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Based on policy review, medical record review, grievance file review and staff interview, the hospital failed to report an allegation of staff to patient abuse to the Health Care Personnel Registry as required by State law for 1 of 1 cases of alleged staff to patient abuse reviewed (Patient #5).

The findings include:

Review of current hospital policy entitled "Suspected Abuse, Neglect, Exploitation, and Domestic Violence, Assault, Rape & Other Sexual Molestation" dated 01/2009 revealed, "(Name of Hospital) is also committed to complying with all federal, state and local laws regarding reporting of suspected cases of abuse, neglect, exploitation, domestic violence, assault, rape and other sexual molestation....When there is an allegation of abuse by (Name of Hospital) personnel, the information should be reported as a grievance...." Further review of the policy revealed no requirement for the hospital to report allegations of staff to patient abuse to the Health Care Personnel Registry as required by State law.

Closed medical record review for Patient #5 revealed an 89 year-old female that presented to the Emergency Department (ED) from an Assisted Living Facility on 12/29/2009 at 2208 with a chief complaint of constipation, decreased appetite and intermittent confusion. Record review revealed at 2311 the patient had a urinary catheter inserted and connected to continuous drainage. Record review revealed the patient was admitted and transferred to a room on the Progressive Intensive Care Unit - South (PIC South) on 12/30/2009 at 0300. Record review revealed the urinary catheter remained in place until the afternoon of 12/31/2009. Record review revealed the patient was discharged back to the Assisted Living Facility on 12/31/2009 at 1700.

Review of a grievance file on 02/17/2010 for Patient #5 revealed staff at the Assisted Living Facility where the patient lived sent a letter dated 01/08/2009 to the hospital to notify them the patient had alleged a hospital staff member had inappropriately touched her during a bed bath while at the hospital between 12/29/2009 and 12/31/2009. Review revealed the letter was received by the hospital "late Friday afternoon" on 01/08/2010. Review of the grievance file revealed the hospital administration investigated the allegation of sexual abuse on 01/11-12/2010 and unsubstantiated it on 01/12/2010. Review of the file revealed a letter dated 02/15/2010, which contained the results of the investigation and the resolution of the grievance, was sent to the staff at the Assisted Living Facility that had made the allegation. Further review of the file revealed no documented evidence that the Health Care Personnel Registry (HCPR) was notified of the allegation of staff to patient sexual abuse and the results of the investigation (40 days after the hospital was notified of the allegation).

Interview on 02/17/2010 at 1445 with the Critical Care Nurse Director revealed, "On January 11th I got a call from (name of Guest Services employee). He had a copy of a letter that was sent to us and copied to DSS (the Department of Social Services)." Interview revealed the letter was from the Assisted Living Facility and contained an allegation of sexual abuse of Patient #5 by a black male staff member at the hospital. Interview revealed the Nursing Director looked at the staffing sheets from the time period when the patient was in the hospital and found that Staff #1 was the only black male on duty on PIC South while the patient was in the hospital. Interview revealed, "After the investigation, we didn't feel it was substantiated. We felt he (Staff #1) was doing his job by performing catheter care." Interview revealed the Nurse Director did not know whether or not the allegation of staff to patient sexual abuse had been reported to the HCPR.

Interview on 02/18/2010 at 0930 with the Employee Relations Coordinator revealed the coordinator did not report the allegation of staff to patient sexual abuse to the HCPR. Interview revealed, "I thought the Assisted Living Facility did." Interview revealed the coordinator was not aware of the State requirement to report allegations of staff to patient abuse to the HCPR.

Interview on 02/18/2010 at 1000 with the Assistant Vice President (VP) of Human Resources revealed, "I've never had an occasion of alleged abuse in my 13 years." Interview revealed the Assistant VP was not aware of the State requirement to report allegations of staff to patient abuse to the HCPR.

Interview on 02/18/2010 at 1015 with the Vice President/General Counsel revealed, "The policy came so quickly that probably got us off track....We should report (allegations of staff to patient abuse to the HCPR). I think it's HR (Human Resources) that should report. It wasn't done in this case. We will clean this up and refine our policy."


NC00061601