HospitalInspections.org

Based on interview, record review, and review of the facility's policies and documents, it was determined the facility failed to ensure that each patient's rights were protected and promoted by failing to ensure the facility's policy and procedure protected patients from abuse as evidenced by allowing an employee accused of sexual abuse to continue to provide care to vulnerable patients while the facility was in the process of investigating the allegations.

The findings include:

Review of the facility's policy #P29, titled "Notification of Patient Rights and Notification of Admission to the Facility", dated 02/15, revealed the facility shall notify all patients of their rights upon admission.

Review of the facility's "Patient Rights and Responsibilities", undated, revealed a patient has the right to safe, respectful and dignified care at all times and will receive services and care that are medically suggested and within the hospital's services, its stated mission, and required law and regulation. Further review revealed a patient and the family/guardian have the right to expect a timely response to any complaint or grievance made to the facility.

Review of the facility's policy #A01, titled "Abused, neglected, or exploited children or adults", dated 04/14, revealed the purpose of the policy was to ensure the safety of patients served. Continued review of policy #A01 revealed under the section Procedure, revealed any staff member suspecting abuse, neglect, or exploitation shall immediately report the case to the appropriate supervisor and the supervisor shall gather information, investigate, and if the case meets statutory regulations for reporting, report the case to the appropriate authorities for further investigation. Further review revealed employees who are accused of abuse may be suspended or given leave pay, pending investigation of the accusation. Such staff may also be removed from patient/other services areas and given a job that does not require patient interaction. Additionally, all incidents of actual or suspected neglect or abuse shall be thoroughly investigated and no accusation or affirmation of guilt will be made until the Adult Protective Services and any internal hospital investigation is complete.

Record review revealed the facility admitted Patient #1 on 07/22/15 with a diagnosis of Anoxic Brain Injury which is a condition when the brain was deprived of oxygen for a period of time which causes brain cells to die resulting in permanent brain injury.

Review of Registered Nurse (RN) #1's statement sent to the Nurse Supervisor, on 08/24/15 at 2:56 AM, revealed she had helped Certified Nursing Assistant (CNA) #1 to transfer Patient #1 to the bed and was preparing the patient's medication when she left the room to receive a phone call from a physician. RN #1 then stated when she returned to the room, Patient #1 was quiet and watching TV. RN #1 stated she made an assessment, administered medications and changed the G/T dressing and then left the room to do some charting. RN #1 then stated a few minutes later she was asked by CNA #1 to return to the room. Upon returning to the room, it was reported to RN #1 by Patient #1's mother, that Patient #1 indicated to the mother that he/she had been touched inappropriately in the perineal area. RN #1 further stated she informed the Charge Nurse of the allegations and changed care assignment of Patient #1 to the Charge Nurse. RN #1 further documented the complainant came to the nursing station three (3) or four (4) times asking when the Night Supervisor would be coming to the unit.

Attempted to contact the Registered Nurse (RN) #1, on 09/03/15 at 9:53 AM, but telephone was not answered and was not able to leave a message.

Review of CNA #1's statement sent to the Nurse Supervisor, on 08/24/15 at 1:42 AM, revealed the incident occurred between 10:00 PM to 10:30 PM on 08/23/15. CNA #1 stated RN #1 helped to get Patient #1 into the bed after a shower, cleaned the G-tube site, listened to bowel sounds, and gave her medications. Further review revealed CNA #1 had sent this statement to the Nurse Supervisor under the direction of the Night Supervisor.

Interview with CNA #1, on 09/03/15 at 10:00 AM, revealed she did not talk to the Night Supervisor on the night the incident occurred and further stated no supervisors had spoken with her regarding the allegations except for the Nurse Supervisor calling her to inform her Adult Protective Services (APS) would be contacting her regarding the incident.

Interview with the Charge Nurse, on 09/03/15 at 9:55 AM, revealed she talked to the complainant and changed assignments with RN #1 but stated RN #1 continued to provide care to other patients on the Acquired Brain Injury (ABI) Unit. The Charge Nurse stated the Night Supervisor did come up to the unit and she spoke with her but was not sure if the Night Supervisor interviewed any other staff members. The Charge Nurse further stated she had not been contacted by any other supervisors regarding this incident.

Interview with the Night Supervisor, on 09/03/15 at 10:08 AM, revealed she arrived to the Acquired Brain Injury (ABI) unit at approximately 1:00 AM on 08/24/15. The Night Supervisor stated she did not interview the complainant due to the complainant was sleeping and informed staff to refer the complainant to the Nurse Supervisor later that morning. The Night Supervisor stated she interviewed the Charge Nurse and RN #1 but no other staff members. When asked about RN #1 continuing to provide care to other patients, the Night Supervisor stated when concerns happened at night, the staff was generally reassigned patients but during the day shift, staff members were generally suspended and sent home. The Night Supervisor further stated she was not aware the abuse allegations also included CNA #1 until later during the week.

Review of the facility's investigation revealed no documentation by neither the Charge Nurse nor the Night Supervisor regarding any initial investigations into the allegations of abuse by RN #1.

Interview with the Nurse Supervisor, on 09/03/15 at 10:30 AM, revealed she was not aware of the abuse allegations until she checked her e-mail on the morning of 08/24/15 and read the e-mails from RN #1 and CNA #1. The Nurse Supervisor denied speaking with the Night Supervisor regarding this incident. The Nurse Supervisor stated she was unsure of the procedures to follow concerning the allegation and contacted both Risk Management and the Nurse Manager. The Nurse Supervisor stated she interviewed RN #1 as well as Patient #1 and the complainant.

Review of the Nurse Supervisor investigation revealed an interview with the complainant, undated and untimed, regarding the allegations were submitted.

Interview with the Nurse Manager, on 09/03/15 at 11:00 AM, revealed her expectation of the Night Supervisor would be to investigate the situation the best they could and to talk to all staff involved in the complaint. The Nurse Manager stated the investigation would not have been thorough if all staff members and other persons involved were not interviewed. The Nurse Manager further stated the Night Supervisor had unsubstantiated the allegations but was unable to discuss or produce any documentation of any investigation being initialed by the Night Supervisor.

Interview with the Administrator, on 09/03/15 at 1:40 PM, revealed the facility's policy regarding employees accused of abuse did not state the employee must be removed from providing patient care depending on the situation. The Administrator stated he felt the supervisors present who initiated the investigation had unsubstantiated the allegations from the information gathered and felt allowing the staff member accused of abuse to continue providing care, prior to the completion of the investigation, was appropriate.