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Based on policy review, review of the State Operations Manual, and interview, the Governing Body failed to ensure the facility's abuse policy was written to include all components listed in the State Operations Manual and failed to ensure the facility monitored Social Worker #1 after Patient #1 reported an allegation of sexual abuse by Social Worker #1 occurred in September, 2024 and Patient #2 reported an allegation of sexual abuse by Social Worker #1 in May, 2025.

The findings inclued:

1. Review of the hospital policy titled "Alleged or Suspected Abuse (Child and/or Adult) dated 12/2024 revealed no components listed for an effective abuse protection plan.

Review of the State Operations Manual (SOM) dated 04/19/2024 revealed, " ...§482.13(c)(3) - The patient has the right to be free from all forms of abuse or harassment ...Interpretive Guidelines ... The intent of this requirement is to prohibit all forms of abuse, neglect (as a form of abuse) and harassment whether from staff, other patients or visitors. The hospital must ensure that patients are free from all forms of abuse, neglect, or harassment. The hospital must have mechanisms/methods in place that ensure patients are free of all forms of abuse, neglect, or harassment ...The following components are suggested as necessary for effective abuse protection: Prevent. A critical part of this system is that there are adequate staff on duty, especially during the evening, nighttime, weekends and holiday shifts, to take care of the individual needs of all patients ...Screen. Persons with a record of abuse or neglect should not be hired or retained as employees. Identify. The hospital creates and maintains a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect. Train. The hospital, during its orientation program, and through an ongoing training program, provides all employees with information regarding abuse and neglect, and related reporting requirements, including prevention, intervention, and detection. Protect. The hospital must protect patients from abuse during investigation of any allegations of abuse or neglect or harassment. Investigate. The hospital ensures, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment. Report/Respond. The hospital must assure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law. As a result of the implementation of this system, changes to the hospital's policies and procedures should be made accordingly ..."

During an interview on 05/28/2025 beginning at 10:41 AM, the Vice President (VP) of Quality was asked if there was a hospital abuse policy that listed all the components as written in the SOM. The VP of Quality stated these components were incorporated in other policies, training programs and the "Code of Conduct" but were not listed together in one policy. Further interview with VP of Quality revealed Social Worker #1 was not monitored after the allegation of sexual abuse was reported in September, 2024 and approximately 7 months later Patient #2 reported sexual abuse by Social Worker #1.

The Governing Body failed to ensure that any incidents of abuse, neglect or harassment were reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurred, in accordance with applicable local, State, or Federal law when Social Worker #1 allegedly went to Patient #1's home and sexually assaulted her. Because of the failure to analyze and monitor Social Worker #1 with appropriate corrective action, Patient #2 was allegedly sexually abused 7 months later while she was a patient in the ED on 4/28/2025.
Refer to A-0144, A-0263 and A-286

Based on review of facility policy, review of a facility incident report, review of the Quality Assurance Process Improvement (QAPI) meeting minutes, review of facility video footage, medical record review, and interview, the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) committee analyzed and monitored processes to ensure no future adverse events occurred as part of the facility wide QAPI program for 2 of 3 (female Patient #1 and female Patient #2) sample patients who were seen in the Emergency Department (ED).

The findings included:

1. Review of a policy titled "Patient Grievance and Complaint Management Policy" dated 09/2013 revealed all patient grievances will be addressed while identifying, investigating, and resolving any deeper, systemic problems indicated by the grievance and tracking, trending and analysis of data will be ongoing actions,

2. Review of the medical record revealed Patient #1 was seen in the ED on 08/19/2024 at 2:20 PM. The visit diagnosis was Alcohol Abuse, Uncomplicated. Patient #1 was subsequently seen again in the ED on 09/24/2024 for abdominal pain.

Patient #1 alleged male Social Worker #1 took her home in his personal vehicle (date unknown) and made an additional 2 visits to her apartment for welfare checks in 2024 (dates unknown). Patient #1 reported Social Worker #1 to the hospital via telephone on September 30, 2024. Patient #1 was unable to provide the dates Social Worker #1 came to her apartment. Patient #1 alleged Social Worker #1 fondled her and tried to climb on top of her while visiting her apartment. Social Worker #1 was placed on administrative leave pending the outcome of the investigation. The QAPI investigation was unable to substantiate the allegation however, Social Worker #1 was verbally counseled not to be in a room alone with a female patient and to leave the room doors open.

Review of the facility incident report dated 10/01/2024 revealed, the allegation was not substantiated, and Social Worker #1 came back to work.

There was no documented monitoring provided by the hospital for Social Worker #1.

3. Review of the medical record dated 04/28/2025 revealed Patient #2 was seen in the ED on 04/28/2025 at 10:46 AM for a potential overdose.

Video footage of 4/28/2025 revealed Social Worker #1, a male, entered an ED room, alone where Patient #2, a female, was behind a closed door. The social worker entered the room without knocking at 2:39 PM. Fourteen minutes later both Social Worker #1 and Patient #2 exited the room; and Patient #2 was escorted to a chair to sit down.

On 5/3/2025, Patient #2 called the facility and alleged Social Worker #1 went into Patient #2's ED room on 04/28/2025, closed the door and was alone with Patient #2. Patient #2 reported Social Worker #1 had fondled her while in the ED room.

4. Review of the QAPI meeting minutes from October 2024 through April 2025 revealed no documentation of plans or monitoring of Social Worker #1. There was no documentation of any discussion of the sexual abuse allegation investigation in September and October 2024. The May 2025 QAPI meeting minutes had not been approved at the time of the survey and were unavailable for review.

5. Interview with the VP of Quality revealed Social Worker #1 was suspended pending the outcome of the investigation on 05/08/2025. The facility was unable to substantiate the allegations of sexual abuse but elected to terminate Social Worker #1 out of an abundance of caution.

The facility did not adequately monitor Social Worker #1 after the first allegation of sexual abuse by Patient #1 in September 2024 and in May 2025, Patient #2 alleged sexual abuse by Social Worker #1.

Refer to A-0286

Based on policy review, review of the State Operations Manual and interview, the facility failed to ensure the patients' rights were protected and the patients received care in a safe setting when Patient #1 reported alleged sexual abuse in September 2014 by Social Worker #1 and Patient #2 reported alleged sexual abuse in May, 2025. The facility failed to have an abuse policy that incorporated the 7 components listed in the State Operation Manual (SOM) that included any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law.

1. Review of the hospital policy titled "Alleged or Suspected Abuse (Child and/or Adult) dated 12/2024 revealed no components listed for an effective abuse protection plan.

Review of the State Operations Manual (SOM) dated 04/19/2024 revealed, " ...§482.13(c)(3) - The patient has the right to be free from all forms of abuse or harassment ...Interpretive Guidelines ... The intent of this requirement is to prohibit all forms of abuse, neglect (as a form of abuse) and harassment whether from staff, other patients or visitors. The hospital must ensure that patients are free from all forms of abuse, neglect, or harassment. The hospital must have mechanisms/methods in place that ensure patients are free of all forms of abuse, neglect, or harassment ...The following components are suggested as necessary for effective abuse protection: Prevent. A critical part of this system is that there are adequate staff on duty, especially during the evening, nighttime, weekends and holiday shifts, to take care of the individual needs of all patients ...Screen. Persons with a record of abuse or neglect should not be hired or retained as employees. Identify. The hospital creates and maintains a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect. Train. The hospital, during its orientation program, and through an ongoing training program, provides all employees with information regarding abuse and neglect, and related reporting requirements, including prevention, intervention, and detection. Protect. The hospital must protect patients from abuse during investigation of any allegations of abuse or neglect or harassment. Investigate. The hospital ensures, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment. Report/Respond. The hospital must assure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law. As a result of the implementation of this system, changes to the hospital's policies and procedures should be made accordingly ..."

2. Review of the medical record dated 08/19/2024 revealed Patient #1 was seen in the ED on 08/19/2024 at 2:20 PM. The reason for the visit diagnosis was Alcohol Abuse, Uncomplicated.
3. Review of the medical record dated 09/24/2024 revealed Patient #1 was seen in the Emergency Department (ED) for Generalized Abdominal Pain.

Review of a Free text HPI (History of Present Illness) Notes dated 09/24/2024 revealed Patient #1 stated she was a heavy drinker and drank regularly.

Review of a facility investigation dated 10/01/2024 revealed Patient #1 called the facility on 09/30/2024 to report Social Worker #1 drove her home from one of her multiple ED visits (date unknown) and sexually abused her.

During an interview on 05/28/2025 beginning at 10:41 AM, the Vice President (VP) of Quality was asked if Social Worker #1 was monitored after the allegation of sexual abuse in September, 2024. The VP of Quality stated did not monitor Social Worker #1 at the bedside. The VP of Quality was asked if the facility had an abuse policy that listed the components described in the SOM abuse regulation. The VP of Quality stated these components were incorporated in other policies, training programs and the "Code of Conduct" but were not listed together in one policy.

4. Review of the medical record dated 04/28/2025 revealed Patient #2 was seen in the ED on 04/28/2025 at 10:46 AM for a potential overdose. Patient #2 was found outside during a rainstorm and was brought to the ED via ambulance.

Review of video footage dated 04/28/2025, revealed Social Worker #1 had some clothing rolled up in his left hand and without knocking, went into Patient #2's ED room at 2:39 PM and closed the door. He was in the room for approximately 14 minutes. Further review of video footage at 2:53 PM, revealed Social Worker #1 walked out of the ED room with Patient #2. No one else exited the room with them. Social Worker #1 walked Patient #2 to the ED lobby where she sat down in a chair with her phone and some clothing rolled up under her left arm. Social Worker #1 also had some clothing rolled up in his left hand.

The facility failed to ensure patient safety when the first alleged incident of sexual abuse was reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurred, in accordance with applicable local, State, or Federal law when Social Worker #1 allegedly went to Patient #1's home and sexually assaulted her and 7 months later, Patient #2 was allegedly sexually abused by Social Worker #1 while she was a patient in the ED on 4/28/2025.

Based on review of facility policy, review of a facility incident report, review of the Quality Assurance Process Improvement (QAPI) meeting minutes, review of facility video footage, medical record review, and interview, the facility failed to ensure the QAPI committee identified and implemented appropriate monitoring to ensure patients were safe from sexual abuse for 2 of 3 (female Patient #1 and female Patient #2) sampled patients seen in the hospital's emergency department (ED). Patient #1 reported an allegation of sexual abuse to the hospital on 9/30/2024. Patient #1 had been admitted to the hospital's ED multiple times, and following discharge, Social Worker #1 made three welfare visits to Patient #1's apartment. Patient #1 alleged Social Worker #1 sexually abused her while in her apartment. A second allegation of sexual abuse was reported to the facility on 05/03/2025 when Social Worker #1 went into Patient #2's ED room, closed the door and was alone with Patient #2 for approximately 14 minutes on 04/28/2025. Patient #2 alleged she was sexually abused by Social Worker #1 while he was alone in the room with her.

Patient #1 reported the sexual abuse to the facility on 9/30/2024, via telephone to the patient advocate.

Patient #2 reported the allegation of sexual abuse that occurred on 04/28/2025 to this facility on 05/03/2025.

The findings included:

1. Review of a policy titled "Patient Grievance and Complaint Management Policy" dated 09/2013 revealed, "...Patient Grievance is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient ...regarding ...abuse ...issues related to compliance with the CMS [Centers for Medicare and Medicaid] Conditions of Participation (CoP) ...PROCEDURE ...Grievance Resolution Process ...Upon receipt of a grievance, the Patient Advocate (or designee of the organization) shall confer with the appropriate department director/manager to review, investigate and resolve with the patient ... Regardless of the nature of the grievance, the substance of each grievance must be addressed while identifying, investigating, and resolving any deeper, systemic problems indicated by the grievance ...A grievance is considered resolved when the patient... is satisfied with the actions taken on their behalf...Tracking, Trending, and Analysis of Data... Status and success of any ongoing actions or other activities intended to reduce the number, frequency and/or seriousness of complaints and grievances..."

Review of a policy titled, "2024 Plan for Improvement of Organizational Performance and Patient Safety" dated 03/2024 revealed, "...The objectives of this plan are to preserve/improve the quality of patient care, enhance appropriate utilization of resources, and to reduce or eliminate unnecessary risks and hazards within the facility by promoting ...The employment of qualified, competent, and effectively supervised personnel for patient care, using clear channels of supervision, responsibility, and accountability ...A system in which the findings of patient care monitoring and evaluation are utilized by the hospital in concrete ways to fulfill the objectives of the Performance Improvement/Patient Safety program ..."

The facility was not able to provide an abuse policy that addressed a process for investigating or reporting allegations of abuse or neglect, or the monitoring of any alleged instances of abuse or neglect to ensure patients were safe from further instances when staff were accused of abuse and/or neglect.

2. Review of the medical record dated 08/19/2024 revealed Patient #1 was seen in the ED on 08/19/2024 at 2:20 PM. The reason for the visit diagnosis was Alcohol Abuse, Uncomplicated.

Review of a Free Text History of Present Illness (HPI) Notes dated 08/19/2024 revealed, Patient #1 presented with alcohol use requesting for detoxification (detox)/assistance with rehabilitation (rehab). Patient #1 reports she has a history of alcohol abuse.

Review of a Re-Evaluation/Progress #1 dated 8/19/2024 revealed, "...Patient seen by case management ...Plan for discharge home ..."

Review of a Discharge Planning note dated 8/19/2024 at 4:25 PM by Social Worker #1 revealed, "...Pt (Patient) said she has been to 5 different ERs [Emergency Rooms]and nobody has helped her because she is uninsured ..."

The medical record dated 08/19/2024 revealed Patient #1 was discharged at 5:15 PM and left the ED walking.

On 9/30/2025, Patient #1 reported to the hospital that she had been sexually abused by Social Worker #1.

Review of a portion of the facility investigation dated 10/1/2024, the Vice President of Quality, the Manager of Social Work, and Clinical Risk Manager interviewed Social Worker #1. The investigation findings revealed, "...At the conclusion of this interview, the social worker was advised that he was being placed on administrative leave while the investigation was continuing ...10/15/2024: at this time, after a thorough and credible investigation, we have been unable to substantiate with evidence the concern shared by this former patient [Patient #1] ..."

Review of the QAPI meeting minutes from October 2024 through April 2025 did not reveal any evidence of a plan to monitor Social Worker #1 to ensure the safety of future female patients.

During a telephone interview on 06/05/2025 beginning at 2:35 PM, Patient #1 stated after one of her visits to the ED, Social Worker #1 gave her a ride home from the hospital "because he was concerned about me taking an [Named share ride company] and so he asked me to meet him ...around the corner and that's when I got in his car and he drove me home and walked me up to my apartment ..." Patient #1 confirmed Social Worker #1 came to her apartment and checked on her a second time and she let him into her apartment. Patient #1 stated, "...all I had was a bed studio apartment ...so I was just alone dealing with addiction and he was just lending an ear ...I just talked about things ...I'd also just lost my dad a couple months prior to that who I was really close to so it's kind of a perfect storm in my life ...the first time coming back from the hospital he [Social Worker #1] ...tucked me into bed ...he's a lot older than I am so it seemed kind of fatherly when I just lost my dad like 2 months prior ...the second time he came over nothing happened ... and then the third time ...he came over, I was drinking ...I had just done my nails and I couldn't ...open it [alcohol] ...so he was opening it for me ...I was going through it really bad, I was kind of slamming them ...he told me that I shouldn't stop drinking because I'll have withdrawals so ...he was kind of encouraging the alcohol and then that's when I realized something was kind of up ...He kept insisting on giving me a massage ...then he kept putting his hands under my clothes and up my bra and I was saying please just keep your hands outside of my clothes and then he would stop ...a couple seconds later he was doing it again ...then he abruptly started to pull me over to get on top of me and that's when I started to scream really loud to get away from me, get off of me ...screaming as loud as possible ... then he ran out ..." Patient #1 was asked if she called the police. Patient #1 confirmed she called the police. Patient #1 stated, " ...they [hospital investigation team] listened to me ...he [Social Worker #1] didn't penetrate me so there was no need for like a rape kit but they encouraged me to go to the hospital. I went to the hospital. I reported the whole thing, but nothing was really done and I just I don't want this to happen to another girl like this, because it's clear that this is a predator ...I'm an addict so ...I'm not credible and he is. I was ...perfect for him and I know that there's a lot of people like me out there and we're just trying to get better ... and I put my faith in the wrong person ..." Patient #1 was asked if anyone from [Named Hospital] contacted her after she reported it to the facility. Patient #1 stated, " ...yes ...they were asking me questions, they didn't really ask what happened, they asked me what car he was in and if I could get the video footage from my apartment. I couldn't ...I've even called the company that they have their surveillance footage through ... I can't get it...I didn't know the make of his car but I said it was like a maybe a 2015 black or green sedan like a [Make of Named Car] ...I don't know, that's all that's all I could tell them, and they just started to completely brush me off and act like that was a problem ...I was forthcoming with what happened so they didn't really ask too many questions ...I let them know what happened and the history and they were just asking for proof, really that's the only thing they cared about and I unfortunately couldn't really provide them proof ..."

3. Review of the medical record dated 04/28/2025 revealed Patient #2 was seen in the ED on 04/28/2025 at 10:46 AM for a potential overdose. Patient #2 was found outside during a rainstorm and was brought to the ED via ambulance.

Further review of the medical record revealed Patient #2 had a history of polysubstance (use of multiple substances, including drugs and alcohol) abuse and homelessness.

Patient #2 was not interviewed. She was unable to be reached at the time of this survey.

Review of video footage dated 04/28/2025, revealed Social Worker #1 had some clothing rolled up in his left hand and without knocking, went into Patient #2's ED room at 2:39 PM and closed the door. He was in the room for approximately 14 minutes. Further review of video footage at 2:53 PM, revealed Social Worker #1 walked out of the ED room with Patient #2. No one else exited the room with them. Social Worker #1 walked Patient #2 to the ED lobby where she sat down in a chair with her phone and some clothing rolled up under her left arm. Social Worker #1 also had some clothing rolled up in his left hand.

During an interview on 5/27/2025 beginning at 10:45 AM, the Vice President (VP) of Quality was asked about the incident with Patient #2 and Social Worker #1 that took place on 04/28/2025. The VP of Quality confirmed the facility was first notified of the incident on 05/03/2025 (5 days after the incident occurred). She stated Patient #2 called the facility through the switchboard operator on 05/03/2025, and the complaint was elevated to her via text on that same day. The VP of Quality stated she had trouble getting in touch with Patient #2 and she first talked to Patient #2 on Wednesday 05/08/2025 via telephone. The VP of Quality was asked about the conversation with Patient #2. The VP of Quality stated, "...She [Patient #2] said he [Social Worker #1] had brought her some clothes from the clothes closet and while she was changing her clothes that he had put his hand between her legs, put his fingers up inside her he also had touched her on her breast had put his mouth on her breast and just stroked her on her back ...I asked her if she told anybody ...I said ...I'm sure there was a nurse and people in and out of the room, did you tell anybody while you were there and she said no that she did not tell anybody about it while she was there, that she had called back and talked to somebody at the hospital ..."

Social Worker #1 was not interviewed. The VP of Quality stated they did not have a personal phone # for him on file. The facility was unable to provide Social Worker #1's employment application.

The VP of Quality confirmed she entered the allegations in the facility incident reporting system and reported it to the state.

The VP of Quality also confirmed that she and the Supervisor of Case Management interviewed Social Worker #1 together via telephone. The VP of Quality stated she asked Social Worker #1 what he remembered about Patient #2. She stated, " ...he [Social Worker #1] remembered her, he remembered she came in by EMS [Emergency Medical Service], that she had overdosed and he remembered going and getting her some clothes out of the closet ... her clothes were wet ...it was raining outside that day ..."

The VP of Quality was asked about the facility's investigation. The VP of Quality stated, she finished the investigation, and it was a "he said she said". She stated they did a thorough investigation, there were no witnesses. The VP of Quality confirmed she was unable to substantiate the allegation.

The Director of Case Management was asked about Social Worker #1's demeanor during the interview with him. The Director of Case Management stated, "...he was calm ...he's pretty stoic, he has a military background..."

The VP of Quality and The Director of Case Management were asked if Social Worker #1 had ever had any other allegations of sexually inappropriate behavior. The VP of Quality stated, " ...In October last year I had the chance to talk to [Named Social Worker #1] about another incident ...it was young lady who had come into our emergency department who also did not immediately let us know that she had a concern ...that he had come to her apartment. She had given him her address, they had exchanged phone numbers and she was alleging that ...he had touched her inappropriately in her apartment ..." The VP of Quality stated that happened off this campus he took her home from the hospital. She stated Patient 1 had filed a police report. The VP of Quality stated, " ...we even tried to get video footage from her apartment complex to show whether or not his car was pulled up there and we never could get that ...she never alleged anything happened at the hospital, this was at her apartment ...of course he said it never happened, he never went there..." The VP of Quality was asked what the process was for the investigation in October, 2024. The VP of Quality confirmed Social Worker 1 was suspended pending the outcome of the investigation but was brought back to work because it was not substantiated. The VP of Quality was asked if any education and monitoring were done after the allegations were made in October of last year. The VP of Quality stated, "...I told him if it is a female patient, I'm recommending you have an escort when you're in the room and never close the room door, you can have a private conversation with somebody where nobody else can hear what you're saying ..." The VP of Quality was asked if there was documentation of the education and recommendations to Social Worker #1. The VP of Quality stated there was nothing in writing. The VP of Quality was asked when the second allegation came in regarding Social Worker #1, what was the conversation with Social Worker #1. The VP of Quality stated, "...the first thing I asked him on May 5th [2025], was do you remember those things we talked about ...he did remember, he forgot to do it though...he told me for [Named Patient #2], the door was not closed ..." The VP of Quality confirmed Social Worker #1 was suspended on 5/8/2025 pending the outcome of the investigation and was ultimately terminated out of an "abundance of caution".

During an interview on 5/28/2025 beginning at 11:20 AM, the Director of Case Management was asked to describe Patient #2's demeanor during the interviews because there were allegations from both Patient #1 and Patient #2. The Director of Case Management stated, "...initially he was pretty nervous, and he said ... 'I just need to quit trying to help people if this is what's happening ...' This person [Patient #1] came through the ER in October [2024] and it was a substance issue with her ...she may have been a person that had come through the ER couple of times and he connected with her a couple of times ...he came to her house afterwards and it wasn't ever substantiated, I think they tried to pull video and the apartment complex didn't have it, he denied it of course ...there was no other issues between then and now with any patient ..." The Director of Case Management was asked what was Social Worker #1's main job duty and what type of patients did he routinely see. The Director of Case Management confirmed Social Worker #1 was the designated ED Social Worker ...so he has to do the initial discharge plan and evaluations and get all of that before the patients can get on the floor ...or make some decisions from that first review that may even circumvent an inpatient stay. That's his role primarily ..."