP-all reminded to assure that MD notified and part of investigation."
Further review of the Complaint Resolution Form revealed no documented evidence the complaint was reviewed by Risk Management, the CEO or Administrative Representative. e. There was no documented evidence the alleged sexual abuse was reported within 24 hours to the Department of Health and Hospitals or New Orleans Police Department. (Reference LA R.S.-Public Health and Safety (3) " Department" shall mean the Department of Health and Hospitals.?2009.20. B. Duty to make complaints; penalty; immunity). (1) "Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, licensed practical nurse, nurse's aide, home- and community-based service provider employee or worker, personal care attendant, respite worker, physician's assistant, physical therapist, or any other direct caregiver having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report. For the purposes of this Paragraph, the chief law enforcement agency of Orleans Parish shall be the New Orleans Police Department."

There was no documented evidence S10, had reported the allegation of sexual abuse immediately to the CEO, DON, attending physician, and medical director on 12/05/09 and completed an Health Care Peer Review (HPR) document as per hospital policy.. There was no documented evidence the hospital notified the Department of Health and Hospitals or the chief law enforcement agency of the parish in which the incident occurred prior to the end of the business day subsequent to the day on which the hospital received the report.

The Personnel Record for S17, PC and the alleged perpetrator, was reviewed. Documentation revealed S17 was hired on 12/02/08. Criminal back ground checks dated 11/18/08 revealed no documented evidence of past sex offender charges or other evidence of past criminal history.
References obtained from two previous employers revealed in part, "hard worker, conscientious, outstanding, honest, and trustworthy. "There was documented evidence S17 resigned from the previous employers voluntarily and was not dismissed for misconduct. Further review of the personnel record revealed S17 attended an annual update in service training, regarding "Sexual Harassment/Injuries, Standards of Conduct/ Abuse and Neglect/Duty to Warn."

Review of the Personnel Activity Request signed on 11/16/09 by S7, Human Resource Director and S1, CEO revealed S17 was terminated for failure to follow standard practice and patient safety violation.

Policy reviews:
Review of the policy entitled "Abuse and Neglect" presented as the hospital's current policy revealed in part, "A. Abuse: Any sexual, physical, verbal or socializing action that is detrimental to the treatment or well being of the patient. Policy: Allegation of Staff Abuse of a Patient:
A. Any suspected or witnessed incidents of either abuse or neglect shall be reported immediately to the staff member's immediate supervisor, or, in his her absence, to the Hospital supervisor, and the Risk Manager, an HPR (Health Care Peer Report) shall be completed.
B. All allegations shall be immediately investigated. The investigation shall be conducted in a fair and impartial manner.
C. All allegations of patient abuse or neglect shall be taken seriously. Risk Management shall conduct a thorough and complete written investigation in collaboration with the appropriated Department Head supervisor. The Director of Human Resources must also be notified.

Investigation: The investigation should include, but not limited o the following.
A. Review of the patient's clinical record and the personnel records of the employee: Prior complaints or counseling shall be considered.
B. Interview with person(s)/patient(s) making allegation
C. Interview and written statement with employee who is accused of abuse or neglect..
D. Interview and/or written statements from other staff that were on duty at the time of the alleged incident(s)
E. The investigation may also include interviews with current or former patients to determine whether there are corroborating evidence or other possible transgressions.
The hospital investigation shall occur as quickly as possible, preferably within 3-5 working days. A decision may be delayed pending the results of external agency investigation. The employee may not be permitted to return to patient contact until after a CEO level decision is made.
The decision whether to terminate an employee is an administrative and not a criminal judgment and is based on the preponderance of evidence. When the evidence is unclear and it is one word against the other, it may be necessary to decide that the employee should not continue to work in any patient area or at the hospital..The hospital shall err on the side of patient safety."

Review of the policy entitled "Mandatory Reporting" presented as the hospital's current policy revealed in part, "To ensure compliance with State of Louisiana statutes regarding mandatory reporting requirements of the following:
? Carnal knowledge of a juvenile
? Indecent behavior with juveniles
? Pornography involving juveniles
? Molestation of a juvenile
? Abuse
? Neglect

The following is the hospital procedure for addressing the prescribed law.
Procedure:
1. Any medical staff member, employee or hospital staff practicing (working) in the hospital upon learning of or directly witnessing an incident suspected to be subject to the mandatory reporting requirements as described and attached, shall immediately report same to the attending physician, administrator and medical director. The staff member or other licensed professional who received the information will notify the appropriate agency or law enforcement division.

Review of the policy entitled "Guidelines for Potential Violations of Professional Conduct" presented as the hospital's current policy revealed in part, "Guidelines for Potential violations:
* Patient neglect or abuse-Any violation of the nature will result in waiver of all warnings and disciplinary systems and result in immediate termination of the employee responsible for such actions. *Failure to follow hospital policies or procedures as presented in the manuals. *Staff members are not to be in patient's rooms with the door closed for the protection of staff and patient."

Staff Interviews:
S20, Lieutenant Commander of Personal Violence Unit Jefferson Parish Sheriff Office was interviewed per telephone on 01/04/10 at 3pm. S20 indicated the department had received a complaint of 2 alleged sexual abuse cases at River Oaks Hospital. The case was assigned to S21, Detective and the case was being investigated. Further he indicated the hospital had not reported the alleged abuse but the patient and/or patient husband had reported the abuse.

S3, PC was interviewed face to face on 01/05/10 at 2:15pm. S3 indicated she had been employed for 2 ? years and rotated shifts on DDU (Dual Diagnosis Unit), Detox, Building 5. S3 indicated she had cared for Patient #2 on the DDU and the Trauma Unit (Building 3) after she was transferred. Further S3 indicated Patient #2 had reported to her, when she worked on the Trauma unit, about S17, coming into her room and having an alleged sexual encounter while she was a Patient on the CCU about a month prior to her reporting. Further S3, indicated she told Patient #2 she would have to notify someone about the alleged event and she called the weekend House Supervisor, S10, and S7, HR Director on 12/05/09 to inform them of the alleged sexual abuse.

S4, RN Nurse Manager DDU was interviewed face to face on 01/05/10 at 2:40pm. She indicated she was employed 5 years and was the Nurse Manager for 2 years. S4 indicated Patient #2 had not reported any abuse allegations while she was a patient on DDU from 10/26/09 through 11/24/09. Further, Patient #2 had not reported the allegation of abuse, which was alleged to occur on 10/26/09, until 12/05/09.

S2, RN Risk Management was interviewed per telephone on 01/22/10 at 10:15am S2 indicated the DON, CEO were not notified of the written journal presented by Patient #2 alleging sexual abuse on 12/05/09 and the HPR was not completed. Further the abuse allegation was not reported to the chief law enforcement agency of the parish but the patient had called the police department to report the alleged abuse and had discussed the incident with the police officer on the unit on 12/08/09.

S22, Director of Nurses was interviewed on 01/22/10 at 10:25am. She verified she was not notified of the abuse allegations made by Patient #2 until Monday 12/08/09.

S6, Patient Advocate was interviewed face to face on 01/06/10 at 9am. S6 indicated he met with Patient #2 on 12/08/09 but she did not want to talk about the incident. S6 indicated he asked her if she wanted to report it to the police, he gave her the phone number, and the police came to the hospital to take her statement.

S2, RN Risk Management was interviewed face to face on 01/06/10 at 10:10am. S2 indicated Patient #2 was not cooperative with the investigation and kept refusing to speak with her. Further Patient #2 was confused regarding the events of the alleged abuse and had kept a journal which she had given to S10, RN House Supervisor on 12/05/09 when she reported the alleged abuse.

S10, RN weekend House Supervisor was interviewed per telephone on 01/06/10 at 10:30am. S10 indicated she worked 7p to 7a on 12/05/09 and was called by S3, PC regarding Patient #2's allegations of sexual abuse and she had gone over to Building 3 (Trauma Unit) to speak with her. Further Patient #2 did not want to talk about it because she was writing the events in a journal and just said she remembered she had been sexually assaulted while a patient in DDU. Further S10 took the journal notes to S22, DON's office and placed the notes under her door. Further there was no documented evidence the CEO, or attending physician was notified immediately of the alleged abuse. Further she indicated she assured Patient #2 the Administrator would follow up on her complaint of abuse.

S15, Psychiatrist was interviewed face to face on 01/06/10 at 2pm. S15 reviewed the record for Patient #2 and verified Patient #2 had alleged to him on 12/09/09 during a counseling session that she was raped while a patient on DDU.

Patient #5
The Medical Record for Patient #5 was reviewed. Review of the Psychiatric Discharge Summary dated 01/05/10 revealed, "Admitting Diagnosis Polysubstance Dependence, Substance Induced Mood Disorder. Patient's date of admission was 10/28/09 with a discharge date of 11/12/09. Review of the Physician Problem Oriented Progress Note dated 11/03/09 revealed in part, "Tearful-drooling-slurred speech states staff locked her in laundry room."

The hospital investigative report dated 11/09/09 was reviewed. Documentation revealed in part, "On 11/09/09 it was reported to HR that a patient in the DDU report improper behavior between (name of Staff S17) and herself via a note. Shortly thereafter, Name of Patient #5's husband came to the hospital with a (Name of Police Department) Officer and (Name of S22, DON) informed HR of their presence. Further documentation revealed, "On 11/04/09 S2, PC reported that (Patient #5) said that (S17) had locked her in the laundry room. The question was brought up if that was true to the fact that the door opens without a key from the inside. Monday, 11/09/09 S10, RN Night supervisor stated that there were reports that S17 had sexually abused a Patient. (Name of Patient #5) On Monday, 11/02/09 (Name of Staff #23, PC) had been escorting another patient to (Name of Hospital) and arrived on the unit at 11:45pm. Patient #5 reported that S17 had trapped her in the laundry room. S23 told her she had a right to file a complaint, but since he did not witness he could not verify it happened. S23 did no report it to anyone. Patient #5 seemed upset and wanting to talk about the incident, however, Patient #5 was not able to state when the incident happened. Further review revealed, Video Surveillance Report:; Video surveillance tapes were viewed by S22, DON and S2, Director of Risk Management, and S7, HR Director for confirmation. The dated viewed were 10/28/09 through 11/02/09. On 11/02/09 the following observation was noted:
*8:22:46pm Patient #5 and S17 enters Laundry Room.
*8:23:30pm Laundry Room door closes
*8:24:30pm Laundry Room door opens partially and closes
*8:25:06pm Laundry Room door opens partially and closes
*8:25:21 Laundry Room doorknob moving back and forth
*8:26:50 Laundry Room door open without any reflection of lights on, S17 exits Laundry Room with clipboard in front of genital area.
*8:27:30pm Laundry Room door open with reflection of light on, Patient #5 exits the Laundry Room adjusting pants."

The hospital could not present documented evidence S23, PC had reported the allegation of sexual abuse immediately to the Nurse Manager and completed an Health Care Peer Review (HPR) document as per hospital policy on 11/02/09. There was no documented evidence the Nurse Manager immediately investigated Patients #5's complaint, 11/04/09 that (S17) had locked her in the laundry room. There was no documented evidence the the incident was reported immediately to the CEO, DON, and patient's attending physician. There was no documented evidence the hospital notified the Department of Health and Hospitals or the chief law enforcement agency.

S3, PC was interviewed face to face on 01/05/10 at 2:15pm. S3 indicated Patient #2 had come to her and stated Patient #5 had told her she had been locked in the laundry room by S17. Further S3 stated it was reported to S4, Nurse Manager. However, they didn't think the allegation made any sense because the laundry door can't be locked from the inside. However a couple of days later (S3 couldn't recall the dates) Patient #5 requested to talk to S16, RN Weekend Supervisor about being sexually assaulted by S17 in the laundry room. Further S16 had come to the unit to speak with Patient #5 and wrote a report.

S16, RN Weekend Supervisor was interviewed per telephone on 01/06/10 at 2:10pm. S16 indicated she worked 3p to 11pm on weekends. Further she indicated S3, PC had reported to her on 11/08/09 Patient #5's allegations of sexual abuse and she had talked to the patient. Further Patient #5 was confused, heavily sedated and was confused regarding the day the incident had occurred. Further she had reported the incident to S22, DON.

S23, PC was interviewed per telephone on 01/21/10 at 10am. S23 indicated his date of employment was 09/01/09. Further he indicated he was escorting a patient from another hospital (confirmed date 11/02/09) and had returned to River Oaks Hospital about 11:45pm and Patient #5 was standing at the desk. "I asked if she was OK." She was crying and told me of an event between herself and S17 and stated S17 had trapped her in the laundry room. Further S23 indicated he had not witnessed the event so he told Patient #5 to file a complaint and she said OK. Further he left at that point to go home as his shift was over. Further he didn't know if she was telling the truth so he didn't report the allegation to the charge nurse.

S4, RN Unit Manager DDU was interviewed face to face on 01/05/10 at 2:40pm. She indicated it was reported to her by S3, PC S17 had locked Patient #5 in the laundry room but it didn't seem logical because the laundry door doesn't lock from the inside. Further there was suspicion Patient #5 had drugs on the unit and was offering money for sexual favors. Further the Patient's report of staff abuse was not was not documented or investigated at this time.

S2, RN Risk Management, was interviewed face to face on 01/06/10 at 9:15am. S2 indicated Patient #5's husband reported the alleged sexual abuse between S17 and Patient#5 to the hospital on 11/09/09 and the hospital investigation began on 11/09/09. During the investigation it was determined Patient #5 reported the alleged abuse to S3 on 11/06/09. Further the police came with the husband to the hospital on 11/09/09.

Patient #R1
The hospital investigative report dated 11/09/09 was reviewed. Documentation revealed in part, (Name of S3, PC) "Interview with HR on 11/09/09. The following is S3's recollection of the dates she worked during the time in question. 11/05/09-S3 approached S17 and asked if he knew of the allegations. He acknowledge that on Tuesday (Name of PC) had approached him about getting too friendly with patients and saying inappropriate statements. S17 also stated to S3 that he was waiting for (Name of S4 Nurse Manager) to approach him with the allegations because, the last time he had something similar happen, (Name of S4 Nurse Manager) instructed him that he had handled incorrectly (Name of Patient R1 incident). 11/08/09 S3 witnessed S17 making sexual implicit comments around staff. He has also made comments about other staff member in sexual manner."

S3, PC was interviewed per telephone on 01/21/10 at 10:20am. S3 indicated she had heard from other staff S17, PC had walked into the room on R1 while she was changing her clothes. Further she was told S17 had made an obscene gesture to R1 and said, "Don't worry I don't fool with trash." S3 indicated she had not reported what she had heard to the Nurse Manager and she not aware if the incident was reported and investigated.

S4 Nurse Manager DDU was interviewed face to face on 01/22/10 at 10am. S4 indicated R1 had reported to her staff S17, PC had come into her room while she was taking a shower. R1 indicated the staff was S17, PC. S4 indicated she told S17 what the patient had said and S17 was upset. Further S17 left to go talk to Patient R1. She later learned S17 had told the patient while pointing to his wedding ring, "I look at my wife, I don't look at trash." Further S4 indicated she had verbally counseled S17. Further she had not reported the incident to the CEO or DON. Further the incident was not documented and not thoroughly investigated.

Based on record review (medical records, policy and procedure) and interview the registered nurse failed to supervise and evaluate the nursing care on an ongoing basis for each patient by failing to throughly investigate patients' complaints of staff verbal/sexual abuse and failed to immediately report the allegations to the attending physician and CEO for 3 of 3 patients who alleged abuse out of a total sample of 7 patients and 1 random patient. (Patients #2, #5 and R1) Findings:

Patient #2
The Medical Record for Patient #2 was reviewed. Review of the History and Physical Examination dated 10/27/09 revealed in part, "This is a 41-year old white female admitted for intravenous heroin dependency."
Documentation on 12/07/09, no time indicated, in the counseling progress notes revealed in part, "Pt. appeared in depressed and tearful mood. Pt stated she was struggling with feeling of guilt, shame and anger related to sexual abuse that patient stated occurred while she was on Bldg 5."
Documentation on the Psychiatric Progress Note dated 12/07/09 1445 (3:45pm) revealed in part, "Pt requesting sexually transmitted disease test due to reported sexual assault while hospitalized on DDU. Labs ordered. "Documentation on the Psychiatric Progress Note dated 12/09/09 1:15pm revealed in part, "I'm sorry I said anything." Pt alleged she was raped while on Building 5. Pt. admits to being under the influence while having a sexual encounter on Bld 5 Administrator and police notified."

Review of the typed Investigative Notes, not signed or dated, presented to the surveyor by S2, Risk Management/Staff Development revealed, "12/08/09 RM (Risk Management, S2) met with patient with S18, at pt's request-patient stated that she gave Nsg. Supervisor (S10) her journaling and did not really want to discuss further-did say she remembered being in tub with hands on her, then blankets being brought to her room, and then showering with discharge present-then went back to saying that she did not want to talk further, but did give additional page of journaling to be added to her complaint-pt."

There was no documented evidence S10, had reported the allegation of sexual abuse immediately to the CEO, DON, attending physician, and medical director on 12/05/09 and completed an Health Care Peer Review (HPR) document as per hospital policy.

Policy reviews:
Review of the policy entitled "Abuse and Neglect" presented as the hospital's current policy revealed in part, "A. Abuse: Any sexual, physical, verbal or socializing action that is detrimental to the treatment or well being of the patient. Policy: Allegation of Staff Abuse of a Patient:
A. Any suspected or witnessed incidents of either abuse or neglect shall be reported immediately to the staff member's immediate supervisor, or, in his her absence, to the Hospital supervisor, and the Risk Manager, an HPR (Health Care Peer Report) shall be completed.
B. All allegations shall be immediately investigated. The investigation shall be conducted in a fair and impartial manner.
C. All allegations of patient abuse or neglect shall be taken seriously. Risk Management shall conduct a thorough and complete written investigation in collaboration with the appropriated Department Head supervisor.
Review of the policy entitled "Mandatory Reporting" presented as the hospital's current policy revealed in part, The following is the hospital procedure for addressing the prescribed law.
Procedure:
1. Any medical staff member, employee or hospital staff practicing (working) in the hospital upon learning of or directly witnessing an incident suspected to be subject to the mandatory reporting requirements as described and attached, shall immediately report same to the attending physician, administrator and medical director. The staff member or other licensed professional who received the information will notify the appropriate agency or law enforcement division.

Staff Interviews:
S22, Director of Nurses was interviewed on 01/22/10 at 10:25am. She verified she was not notified of the abuse allegations made 12/05/109 by Patient #2 until Monday 12/08/09.

S10, RN weekend House Supervisor was interviewed per telephone on 01/06/10 at 10:30am. S10 indicated she worked 7p to 7a on 12/05/09 and was called by S3, PC regarding Patient #2's allegations of sexual abuse and she had gone over to Building 3 (Trauma Unit) to speak with her. Further Patient #2 did not want to talk about it because she was writing the events in a journal and just said she remembered she had been sexually assaulted while a patient in DDU. Further S10 took the journal notes to S22, DON's office and placed the notes under her door. Further there was no documented evidence the CEO, or attending physician was notified immediately of the alleged abuse. Further she indicated she assured Patient #2 the Administrator would follow up on her complaint of abuse.

S15, Psychiatrist was interviewed face to face on 01/06/10 at 2pm. S15 reviewed the record for Patient #2 and verified Patient #2 had alleged to him on 12/09/09 during a counseling session that she was raped while a patient on DDU.

Patient #5
The Medical Record for Patient #5 was reviewed. Review of the Psychiatric Discharge Summary dated 01/05/10 revealed, "Admitting Diagnosis Polysubstance Dependence, Substance Induced Mood Disorder. Patient's date of admission was 10/28/09 with a discharge date of 11/12/09. Review of the Physician Problem Oriented Progress Note dated 11/03/09 revealed in part, "Tearful-drooling-slurred speech states staff locked her in laundry room."

The hospital investigative report dated 11/09/09 was reviewed. Documentation revealed in part, "On 11/09/09 it was reported to HR that a patient in the DDU report improper behavior between (name of Staff S17) and herself via a note. Shortly thereafter, Name of Patient #5's husband came to the hospital with a (Name of Police Department) Officer and (Name of S22, DON) informed HR of their presence. Further documentation revealed, "On 11/04/09 S2, PC reported that (Patient #5) said that (S17) had locked her in the laundry room. On Monday, 11/02/09 (Name of Staff #23, PC) had been escorting another patient to (Name of Hospital) and arrived on the unit at 11:45pm. Patient #5 reported that S17 had trapped her in the laundry room. S23 told her she had a right to file a complaint, but since he did not witness he could not verify it happened.

There was no documented evidence the Nurse Manager immediately investigated Patients #5's complaint, 11/04/09 that (S17) had locked her in the laundry room. There was no documented evidence the the incident was reported immediately to the CEO, DON, and patient's attending physician.

S3, PC was interviewed face to face on 01/05/10 at 2:15pm. S3 indicated Patient #2 had come to her and stated Patient #5 had told her she had been locked in the laundry room by S17. Further S3 stated it was reported to S4, Nurse Manager. However, they didn't think the allegation made any sense because the laundry door can't be locked from the inside. However a couple of days later (S3 couldn't recall the dates) Patient #5 requested to talk to S16, RN Weekend Supervisor about being sexually assaulted by S17 in the laundry room. Further S16 had come to the unit to speak with Patient #5 and wrote a report.

S16, RN Weekend Supervisor was interviewed per telephone on 01/06/10 at 2:10pm. S16 indicated she worked 3p to 11pm on weekends. Further she indicated S3, PC had reported to her on 11/08/09 Patient #5's allegations of sexual abuse and she had talked to the patient. Further Patient #5 was confused, heavily sedated and was confused regarding the day the incident had occurred. Further she had reported the incident to S22, DON.

S4, RN Unit Manager DDU was interviewed face to face on 01/05/10 at 2:40pm. She indicated it was reported to her by S3, PC S17 had locked Patient #5 in the laundry room but it didn't seem logical because the laundry door doesn't lock from the inside. Further there was suspicion Patient #5 had drugs on the unit and was offering money for sexual favors. Further there was no documented evidence the Patient's report of staff abuse of locking her in the laundry room was reported to the CEO, DON or attending physician immediately.

Patient #R1
The hospital investigative report dated 11/09/09 was reviewed. Documentation revealed in part, (Name of S3, PC) "Interview with HR on 11/09/09. The following is S3's recollection of the dates she worked during the time in question. 11/05/09-S3 approached S17 and asked if he knew of the allegations. He acknowledge that on Tuesday (Name of PC) had approached him about getting too friendly with patients and saying inappropriate statements. S17 also stated to S3 that he was waiting for (Name of S4 Nurse Manager) to approach him with the allegations because, the last time he had something similar happen, (Name of S4 Nurse Manager) instructed him that he had handled incorrectly (Name of Patient R1 incident). ,

S3, PC was interviewed per telephone on 01/21/10 at 10:20am. S3 indicated she had heard from other staff S17, PC had walked into the room on R1 while she was changing her clothes. Further she was told S17 had made an obscene gesture to R1 and said, "Don't worry I don't fool with trash." S3 indicated she had not reported what she had heard to the Nurse Manager and she not aware if the incident was reported and investigated.

S4 Nurse Manager DDU was interviewed face to face on 01/22/10 at 10am. S4 indicated R1 had reported to her staff, S17, PC had come into her room while she was taking a shower. R1 indicated the staff was S17, PC. S4 indicated she told S17 what the patient had said and S17 was upset. Further S17 left to go talk to Patient R1. She later learned S17 had told the patient while pointing to his wedding ring, "I look at my wife, I don't look at trash." Further S4 indicated she had verbally counseled S17. Further she had not reported the incident to the CEO. Further the incident was not documented and not thoroughly investigated. Further there was no documented evidence the Patient's report of staff verbal abuse was reported to the CEO, DON or attending physician at this time.