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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 hospital staff abuser resulting in the potential for unsatisfactory outcomes for all patients served by the facility. Findings include:

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A-0145 Failure to ensure a method was in place to ensure that patients are free from all forms of abuse, neglect, or harassment

Based on interview and document review, the facility failed to develop and implement policies to ensure the prevention and protection of patients from an alleged hospital staff abuser resulting in the potential for unsatisfactory patient outcomes for all patients served by the facility. Findings include:

During an interview with Confidential Informant (CI) #1 on 7/22/2022 at 1136, CI #1 stated Patient #1 had stated a staff member had put her hand down his pants and "groped" him. After this incident, Patient #1 had noticed a "pimple" on his penis and thought he had developed a sexually transmitted disease (STD).

Review of the medical record for Patient #1 on 7/27/2022 at 1300 revealed he was a 19-year-old male who was admitted to the facility from 5/18/2022-5/27/2022 for unspecified psychosis with auditory hallucinations, paranoia, responding to internal stimuli, disorganized thought processes, and bizarre delusions. There was a history of "sexual abuse and psychological trauma."

Review of the physician progress notes and nursing notes revealed no statements or complaints by the patient regarding the alleged incident. There was no indication that Patient #1 was sexually preoccupied or sexually aggressive; although he did admit to having sex for money. It was unclear in the medical record as to if this was part of the patient's psychosis versus reality.

On 7/27/2022 at 1231, review of the Complaint/Grievance Log from 1/2022-present, the Incident Report Log from 1/2022-present, and the Recipient Rights Log from 1/2022-present revealed no entries regarding inappropriate touch and/or sexual assault of Patient #1.

An interview with the alleged perpetrator, Social Worker Staff E, mentioned in the complaint to the State Agency, occurred on 7/28/2022 at 0858. She stated part of her job was to conduct 1:1 sessions with patients including patients who were "isolative." Staff E did recall Patient #1, described him as being isolative, and stated she had met privately with him in his room for a 1:1 session which was permissible within the facility. Staff E denied having put her hand down Patient #1's pants "groping" him, denied touching his private areas through his clothing, and denied having ever touched him at all.

Review of facility policy #11278899 titled, "Tier 1: Investigation of Sexual Misconduct Allegations" effective 2/28/2022 stated, "(Health System Name) has zero tolerance for any type of assault including but not limited to inappropriate touching, sexual contact, or sexual misconduct of a patient by (health system) Staff... Upon notification of the patient complaint, Human Resources will...Collaborate with Area Leadership to determine whether involved Staff member should be placed on temporary paid leave, unpaid leave or be allowed to continue to work pending further investigation. This decision depends upon the facts of the case at the time and what is determined to be in the best interest and safety for all... Based upon the facts and circumstances of the situation, the HR (human resources) BP (business partner) should: a. Pending the investigation, consider allowing the involved Staff to continue working chaperoned during all patient encounters..."

Quality Director Staff C was read a portion of the above policy on 7/28/2022 at 1019 and was queried as to why the policy did not reflect staff members being immediately removed from all patient care pending investigation to which she stated, "Our practice is to suspend."