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Based on the findings of an Abbreviated Survey concluded on 08/08/18, it was determined the Condition of Participation for Patient Rights was not met by the facility. The facility failed to adopt and implement a comprehensive policy that addresses specific actions designed to protect patients from allegations of abuse during the investigation. The facility received an allegation of physical abuse from Patient #1 on 06/15/18 at 10:44 AM, alleging while Hospitalist #1 was performing an abdominal exam, the Hospitalist pulled up Patient #1's shirt and touched her breasts. However, the facility failed to protect Patient #1 and other patients from further potential abuse. After the facility was notified of the allegation, Hospitalist #1, the alleged perpetrator, was directed to have a chaperone with him while providing patient care pending the investigation. However, there was no documented evidence of specific staff assigned to Hospitalist #1, the alleged perpetrator, while providing continued patient care nor was there documented evidence Hospitalist #1 was monitored during the investigation. The facility "Hours Census" revealed Hospitalist #1 had seventeen (17) assigned patients during the time of the investigation from 06/15/18 at 10:44 AM, until the completion of the investigation on 06/15/18 at 6:31 PM. The patients were located throughout the hospital on the Medical Surgical Unit, Transitional Care Cardiac Unit, Intensive Care Unit and Cardiovascular Intensive Care Unit. (Refer to A0145)

The failure of the facility to adopt and implement a comprehensive policy that addresses specific actions designed to protect patients from allegations of abuse during the investigation
resulted in Patient #1 and other patients being at risk for for further potential abuse.

Based on interview, record review and review of facility Policies, it was determined the facility failed to ensure the patient has the right to be free from abuse for one (1) of ten (10) sampled patients (Patient #1).

On 06/15/18 at 10:44 AM, the facility was notified of an allegation of physical abuse towards Patient #1 by Hospitalist #1, the alleged perpetrator. The facility immediately initiated an investigation and directed Hospitalist #1 to ensure he had a chaperone during patient care. However, the facility failed to protect the patients as there was no documented evidence of specific staff assigned to Hospitalist #1 while providing continued patient care nor was there documented evidence Hospitalist #1 was monitored during the investigation from 06/15/18 at 10:44 AM, until the completion of the investigation on 06/15/18 at 6:31 PM. Per the facility "Hours Census", Hospitalist #1 had seventeen (17) assigned patients during the investigation which were located throughout the hospital on the Medical Surgical Unit, Transitional Care Cardiac Unit, Intensive Care Unit and Cardiovascular Intensive Care Unit. The facility failed to adopt and implement a comprehensive policy that addresses specific actions designed to protect patients from allegations of abuse during the investigation.

The findings include:

Review of the facility Policy titled "Patients' Rights and Responsibilities" dated 07/12/17, revealed patients have the right to receive support and protection of fundamental human rights, free from all forms of abuse.

Review of the facility Policy titled "Identification and Reporting of Victims of abuse, Neglect, Exploitation and Domestic Violence" dated 06/28/17, revealed the actual or suspected physical or sexual abuse of a patient by Saint Elizabeth Hospital Associate and believed to be committed on the property should be reported immediately to the supervisor or the Nursing Supervisor on duty. The Associate supervisor or the Nursing Supervisor should report to the Risk Management Department. Further review, revealed the Policy did not address investigation of an allegation of abuse or how to protect patients during the investigation of an allegation of abuse.

Review of the facility Physician Agreement titled "Physician Responsibilities" dated and initialed 07/01/12 by Hospitalist #1, revealed under applicable standards the Physician is responsible to perform all services in a cooperative, ethical, collegial and non-disruptive manner and in compliance with federal and state laws regulations and standards governing the practice of medicine. The Physician will independently exercise his/her judgement in accordance with good medical practice in the care and treatment of patients. Continued review revealed the Physician agrees not to practice his/her profession in conflict with any ethical and moral directives or standards applicable to or adopted by Saint Elizabeth Hospital.

Review of Patient #1's Medical Record revealed the facility admitted the resident 06/09/18 to the Unit 4 South West, and the patient was seen by Hospitalist #1 for the chief complaint of Abdominal Pain. The Patient was discharged on 06/12/18.

Additional review of Patient #1's Medical Record revealed the facility admitted the resident on 06/14/18 to the Unit 4 South, and the patient was seen by Hospitalist #2 with the chief complaint of Abdominal Pain.

Review of the "Saint Elizabeth Healthcare Patient Relations Worksheet Confidential Information", dated 06/15/18 at 2:00 PM, completed by the Patient Representative, revealed Patient #1 reported Hospitalist #1 lifted up her shirt during a stomach examination, and while she had her shirt covering her breast, he pulled her shirt up, exposing the breasts and grabbed both of them. Further review of the Worksheet, revealed the next day Hospitalist #1 told Patient #1 her anxiety issues caused health issues. Per the Worksheet, the allegation occurred a few days earlier on 06/12/18, and Patient #1 did not want to say anything about the allegation due to possible retaliation.

Review of the facility "Reporting Form (Summary)", dated 06/15/18, sent to the Cabinet for Health and Family Services (CHFS) Adult Protective Services (APS) on 06/15/18, revealed Patient #1 was admitted to the facility 06/09/18 through 06/12/18 during which time she was under the care of Hospitalist #1. Per the Summary, Patient #1 was likewise admitted under the care of Hospitalist #1 during the 06/14/18 admission. On 06/15/18, the Patient contacted a patient advocate to lodge a complaint that during the 06/09/18-06/12/18 admission, Hospitalist #1 had "lifted up her shirt while doing a stomach examination, and pulled up her shirt to expose her breasts, and also grabbed both breast." Upon the facility learning of the allegation, Patient #1 was assigned to a different Hospitalist. Hospitalist #1 denied the allegation, stating although he did perform an abdominal examination, it was uneventful and he did not expose or touch the patient's breast. A review of Hospitalist #1's credentialing information revealed no prior history of any such complaints from any patient. Further review of the Summary, revealed the investigation performed to date indicated the patient made no mention of the allegations during the prior admission, nor when the physician was initially assigned to care during the current admission, and the allegation was only made after the physician refused to continue the prescription of narcotics. Per the Summary, Hospitalist #1 was removed from Patient #1's care, but was allowed to continue to treat other patients as the facility could not substantiate the allegation.

Interview on 08/06/18 at 3:30 PM, with the Patient Representative, revealed Patient #1 requested a different Hospitalist upon admission on 06/14/18, but did not state why she did not want Hospitalist #1 on that date. Per interview, on 06/15/18 Patient #1 made a complaint concerning her prior admission dating 06/09/18 through 06/12/18. The Patient Representative stated Patient #1 alleged on 06/12/18, Hospitalist #1 pulled up her top and held her breasts and stated he needed to see the breasts during the abdominal exam. However, per interview, Patient #1 did not make the accusation until 06/15/18 after she learned narcotic pain medications had not been prescribed. Per interview, on 06/15/18 the Patient Representative notified the Unit 4 South Nurse Manager and Risk Management of the allegation.

Phone interview was attempted with Patient #1 by the State Agency Representative on 08/06/18 at 8:57 AM, and a message was left; however, the call was not returned.

Interview on 08/07/18 at 10:15 AM, with the Registered Nurse (RN) /Assistant Manager Unit 4 South, revealed Patient #1 requested another Hospitalist upon admission on 06/14/18; however, did not make an allegation of abuse at that time. Per interview, Hospitalist #2 saw Patient #1 as requested on admission, 06/14/18.

Interview on 08/07/18 at 10:42 AM, with the RN/Manager Unit 4 South, revealed Patient #1 was admitted to the Unit on the evening of 06/14/18. She stated every morning she conducted patient rounds on the Unit, but was not notified of the allegation made by Patient #1 until 06/15/18 by the Patient Representative. Per interview, the allegation by Patient #1 occurred after the narcotic pain medication was not prescribed for the patient. Further interview revealed she notified Risk Management of the allegation.

Interview on 08/07/18 at 4:20 PM, with RN #2 who worked Unit 4 South West, revealed during Patient #1's admission from 06/09/18 through 06/12/18, there were no concerns voiced related to Hospitalist #1. Per interview, Patient #1 would always ask for narcotic pain medications on the minute that the medication was due or before the medication was due. Continued interview revealed Patient #1 had mood swings and behaviors. Per interview, Patient #1 would tell you she loved you, and the next day you were her worst enemy.

Interview on 08/06/18 at 3:50 PM, with RN #1, who worked 4 South West, revealed Patient #1 was admitted to 4 South West on 06/09/18 through 06/12/18, and wanted pain medication prior to time for administration. Per interview, Patient #1 would "trash talk" staff if the pain medications were not administered on time. Further interview revealed during prior admissions, Patient #1 had not expressed any concerns about any Medical Doctor or Hospitalist being inappropriate. Additional interview revealed she assisted Hospitalist #1 in the past during patient care, and was unaware of any inappropriate behavior by the Hospitalist with patients.

Interview on 08/07/18 at 8:20 AM, with the Unit 4 South West Manager, revealed the Patient Representative informed her concerning the allegation by Patient #1 on 06/15/18. She stated she was not aware of the allegation of an inappropriate touch by Hospitalist #1 from the prior admission, and when she was notified of the allegation, she notified Risk Management.

Interview on 08/07/18 at 10:25 AM with Hospitalist #1, the alleged perpetrator, revealed Patient #1 did not voice any concerns about treatment during her first hospital stay 06/09/18 through discharge on 06/12/18. Per interview, Patient #1 had agreed to cut back on her pain medications and had an appointment to the Hepatic Clinic for follow up. He stated Patient #1 was re-admitted to the hospital on 06/14/18 with the same complaint of abdominal pain. He further stated it was hospital policy to keep your original Hospitalist, but he was informed by one of the nurses or the Nurse Manager, that Patient #1 requested another Hospitalist upon the 06/14/18 admission.

Continued interview with Hospitalist #1, revealed during Patient #1's admission from 06/09/18 through 06/12/18, he examined the patient's abdomen, scar areas and right shoulder PICC line(peripherally inserted central catheter line which is inserted into the arm). He stated he was looking for signs of infection, pain in the abdomen and checked for an infected port site. He further stated during this admission he only examined Patient #1 three (3) times. Per interview, he always had another staff member with him during examinations except there was one (1) time he did not have another staff member with him when he examined Patient #1. Additional interview revealed the Chief Medical Officer (CMO) informed him of the allegation and instructed him verbally to always have a witness during all patient care. Per interview, Patient #1 was assigned to another Hospitalist and he continued to provide care to other patients. He confirmed he did have other staff members with him during patient visits and examinations during the investigation; however, he could not recall which staff.

Interview on 08/07/18 at 11:00 AM, with Hospitalist #2, revealed Patient #1 was admitted on 06/09/18 with abdominal pain and received pain medication, felt better, and was discharged on 06/12/18. Per interview, the patient was re-admitted again on 06/14/18 due to abdominal pain. He stated Patient #1 did not discuss the allegation related to Hospitalist #1 grabbing her breasts with him. Further interview revealed during examination of Patient #1 06/15/18, he observed there was no bruising of the skin. He further stated he always ensured a nurse was present during patient exams.

Interview on 08/06/18 at 3:00 PM, with the Risk Manager, revealed the Patient Representative reported the allegation related to Patient #1 being touched inappropriately by Hospitalist #1 on 06/15/18. Per interview, the investigation was immediately initiated on 06/15/18 and was concluded the same day. Further interview revealed he spoke with Patient #1 to explain the seriousness of the allegation and told the patient the allegation would be investigated. He further stated he talked with nursing staff from the prior patient admission 06/09/18-06/12/18, and staff reported no voiced concerns or allegations by Patient #1. The Risk Manager stated Hospitalist #1's abuse background checks revealed no concerns and his employee file revealed there were no past allegations. Further, the Grievance Reports were reviewed for any prior concerns or allegations for Hospitalist #1 with no other allegations documented.

Continued interview with the Risk Manager, revealed a Self Report was made to the Cabinet for Health and Family Services (CHFS) Adult Protective Services (APS) on 06/15/18. Additional interview revealed there was no written policy to address how to investigate/protect patients during an investigation of an allegation of abuse. However, he stated facility protocol was to remove the Non Clinical and Clinical staff who were accused of an allegation from the facility during the investigation. Additional interview revealed during an abuse investigation, if the alleged perpetrator was a Medical Doctor or Hospitalist, they were removed from the Patient's care who made the allegation, but were allowed to work with other patients as long as other staff were present during exams.

Interview on 08/08/18 at 9:03 AM, with the Director of Patient Safety and Infection Control, revealed the Nurse Managers for units 4 South and 4 South West could not identify who chaperoned Hospitalist #1 during the investigation.

Review of the facility "Hours Census", revealed Hospitalist #1 had seventeen (17) assigned patients during the investigation on 06/15/18 from 10:44 AM through 06/15/18 at 6:31 PM. The patients were located throughout the hospital on the Medical Surgical Unit, Transitional Care Cardiac Unit, Intensive Care Unit and Cardiovascular Intensive Care Unit.

Interview on 08/07/18 at 1:45 PM, with the Chief Medical Officer (CMO), revealed it was facility practice to always have another staff member present when a physician or Hospitalist was performing patient examinations. Per interview, if there was an allegation of a staff member abusing a patient, the staff member/alleged perpetrator were to be removed from patient care pending the investigation. However, he stated if the alleged perpetrator was a Physician or Hospitalist they would be chaperoned during patient care pending the investigation. He further revealed there was no written policy to address investigation of an allegation of abuse or protecting the patients during the investigation.

Continued interview with the CMO, revealed the Risk Manager notified him of the allegation related to Hospitalist #1 touching Patient #1 inappropriately, and he and the Risk Manager conducted the investigation. He stated he reviewed Hospitalist #1's employee file for past allegations of abuse or touching patients inappropriately and found no past history of allegations. Continued interview revealed he notified Hospitalist #1 of the allegation and educated him to have a chaperone during patient care. However, the CMO stated there was no specific staff assigned to Hospitalist #1 while providing continued patient care nor was there a system in place to monitor Hospitalist #1 during the investigation. The CMO further stated he did not know how many patients Hospitalist #1 saw during the investigation. Additional interview revealed the facility should have ensured Hospitalist #1 had a chaperone for patient visits after the facility learned of the allegation, and should have ensured there was documented evidence of this.