HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 4 (Pt. #1) patient records reviewed for suspected abuse, the Hospital failed to ensure that the patient had the right to be free from all forms of abuse by failing to report the allegation of abuse to State agencies, as required.

Findings include:

1. The Hospital's policy titled, "Abuse or Neglect of Patients" (revised 8/2020), was reviewed on 8/16/2022 and required, "All allegations or suspicions of neglect, abuse, or other harm must be investigated... When there is reasonable cause to believe that a patient has been subjected to abuse in the hospital, a report will be promptly made to the appropriate regulatory agencies... licensed or certified professionals... are expected by law to report suspected abuse or neglect...(see definition of Mandated Reporter)... The report will be made within 24 hours after obtaining such a report... 'Mandated reporter' means any of the following persons while engaged in carrying out their professinal duties... while engaged in... care of an eligible adult [means either an adult with disabilities aged 18 through 59 or a person aged 60 or older... and is alleged to be abused, neglected, or financially exploited by another individual]... References: ...2. The [State] Department of Aging Adult Protective Services Act... 3. [State] Department of Public Health..."

2. The clinical record of Pt. #1 was reviewed on 8/15/2022 and 8/16/2022. Pt. #1 [adult female] was transferred from an outside acute care hospital and admitted to the Hospital's B-2 Unit on 4/22/2022, with a diagnosis of acute hypoxemic respiratory failure secondary to post-operative aspiration pneumonia.

- Physician Progress notes from 6/3/2022-6/11/2022 indicated that Pt. #1 was becoming increasingly lethargic and had altered mental status. A Neurology Consultation Report, dated 6/8/2022 at 5:17 PM included, "Assessment: Altered mental status ... Plan: CT [computerized tomography] of the head ... UA [urinalysis] ... Awake, drowsy, slowly will follow commands."

- A Urine Analysis (UA) was ordered and collected on 6/10/2022 at 6:40 AM. The UA result included, "Specimen Source: urine clean catch ... Urine Sperm: Present."

- Pt. #1 was discharged on 6/28/2022 and re-admitted to the Hospital on 7/7/2022 for continued medical care.

- Psychologist assessments and progress notes from 4/22/2022 to 8/12/2022 were reviewed and indicated that Pt. #1 did not have decisional capacity and included notes on 7/12/2022 and 7/18/2022 stating "Insight and safety awareness impaired due to cognitive, and communication deficits ..."

- A Nurse's (E#9) Note, dated 7/16/2022 at 2:30 PM, included, "Upon reviewing the patient's chart, urine analysis noted from 6/10/2022 with the presence of semen. House supervisor notified. House supervisor with statement that she plans to inform unit director, MD and director of nursing first thing AM to determine next course action. Patient is resting comfortable at this time. Alert to person only ..."

3. Visitor Logs, Room Entry Logs, and B2 Unit Staffing Assignments from 6/4/2022 to 6/10/2022 were reviewed and indicated that Pt. #1 had potential contact with male persons (visitor, staff, etc) during this time period.

4. An email from the Night Shift Supervisor, dated 7/16/2022 at 3:10 AM, included the following:
"[Nurse E#9] came to see me this morning around 2:00 AM reporting her 'emergency and serious' problem. She presented a U/A result of one of her patients [Pt. #1] dated 6/10/2022 showing a Urine Sperm PRESENT. She was so worried and very concerned telling me that this is a criminal case for the fact that [Pt. #1] is a 'special child' case with history of Cerebral Palsy/Muscular Dystrophy. She was then urging me to call the Doctor and get the Police involved. She felt that [Pt. #1] is not safe here at [Hospital]... There was a serum HCG, Qualitative [pregnancy test] done 7/8/202 and was NEGATIVE. After I told her about this lab result - she calmed down and still insisting that this should be reported to authorities. She believed that somebody did an inappropriate act on [Pt. #1] as evidenced by the presence of the Sperm in her urine during her period of hospitalization ..."

5. An Incident Report was filed for Pt. #1 on 7/18/2022 at 5:38 PM and included, "... On 7/16/2022, Agency night nurse [E#9] conducted chart review of this patient's lab results as she was assigned to this patient. Upon review, she noted the finding of sperm in urine on a 6/10/2022 U/A ... [E#9] notified night supervisor, who then sent email to DON [Director of Nursing] and unit manager [E#4]. This writer [E#4] read email the next day on 7/17/202 and immediately notified Director of Risk Management, CNO [Chief Nursing Officer], and CMO [Chief Medical Officer]. An action plan for further investigation was placed and patient was immediately placed on 2 caregiver precautions and no male caregiver list, even though patient is a/o [alert and oriented] x 2 to 3, very vocal, and easily follows commands. In addition, part of plan of action involved MD ordering urine hCG and qualitative beta HCG [pregnancy tets], which both resulted as negative... Reported to Agencies: [none listed] ..."

6. An interview was conducted with the Director of Risk Management (E#7) and B2 Unit Manager (E#4) on 8/16/2022, at approximately 12:13 PM. E#7 stated that the UA results could have indicated a possible sexual assault, and the Hospital put precautions in place to ensure that only female caregivers worked with the patient thereafter. E#7 stated that the laboratory results could have been correct, but by the time the Hospital was made aware of the concern, there was no way to validate the test or to obtain any additional evidence due to the lapse in time. E#7 stated that this concern was not reported to any external agencies (such as the State Department of Public Health and Department of Aging). E#7 stated that the Hospital questioned the integrity of the lab results and the patient did not actually report the abuse. E#7 stated, "We would have reported it if we had evidence ... but since it most likely occurred in June, we did not have any specific information to report."

7. An interview with the Chief Executive Officer (E#12) was conducted on 8/17/2022, at approximately 9:25 AM. E#12 stated that the concern that sperm was detected in Pt. #1's urine (possible indicator of sexual assault) was not reported to any external agencies in this case because it did not rise to the "level of other accusations" in that the patient and/or father (healthcare surrogate) never verbalized that Pt. #1 had been touched inappropriately and the Hospital could not validate whether something suspicious had occurred. E#12 stated that it [sexual assault] could have possibly happened but there were no other warning signs that abuse had occurred.