HospitalInspections.org

Based on interview, record review, and review of Policy and Procedure the Governing Body failed to ensure clear expectations of patient safety were implemented by the Quality Assurance Performance Improvement program (QAPI). The QAPI system failed to analyze and react to adverse incidents after four allegations by three patients (Patient #1, #6, and #14) of sexual abuse by two staff members (Staff A, and Staff D). The Governing Body failed to ensure QAPI developed and implemented measures to prevent further occurrences of sexual abuse.

The condition is not met due to the failure of the Governing Body to ensure a functioning QAPI system investigated, tracked, and trended sexual abuse. The board and administration failed to ensure sentinel events were thoroughly investigated including completion of a root cause analysis. The facility also failed to ensure interventions were put in place to prevent potential incidents of abuse. These contributed to the Immediate Jeopardy of patients in the hospital and the behavioral unit. Refer to A0057 - Chief Executive Officer, A0263 - QAPI and A0115 - Patient Rights. The hospital was informed of this on 11/8/21 at 5:37 p.m.

The Immediate Jeopardy was removed on 11/10/21 at 12:30 p.m. after the hospital provided documentation and demonstrated they had revised the process that all serious adverse/sentinel events are reported to the Governing Body and corrective actions are taken to ensure an effective QAPI system is in place to investigate cases, and to develop and implement interventions to ensure immediate patient safety and prevention of sexual abuse. The hospitals QAPI department and Governing Body provided documentation and showed that all departments were involved with input regarding quality measures that were implemented to ensure there were no opportunities for further sexual abuse, and corrective action plans were in place to ensure the hospital would audit interventions and monitor ongoing compliance of quality indicators/interventions that were put in place.

Based on interviews, medical record review, hospital document review, and Governing Body meeting minutes review, the Governing Body (Executive Board) appointed a chief executive officer (CEO) who is responsible for managing the hospital.

The CEO failed to: a) direct the administrative team investigation once it was determined that allegations of sexual abuse was reported by Risk Management; b) to ensure that a quality systems review was performed; c.) to ensure that QAPI department developed and implemented quality measures to prevent further sexual abuse upon the allegations of sexual abuse of three (3) vulnerable adults (Patient #1, Patient #6, and Patient #14) by two (2) facility staff members, Staff A and Staff D. Patient #1 and #14 alleged the sexual abuse occurred in the behavioral unit by mental health technician Staff D. Patient #1 and #6 alleged the sexual abuse occurred in the hospital by Staff A who was assigned to be a sitter for both patients to prevent them from harming themselves or others.

The Chief Executive Officer and the Executive Board failed to ensure a Quality Assurance Performance Improvement (QAPI) program investigated, tracked, and trended allegations of sexual abuse, ensured completion of root cause analyses, and provided interventions that were audited to ensure compliance for the prevention of further sexual abuse in both the hospital and the behavioral unit.

The systemic failure to ensure a functioning QAPI system investigated, tracked, and trended sexual abuse, ensured the root cause analysis of serious adverse/sentinel events, and developed and implemented measures to prevent the opportunity for further abuse caused Immediate Jeopardy to the safety of patients in the hospital and the behavioral unit. The hospital administration was informed of this on 11/8/21 at 5:37 p.m.

The Immediate Jeopardy was removed on 11/10/21 at 12:30 p.m. after the hospital demonstrated they had revised the process that serious adverse/sentinel events are reported to the Governing Body and actions were taken to ensure a QAPI system was in place to investigate cases and an effective system to develop and implement interventions to ensure immediate patient safety and prevention of sexual abuse. The hospital showed all departments were involved in input regarding interventions put in place to ensure there was no opportunity for further sexual abuse, and a plan was in place to ensure the hospital would audit interventions and monitor on-going compliance of interventions put in place.

The findings included:

A review of the Director of Risk Management and Patient Safety job description found the Risk Manager is "responsible for coordinating, implementing, and directing the Risk management, Patient Safety and High Reliability Program to maintain an environment where patients and staff are safe ..." The duties of the Risk Manager include but are not limited to: "16. Serves as the Patient Safety Officer and directs the Patient Safety Program, including facilitating systems analysis to promote and improve patient safety, ... 20. Promotes Risk management by the identification, investigation, root cause analysis and evaluation of risks and the selection of the most advantageous method of correcting, reducing, or eliminating identifiable risks. The purpose of the hospital risk management function is to coordinate and facilitate the activities ... to prevent patient harm. 21. Analyst in the Cause Analysis process in response to a safety event by investigating the event, determining the sequence of events and proximate causes, determining the individual and system failures, and confirming the Root Causes. Assists and supports Operational Leaders with developing root solutions to identified root causes." In regard to Safety, the Risk Manager, "3. ... ensures stabilization of the immediate situation, assists in information gathering, operationalizes correct actions for root causes and promotes organization learning."

In an interview on 11/3/21 at 2:00 p.m. the Chief Quality Officer (CQO) said she had not reported the root cause analyses of the sexual abuse allegation investigations to the Patient Safety Committee or the Executive Board because she was waiting on the Report from the Agency for Health Care Administration to be issued to the hospital after the surveyors had exited on 10/6/21.

In an interview on 11/6/21 at 3:30 p.m., the Chief Administrative Officer (CAO) said the Risk Manager reports the occurrence of adverse incidents/sentinel events to the hospital administrative team. The CAO said neither he nor the CQO reported the sexual abuse incidents to the Executive Board. The CAO said he did not oversee review of Abuse and Patient Sitter Policies and Procedures in response to allegations of sexual abuse and did not direct implementation of measures to ensure no recurrence of sexual abuse.

A review of the Governing Board minutes dated February 11, 2021, May 13, 2021, June 10, 2021, and October 14, 2021, found no reference to allegations of sexual abuse.

In an interview on 11/9/21 at 10:00 a.m. The Chief Nursing Officer, who is a member of the Patient Safety Committee, said she would expect that the hospital process would be followed, and a root cause analysis would be completed within 24 hours of the allegations on 7/16/21 and 7/18/21. She said she would expect training and auditing of staff to ensure patient safety.

In an interview on 11/9/21 at 11:00 a.m. The Director of Laboratory Services who is a member of the Patient Safety committee said she was never made aware of the multiple allegations of sexual abuse or the two staff members involved. She stated she would expect the hospital to put interventions in place to ensure supervision of both the hospital and the behavioral unit to ensure patient safety.

In an interview on 11/9/21 at 1:30 p.m. the Medical Director of the Behavioral Unit said he was not aware of the allegations Patient #1, admitted 5/19/21 to the behavioral health unit under Baker Act for threat of harm to others, had reported to staff on 6/2/21 regarding Staff D sexually abusing her during the previous 2-3 nights (approximately May 30-31, 2021). An event report was generated by the facility, however, there is no documentation the facility implemented the abuse protocol. No Root Cause Analysis was produced, and no documentation of interventions was provided. The Medical Director said Patient #14 admitted 10/7/21 with a diagnosis of Major Depression had told him on 10/15/21 about being sexually abused on 10/12/21 by Staff D. The Medical director said he reported the allegation to the charge nurse. The nursing notes, dated 10/15/21, documented the patient's detailed description of the unwanted encounters. An event report was generated by the facility, however, there was no documentation the facility implemented the abuse protocol. No Root Cause Analysis was produced, and no documentation of interventions was provided. There is no reference in the physician notes in the patient record of the unwanted encounter with the Mental Health Technician for the dates 10/12/21 through 10/16/21. The Medical Director said we need to listen and take allegations of abuse seriously.
In an interview on 11/9/21 at 4:00 p.m., the Hospital Chief Medical Officer said he was recently made aware of the allegations but was not given many details regarding the allegations. He said there would be an Executive Board meeting in two weeks and if Risk Management wanted to attach the allegations the board would review what was needed to be reviewed and give their recommendations.

The occurrence of four sexual assault events reported by three patients was not responded to with the full measure of the hospital abuse protocol by the facility staff members and officers whose duty it was to act.

Based on medical record review, review of facility documents, review of policy and procedure, and interviews, the hospital failed to ensure a safe environment free from sexual abuse for three of five patients surveyed (Patient #1, #6 and #14) for allegations of sexual abuse.

The Condition of Participation is not met due to:

1. The hospital failed to provide information to the victim of sexual abuse related to evidence collection, Hepatitis B testing, Human Immunodeficiency Virus testing, prevention of pregnancy, and crisis intervention related to sexual assault as provided by the hospital Emergency Department. (Refer to A0131)

2. The hospital failed to report to the police knowledge of an inappropriate sexual relationship with a hospital staff member and Patient #1 while Patient #1 was in the hospital on a Baker Act (involuntary psychiatric admission). The facility further failed to appropriately investigate allegations of sexual abuse regarding three patients (Patients #1, #6 and #14) and implement corrective actions. The hospital failed to provide supervision of sitters and CNAs to eliminate the opportunity for the staff assigned to vulnerable adults to be sexually inappropriate with Patient #1 and #6. After being informed on 10/6/21 by the police of an on-going police investigation of staff member (Staff D) for sexual misconduct, the hospital allowed Staff D to continue working with vulnerable adults. On 10/15/21 Staff D was alleged to have been sexually inappropriate with Patient #14. (Refer to A0145)

The failure of the hospital to act to ensure patient safety for vulnerable adults caused Immediate Jeopardy to the safety of patients at the hospital and the behavioral unit. The hospitals administrative team was informed of this on 11/8/21 at 5:37 p.m.

The Immediate Jeopardy was removed on 11/10/21 at 12:30 p.m., after the hospital demonstrated they had revised the process that serious adverse/sentinel events are reported to the Governing Body and actions were taken to ensure a QAPI system was in place to investigate cases and develop and implement interventions to ensure immediate patient safety and prevention of sexual abuse. The hospital showed all departments were integrated and involved regarding measures implemented to ensure there was no opportunity for further sexual abuse and a plan was in place to ensure the hospital would audit interventions and monitor on-going compliance of interventions put in place.

Based on interviews, medical record reviews, review of policy and procedure, and review of event reports, the hospital failed to inform one of five patients surveyed for allegations of sexual abuse (Patient #1) of the services provided by the hospital related to evidence collection, Hepatitis B testing, Human Immunodeficiency Virus testing, prevention of pregnancy, and crisis intervention related to sexual assault as provided by the hospital Emergency Department. Failure to provide information related to these services left the patient (Patient #1) with the inability to make an informed decision regarding her physical and mental health.
"Sexual abuse is unwanted sexual activity, with perpetrators using force, making threats, or taking advantage of victims not able to give consent. Most victims and perpetrators know each other. Immediate reactions to sexual abuse include shock, fear, or disbelief. Long-term symptoms include anxiety, fear, or post-traumatic stress disorder. (American Psychological Association, 2021)."

The facility's failure to take immediate action and protect a vulnerable patients' rights to be free from sexual abuse resulted in noncompliance at the Immediate Jeopardy level starting on 7/16/21.

The Administrator was notified of the Immediate Jeopardy on 11/8/21 at 5:37 p.m. and provided the IJ templates. After the facility submitted an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed on 11/10/21 at 12:30 p.m.

The findings included:

According to the hospital policy, "Sexual Assault", number ED159, effective date 9/1995 and revised 07/02, 06/07, and 03/18, "it is the responsibility of the Emergency Department staff to provide confidential care and examination of the suspected sexual assault victim; to collect legal specimens properly when suspected rape has occurred; provide initial crisis intervention, medical care and follow-up care . . . K. The Emergency Department Nurse will gather evidence, utilizing the sex crimes kit. Document exam on nurse's notes. The Emergency Department Physician will gather medical evidence and complete the medical exam. HIV and Hepatitis testing will be offered. Give discharge instructions and administer medications for sexually transmitted diseases and pregnancy prevention as ordered by Emergency Room Physician".

Review of the policy "Abuse of Patients, Elderly, or Disabled Persons, Assessment and Reporting", Number RI 118, effective date 9/13/94, revised 4/97, 2/00, 7/00, 6/02, 6/07, 4/09, 8/09, 3/11, and 9/13 reads, "If a patient alleges that they have been sexually assaulted while a patient at [hospital], an investigation by law enforcement will take place and the patient will be taken to the Emergency Department for the collection of evidence".

A review of the "Report of Law Enforcement initiating Involuntary Examination" shows Patient #1 was brought to the Emergency Department under a Baker Act on 7/13/2021 at 3:37 a.m. A Baker Act is initiated by law enforcement or Medical Staff when it is determined a person is a danger to themselves or others and due to their mental health decline, the patient is unable to voluntarily submit to a mental health examination.

A review of Patient #1's medial record, upon admission to the hospital, Patient #1 with a diagnosis of acute psychosis, was placed on 15-minute checks due to her being under a Baker Act commitment. Documentation of every 15-minute checks shows Certified Nursing Assistant Staff A was assigned to monitor Patient #1 on 7/14/21 from 7:00 a.m. to 7:00 p.m., on 7/15/21 from 7:00 a.m. to 7:00 p.m., and on 7/16/21 from 7:00 a.m. to 12:00 p.m. Patient #1 remained in the hospital under a Baker Act commitment from 7/13/21 until 7/16/21 at 12:29 p.m. when the Baker Act was lifted. Patient #1 was discharged on Friday, 7/16/21.

In an interview on 10/5/2021 at 11:32 a.m., Nursing Supervisor Staff B said she received a call on 7/18/21 in the afternoon from Patient #1. The patient reported she had been attacked by a sitter while she was a patient at the hospital. Nursing Supervisor Staff B said she took Patient #1's phone number and told her a Patient Advocate would be in touch with her. Staff B said the patient Advocate tried to return the call to patient #1 on 7/18/21 but was unsuccessful because the phone number was wrong.

In an interview on 10/5/2021 at 11:40 a.m., Patient Advocate Staff C, said Patient #1 called the facility again on 7/19/21. Staff C said Patient #1 reported she had been sexually assaulted by a hospital employee while she was a patient at the hospital. Staff C reported the allegation to the hospital Risk Manager who took Patient #1's statement on 7/19/21.

A review of an incident report dated 7/19/21 includes a statement written by the Risk Manager: "Patient #1 states that [Staff A] abused her three times sexually, once in the shower and twice on a recliner chair. Patient #1 states the first morning she was on the medical unit of the hospital [Staff A] was her sitter and she felt he was a little too friendly. She says he kept drawing on her face with his finger and caressed her face. She [Patient #1] said she pushed his hand away. She states she threw her cup at him. She said she needed assistance in the shower and that is where the first sexual encounter was from behind. Patient #1 said the other two times he forced himself on her in the recliner chair. She states that all three times he did penetrate her to orgasm. She states she has shorts, wash cloth and pad that has his semen on them. She states she is afraid because he came to her house Friday night uninvited, and she states she does not know how he got her phone number." The Risk Manager then documents he advised Patient #1 to contact the police. There was no documented evidence that the Risk Manager had reported the alleged sexual abuse allegations to law enforcement.

In an interview on 10/6/21 at 9:25 a.m., the Risk Manager stated he had spoken with both Patient #1 and Staff A on 7/19/21. The Risk Manager said that from interviews and his review of the text messages on Staff A's phone he determined Staff A had had an inappropriate relationship with Patient #1 while she was Baker Acted at the hospital. The Risk Manager said he never reported the relationship, the text messages, or the victims' statements to the police. The Risk Manager verified he had not requested the victim (Patient #1) to come to the Emergency Department to collect the evidence she stated she had, and he had not offered her sexually transmitted disease testing or any type of crisis intervention services through the hospital Emergency Department as per hospital policy.

Based on interview, record review, review of policy and procedure, and review of event reports, the hospital failed to ensure 3 (Patients #1, #6, and #14) of 5 patients surveyed were free from sexual abuse. The hospital failed to ensure Staff D and Staff A, who were sitters for patients, were supervised and did not have the opportunity to sexually assault patients. The hospital failed to provide documentation of a thorough investigation of all reported allegations of sexual abuse and failed to ensure interventions were in place for the prevention of sexual abuse in the hospital and the behavioral unit of the hospital for all patients.

"Sexual abuse is unwanted sexual activity, with perpetrators using force, making threats, or taking advantage of victims not able to give consent. Most victims and perpetrators know each other. Immediate reactions to sexual abuse include shock, fear, or disbelief. Long-term symptoms include anxiety, fear, or post-traumatic stress disorder. (American Psychological Association, 2021)".


The facility's failure to take immediate action and protect vulnerable patients' rights to be free from sexual abuse by Staff D and Staff A resulted in noncompliance at the Immediate Jeopardy level starting on 7/16/21.

The hospitals administration was notified of the Immediate Jeopardy on 11/8/21 at 5:37 p.m. After the facility submitted an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed on 11/10/21 at 12:30 p.m.

The findings included:

Review of the policy "Abuse of Patients, Elderly, or Disabled Persons, Assessment and Reporting", Number RI 118, effective date 9/13/94, revised 4/97, 2/00, 7/00, 6/02, 6/07, 4/09, 8/09, 3/11, and 9/13 reads, "If a patient alleges that they have been sexually assaulted while a patient at [hospital], an investigation by law enforcement will take place and the patient will be taken to the Emergency Department for the collection of evidence".

A review on 10/5/21 of the hospital policy, "Sexual Assault", number ED159, effective date 9/1995 and revised 07/02, 06/07, and 03/18 finds; "it is the responsibility of the Emergency Department staff to provide confidential care and examination of the suspected sexual assault victim; to collect legal specimens properly when suspected rape has occurred; provide initial crisis intervention, medical care and follow-up care...K. The Emergency Department Nurse will gather evidence, utilizing the sex crimes kit. Document exam on nurse's notes. The Emergency Department Physician will gather medical evidence and complete the medical exam. Human Immunodeficiency Virus and Hepatitis testing will be offered...S. Give discharge instructions and administer medications for sexually transmitted diseases and pregnancy prevention as ordered by Emergency Room Physician".


A review of an incident event report dated 6/2/21 revealed Patient #1, a 45-year-old female had been at the hospital since 5/19/21 for threatening to kill another resident at her place of residence. The Clinical Coordinator documented, "6/2/21 the Activities therapist notified the facility clinical coordinator to talk to the patient who was distraught and crying. Patient #1 stated to her (Clinical Coordinator) that two nights ago on the evening/night shift there was a man named [Staff D] who attacked her. She stated this [Staff D] came into her room late at night ... pushed her into the bathroom and lifted up her shirt and started to lick her on her breast and chest ... The patient said she screamed at the attacker which startled him, and he left". The report noted the patient did not report it to anyone because she felt no one would believe her. The facility notified the police and the Florida Department of Children and Families (DCF) (the Florida State Agency that investigates adult abuse and neglect). On 7/6/21 the Risk Manager documented in the investigative findings, DCF was closing the case regarding Patient #1 with no findings.

In an interview on 10/4/21 at 9:40 a.m., the Risk Manager said the allegation was not substantiated because DCF closed the case, and the staff member did not have opportunity to assault the patient because he was not working on the adult unit were Patient #1 was being housed. Patient #1, a middle-aged female, was admitted to the 8100 services in the behavioral Health Unit. On 5/30/21 and 5/31/21, Staff D was assigned to the Geriatric 8900 service. However, staff can access both ends of the Behavioral Health Unit. Staff D was not in the facility on 6/1/21 or 6/2/21. The Risk Manager said Staff D was allowed to return to work on 7/6/21 after DCF closed their investigation.
In an interview on 10/5/21 at 2:00 p.m., the Chief Quality Officer said the hospital did not have documentation the Risk Manager investigated the incident. The Chief Quality Officer stated she could not locate the "yellow pad" where he documented the investigation.

During an interview on 10/6/21 at 9:20 a.m., the Chief Quality Officer received a call from the police detective informing her the investigation of the alleged sexual assault incident involving Staff D and Patient #1 was ongoing.

The facility did not have documentation of investigative steps taken to support the documented conclusion.

2. Review of the event report dated 7/16/21 noted Patient #6 reported a guy [Staff A] at the hospital had "put his tongue down her throat" while she was at the hospital under a Baker Act (involuntary psychiatric admission). The patient reported Staff A was assigned to her as a sitter.

The hospital investigated, substantiated the allegation, and terminated Staff A on 7/22/21.

On 11/4/21 the facility failed to provide documentation of any systemic changes after multiple allegations of sexual abuse/misconduct occurring with staff being assigned supervision of vulnerable adults.

3. A review on 10/5/21 of the document, 'Report of Law Enforcement Initiating Involuntary Examination' shows Patient #1 was brought to the Emergency Department under a Baker Act commitment on 7/13/21 at 3:37 a.m. A Baker Act involuntary commitment is initiated by law enforcement or Medical Staff when it is determined a person is a danger to themselves or others and due to their mental health decline, the patient is unable to voluntarily submit to a mental health examination.

Review of medical record revealed on admission to the hospital, Patient #1 was placed on 15-minute checks due to her being under a Baker Act commitment. Documentation of every 15-minute checks shows Certified Nursing Assistant, Staff A was assigned to monitor Patient #1 on 7/14/21 from 7:00 a.m. to 7:00 p.m., on 7/15/21 from 7:00 a.m. to 7:00 p.m., and on 7/16/21 from 7:00 a.m. to 12:00 p.m. Patient #1 remained in the hospital under a Baker Act commitment from 7/13/21 until 7/16/21 at 12:29 p.m. when the Baker Act was lifted. Patient #1 was discharged on Friday, 7/16/21.

In an interview on 10/5/2021 at 11:32 a.m., Nursing Supervisor Staff B said she received a call on 7/18/21 in the afternoon from Patient #1 who told her she had been attacked by a sitter while she was a patient at the hospital. Staff B said she took Patient #1's phone number and told her a Patient Advocate would be in touch with her. Staff B said the Patient Advocate was not able to call Patient #1 back on 7/18/21 because Patient #1 had given a wrong phone number.

In an interview on 10/5/2021 at 11:40 a.m., Patient Advocate Staff C, said she received a call back from Patient #1 on 7/19/21. Staff C said Patient #1 reported she had been sexually assaulted by a hospital employee while she was a patient at the hospital. Staff C said the hospital Risk Manager took Patient #1's statement on 7/19/21

A review of an incident event report on 10/5/21, dated 7/19/21 includes a statement written by the Risk Manager: "Patient #1 states that [Staff A] abused her 3 times sexually, once in the shower and twice on a recliner chair. Patient #1 states the first morning she was on the unit [Staff A] was her sitter and she felt he was a little too friendly. She says he kept drawing on her face with his finger and caressed her face. She [Patient #1] said she pushed his hand away. She states she threw her cup at him. She said she needed assistance in the shower and that is where the first sexual encounter was from behind. Patient #1 said the other two times he forced himself on her in the recliner chair. She states that all three times he did penetrate her to orgasm. She states she has shorts, wash cloth and pad that has his semen on them. She states she is afraid because he came to her house Friday night uninvited, and she states she does not know how he got her phone number." The Risk Manager then documented he advised Patient #1 to contact the police.

In an interview on 10/6/21 at 9:25 a.m., the Risk Manger stated he had spoken with both Patient #1 and Staff A on 7/19/21. The Risk Manager said from interviews and his review of text messages on Staff A's phone he determined Staff A had had an inappropriate relationship with Patient #1 while she was Baker Acted at the hospital. The Risk Manager said he never reported the relationship, the text messages, or the victim's statements to the police. The Risk Manager verified he had not requested the victim come to the Emergency Department to collect the evidence she stated she had, and he had not offered her any type of crisis intervention services through the hospital Emergency Department per hospital policy.

In an interview on 10/6/21 at 2:00 p.m., the Chief Quality Officer verified the hospital did not notify the police of Patient #1's allegations of being sexually abused three times while in the hospital under a Baker Act involuntary commitment and not able to consent to sexual activity.
The Chief Quality Officer said there had been a staff meeting on 7/22/21, which she attended, regarding the incident. The Chief Quality Officer could not provide documentation of the meeting or of any actions the hospital took such as in-services with staff, or greater supervision of bedside sitters to prevent further incidents of sexual misconduct and sexual abuse of vulnerable patients requiring bedside sitters.

In an interview on 10/6/21 at 3:30 p.m., the Director of Human Resources stated she had been involved in the investigation of the allegations reported by Patient #1. The Director of Human Resources stated once Staff A had been suspended and subsequently terminated, they did not need to continue the investigation and talk with other staff or patients about the incident to identify other potential victims. It was her opinion there were no further actions the hospital needed to take in the matter.

4. Patient #14 was admitted to the Behavioral Health Unit on 10/7/21 with a diagnosis of Major Depression. A review of the incident event report dated 10/15/21 showed documentation the psychiatrist asked a nurse to go assess and listen to Patient #14's statement. The report noted, [Patient #14] states that a MHT [Mental Health Technician] had been inappropriate with her. The patient stated the event occurred about 2 to 3 nights ago, he [Staff D] came into her room and was sitting on her bed and she asked him to not sit there. "He would rub my hand when he takes my vital signs, he inappropriately touches my breast when he places the cuff on my arm. I think he is intrigued by me ..." Patient #14 described the MHT. Patient #14 said, "He tells me he wants to protect me, and I just don't want him near me. He has even kissed my hand and I told him that is unprofessional. He only leaves the room when someone comes down the hall. I don't want to cause trouble or get anyone in trouble. I just don't want him near me ..."

In an interview on 11/9/21 at 1:30 p.m., the Medical Director said Patient #14 told him on 10/15/21 about being sexually assaulted on 10/12/21 by Staff D. The Medical director said he reported the allegation to the charge nurse. The nursing notes, dated 10/15/21, document the patient's detailed description of the unwanted encounters. An event report was generated by the facility, however, there is no documentation the facility implemented the abuse protocol. No Root Cause Analysis was produced, and no documentation of interventions was provided. There is no reference in the physician notes in the patient record of the unwanted encounter with the Mental Health Technician for the dates 10/12/21 through 10/16/21.

In an interview on 11/5/21 at 3:45 p.m., the Chief Quality Officer said she verified with the police department there was still an on-going investigation of Staff D regarding the incident reported by the facility on 6/2/21. The Chief Quality Officer verified the hospital did not take any action to protect vulnerable patients from unsupervised interactions with Staff D while the police investigation was on-going.




25618

5. A review on 10/4/21 of the hospital's incident event report dated 7/17/2021 revealed Patient #6 filed a report stating she was sexually harassed at the hospital by Staff A on 7/10/21.

The event report states the Risk Manager interviewed Patient #6 on 7/20/21 and documented Patient #6 told him the sitter, Staff A, sexually assaulted her at the main hospital. Patient #6 stated Staff A kissed her several times and tried to fondle her breast 3 times. The Risk Manager documented that he called the police who interviewed Patient #6 and Staff A. The Risk Manager documented the police officer called him on 7/22/21 to report that Staff A confessed to kissing Patient #6 and tried to fondle her breast on 7/10/21 when he was her appointed hospital sitter. The Risk Manager noted Staff A's hospital employment was terminated on 7/23/21.

A review of Patient #6's medical record on 10/4/21 revealed she came to the Emergency Department on 7/09/21 and was admitted to the Medical/Surgical unit at 5:28 p.m., with diagnoses of Major Depression, Suicidal Ideation, Strep A, and a Baker Act precaution order.
Patient #6 was admitted to a medical/surgical unit for antibiotic treatment for 24 hours prior to being transferred to the Behavioral Health unit.

A review of the nursing progress note dated 7/09/21 at 11:40 p.m., found the nurse documented Patient #6 was a high risk for suicide and was on 1-on-1 continuous monitoring. The patient's room was adjacent to nurse's desk with safety precautions and suicide precautions in place.

A review of the nursing progress note dated 7/10/21 at 10:32 a.m., found the nurse documented Patient #6 was repeatedly requesting her cell phone. Patient #6 was informed she could not have her cell phone due to hospital policies. Patient #6 stated, "I never should have come here, next time I will just slit my throat."

In a nursing progress note dated 7/10/21 at 7:45 p.m., the nurse documented Patient #6 was being transferred to the hospital's behavioral center for admission.

In an interview on 10/04/21 at 11:45 a.m., the Chief Quality Officer confirmed the hospital received two allegations of sexual abuse/harassment on 7/18/21 stating Staff A had sexually abused/harassed two patients (Patient #1 and #6) from 7/10/21 to 7/16/21, while he was assigned to monitor vulnerable female patients who were under Baker Act involuntary commitment for their safety. The Chief Quality Officer stated she was unable to find documentation the Risk Manager and/or the Director of Human Resources had interviewed other hospital staff and/or patients to determine the severity of allegations of abuse and harassment against Staff A. The Chief Quality Officer said the hospital had a senior leadership meeting at an unknown time, either on 7/23/21 or 7/24/21, to discuss what they should do to address the sexual abuse/harassment allegations made by two patients on 7/18/21 which were confirmed by law enforcement on 7/22/21. The Chief Quality Officer said the facility was unable to provide documentation of what was discussed in the senior leadership meeting. The Chief Quality Officer was unable to show they had done a root cause analysis to be able to determine if the hospital had an adequate system in place to protect patients from abuse and harassment of all forms. The Chief Quality Officer said she is unable to provide documentation the facility had put a plan in place to ensure hospital staff were adequately trained to prevent and report abuse, neglect, and harassment. She also said there is no documentation of the senior leadership meeting to show the facility management had discussed, reviewed, and updated the facility's policies and procedures to ensure patients are free from all forms of abuse, neglect, or harassment.

On 11/4/21 a request was made for documentation the facility followed the Abuse protocol. The facility failed to provide documentation of any systemic changes after multiple allegations of sexual assault/misconduct occurring by staff assigned supervision of vulnerable adults.

Based on record review, interviews, review of facility documents, and review of policy and procedure, the hospital failed to ensure that clear expectations for patient safety were implemented by Quality Assurance Performance Improvement (QAPI). The QAPI system failed to react to adverse incidents and failed to develop and implement measures to prevent further occurrences after four allegations by three patients (Patient #1, #6, and #14) of sexual misconduct by two staff members (Staff A, and Staff D).

The condition is not met due to the systemic failure to maintain a functioning QAPI system to investigate, track and trend, and implement measures to prevent sexual abuse. The Chief Quality Officer failure to ensure a root cause analysis of serious adverse/sentinel events was completed which included developing and implementing interventions and auditing of interventions to prevent the opportunity for further abuse caused Immediate Jeopardy to the safety of patients in the hospital and the behavioral unit. The hospital was informed of the Immediate Jeopardy on 11/8/21 at 5:37 p.m. (Refer to A0115, and A0286)

The Immediate Jeopardy was removed on 11/10/21 at 12:30 p.m. after the hospital demonstrated they had revised the process that serious/sentinel events are reported to the Governing Body and actions were taken to ensure a QAPI system was in place to investigate cases and to develop and implement interventions to ensure immediate patient safety and prevention of sexual abuse. The hospital showed all departments were involved in input regarding interventions put in place to ensure there was no opportunity for further sexual abuse, and a plan was in place to ensure the hospital would audit interventions and monitor on-going compliance of interventions put in place.

Based on medical record and hospital documents review, staff interview, review of incident event reports, and review of policy and procedure the hospital failed to ensure patient safety in their Quality Assurance Performance Improvement (QAPI) Program for three of five patients surveyed (Patient #1, #6 and #14) alleging sexual assault. The QAPI program failed to investigate, track and trend allegations of sexual abuse, ensure completion of root cause analyses, and develop and implement measures with monitoring to ensure compliance for the prevention of further sexual abuse for both the hospital, and the Behavioral Unit. Also, the facility Governing Body and administration failed to enforce patient safety expectations.

The systemic failure to ensure patient safety through a functioning QAPI system to prevent the opportunity for further abuse caused an immediate jeopardy to the safety of patients in the hospital and the behavioral health unit. The hospital was informed of this on 11/8/21 at 5:37 p.m.

The immediacy was removed 11/10/21 at 12:30 p.m. after the hospital demonstrated they had revised the process that serious adverse/sentinel events are reported to the Governing Body and actions are taken to ensure a QAPI system was in place to investigate, develop, and implement interventions to ensure immediate patient safety and prevention of sexual abuse. The hospital showed that all departments provided input regarding measures implemented to ensure there was no opportunity for further sexual abuse, and a plan was in place to ensure the hospital would audit interventions and monitor ongoing compliance of interventions put in place.

The findings included:

A review on 10/5/21 of the hospital policy, "Sexual Assault", number ED159, effective date 9/1995 and revised 07/02, 06/07, and 03/18 finds; "it is the responsibility of the Emergency Department staff to provide confidential care and examination of the suspected sexual assault victim; to collect legal specimens properly when suspected rape has occurred; provide initial crisis intervention, medical care and follow-up care.

Review of the policy "Abuse of Patients, Elderly, or Disabled Persons, Assessment and Reporting", Number RI 118, effective date 9/13/94, revised 4/97, 2/00, 7/00, 6/02, 6/07, 4/09, 8/09, 3/11, and 9/13 reads, "If a patient alleges that they have been sexually assaulted while a patient at [hospital], an investigation by law enforcement will take place and the patient will be taken to the Emergency Department for the collection of evidence".

A review of the Director of Risk Management and Patient Safety job description found the Risk Manager is "responsible for coordinating, implementing, and directing the Risk management, Patient Safety and High Reliability Program to maintain an environment where patients and staff are safe ..." The duties of the Risk Manager include but are not limited to: "16. Serves as the Patient Safety Officer and directs the Patient Safety Program, including facilitating systems analysis to promote and improve patient safety, ... 20. Promotes Risk management by the identification, investigation, root cause analysis and evaluation of risks and the selection of the most advantageous method of correcting, reducing, or eliminating identifiable risks. The purpose of the hospital risk management function is to coordinate and facilitate the activities ... to prevent patient harm. 21. Analyst in the Cause Analysis process in response to a safety event by investigating the event, determining the sequence of events and proximate causes, determining the individual and system failures, and confirming the Root Causes. Assists and supports Operational Leaders with developing root solutions to identified root causes." In regard to Safety, the Risk Manager, "3. ... ensures stabilization of the immediate situation, assists in information gathering, operationalizes correct actions for root causes and promotes organization learning."


1. A review of an incident event report dated 6/2/21 revealed Patient #1, a 45-year-old female had been at the hospital since 5/19/21 for threatening to kill another resident at her place of residence. The Clinical Coordinator documented, "6/2/21 the Activities therapist notified the facility clinical coordinator to talk to the patient who was distraught and crying. Patient #1 stated to her (Clinical Coordinator) that two nights ago on the evening/night shift there was a man named [Staff D] who attacked her. She stated this [Staff D] came into her room late at night ... pushed her into the bathroom and lifted up her shirt and started to lick her on her breast and chest ... The patient said she screamed at the attacker which startled him, and he left". The report noted the patient did not report it to anyone because she felt no one would believe her. The facility notified the police and the Department of Children and Families (DCF). On 7/6/21 the Risk Manager documented in the investigative findings, DCF was closing the case regarding Patient #1 with no findings.

In an interview on 10/4/21 at 9:40 a.m., the Risk Manager said the allegation was not substantiated because DCF closed the case, and the staff member did not have opportunity to assault the patient because he was not working on the adult unit were Patient #1 was being housed. Patient #1, a middle-aged female, was admitted to the Adult 8100 services, in the Behavioral Health Unit. On 5/30/21 and 5/31/21, Staff D was assigned to the Geriatric 8900 service. However, staff can access both ends of the Behavioral Health Unit. Staff D was not in the facility on 6/1/21 or 6/2/21. The Risk Manager said Staff D was allowed to return to work on 7/6/21 after DCF closed their investigation.

In an interview on 10/5/21 at 2:00 p.m., the Chief Quality Officer said the hospital did not have documentation the Risk Manager investigated the incident. The Chief Quality Officer stated she could not locate the "yellow pad" where he documented the investigation.

During an interview on 10/6/21 at 9:20 a.m., the Chief Quality Officer received a call from the police detective informing her the investigation of the alleged sexual assault incident involving Staff D and Patient #1 was ongoing. The facility did not have documentation of investigative steps taken to support the documented conclusion.

2. A review on 10/5/21 of the document, 'Report of Law Enforcement Initiating Involuntary Examination' shows Patient #1 was brought to the Emergency Department under a Baker Act commitment on 7/13/21 at 3:37 a.m. A Baker Act involuntary commitment is initiated by law enforcement or Medical Staff when it is determined a person is a danger to themselves or others and due to their mental health decline, the patient is unable to voluntarily submit to a mental health examination.

A review of an event report on 10/5/21, dated 7/19/21 includes a statement written by the Risk Manager: "Patient #1 states that [Staff A] assaulted her 3 times sexually, once in the shower and twice on a recliner chair. Patient #1 states the first morning she was on the unit [Staff A] was her sitter and she felt he was a little too friendly. She says he kept drawing on her face with his finger and caressed her face. She [Patient #1] said she pushed his hand away. She states she threw her cup at him. She said she needed assistance in the shower and that is where the first sexual encounter was from behind. Patient #1 said the other two times he forced himself on her in the recliner chair. She states that all three times he did penetrate her to orgasm. She states she has shorts, wash cloth and pad that has his semen on them. She states she is afraid because he came to her house Friday night uninvited, and she states she does not know how he got her phone number." The Risk Manager then documented he advised Patient #1 to contact the police.

In an interview on 10/6/21 at 9:25 a.m., the Risk Manager stated he had spoken with both Patient #1 and Staff A on 7/19/21. The Risk Manager said from interviews and text messages on Staff A's phone he determined Staff A had had an inappropriate relationship with Patient #1 while she was Baker Acted at the hospital. The Risk Manager said he never reported the relationship, the text messages, or the victim's statements to the police. The Risk Manager verified he had not requested the victim to come to the Emergency Department to collect the evidence she stated she had, and he had not offered her any type of crisis intervention services through the hospital Emergency Department as per hospital policy.

In an interview on 10/6/21 at 2:00 p.m., The Chief Quality Officer verified the hospital did not notify the police of Patient #1's allegations of being sexually abused three times while in the hospital under a Baker Act involuntary commitment and not able to consent to sexual activity.
The Chief Quality Officer said there had been a staff meeting regarding the incident of 7/22/21 which she attended. The Chief Quality Officer could not provide documentation of the meeting or of any actions the hospital took such as in-services with staff, or greater supervision of bedside sitters to prevent further incidents of sexual misconduct and sexual abuse of vulnerable patients requiring bedside sitters.

In an interview on 10/6/21 at 3:30 p.m., the Director of Human Resources stated she had been involved in the investigation of the allegations reported by Patient #1. The Director of Human Resources stated once Staff A had been suspended and subsequently terminated, they did not need to continue the investigation and talk with other staff or patients about the incident to identify other potential victims. It was her opinion there were no further actions the hospital needed to take in the matter.

On 11/3/21 at 2:00 p.m., the Director Quality verified a root cause analysis had been completed after the AHCA investigative findings. The Director of Quality said she had not reported the root cause to the Patient Safety Committee or the Executive Board because she was waiting on the report from the Agency for Health Care Administration to be issued to the hospital after the surveyors had exited on 10/6/21.

3. A review on 10/4/21 of the hospital's event report dated 7/17/2021 revealed Patient #6 filed a report stating she was sexually harassed at the hospital by Staff A on 7/10/21. The Event Report states the Risk Manager interviewed Patient #6 on 7/20/21 and documented Patient #6 told him the sitter, Staff A, sexually abused her at the main hospital. Patient #6 stated Staff A kissed her several times and tried to fondle her breasts 3 times. The Risk Manager documented that he called the police who interviewed Patient #6 and Staff A. The Risk Manager documented the police officer called him on 7/22/21 to report that Staff A confessed to kissing Patient #6 and trying to fondle her breasts on 7/10/21 when he was her appointed hospital sitter. The Risk Manager noted Staff A's hospital employment was terminated on 7/24/21.

A review of Patient #6's hospital record on 10/04/21 revealed she came to the Emergency Department on 7/09/21 and was admitted to the Medical/Surgical unit at 5:28 p.m. with diagnoses of Major Depression, Suicidal Ideation and a Baker Act precaution order.

In an interview on 10/04/21 at 11:45 a.m., the Chief Quality Officer confirmed the hospital received two allegations of sexual abuse/harassment on 7/18/21 stating Staff A had sexually abused/harassed two patients (#1 and #6) from 7/10/21 to 7/16/21 when he was assigned to monitor vulnerable female patients who were under Baker Act involuntary commitment for their safety. The Chief Quality Officer stated she was unable to find documentation the Risk Manager and/or the Director of Human Resources had interviewed other hospital staff and/or patients to determine the scope and severity related to the allegations of abuse and harassment against Staff A. The Chief Quality Officer said the hospital had a senior leadership meeting at an unknown time, either on 7/23/21 or 7/24/21, to discuss what they should do to address the sexual abuse/harassment allegations made by two patients on 7/18/21 which were confirmed by law enforcement on 7/22/21. The Chief Quality Officer said the facility was unable to provide documentation of what was discussed in the senior leadership meeting. The Chief Quality Officer was unable to show they had done a root cause analysis to be able to determine if the hospital had an adequate system in place to protect patients from abuse and harassment of all forms. The Chief Quality Officer said she is unable to provide documentation the facility had put a plan in place to ensure hospital staff were adequately trained to prevent and report abuse, neglect, and harassment. She also said there is no documentation of the senior leadership meeting to show the facility management had discussed, reviewed, and updated the facility's policies and procedures to ensure patients are free from all forms of abuse, neglect, or harassment.

5. A review of the event report dated 10/15/21 showed documentation the psychiatrist asked a nurse to go assess and listen to Patient #14's statement. The report noted, "[Patient #14] states that a MHT [Mental Health Technician] had been inappropriate with her. She stated the event occurred about 2 to 3 nights ago, he [Staff D] came into her room and was sitting on her bed and she asked him to not sit there. He would rub my hand and when he takes my vital signs, he inappropriately touches my breast when he places the cuff on my arm. I think he is intrigued by me ..." Patient #14 described the MHT. Patient #14 said, "He tells me he wants to protect me, and I just don't want him near me. He has even kissed my hand and I told him that is unprofessional. He only leaves the room when someone comes down the hall. I don't want to cause trouble or get anyone in trouble. I just don't want him near me ..."

In an interview on 11/9/21 at 1:30 p.m., The Medical Director said Patient #14 had told him on 10/15/21 about being sexually abused on 10/12/21 by Staff D. The Medical director said he reported the allegation to the charge nurse. The nursing notes, dated 10/15/21, document the patient's detailed description of the unwanted encounters. There is no reference in the physician notes in the patient record of the unwanted encounter with the Mental Health Technician for the dates 10/12/21 through 10/16/21.

An event report was generated by the facility, however, there is no documentation the facility implemented the abuse protocol. No Root Cause Analysis was produced, and no documentation of interventions was provided.

In an interview on 11/5/21 at approximately 3:45 p.m., the Chief Quality Officer said she verified with the police department there was still an on-going investigation of Staff D regarding the incident reported by the facility on 6/2/21. The Chief Quality Officer verified the hospital did not take any action to protect vulnerable patients from unsupervised interactions with Staff D while the police investigation was on-going.

In an interview on 11/6/21 at 3:30 p.m., the Chief Administrative Officer (CAO) said the Risk Manager reports the occurrence of adverse incidents/sentinel events to the hospital administrative team. The CAO said neither he nor the Chief Quality Officer reported the sexual abuse incidents to the board. The CAO said he did not oversee review of Abuse and Patient Sitter Policies and Procedures in response to allegations of sexual abuse and did not direct implementation of measures to ensure no recurrence of sexual abuse.

In an interview on 11/9/21 at 4:00 p.m. The Hospital Chief Medical Officer said he was recently made aware of the allegations but was not given many details regarding the allegations. He said there would be an executive board meeting in two weeks and if Risk wanted to attach the allegations the board would review what was needed to be reviewed and give their recommendations.
The occurrence of four sexual assault events reported by three patients was not responded to with the full measure of the hospital abuse protocol by the facility staff members and officers whose duty it was to act.