HospitalInspections.org

Based on medical record review, review of police reports and statements, review of facility policy, and interview, the facility failed to ensure protection from staff abuse for two patients (#1, #2) of five records reviewed; and failed to ensure prompt resolution of grievance for one patient (#1) of five records reviewed.

The failure of the facility to ensure protection from abuse placed patients #1 and #2 in an Immediate Jeopardy.

On August 24, 2010 at 4:15 p.m., in the CEO's office, the Chief Executive Officer (CEO) was informed of the Immediate Jeopardy.


The findings included:

Refer to A-118: Standard citation: The facility failed to ensure a prompt resolution to a grievance regarding patient #1 with an allegation of sexual assault from an identified employee.

Refer to A-145: Standard citation: The facility failed to protect the patients (#1, #2) from sexual abuse.

Based on medical record review, policy review, review of facility documents, and interview, the facility failed to ensure the grievance/complaint regarding sexual abuse made by one (#1) patient was promptly resolved.

On August 24, 2010 at 4:15 p.m., in the CEO's office, the Chief Executive Officer (CEO) was informed of the Immediate Jeopardy.


The findings included:


Medical record review revealed patient #1 arrived at the Emergency Department (ED) on June 11, 2010 at 12:51 PM, with chief complaint of injury to Head, Face and Upper Extremities. Medical record review revealed patient #1 was in an ATV (all-terrain vehicle) accident 14 hours previously in which the ATV struck a ditch causing the patient to be ejected; and had loss of consciousness for an unknown period of time.

Medical record review revealed Radiology Orders for a CT (Computed Tomography) of the Head, X-Ray of Cervical Spine, and extremity X-Rays of the right Humerus, right Forearm, right hand, and left hand.

Review of the radiology reports revealed the CT and the X-rays were performed in the Radiology department on June 11, 2010.

Medical record review of the results of the CT of the Head performed June 11, 2010 revealed patient #1 had a fracture of the Zygomatic Arch (The part of the temporal bone of the skull that forms the prominence of the cheek). Additional results by the Radiologist included, "There is a transverse fracture through the temporal bone which I believe affects the anterior aspect of the external auditory canal. This extends up to and around the carotid artery region. There may be a fracture of the left occipital bone involving the left side of the Foramen Magnum." (The hole at the base of the skull through which the spinal cord passes.) Review of the Radiologist's impression included, "...Some mild intracerebral hemorrhage posteriorly representing contrecoup injuries." (Injuries on the opposite side of impact).

Review of the X-Ray of the right Forearm performed on June 11, 2010 revealed a non-displaced fracture of the proximal right Radius.

Medical record review revealed patient #1 was transported via Emergency Medical Services (EMS) in stable condition to a Level I Trauma Center on June 11, 2010 at 3:15 PM.

Interview with the complainant via telephone on August 24, 2010, at 2:10 PM, revealed patient #1 phoned the facility on July 13, 2010 and filed a complaint regarding inappropriate sexual contact from a radiology technician (RT #1). Continued interview with patient #1 included information consistent with the facility documentation of the telephone call received on July 13, 2010.

Review of the report prepared by the Director of Patient Access (employee who received the complaint) dated July 13, 2010 revealed patient #1 was taken from the ED via gurney to the radiology department by RT #1. After the X-Rays were performed the RT #1 stated the films had to be checked, came back and stated more X-rays needed to be done. The RT #1 took patient #1 to another room (a bathroom) and closed the door; told the patient needed to see the chest. Patient #1 stated, "I cannot raise my arms to take my shirt off." The RT #1 "proceeded to raise my shirt, bra, and placed...mouth on my breast ...I told...to stop...then...put...hands down the front and back of my shorts and asked if...could see my back and I said 'no' and told...to stop."

Review of the facility documentation and interview with patient #1 on August 24, 2010 at 2:10 PM revealed the RT #1 then took patient #1 back to the emergency room.

Interview with Director of Patient Access in conference center B on August 24, 2010 at 8:20 AM, verified did receive the complaint via telephone from patient #1 on July 13, 2010. Interview revealed the Director prepared the document "within 10 minutes" after concluding the phone call; and took the report to the Executive Vice President, "my supervisor."
The Director stated, "the patient did call me back a week or two later because...had not heard anything from us (the facility)...had not received a phone call from us...just wanted to make sure something was done to prevent it from happening to someone else."


Continued interview revealed the Executive Vice President and the Director of Patient Access took the report to the Director of Human Resources after brief discussion which confirmed it was a complaint involving an identified employee.

Interview in conference center B with the Director of Human Resources (HR) on August 23, 2010 at 2:45 PM, verified receipt of the documentation of the complaint on July 13, 2010. Continued interview revealed the Director of HR attempted to contact the Director of Radiology "but was not able to meet with...until July 21." (8 days after the complaint was received). Continued interview with the Director of Human Resources confirmed no action was taken at that meeting toward resolution of the complaint.

Review of the facility investigation documentation titled, 'Timeline', read, "July 21: Meeting with (Director of Radiology) in Dr...office. No new information available."

Interview with the Director of Radiology on August 23, 2010 in conference room B, at 2:30 PM, revealed the Director was informed on July 14, 2010 of the phone call alleging sexual abuse against RT #1. Continued interview revealed the Director had received abuse training, is part of the Administrative staff, and verified the Director took no action to initiate resolution of the complaint.

Review of the facility policy titled, Patient/Family Grievance, revealed the purpose was to "Provide a systematic process by which patients...can express a complaint or grievance, resolve disputes, or bring attention to incidents, conditions, practices, and/or policies ...that may violate patient rights." Review of the policy revealed no timelines to complete the systematic process. Review of the policy revealed a grievance was either written or verbal. Review of the policy revealed the responsibility of oversight of reviewing and resolving patient complaints was delegated to the Occurrence Review Committee which, "Always consisting of Representatives from Administration..." and other disciplines.

Interview with the Executive Vice President (EVP) in conference center B on August 24, 2010 at 8:00 AM, verified the EVP received the complaint report on July 13, 2010. Continued interview revealed the Executive VP and Director discussed the issue and determined it was a complaint and "deferred" it to the Director of Human Resources. Continued interview verified the Executive VP is a member of the Administration, confirmed the Executive VP did not take any action to resolve the grievance; and confirmed did not initiate action by the Occurrence Review Committee.

Interview with the Security Manager on August 24, 2010 in the conference center B at 10:00 AM, confirmed a meeting was held on July 26, 2010 at 10:30 AM, with the Director of HR, Director and Assistant Director of Radiology, and the Security Manager; "That was the first time we had met regarding this matter...After reading the report prepared by (Director of Patient Access)...It is clearly sexual assault...The police needed to be involved."

Continued interview revealed the information discovered by the Security Manager at the 10:30 AM meeting, prompted a call to the police department who agreed to come in at 1:30 PM to allow the Security Manager to share the "relevant" discovery that a complaint alleging sexual abuse had been received by the facility on July 13, 2010 identifying the same employee that was named in the complaint filed at the Police department.

Interview in the conference center B with the Director of Human Resources on August 24, 2010, at 7:30 AM, confirmed the complainant was not contacted by the facility until July 26, 2010; 13 days after the complaint was made.

Interview in the Chief Executive's office (CEO) with the CEO, on August 23, 2010 at 4:15 PM, after review of the phone call and the facility's actions, confirmed, "We dropped the ball."

Based on medical record review, policy review, review of police reports and statements, review of facility investigation documents, and interview, the facility failed to ensure two (#1, #2) patients were free from sexual abuse of five records reviewed. The facility's failure resulted in an Immediate Jeopardy.


The findings included:


Medical record review revealed patient #1 arrived at the Emergency Department (ED) on June 11, 2010 at 12:51 PM with chief complaint of injury to Head, Face and Upper Extremities. Medical record review revealed patient #1 was in an ATV (all-terrain vehicle) accident 14 hours previously in which the ATV struck a ditch causing the patient to be ejected; and had loss of consciousness for an unknown period of time.

Medical record review of the Emergency Provider Record for Multiple Trauma dated June 11, 2010 revealed patient #1 was evaluated by the Physician Assistant and Physician at 12:56 PM.

Review of the evaluation revealed patient #1 had moderate pain/injuries of head, face, neck; right shoulder, arm, forearm, and hand; and left arm and hand. Further review revealed the patient had a headache, raccoon eyes, Subconjunctival Hemorrhage (bleeding) in the left eye, Bilateral Hemotympanum (Bleeding in both ear canals); limited range of motion of the extremities; tenderness, swelling and Ecchymosis (bruising) of hands and arms; and neurologically was grossly intact including oriented to person, place and time. Evaluation revealed patient #1's mood and affect were normal.

Medical record review revealed Radiology Orders for a CT (Computed Tomography) of the Head, X-Ray of Cervical Spine, and extremity X-Rays of the right Humerus, right Forearm, right hand, and left hand.

Review of the radiology reports revealed the CT and the X-rays were performed in the Radiology department on June 11, 2010.

Medical record review of the results of the CT of the Head performed June 11, 2010 revealed patient #1 had a fracture of the Zygomatic Arch (The part of the temporal bone of the skull that forms the prominence of the cheek). Additional results by the Radiologist included, "There is a transverse fracture through the temporal bone which I believe affects the anterior aspect of the external auditory canal. This extends up to and around the carotid artery region. There may be a fracture of the left occipital bone involving the left side of the Foramen Magnum." (The hole at the base of the skull through which the spinal cord passes.) Review of the Radiologist's impression included, "some mild intracerebral hemorrhage posteriorly representing contrecoup injuries." (Injuries on the opposite side of impact).

Review of the X-Ray of the right Forearm performed on June 11, 2010 revealed a non-displaced fracture of the proximal right Radius.

Medical record review revealed the physician performed a medical screening examination and determined necessity to transfer to another hospital, a Level I Trauma Center. After case review with the accepting physician, patient #1 was transported via Emergency Medical Services (EMS) in stable condition on June 11, 2010 at 3:15 PM.

Interview via telephone on August 24, 2010 at 2:10 PM, revealed patient #1 phoned the facility on July 13, 2010 and filed a complaint regarding inappropriate sexual contact from a radiology technician (RT #1). Continued interview with patient #1 included information consistent with the facility documentation of the telephone call received on July 13, 2010.

Review of the report prepared by the Director of Patient Access (employee who received the complaint) dated July 13, 2010 revealed patient #1 was taken from the ED via gurney to the radiology department by RT #1. After the X-Rays were performed the RT #1 stated the films had to be checked, came back and stated more X-rays needed to be done. The RT #1 took patient #1 to another room (a bathroom) and closed the door; told the patient needed to see the chest. Patient #1 stated, "I cannot raise my arms to take my shirt off." The RT #1 "proceeded to raise my shirt, bra, and placed...mouth on my breast ...I told...to stop...then...put...hands down the front and back of my shorts and asked if...could see my back and I said 'no' and told...to stop."

Review of the facility documentation and interview with patient #1 on August 24, 2010 at 2:10 PM revealed the RT #1 then took patient #1 back to the emergency room.

Review of the facility policy titled, Sexual/Physical Abuse-Patient, revealed, "All (named facility) employees are responsible and required to report any incident or suspected incident of patient abuse." The policy instructs for reporting of abuse, "Upon receiving a report of sexual abuse, the following are to be notiffied: Charge Nurse, Nursing Supervisor, (named facility) Security Manager, Physician, Corporate Officer on Call, Risk Manager, Social Services, Human Resources Director, Department Head responsible for area patient is assigned to and legal counsel. An Incident form will be completed and forwarded to the Risk Manager. An Abuse Report will be completed and forwarded to the Social Services Department."

Interview with Director of Patient Access in conference center B on August 24, 2010 at 8:20 AM, verified did receive the complaint via telephone from patient #1 on July 13, 2010. Interview revealed the Director prepared the document "within 10 minutes" after concluding the phone call; and took the report to the Executive Vice President, "my supervisor."
The Director stated, "the patient did call me back a week or two later because...had not heard anything from us (the facility)...had not received a phone call from us...just wanted to make sure someting was done to prevent it from happening to someone else."

Interview with the Executive Vice President (EVP) in conference center B on August 24, 2010 at 8:00 AM, verified the EVP received the complaint report on July 13, 2010. Continued interview revealed on July 23, 2010 EVP and the Assistant Director of Radiology viewed the hospital security video filmed on July 13, 2010 of the hallway from the ER to the Radiology department; and verified the RT identified in the complainant, the RT who transported patient #1 to the radiology department, was verified as RT #1.

Continued interview revealed the Executive Vice President and the Director of Patient Access took the report to the Director of Human Resources after brief discussion which confirmed it was a complaint involving an identified employee.

Interview in conference center B with the Director of Human Resources (HR) on August 23, 2010 at 2:45 PM, verified receipt of the documentation of the complaint on July 13, 2010. Continued interview revealed the Director of HR attempted to contact the Director of Radiology "but was not able to meet with ...until July 21." (8 days after the complaint was received).
Continued interview revealed no other investigative process was initiated until the Executive VP and Assistant Director of Radiology viewed film on July 23, 2010 to confirm identity of the accused.

Continued interview revealed the next step in the facility investigation of patient #1's complaint was on July 26, 2010 when a local police officer called and informed the facility of a complaint filed with the police department (PD) regarding an X-Ray technician inappropriately touching another patient. Interview and review of the facility investigation reveal the police called the facility at "approximately 9:00 AM."

Interview with the Security Manager in conference center B on August 24, 2010 at 10:00 AM, confirmed the local police called the security office on July, 26, 2010 and informed the facility of a complaint filed against an employee, a radiology technician (first name given) concerning sexual abuse.

Review of the Police Department (PD) report dated July 20, 2010 revealed patient #2 reported the crime "Forcible Fondling" and named an RT at the facility which matched RT #1. Review of the report revealed the crime occurred on June 21, 2010 at the facility and the narrative report included patient #2 went to the facility for an IVP procedure, (Intravenous Pyelogram, a radiologic procedure to visualize the urinary system). During the procedure the RT #1, "opened the back of (my) gown and stated to(me)that(I) had a nice ass." RT #1 asked me if I could "keep a secret." (RT #1) "Began to rub (my legs) and pick up a corner of (my) gown; asked if...could place...hand inside the gown and touch (my) vagina...stated 'no.' (RT #1) "asked three times and I said 'no' three times" (RT #1) asked if I was sure while (RT #1) moved...hand toward my vagina. ...While (RT #1) was talking to me at the same time...was rubbing my back and butt." Patient #2 stated RT #1 asked if "could help me pee pee"...said 'no;' followed me towards the bathroom." Patient #2 stated another technician entered the radiology room.

Continued interview with the Security Manager in conference center B on August 24, 2010 at 10:00 AM, revealed the Security Manager assisted the police to facilitate interviews with employees regarding the complaint filed with the police. Interview revealed the Security Manager phoned the Director of HR to arrange location for the police interviews; "I was then informed there had been another complaint regarding the same employee...I knew nothing of that allegation until July 26...That was the first I had heard of it."

Continued interview revealed the Security Manager was given the report of the phone call received July 13; and stated, "As soon as I read the statement I knew a crime had been committed and asked (the Director of HR) if the police had been contacted...said no."

Continued interview confirmed on July 26, 2010 at 10:30 AM, a meeting was held with the Director of HR, Director and Assistant Director of Radiology, and the Security Manager; "That was the first time we had met regarding this matter...It is clearly sexual assault."

Continued interview revealed the security manager called the police officer and asked the police to come in early to receive additional information.
Continued interview with the Security Manager revealed during the interview of the police officers and the Security Manager on July 26, 2010 RT #1 confessed to sexual interactions with patients, (radiology students, and employees).

Review of the Police Department Voluntary Statement (a written confession) dated July 26, 2010 and timed 2:30 PM, revealed it was signed by RT #1.
The statement included, "I was X-Ray (tech)...brought (to facility) for ATV accident. While was flirting ended with in restroom kissed breast touched vagina...Had sexual intercourse with a...in restroom. Don't recall name. Never saw again...Whistled and asked (employee) to go to dark room...(Employee) refused and reported and nothing else said. Commented on a...with an IVP on...tattoos and legs. Comments were sexy, don't recall but likely said...had a nice butt. Advances were denied ...did put hard on knee."

Review of the Investigator Statement prepared by the Security Manager included an addendum which revealed one of the Detectives called the Security Manager on July 27, stated RT #1 came by the PD and stated...had sex with another patient in the restroom in the fall of last year with a blonde with a neck injury.

RT #1 was contacted by telephone on August 24, 2010 at 2:00 PM, and stated, "I have been advised not to make any comment" and declined to answer any questions.

Interview with the Director of Radiology on August 23, 2010 in conference room B, at 2:30 PM, revealed the Director was informed on July 26, 2010 of RT #1's admission of sexual contact with patients on the day of the interview with police.
Continued interview with the Director revealed on July 14, 2010 the Assistant Director of Radiology informed the Director of the allegation of sexual abuse received by the facility on July 13, 2010.

Continued interview and review of the "Punch Detail" report (a computer printout of when the employee 'swiped' badge at the beginning and at the end of the shift indicating time worked), revealed RT #1 completed an eight hour shift in the radiology department performing RT duties on July 14, 15, 16, 19, 20, 21, 22, 25, 2010. Review of the Punch Detail report revealed RT #1 reported to work on July 26, 2010 at 6:53 AM; and clocked out at 4:00 PM. (The facility received phone call from PD at 9:00 AM which named RT#1 in a second allegation of sexual abuse; the facility met and shared the knowledge with Director of Human Resources, Director of Radiology, Assistant Director of Radiology, and Security Manager; and RT #1 was interview by the police and confessed at 2:30 PM.)

Continued interview revealed RT #1 was not monitored, restricted, or supervised, in any manner differently than before July 13, 2010 (the day the facility received the allegation of sexual abuse identifying RT#1.)

Review of the personnel file of RT #1 and interview with the Director of HR on August 23, 2010, at 2:45 PM, revealed RT was suspended on July 26, and on July 29, was terminated effective date of July 26, 2010.

Interview in the conference center B with the Director of Radiology on August 24, 2010, at 8:40 AM, confirmed the facility "did nothing differently" from July 13-26, 2010, to protect patients from abuse concerning RT #1; and verified RT #1 was allowed to work for 9 shifts after the knowledge of the allegation of sexual abuse.

Interview in the conference center B with the Director of Human Resources on August 24, 2010, at 7:30 AM, confirmed the facility failed to promptly, thoroughly, or completely investigate the allegation of abuse; and failed to act to protect patients from abuse and failed to promote patient's right to safe care.

Continued interview with the Director of Human Resources revealed the facility failed to follow the policy and verified the Nursing Charge Nurse or Supervisor were not notified; the Physician, Corporate Officer on Call, Risk Manager, Social Services, were not notified of the allegation of sexual abuse.

Continued interview revealed the supervisory level staff members received an inservice on Sexual Harrassement on August 4, 2010 (22 days after the allegation was called in) and were instructed to provide/share the information with the rest of the employees. Continued interview revealed 514 of 1,008 employees ( equals 51%) had been inserviced by the end of August 23, 2010.

Review of the power-point inservice provided to the supervisors and the facility employees revealed it did not include prevention, identification, investigation, protection, and reporting of abuse of patients.

Continued interview confirmed the facility has not provided education to the employees regarding sexual abuse since the allegation of abuse on July 13, 2010 which was substantiated on July 26, 2010 by the employee's written statement.

On July 13, 2010 the facility received an allegation of sexual abuse to a patient by an X-ray technician employed by the facility. On July 26, 2010 the facility learned of a second allegation of sexual abuse to another patient by this same employee. Based on investigation the facility failed to immediately act on the allegations of sexual abuse, failed to thoroughly investigate the allegations, failed to follow facility policies and procedures, and allowed the accused employee to continue working unsupervised until July 26, 2010. The facility's failure placed all patients receiving radiology procedures by this employee at risk of sexual abuse and in Immediate Jeopardy.

Based on review of facility investigation documents and interview, the facility failed to have an effective Quality Assessment and Quality Improvement program as evidenced by lack of involvement in the investigation of the facility's failure to protect two patients (#1, #2) from sexual abuse from an employee in the radiology department of five records reviewed.


The findings included:


Please refer to A-145 Patients Rights: Free from Abuse


Interview in conference center B with the Director of Human Resources (HR) on August 23, 2010 at 2:45 PM verified receipt of the documentation of the complaint on July 13, 2010. Continued interview revealed the Director of HR attempted to contact the Director of Radiology "but was not able to meet with ...until July 21." (8 days after the complaint was received).

Interview with the Director of Radiology on August 23, 2010 in conference room B, at 2:30 PM, was made aware on July 14, 2010 of the allegation of abuse by RT #1 in the Radiology department.
Continued interview revealed the Director had received abuse training, is part of the Administrative staff, and verified the Director did not notify the Occurrence Review Committee; and verified the Director took no further action for quality improvement.

Interview with the Executive Vice President (EVP) in conference center B on August 24, 2010 at 8:00 AM, verified the EVP received the complaint report on July 13, 2010. Continued interview revealed the Executive VP and Director discussed the issue and determined it was a complaint and "deferred" it to the Director of Human Resources. Continued interview verified the Executive VP is a member of Administration, verified had received abuse training, and confirmed the Executive VP did not initiate action by the Occurrence Review Committee, and did not take any further action on the allegation of abuse.

Interview with the Security Manager confirmed in conference center B on August 24, 2010 at 10:00 AM, revealed a meeting was held on July 26, 2010 with the Director of HR, Director and Assistant Director of Radiology, and the Security Manager; "That was the first time we had met regarding this matter...It is clearly sexual assault."

Interview in the conference center B with the Director of Human Resources, on August 24, 2010 at 9:10 AM summarized the first complaint came in by telephone on July 13, 2010 and identified the title and first name of the employee; and the second complaint came in by notification by the police department on July 26, 2010 which identified the same employee.

Interview in the conference center B with the Risk Manager on August 23, 2010 at 9:30 AM revealed, "I was not involved in the investigation at all...I did not know anything...except was the Director of Human Resources told me and that was just in case I needed to know...in case someone sued the (facility)."

Continued interview verified the Risk Manager failed to recognize the allegation of sexual abuse by an employee as an indicator for performance improvement, and verified the Risk Manger had received abuse training, and failed to notify the Occurrence Review Committee.

Interview in the Chief Executive's office (CEO) with the CEO, on August 23, 2010 at 4:15 PM, after review of the phone call and the facility's actions, confirmed, "We dropped the ball."