HospitalInspections.org

Based on interview, medical record review, review of police department investigation, review of employment files, review of facility investigation, review of a plan of correction employment plan, review of the Employee Handbook, and review of facility policy, it was determined the facility failed to follow their policy and condition of employment plan to ensure a staff member safely transported a patient for admission from another state in a timely and safe manner. (A144) The cumulative effects of these systemic practices resulted in the agency's inability to ensure patient safety needs would be met.

Based on interview, medical record review, review of police department investigation, review of employment files, review of facility investigation, review of a plan of correction employment plan, review of the Employee Handbook, and review of facility policy, it was determined the facility failed to follow their policy and condition of employment plan to ensure a staff member safely transported a patient for admission from another state in a timely and safe manner. This affected one (Patient #3) of ten patients reviewed for patient rights. The facility census was 48.

Findings include:

Review of the medical record revealed Patient #3 admitted to the facility on 07/12/2023 at 5:55 PM and discharged on 07/13/2023 to her private residence. Diagnoses included obsessive-compulsive disorder, bipolar disorder, attention deficit hyperactivity disorder, and anxiety.

Review of urine drug screen completed on 07/12/2023 revealed Patient #3 was positive for tetrahydrocannabinol (THC/marijuana), methamphetamine (meth), amphetamines, and methylenedioxy-methamphetamine (MDMA/ecstasy) upon admission to the facility.

Review of the nursing notes dated 07/12/23 at 10:15 PM revealed Patient #3 stated she thought she raped by the male driver who brought her to the facility. Patient #3 reported they were both smoking marijuana and meth on the trip to the facility. They also stopped at several casinos. She woke up at one time parked in a cornfield with the doors to the car all open and the driver picking things out from under the front seat. He took her to some stores to buy some clothing and back to his place where he showered and kept insisting she shower also. Patient #3 stated she is sore "down there" wants to report it and wants a rape kit done. At 10:25 PM the patient was transferred to a hospital for an assessment.

Review of the Admission Pickup form revealed Patient #3 arrive on 07/12/23 at 5:55 PM from a private address in Parkersburg, West Virginia. Under the area of driver it was listed MHT, which is the abbreviation for the job title of mental health technician.

Review of incident report written on 07/13/23 revealed on 07/12/2023 Patient #3 stated Director of Operations (DOO) A gave her money to buy meth and smoked it with her while driving. Patient #3 stated her vagina was sore. She was unsure if she had been touched or raped and asked to go to the hospital to be evaluated. Registered Nurse (RN) B notified the Administrator, physician, police, family, and supervisor by 10:03 AM on 07/13/2023. Patient #3 was sent to the emergency room (ER) at the local hospital and and transferred to a second ER to complete a rape kit. The sexual assault nurse examiner (SANE) nurse was to be available on 07/13/23 at 7:00 AM on to perform a vaginal exam.

Review of Patient #3's handwritten witness statement, dated 07/13/2023 at 4:45 AM revealed DOO A picked her up on 07/11/2023 at 9:30 PM to transport her to the facility in Ohio. DOO A gave Patient #3 money to buy drugs and they smoked both marijuana and meth during the trip. Patient #3 stated DOO A stopped at two casinos, one in Parkersburg, West Virginia and one in Columbus, Ohio, before she fell asleep in the car. When she woke up they were parked in a cornfield. All the car doors were open and DOO A was picking lint off the driver's front-side floor. Patient #3 stated he propositioned her and what should have been a four hour trip took almost 24 hours.

Review of the witness statement dated 07/13/2023 by Admissions Director C revealed Patient #3 was approved for admission and on 07/11/23 DOO A volunteered her up. DOO A arrive to pick up Patient #3 on 07/11/2023 at 11:30 PM and reported the patient was not ready for transport. DOO A sent a text on 07/12/23 saying he had picked the patient up at 7:00 AM with the estimated time of arrival at the facility between 11:00 AM and 12:00 PM. Admissions Director C stated she called DOO A for an update at 11:32 A.M. and DOO A stated they would arrive at the facility closer to 12:30 PM. When they had still not arrived, Admission Director C called for an update at 2:53 PM. DOO A stated they had stopped at another Dollar Tree, gotten food, and Patient #3 had "cold feet." The patient did not arrive at the facility until 6:00 PM.

Review of the local police department (PD) Incident/Offense Report, initiated on 07/13/2023 and concluded on 09/27/2023, revealed a neighboring PD contacted the local PD on 07/13/2023 to advise of a potential sexual assault that may have occurred in their jurisdiction. The neighboring PD reported Patient #3 interviewed at a local ER and alleged DOO A picked her up from her home in Parkersburg, West Virginia on 07/11/2013 at approximately 11:30 P, exposed his genitals, asked for sexual favors, provided and used methamphetamines with her, made multiple stops to buy food and clothing, stopped at a casino in Columbus, and took the patient to his apartment located above a nutrition store, where the employee showered and tried to encourage the patient to shower with him before transporting her to the facility for admission. Patient #3 stated she experienced pink discoloration and soreness to her vagina and thought she may have been sexually assaulted. Patient reported her concerns to nursing staff and RN C escorted the patient to the local ER for a SANE evaluation. The local PD collected the patient's clothing, rape kit, and forensic examination chart and entered them into evidence. The rape kit was inconclusive and did not have evidence of DOO A's DNA present.

The police investigation revealed DOO A was voluntarily interviewed at the local PD on 07/17/2023. DOO A stated for at least a year or more he had been prohibited from transporting patients and was aware he could lose his job for transporting patients. He stated he was sent to the facility in January 2023 to assist with admissions and had transported multiple patients when other drivers were not available. On 07/11/2023 he transported an unidentified male patient to South Bend, Indiana and back in the morning. Around 5:00 PM he was told Patient #3 needed to be picked up from her home in West Virginia, so he volunteered to get her. DOO A stated he had picked her up around 9:30 PM on 07/11/23. He admitted to stopping at a casino in Columbus, Ohio, and making multiple additional stops to purchase illegal drugs, food, and clothing. DOO A indicated this was not the first time he had allowed patients to use illegal drugs during transport prior to admission to the hospital. DOO A admitted to smoking what he assumed was meth with the patient three times during the trip. DOO A denied any sexual contact with Patient #3. DOO A did admit to stopping at his apartment for approximately one hour where he showered before bringing Patient #3 to the facility on 07/12/23 around 6:00 PM. DOO A voluntarily participated in a DNA test and polygraph. The polygraph was inconclusive.

The police investigation included a copy of an e-mail sent on 07/12/2023 at 11:31 PM from DOO A to the Chief Executive Officer (CEO) and other corporate staff in which DOO A admitted to periodically picking up patients and doing "whatever it took to get this place on track" with the full awareness that it was against the company's directives and was a terminable offense.

Review of DOO A's employment file revealed DOO A was enrolled in a residential drug treatment program from 06/19/12 through 06/30/12. A urinalysis drug screen dated 04/04/20 revealed DOO A tested positive for cocaine and amphetamines. On 04/08/20 DOO A was provided a two week suspension without pay. A urinalysis drug screen dated 04/13/20 revealed DOO A again tested positive for cocaine and amphetamines. There were no further drug screens in the employee file. From 08/08/2022 to 11/06/2022 DOO A was placed on probationary status by the CEO following an incident at a facility located in Florida. DOO A was subject to immediate termination for any incident or substantiated complaint of misconduct during that time.

Review of a form in DOO A's file revealed on 09/08/22 he signed to attest he had been trained on and understand the following: The facility cannot provide transportation via the following methods: Lyft, Uber, personal vehicle, plane or bus ticket. Transportation cannot exceed a 200 mile radius and all policies pertaining to transportation must be followed at all times. Failure to abide by the above guidelines will result in disciplinary action up to and including termination.

Review of a document titled "Plan of Correction: January 23, 2023 -July 23, 2023" revealed DOO A and the CEO signed a contract which stated effective immediately, DOO was reassigned to the facility in Ohio. This was the final time the company would extend employment following a serious violation of company policy and/or code of conduct that created a hostile work environment. DOO A was to serve in the capacity and an admission intake specialist without any supervisory responsibilities related to staff. Specific requirements of the plan included 1. daily telephone contact with the CEO to confirm plan compliance, 2. Weekly therapy sessions to address behaviors that contribute to a hostile work environment, 3. No texting or emailing employees who work at the hospital, and 4. Regular urine screens, and regular contact with a sponsor.

Review of DOO A's employment file revealed a letter titled "RE: Termination of Employment," dated 07/14/2023, which revealed the CEO terminated DOO A's employment without eligibility for re-hire regarding allegations of inappropriate behavior filed against him by a prospective patient, the use of poor judgement, and violation of hospital policy in transport of a patient.

Interview on 09/14/2023 at 10:19 AM, Admission's Specialist D stated on 07/13/2023 around 3:30 PM she observed DOO A at the Dollar Tree store in town. He appeared unusually disheveled with clothing untucked, pants sliding below waist, and hair sticking out in places. His car was parked askew between two handicap spaces, and he was rummaging through multiple black locked boxes in his trunk. She did not engage in conversation and went into the store. She left the shop approximately 30 minutes later and DOO A was still rummaging through his car. They spoke briefly and the Admission's Specialist left. Admissions Specialist D stated DOO A had picked up multiple patients while he was working for the facility. She stated DOO A insisted she write "MHT" in the documentation for driver instead of identifying DOO A as the driver.

During a telephone interview on 09/14/2023 at 3:32 PM the CEO stated DOO A was involved in an incident at a facility in Florida in which he was having improper interactions with staff and was creating a hostile work environment. The CEO put him on a plan of correction and sent him to the facility in Ohio to work as an admission consultant. DOO A had no prior disciplinary actions involving patient interactions. His plan of correction included he was to have no interaction with staff outside of work. He should never have volunteered to transport patients. The facility staff were unaware of his plan of correction and may not have been aware it was inappropriate that he act as a driver.

During an interview on 09/18/2023 at 10:09 AM the Administrator stated he was unaware of DOO A's plan of correction for continued employment and was unaware he was not supposed to be working as a driver. The Administrator sent a letter to the Corporate Compliance Office on 07/13/2023 stating DOO A had assisted with transportation for patients when other drivers were unavailable. DOO A was terminated from employment on 07/14/2023.

During a telephone interview conducted on 09/28/2023 at 11:06 AM, the investigating Police Detective stated DOO A admitted to making several stops to casinos, stores, and restaurants, admitted to smoking meth three times with Patient #3 during the transporting of the patient to the facility. The Police Detective stated DOO A admitted to stopping at his apartment to shower during transport prior to admitting Patient #3 to the facility, but denied any sexual contact. DOO A stated he would be willing to take a drug test but was not tested after later admitting to drug use. The rape kit was inconclusive which was why the investigation was closed and there were no charges filed.

Review of policy titled "Drug-Free Workplace Policy," dated 12/01/2012 revealed applicants are drug-tested prior to hire, at random after hire, per reasonable suspicion, and quarterly for two years following completion of an alcohol or drug rehabilitation program.

Review of the Employee Handbook, dated March 2019, revealed "Company employees may not use, possess, distribute, sell, or be under the influence of alcohol or have illegal drugs present in their system while on Company premises or conducting any business-related activity away from Company premises." Regarding patient contact, each contact with patients should be professional. Regarding ethics, ethical business behavior was the responsibility of every employee. Failure to act in an ethical manner was cause for disciplinary action up to and including termination.

The facility failed to provide evidence drug testing was completed per the facility policy and the conditions for continued employment contained in the Plan of Correction for DOO A.

During a telephone interview conducted on 09/29/2023 at 9:18 AM, the Administrator confirmed the facility could not provide evidence that DOO A's conditions of continued employment had been monitored or met, including evidence of routine drug tests.