HospitalInspections.org

Based on medical record (MR) review, document review and interview, in one (1) of one (1) sexual abuse allegations, the facility failed to implement their sexual abuse allegation policies.

This failure placed all patients at increased safety risk.

Findings:

- The facility failed to identify, report/escalate, and investigate a patient's allegation of sexual abuse (See Tag A-0118).

Based on medical record (MR) review, document review and interview, in one (1) of one (1) sexual abuse allegations, the facility failed to identify, report/escalate and investigate a patient's allegation of sexual abuse.

This failure placed all patients at increased safety risk.

Findings:

Review of Patient #1's MR identified that on 12/29/2021 at 3:40PM, Patient #1 presented to the Valley Stream Emergency Department (ED) via ambulance with complaints of abdominal pain. Patient #1 was alert and oriented to person, place, and time. She was treated and discharged home on 12/30/2021 at 2:31PM.

On 12/30/2021 at 5:50PM, Patient #1 presented to the New Hyde Park ED via ambulance with a complaint of sexual abuse that occurred in the Valley Stream ED. The patient was treated and discharged home on 12/31/2021 at 10:40AM.

The facility's Incident Report List from 6/1/2021 to 1/6/2022 identified the facility had no Incident Reports for this allegation of abuse.

The facility's Complaints and Grievances List dated from 6/1/2021 to 1/6/2022 identified the facility had no grievance listed for this allegation of abuse, nor reports of internal investigations conducted.

The facility policy and procedure (P&P) titled, "Management of Patient Complaints and Grievances," last dated 4/1/2020, defined "patient harm" and "abuse" as a grievance and stated, "All grievances will be entered in the electronic reporting system;" and "Reports on grievance investigations, resolutions, and corrective actions will be reported at the site Performance Improvement Coordinating Group and the Medical Board."

The policy further stated, "All complaints will be reviewed, responded to and resolved by the staff present. Whenever possible, staff is empowered to immediately resolve complaints and to offer appropriate service recovery. If the staff member receiving the complaint cannot immediately resolve the issue, the staff member will escalate the complaint to the appropriate staff member for resolution."

The facility P&P titled, "Abuse and Neglect/Mistreatment Allegation of Patients," last dated 12/14/2021, stated the following: "A full investigation of the incident will be done by the facility immediately;" "Allegations of abuse or neglect must be reported to Quality Management and Risk Management;" and "The department supervisor or manager, in conjunction with Quality Department and Human Resources, will begin an immediate and comprehensive investigation."

The policy further stated, "An allegation against an employee or other Healthcare Provider regarding patient abuse, neglect or mistreatment must be immediately escalated to the employee's/Healthcare Provider's supervisor or manager. The department or managing supervisor must immediately inform site specific leadership, including: Quality Management (the Associate Executive Director/Quality Site Leader, Chief Nursing Officer/Associate Executive Director for Patient Care Services or Chief Medical Officer) who will escalate to other site leadership as indicated."

Upon request, the facility could not furnish any documented evidence this sexual abuse allegation was identified as an Incident and/or Grievance, entered into the facility's Electronic Reporting System, reported/escalated, reviewed and internally investigated. The facility could not furnish documented evidence that Patient #1 ' s allegation of abuse was communicated from the receiving campus (New Hyde Park ED) to its sister campus (Valley Stream ED) where the alleged abuse occurred.

During interview of Staff A (Quality Manager) on 1/6/2022 at 4:30PM, Staff A confirmed that the Quality Management Department was not aware of this sexual abuse allegation, and that no internal investigation was performed.