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Based on interview, record review, and review of the facility's documents, it was determined the facility failed to ensure patient rights were protected and promoted for one (1) of ten (10) patients (Patient #1). The facility failed to protect Patient #1 from abuse. The facility also failed to ensure allegations of abuse were reported immediately, and failed to conduct investigations of abuse allegations.

The findings include:

Record review revealed the facility admitted Patient #1 a 46 year old with a history of Mental Retardation and Traumatic Brain Injury on 09/09/13 due to acute Respiratory Failure and Ventilator Dependency. During the patient's in-patient stay the patient experienced a massive stroke on 11/18/13 and had been unresponsive since.

Interviews with staff revealed sometime during the second week of November 2013, staff observed Patient #1's parent with her hands under the patient's bed linen and movement was observed under the linen. After the observation, the parent stated she had been shaving the resident's chest and groin areas. This observation was reported to a member of the facility's nursing staff by two staff members; however, there was no evidence the incident was documented or investigated by the facility to determine if abuse was occurring or if protection measures should be implemented.

Further interviews with facility staff revealed staff observed Patient #1's parent patting/stroking Patient #1's scrotum and penis on two occasions, once on 12/02/13 and once on 12/04/13. On 12/02/13, Patient #1's parent summonsed Registered Nurse (RN) #1 to watch the patient "respond" to the parent. The parent was observed to pat the patient's scrotum with a washcloth in her hand, then, patted the patient's penis and proceeded to rub up and down the shaft of the penis with her bare hands. The parent stated to RN #1 while touching the patient, "Watch this". The parent then stated to the patient, "Do you want me to pat that ball sac?" and, "Do you want me to pat that turkey neck?" while RN #1 was standing at the bedside. According to RN #1, the parent did this several times and Patient #1 smiled. The parent said, "See him smile." while stroking Patient #1's penis. Staff did not report this allegation until the next day, 12/03/13, when it was reported to the facility Clinical Service Director (CSD) and Chief Nursing Officer (CNO); however, no action was taken to protect the patient to prevent further abuse. In addition, the allegation was not investigated or reported to the appropriate state agency. On 12/04/13, a Registered Respiratory Therapist (RRT) observed Patient #1's parent had the patient's genitals exposed and was stroking the patient's penis with a stuffed animal. The RRT reported the observation to the CSD. The allegation was reported to the state agency on 12/04/13, and on 12/05/13 the patient's parent was denied visitation with the patient by the state agency. However, there was no evidence the facility investigated the abuse allegations per the facility's policy. Facility administrative staff was not aware of the incident observed by the RRT in November 2013.

As of 12/12/13, (ten days after the nursing staff observed the parent stroking Patient#1's penis) there was no evidence the facility had conducted an internal investigation of the above abuse allegations. An incident report was completed on 12/04/13 for the incident that occurred on 12/04/13 and an incident report completed on 12/05/13 for the incident that occurred on 12/02/13. According to interviews with staff, the incident reports were supposed to initiate an internal investigation; however, there was no further documented evidence of an investigation.

Review of the facility's policy revealed the facility also failed to ensure their abuse policy addressed protection of patients from further potential abuse when a parent or someone other than staff was named as the perpetrator.

The failure of the facility to protect patients from abuse; failure to ensure the abuse policy addressed protection of patients during abuse investigations; and failure to ensure allegations of abuse were immediately reported, investigated timely, and failure to protect patients from further potential abuse placed patients at risk for serious injury, harm, impairment or death. It was determined Immediate Jeopardy existed on 12/02/13 and is ongoing.

Refer to A0145.

Based on interviews and review of patient records, facility investigative reports, and policies and procedures, it was determined the facility failed to ensure the safety of one (1) of ten (10) sampled patients (Patient #1), due to the facility's failure to protect patients from abuse, and failure to ensure nursing staff adhered/implemented the facility's policies and procedures related to abuse prevention.

These failures placed patients at risk for injury, harm, impairment or death. Immediate Jeopardy was identified on 12/13/13, and determined to exist as of 12/02/13, related to the facility's failure to protect patients from abuse.

The findings include:

The facility's policy entitled "Abuse and Neglect" dated 04/08/13, stated "Any person that knows or has cause to suspect abuse/neglect of a child or adult is mandated by Kentucky State Laws and Statues (KR199.011, 199.335, 199.990 and 209.030) to report the following situation: suspected child/adult neglect; physical, psychological or sexual abuse; domestic violence; exploitation." The policy revealed anyone, including physician, nurse, social worker, emergency medical technician, health professional, or any organization that has reasonable cause to believe an adult has suffered abuse "has the duty to immediately cause an oral or written report to the Protection Hotline at 1-800-727-6200." The policy stated "When an incident or suspected incident of abuse or neglect, or injury of unknown origin is reported, the Administrator on call will be notified." Finally the policy stated "Reporting of suspected/alleged abuse/neglect of adults or children should be documented in the medical record."

A review of Patient #1's medical record revealed the 46 year old patient with a history of Mental Retardation and Traumatic Brain Injury was admitted on 09/09/13, due to Acute Respiratory Failure and Ventilator Dependency. During the patient's in-patient stay the patient experienced a massive stroke on 11/18/13 and had been unresponsive since the stroke.

Staff interviews revealed sometime during the second week of November 2013, staff observed Patient #1's parent with her hands under the patient's bed linen and movement was observed under the linen. This observation was reported to a member of the facility's nursing staff by two staff members; however, there was no evidence the incident was documented, reported or investigated by the facility to determine if abuse was occurring or if protection measures should be implemented.

Further interviews with facility staff revealed nursing staff observed Patient #1's parent patting/stroking Patient #1's scrotum and penis on two occasions, once on 12/02/13 and once on 12/04/13. On 12/02/13, Patient #1's parent summonsed Registered Nurse (RN) #1 to watch the patient "respond" to the parent. The parent was observed to pat the patient's scrotum with a washcloth in her hand, then, patted the patient's penis and proceeded to rub up and down the shaft of the penis with her bare hands. Nursing staff failed to report this allegation until the next day, 12/03/13, when it was reported to the facility Clinical Service Director (CSD) and the Chief Nursing Officer (CNO); however, no immediate action was taken to protect the patient to prevent further abuse. On 12/04/13, a Registered Respiratory Therapist (RRT) observed Patient #1's parent had the patient's genitals exposed and was patting the patient's scrotum. The RRT notified the CSD who came to the unit and witnessed the parent stroking the patient's penis with a stuffed animal. The allegation was reported to the state agency on 12/04/13, and on 12/05/13 the patient's parent was denied visitation with the patient by the state agency.

Although, the facility had in-serviced nursing staff on the facility policy on abuse prevention, the facility's policy failed to address protection of patients and actions to be implemented when the alleged perpetrator was a family member, or someone other than facility staff.

The failure of the facility to protect patients from abuse; failure to ensure the abuse policy addressed protection of patients; and failure to ensure allegations of abuse were immediately reported, and failure to protect patients from further potential abuse placed patients at risk for serious injury, harm, impairment or death. It was determined Immediate Jeopardy existed on 12/02/13 and is ongoing.

Refer to A0395.

Based on interview, record review, and review of the facility's documents and abuse policy, it was determined the facility failed to ensure patient rights were protected and promoted for one (1) of ten (10) patients (Patient #1). The facility failed to protect Patient #1 from abuse, failed to ensure allegations of abuse were reported immediately, and failed to conduct an investigation of abuse allegations.

The failure of the facility to protect patients from abuse; failure to ensure the abuse policy addressed protection of patients abused by anyone other than staff, and failure to ensure allegations of abuse were immediately reported and investigated placed patients at risk for serious injury, harm, impairment or death. It was determined Immediate Jeopardy existed on 12/02/13, the facility was notified of the Immediate Jeopardy on 12/13/13 at 9:30 AM and is ongoing.

The findings include:

The facility's policy entitled "Abuse and Neglect" dated 04/08/13, revealed the purpose of the policy was to identify victims of alleged or suspected abuse to include sexual molestation, domestic abuse of adults and children, and the notification of the proper authorities as legally required by the statutes of the state of Kentucky. The policy stated "Any person that knows or has cause to suspect abuse/neglect of a child or adult is mandated by Kentucky State Laws and Statues (KR199.011, 199.335, 199.990 and 209.030) to report the following situation: suspected child/adult neglect; physical, psychological or sexual abuse; domestic violence; exploitation". The policy revealed anyone, including a physician, nurse, social worker, emergency medical technician, health professional, or any organization that had reasonable cause to believe an adult had suffered abuse "has the duty to immediately cause an oral or written report to the Protection Hotline at 1-800-727-6200." Further review revealed hospital social services staff was available to assist in making a report and if outside normal working hours, the House Patient Care Coordinator could contact the social worker. Review of the policy revealed the facility could request an "Emergency Court Order for Adult Protective Services"; however, the policy failed to address how to protect the patient until the court order was obtained. The policy stated "When an incident or suspected incident of abuse or neglect, or injury of unknown origin is reported, the Administrator on call will be notified." The policy further stated that the Risk Management department and facility Legal Counsel, "will lead the investigation and shall consist of": 1) An interview with the person reporting the incident, 2) A statement of the patient's physical condition, 3) Interviews with any witness to the incident, 4) An interview with the patient if possible, 5) A review of the patient's medical record if appropriate, 6) An interview with other patients in which the employee has provided care, 7) An interview with all staff members having contact with this patient, 8) An interview of all circumstances surrounding the incident, 9) Results of the investigation will be recorded in the employees personnel file and, 10) A report of the investigation will be handled as per state and regulatory guidelines. Finally the policy stated "Reporting of suspected/alleged abuse/neglect of adults or children should be documented in the medical record."

Interviews conducted on 12/12/13 with the Chief Executive Officer (CEO) at 4:25 PM, the Chief Nursing Officer (CNO) at 3:40 PM and the Clinical Service Director (CSD) at 3:10 PM all of which had worked at the facility since the facility opened nine (9) years prior, denied that the facility had any allegations of abuse and had not conducted any investigation of abuse in the nine (9) years the facility had been in operation.

Review of Patient #1's medical record revealed the patient was 46 years old with a history of Mental Retardation and Traumatic Brain Injury. The facility admitted Patient #1 on 09/09/13, due to acute respiratory failure and ventilator dependency. Interviews conducted on 12/12/13 with Registered Respiratory Therapist (RRT) #1 at 1:15 PM and with Registered Nurse (RN) #1 at 2:00 PM revealed when Patient #1 was admitted, the patient was able to communicate verbally. However, during the patient's in-patient stay, he/she experienced a massive stroke on 11/18/13 and had been unresponsive since the stroke.

Interview conducted on 12/11/13 at 1:15 PM with RRT #1 revealed Patient #1 resided on the Transitional Care Unit (TCU). The front wall of each patient's room on the unit was glass which allowed staff to monitor the patients easily. The RRT stated approximately the second week of November 2013, RRT #1 was exiting another patient's room to obtain supplies for a ventilator, when the RRT observed Patient #1 in bed and the Patient's parent was crouched over the patient. The parent's head was at the patient's groin area and the parent's hands were under the blanket and movement was observed. The RRT obtained the needed supplies, completed the ventilator care for the other patient and exited the room. RRT #1 stated the parent realized RRT #1 was observing the situation, so when RRT exited the room, Patient #1's parent was at the patient's doorway and requested a band-aide. The parent stated he/she had cut the patient's nipple while shaving the patient's arms, chest, groin, and thighs. RRT #1 reported he retrieved a band-aide as requested and then reported the observation and interview with Patient 1's parent to the nurse. RRT #1 was unable to recall the exact date of the observation or the nurse's name.

There was no documented evidence the facility investigated RRT #1 s observation and interview with Patient #1's parent in November 2013, to determine if abuse was occurring or if interventions were needed to prevent further abuse of Patient #1.

Interview conducted on 12/11/13 at 2:55 PM with Patient Care Assistant (PCA) #1 revealed approximately the second week of November 2013, Patient #1's parent shaved the patient's chest and groin area. PCA #1 revealed she reported the incident to the nurses, but was unable to recall the exact date or the nurse's name.

Interview conducted on 12/11/13 at 2:00 PM with Registered Nurse (RN) #1 revealed Patient #1 had been non-responsive, with no reflexes since a massive stroke, on 11/18/13. RN #1 stated on 12/02/13 at approximately 7:00 PM, Patient #1's parent requested that the RN come to the patient's room to observe the patient responding to the parent. The interview revealed RN #1 followed the parent into the room and observed Patient #1's parent patting the patient's scrotum and penis. Then the parent proceeded to rub up and down the shaft of the penis. RN #1 stated while the parent was touching the patient, the parent stated, "He likes it when mommy washes him." The RN stated the parent was speaking to the patient like speaking to a child, and then the parent said, "Watch this". The parent then stated, "Do you want me to pat that ball sac?" The parent then stated, "Do you want me to pat that turkey neck?" According to RN #1, the parent asked the patient these questions and patted/rubbed the patient's scrotum and penis several times. RN #1 observed Patient #1 smile, and the parent said, "See him smile." while stroking Patient #1's penis. RN #1 exited Patient #1's room and discussed the incident with Licensed Practical Nurse (LPN) #1. RN #1 reported she called-in sick on 12/03/13 and was not at the facility again until 12/05/13. The interview revealed RN #1 did not report the incident observed to any administrative staff, did not report the incident to the DCBS hotline as required by the facility policy, and did not document the incident until 12/05/13. RN #1 stated the incident happened during shift change and she was very busy.

Interview conducted on 12/12/13 at 4:05 PM with LPN #1 confirmed on 12/02/13, RN #1 reported that she had observed Patient #1's parent patting/stroking the patient's scrotum and penis. LPN #1 stated Patient #1's parent then requested LPN #1 to go to the patient's room. Patient #1's parent proceeded to inform LPN #1 that earlier when the parent had tapped on the patient's "ball sac", the patient responded and that RN #1 had observed the incident. The interview revealed the nurses discussed the situation and RN #1 attempted to inform the CSD; however, there was no answer to the telephone call and the RN did not leave a message. LPN #1 stated on 12/03/13, the day after the incident, she attempted to notify the facility social worker; however, the social worker was off work for the week. The interview revealed later in the day on 12/03/13, LPN #1 reported the incident to the CSD. There was no documented evidence that the incident was reported to the state agency, no evidence an investigation was conducted, and no evidence that any protective measures were implemented at that time to protect Patient #1 from abuse.

Interview conducted on 12/11/13 at 2:40 PM with RRT #2 revealed on 12/04/13 at approximately 2:15 PM, RRT #2 observed Patient #1's parent standing at the patient's bed side, the patient's penis was exposed, the patient's knee was bent, and the parent was patting the patient's scrotum. RRT #2 notified the CSD of the observation and the CSD came to the unit.

Interview conducted on 12/11/13 at 3:50 PM with the CSD revealed on 12/03/13 at approximately 6:00 PM (23 hours after Patient #1's parent was observed by RN #1 and verbally admitted to LPN #1. to patting/rubbing the patient's scrotum and penis) LPN #1 reported the incident to the CSD. The interview revealed the CSD instructed LPN #1 to have staff notify the CSD when Patient #1's parent arrived at the facility the following day (12/04/13). The CSD stated she also informed the CNO of the allegation. The interview confirmed the CSD did not report the allegation to the appropriate state agency, document the allegation reported by LPN #1 or initiate an investigation into the allegation on 12/03/13. The CSD stated on 12/04/13 at approximately 2:15 PM, RRT #2 left a message on her telephone that an incident was occurring with Patient #1. The CSD went to the unit where Patient #1 resided and observed Patient 1#'s right knee bent and leaning on the side rail, with his genitals exposed. Patient #1's parent had the patient's penis in one hand with her fingers under the patient's scrotum and the other hand was holding a stuffed animal that was being utilized to rub up and down the shaft of the patient's penis. The interview revealed the CSD entered the patient's room, instructed Patient #1's parent to stop and requested the parent come with the CSD into a private room. Continued interview with the CSD revealed the CSD proceeded to inform the parent what the parent was doing was wrong and not to touch Patient #1 in that way again. The CSD stated she instructed nursing staff that the parent was not to touch Patient #1, and exited the unit to report the observation to the CNO, leaving the parent on the unit with the patient and nursing staff. The interview revealed she and the CNO informed the CEO of the incident and was instructed by the CNO to speak to the hospital's social worker for instructions. The CSD revealed the hospital's social worker instructed the CNO and CSD to notify the Department of Community Based Services (DCBS) of the incident. The interview revealed the CSD notified DCBS and obtained a physician's order for that particular parent to have only supervised visitation with Patient #1.

According to the CSD, DCBS arrived shortly after being notified and initiated an investigation. At that time, the facility turned the investigation over to DCBS and did not continue with the facility's internal investigation. The interview with CSD revealed DCBS did not instruct the facility not to conduct an investigation; however, the CSD believed that since DCBS was investigating, the facility had completed their obligation.

Interview on 12/12/13 at 3:10 PM, with CSD revealed the facility's abuse policy did not address how staff was to protect an adult patient when the alleged perpetrator was not an employee. The interview revealed the facility had not conducted an investigation because the Administrative staff was under the impression that when DCBS was involved, the facility had completed their obligation. The CSD stated she did not report the allegation on 12/03/13 because she did not think the allegation was sexual abuse until she witnessed the incident on 12/04/13. The CSD confirmed she did not access the facility's abuse policy to ensure she implemented the policy as required.

Interview on 12/12/13 at 3:40 PM with the CNO revealed she worked with the Risk Manager to conduct investigations of abuse allegations. The CNO revealed an abuse investigation normally consisted of interviewing all witnesses, assessing the patient, and assessing to determine if there was any history of abuse. According to the CNO, the facility also usually conducted a follow up of the allegation after the completion of the state agency's investigation and then initiated corrective actions; however, when allegations of abuse regarding Patient #1 were reported, the facility only interviewed the staff that reported the allegation.

Interview on 12/12/13 at 4:50 PM with the Risk Manager (RM) revealed he was responsible for assisting the CSD and the CNO with conducting abuse allegation investigations. The RM stated when an allegation of abuse occurred, staff was required to complete an incident report and submit it to the Risk Manager Monday thru Friday from 8:00 AM to 4:30 PM. The interview revealed after hours and on weekends, staff was required to leave the incident reports in a locked box that he checked the following work day. The Risk Manager stated he then reviewed the incident report, logged the incident in a log book for tracking and trending purposes, then sent the incident report to the CNO or CSD to conduct an investigation. The RM stated the CNO and CSD completed the investigation and the findings were submitted to the RM for review. According to the RM, once DCBS was involved in the allegation, DCBS was then responsible for the investigation and the facility conducted a follow-up after DCBS's investigation was complete.

Interview on 12/12/13 at 4:30 PM, with the CEO revealed Administrative staff was responsible for notifying him of any allegations of abuse/neglect. The CEO stated he would then be involved after the completion of the investigation for determining the right course of action for the facility. The CEO stated that in reference to the abuse allegations involving Patient #1, "In this case we have an adult patient unresponsive and the mother was doing something inappropriate." "We never seen or expected it from her, and we had to think about it because we are going to change lives." The interview revealed after being informed of the allegation and instructing staff to seek guidance from the hospital social worker, the CEO had no more involvement with this allegation. According to the CEO, he knew the appropriate people were involved, and felt there was no need for him to be involved. The CEO further stated that since another company had just bought the facility, things were very busy and the CEO was in training. The interview revealed the CEO would have reported the results of the investigation to the Governing Body in February 2014, during the next meeting.

Review of documentation provided by the facility revealed as of 12/12/13 (ten days after nursing staff first observed Patient #1's parent patting/rubbing on the patient's scrotum and penis) there was no evidence the facility had conducted an internal investigation of the above allegations, as per facility policy, to determine if there were other incidents of abuse with Patient #1. Further, Incident reports were not completed for the 12/02/13 incident until 12/05/13. According to the RM interview, the incident reports initiated an internal investigation; however, there was no further documented evidence of an investigation conducted by the facility.

Based on interview, record review, and review of the facility's documents and abuse policy, it was determined the facility failed to provide patients with nursing care to ensure patient safety for one (1) of ten (10) patients (Patient #1). Interviews with staff revealed two incidents of alleged abuse were reported to nursing staff, once in November 2013 and on 12/02/13. On 12/02/13, nursing staff observed Patient #1's parent patting/stroking the patient's penis. Nursing staff failed to report the allegations of abuse to the Department for Community Based Services (DCBS) and administrative staff as required per the facility's policy regarding abuse. Nursing staff also failed to document the incident in the medical record as required per facility policy.

The failure of the facility to ensure allegations of abuse were immediately reported and investigated placed patients at risk for serious injury, harm, impairment, or death. It was determined Immediate Jeopardy existed on 12/02/13 the facility was notified of the Immediate Jeopardy on 12/13/13 at 9:30 AM and is ongoing.

The findings include:

The facility's policy entitled "Abuse and Neglect" dated 04/08/13, revealed any person that knows or has cause to suspect abuse/neglect of a child or adult is mandated by Kentucky State Laws and Statues to report suspected child/adult neglect; physical, psychological or sexual abuse; domestic violence; exploitation. The policy revealed anyone, including a physician, nurse, social worker, emergency medical technician, health professional, or any organization that had reasonable cause to believe an adult had suffered abuse "has the duty to immediately cause an oral or written report to the Protection Hotline at 1-800-727-6200." Review of the policy revealed the facility could request an "Emergency Court Order for Adult Protective Services"; however, the policy failed to address how to protect the patient until the court order was obtained. The policy stated the on-call Administrative staff would be notified when an incident or suspected incident of abuse or neglect, or injury of unknown origin was reported. According to the policy, reporting of suspected/alleged abuse/neglect of adults or children should be documented in the medical record.

Review of the medical record of Patient #1 revealed on 09/09/13, the facility admitted a 46 year old patient with a diagnosis of Acute Respiratory Failure and Ventilator Dependent and a history of Mental Retardation and Traumatic Brain Injury as an infant. On 11/18/13, during Patient #1's in-patient stay the patient experienced a massive stroke and had been unresponsive ever since.

Interview conducted on 12/11/13 at 1:15 PM with Registered Respiratory Therapist (RRT) #1 revealed approximately the second week of November 2013, RRT #1 observed Patient #1's parent crouched over the patient with the parent's head at the patient's groin area, and the parent's hands under the blanket at the groin area with movement noted under the blanket. Patient #1's parent waited for RRT #1 at the patient's doorway and requested a band-aide due to cutting the patient's nipple while shaving the patient's arms, chest, groin, and thighs. RRT #1 retrieved a band-aide as requested and then reported the observation and interview with Patient #1's parent to the nurse. RRT #1 was unable to recall the exact date of the observation or nurse's name. The interview revealed the RRT did not document the observation, did not report the observation to Administrative staff or the Protection Hotline.

Interview conducted on 12/11/13 at 2:55 PM with Patient Care Assistant (PCA) #1 confirmed approximately the second week of November 2013 Patient #1's parent shaved the patient's chest/groin area. PCA #1 reported the incident to the nurses but was unable to recall the exact date or the nurse's name. The PCA revealed she had not been interviewed about the incident until 12/05/13.

Interview conducted on 12/11/13 at 2:00 PM with Registered Nurse (RN) #1 stated Patient #1 had been non-responsive, with no reflex since a massive stroke on 11/18/13. RN #1 stated on 12/02/13, at approximately 7:00 PM, Patient #1's parent requested RN #1 come to Patient #1's room to witness the patient responding to the parent. The interview revealed RN #1 followed the parent into the room and observed Patient #1's parent patting the patient's scrotum, the patient's penis then proceeded to rub up and down the shaft of the penis. RN #1 stated while the parent was touching the patient the parent said, "He likes it when mommy washes him" to the patient like speaking to a child, then the parent said "watch this" to RN #1. The parent stated, "Do you want me to pat that ball sac" "do you want me to pat that turkey neck" to the patient, with RN #1 standing at the bedside. The interview revealed the parent said and did this several times and Patient #1 smiled and the parent said, "see him smile" while stroking Patient #1's penis. RN #1 discussed the incident with Licensed Practical Nurse (LPN) #1. RN #1 reported she called-in sick on 12/03/13 and was not at the facility again until 12/05/13. According to RN #1, the facility's abuse policy required staff to report any allegation of abuse to Administrative staff and to complete an incident report. The interview revealed RN #1 did not report the incident observed to any administrative staff, did not report the incident to the hotline, and did not document the incident until 12/05/13. RN #1 confirmed she did not implement any protective interventions to prevent further abuse. The RN stated the incident happened during shift change and she was very busy.

Interview conducted on 12/12/13 at with LPN #1 revealed after RN #1 reported what she had observed, Patient #1's parent requested LPN #1 to come to the patient's room. The parent proceeded to inform LPN #1 that when the parent had tapped on the patent's "ball sac" the patient had responded and RN #1 had observed the incident. The interview revealed the nurses discussed the situation and RN #1 attempted to inform the Clinical Service Director (CSD); however, there was no answer to the telephone call and left no message reporting the observation. According to LPN #1, on 12/03/13 the day after the incident, she attempted to notify the facility social worker; however, the social worker was off for the week. LPN #1 revealed she was unsure of her responsibility to report to the state agency. The interview revealed later on 12/03/13 LPN #1 reported the incident to the CSD. There was no documented evidence this incident was reported to the state agency, an investigation was initiated, or any protective measures implement to prevent further abuse, at this time.

Interview conducted on 12/11/13 at 2:40 PM with RRT #2 revealed on 12/04/13 at approximately 2:15 PM, RRT #2 observed Patient #1's parent standing at the patient's bedside, with the patient exposed, the patient's knee bent, and the parent was patting the patient's scrotum. RRT #2 notified the CSD of the observation and the CSD came to the unit.

Interview conducted on 12/11/13 at 3:50 PM with the CSD revealed on 12/03/13 at approximately 6:00 PM (23 hours following the observation of RN #1), LPN #1 reported the incident to the CSD. The interview revealed the CSD instructed LPN #1 to have staff notify the CSD when Patient #1's parent arrived at the facility the following day (12/04/13). The CSD stated she then informed the CNO of the allegation. The interview confirmed the CSD did not report the allegation to the appropriate state agency, did not document the allegation reported by LPN #1, and did not initiate an investigation of the allegation which occurred on 12/02/13. Continued interview revealed on 12/04/13 at approximately 2:15 PM RRT #2 left a message on the CSD's telephone that an incident was occurring with Patient #1's parent, so the CSD went to the unit. The CSD revealed she observed Patient #1's right knee bent and leaning on the side rail with his gentiles exposed. The CSD stated Patient #1's parent had the patient's penis in one hand with fingers under the scrotum and with the other hand had a stuffed animal being utilized to rub up and down the shaft of the patient's penis. The interview revealed the CSD instructed Patient #1's parent to stop touching the patient and then requested the parent to follow the CSD to a private room. The CSD proceeded to inform the parent what the parent was doing was wrong and not to touch Patient #1 in that way again. The CSD stated she instructed nursing staff this parent was not to touch Patient #1, and exited the unit to report the observation to the Chief Nursing Officer (CNO), while the parent was still on the unit. The interview revealed she and the CNO informed the Chief Executive Officer (CEO) of the incident and instructed to speak to the hospital's social worker for instructions. The CSD revealed the hospitals social worker instructed the CNO and CSD to notify Department of Community Based Services (DCBS). According to the CSD, DCBS arrived shortly after being notified and initiated an investigation and at that time, the facility turned the investigation over to DCBS and did not continue with the facility's internal investigation. The interview revealed DCBS did not instruct the facility to stop their investigation but the CSD thought since DCBS was investigating the facility had completed their obligation.

Interview on 12/12/13 at 3:10 PM with CSD revealed the facility's abuse policy did not address how staff was to protect an adult patient when the alleged perpetrator was not an employee. The interview stated she did not report the allegation on 12/03/13 because she did not think the allegation was sexual abuse until she witnessed the incident on 12/04/13. The interview revealed there was no problem with staff not reporting until the following day because the parent only visited once a day and would not be back until the afternoon of 12/04/13. The CSD was planning to discuss the issue with Patient #1's parent on 12/04/13. According to the CSD, she did not access the facility's abuse policy to ensure she was implementing the policy as required.

Interview on 12/12/13 at 3:40 PM with the CNO revealed the facility would conduct a follow up of the allegation following the completion of the state agency's investigation and then would initiate corrective actions.

Interview on 12/12/13 at 4:30 PM with the CEO in reference to reporting this incident stated "in this case we have an adult patient unresponsive and the mother was doing something inappropriate, we never seen or expected it from her, and we had to think about it because we are going to change lives."

Review of documentation provided by the facility, as of 12/12/13 (ten days after RN #1 observed the parent patting/rubbing the patient's penis and scrotum) revealed an incident report was completed on 12/05/13 for the incident occurring on 12/02/13.