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Based on interview and record review, the facility failed to ensure that an alleged incident of patient abuse was reported and remediated for one patient (P-1) of 10 patients reviewed, resulting in possible negative outcomes for this patient. Findings include:

During chart review for P-1 on 10/21/2025 at 1415 the record revealed the following entries regarding the patient's allegation of assault:

8/2/2025 - General Medicine Note- "Subjective Patient seen examined at bedside. Overnight, patient called the police and staff. Currently she has no complaints. Ostomy output has decreased. She is feeling hungry. She is open to go home soon. She denies any fevers, chills, chest pain, shortness of breath, nausea, vomiting or abdominal pain."

8/2/2025 at 0149 Nursing Note - 8/2 0140 "Patient called 911 on room phone. Security and police went in room to discuss with patient."

8/2/2025 - 1033 - Nursing to provider notification - "pt is confused and urine smells strong - can we do UA? also pt accusing staff of sexual harrassement [sic] and currently hitting/throwin[sic]"

8/2/2025 - 1418 Nursing provider notification - "Evaluate patient is adamant about leaving again. She called the police to come get her."

On 10/21/2025 at 1545 an interview with the System Manager of Case Management (Staff Q) was conducted and revealed she received a phone call from the staff at the rehabilitation facility P-1 had been transferred back to upon discharge. Staff Q reported that the staff member wanted to report that P-1 had reported she was making allegations of abuse by staff that occurred during her recent admission to the facility. Staff Q explained after she ended the call with the rehabilitation facility staff member, she called the Risk Management Department to report the incident. Staff Q revealed she called the rehabilitation facility back to notify them that she had let the Risk Management Department know about the allegations. When queried if she had heard anything further about the complaint, Staff Q responded, "no".

During an interview with the staff nurse (Staff T) on 10/22/2025 at 0900 that was assigned to care for P-1 during the admission it was revealed that she remembered P-1 and that she was experiencing mental status changes during her admission. Staff T explained that she recalled trying to explain what they are doing to P-1 and she would yell at staff and was confused at times. Staff T recalled that a male patient care associate (Staff Y) needed to perform a bladder scan for urinary retention, and she explained the procedure to P-1 but when the PCA went to perform the scan, P-1 began yelling "he is raping me". Staff T explained that she immediately went into P-1's room and tried to explain the procedure to her again, but P-1 continued to say she was being raped, and the scan was not completed. Staff T revealed she notified the primary care provider that P-1 was yelling at staff, a 2-person "buddy" system was initiated following the incident and a sign was placed outside of her room, so that caregivers were not in her room alone. Staff T recalled she did not remember much else about the incident other that P-1 continued to yell out and her bed alarm kept going off. When queried if she notified leadership about the incident, Staff T stated, "I do not remember". When queried if she was interviewed about the incident by her manager or anyone from Human Resources, Staff T revealed, "no".

On 10/22/2025 at 1030 an interview with the Patient Care Associate (Staff Y) was conducted and revealed that he was told in shift report from the off-going PCA that P-1 had not voided in a long time and there was concern for urinary retention, so he notified the nurse. Staff Y explained that he went in to do a bladder scan and introduced himself to P-1 and explained what the bladder scan was for and how he was going to do it and "she started screaming at me and told me to get out of the room" and he immediately left her room to notify the nurse. Staff Y added, "I never even made it past the curtain in her room." Staff Y explained that he was later notified that P-1 called 911 from her room following this incident and reported she was sexually assaulted. Staff Y revealed, "I never even touched the patient" and added that he heard that P-1 had made the same allegations the following day about the nurse (Staff T). Staff Y said immediately following the incident he changed his assignment, so he would no longer be providing care to P-1 since she was confused, and he did not think it was a good idea to be in a room alone with her.

An interview with the Internal Medicine Hospitalist (Staff Z) was conducted on 10/22/2025 at 1100. Staff Z revealed he remembered P-1 and that after reviewing her record that he evaluated her on 8/1/2025, 8/2/2025 and that she was requesting to be discharged on 8/3/2025. Staff Z explained that P-1 was alert and oriented but had a history of dementia and may have been having Sundown Syndrome (increasing confusion, restlessness, anxiety and paranoia which occurs in the late afternoon and at night) symptoms. Staff Z revealed that he did not recall P-1 telling him about an assault or that she called 911 but does know she was experiencing urinary retention and required a foley catheter insertion. Staff Z revealed P-1 did require a Zyprexa injection on 8/2/2025 for agitation and becoming combative with staff. When queried if he had previous concerns of patient assault on the unit, Staff Z explained, "this a very vulnerable unit because of the patient population and increased confusion" and he did not believe P-1 was assaulted during the admission.

During an interview with the staff nurse (Staff GG) on 10/29/2025 at 0830 by phone, it was revealed she remembered P-1 and that she was not confused at the start of her shift, but her confusion increased as the day progressed. Staff GG revealed that the patient care associate (Staff Y) reported to her that P-1 refused a bladder scan and was inferring that he was trying to get under the covers with her and be inappropriate. Staff GG explained that she went into P-1's room with another female PCA and explained the process of the bladder scan and the patient allowed her to do it. Staff GG revealed the P-1 did not report the incident with Staff Y when she was providing care for her, but she later called 911, which was the next time she heard of the incident, and she saw the police on her unit. Staff GG explained that she notified the charge nurse and that the police shared with her that they were not going to be do anything further about the complaint. Staff GG added P-1's glucose was low and required dextrose and her potassium was also low, so she was very focused on those things. Staff GG added that when she spoke with Staff Y about the incident, he shared with her that he went to do the bladder scan, and she refused and they decided not to assign male caregivers for her moving forward. Staff GG revealed she never spoke with management human resources following the incident and did not complete an incident report.

A phone interview with the Security Officer (Staff DD) was conducted on 10/29/2025 at 0800 and revealed she remembered being called up to P-1's hospital room because she was calling 911. Staff DD explained that Security is notified if anyone uses a hospital phone to dial 911 and Security and the local police department went to speak with P-1 in her room who told them she was calling 911 so she could get a ride out of the facility. Staff DD revealed that P-1 told them that a male patient care associate (PCA) came into her room to do a bladder scan by himself, and she did not think a male should do that without a female present because he could have attempted to harm her or do sexual harm. Staff DD explained that the police asked P-1 if she was harmed and she said "no". Staff DD explained that P-1 was notified that police could not give her a ride home at 0200. When queried if she had any other calls about P-1 or if she called 911 again, Staff DD revealed "no, we did not hear from her again". Staff DD added, we spoke with the facility staff involved and they explained that when P-1 asked for a female PCA, the male PCA stepped out of the room and that was the end of it. Staff DD explained following the incident a report was filed and which was reviewed by the supervisor, and she never heard anything about it after that.

On 10/29/2025 at 0900 an interview with the 4th floor Adult General Medicine Unit Manager (Staff HH) was conducted and revealed she found out about P-1's allegations because of an incident report that was sent to her. Staff HH explained there was some confusion as to which unit P-1 was on when during alleged event and she had spoken with the 3rd Floor Neurovascular Unit Manager (Staff D) and reviewed the charting related to the foley insertion to determine who provided care to P-1. Staff HH explained that when she spoke with the staff members, they did not remember P-1. Staff HH added that she was at an outside function for the facility and ran into the human resource manager (who is no longer with the facility) and was talking to her about the event and was told it was handled and "was going to take care of it". Staff HH explained she attempted to follow-up with an email to the HR manager and found that she no longer worked at the facility, and she assumed that the investigation was managed by Risk Management and Human Resources.

On 10/21/2025 at 1430 an interview with the System Director of Risk Manager (Staff O) was conducted and revealed she was familiar with P-1 and explained, "the whole team was involved with the case because it was an assault allegation". Staff O revealed the case was initially assigned to a risk manager in the office (who is currently on leave and unavailable for interview). Staff O revealed the Risk Management Department received a voicemail from the System Director of Case Management (Staff Q) stating that she had received a phone call from the rehabilitation facility where P-1 was residing and they were reporting that P-1 had reported she was sexually assaulted by facility staff. Staff O explained that Staff Q documented that she called the rehabilitation facility to review the allegations and was told by staff at the facility that P-1 had reported multiple other episodes of false allegations at the rehabilitation facility. Staff O explained that following the phone call with the rehabilitation facility, Staff Q reviewed P-1's record to determine the caregivers and units P-1 was admitted to. Staff O explained that Staff Q found that P-1 was retaining urine, requiring straight catheterization and foley catheter insertion. Staff O continued that Staff Q contacted the Human Resources (HR) Department On 8/12/2025 to report the facility staff that was involved in P-1's care and begin the investigation. Staff O explained that Staff Q documented that she had spoken with a HR representative that is no longer with the facility. Staff O explains the file does not include any interviews that were conducted and that "HR probably considered it unsubstantiated and closed the file on 8/15/2025". When queried if Staff Q documented that HR had provided any additional follow-up, Staff O explained the last note in the file was from 9/4/2025 that stated "significant discrepancies, nothing substantiated, still waiting for APS (Adult Protective Services) report" and a note dated 9/5/2025 from the previously employed HR representative revealed, the matter will be transferred to the System Director of Human Resources (Staff S). When queried if the investigation into the allegations was followed according to the facilities policy/procedure, Staff O revealed, "no this is not how this should have been handled."

On 10/22/2025 at 1130 an interview with the System Director of Human Resources and Employee Engagement (Staff S) was conducted. Staff S revealed she was not aware of the incident investigation pertaining to P-1 until 10/21/2025. Staff S explained that the Manager of Human Resources was responsible for managing the investigation, but she is no longer working at the facility. Staff S revealed she reviewed the file and the expectation would have been that there were notes on the investigation including staff interviews before it was closed, which were not found with the file. Staff S explained the file had been closed and marked as unable to substantiate. When queried if the facility followed their policy/process for incident report investigation, Staff S revealed they did not.

Review of facility policy titled, "Investigation of Physical and Sexual Misconduct Allegations", last revised 5/17/2025, section titled "Procedure, All patient or visitor complaints of misconduct by a [facility] workforce member must be immediately reported to Human Resources and/or Risk Management as well as operational leadership at the location the alleged misconduct occurred. Complaints involving employed individuals and patients, or visitors shall be investigated by Human Resources and Risk Management."