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Based on medical record review, review of investigative documentation provided by the facility, facility policy review, personnel file review, review of physical therapy board documentation, and interview, the facility failed to promote patient rights and protect three patients (#1, #2, #3) of five sampled patients from inappropriate sexual touching at the facility's outpatient rehabilitation center.

The findings included:

Medical record review of a physician's order for Patient #1 dated October 7, 2008, revealed, "Eval and Tx (evaluate and treat) moist heat...electrical stimulation...traction." Medical record review of a Physical Therapy Evaluation dated October 14, 2008, revealed, "...31-year old...with a diagnosis of neck pain...plan to see the patient...for modalities of ultrasound massage..." Medical record review of physical therapy progress notes dated October 21, 23, 29, and 31, 2008, revealed the patient was treated by Physical Therapist #1.

Interview with the director of the facility's outpatient rehabilitation center on May 12, 2010, from 11:32 a.m. through 12:20 p.m., in the director's office, revealed the facility had complaints regarding Physical Therapist #1 in the fall of 2008, into the winter of 2009, from three female patients. Continued interview revealed Patient #1 called the director to determine what constituted appropriate care of a neck problem. Continued interview revealed the patient expressed concern regarding care provided by Physical Therapist #1, and the director stated, "(Patient #1)...voiced...had placed his hands too free and loose, I'm paraphrasing...(Physical Therapist #1) had told...was treating trigger points...felt need to continue treatment, discomfort with (Physical Therapist #1)...agreed to treatment here with no contact with (Physical Therapist #1)...The moment I got the call from that patient I called my supervisor (name deleted). Scheduled a meeting with (Physical Therapist #1) the next morning...told me he was working in chest area not breast. Told him patient's care would be transferred to another therapist and told him not to treat any female patient in a closed room. Cautioned him to make sure treatment was appropriate...supervisor told me to monitor and let him know if any other concerns..." Continued interview revealed the director inquired of the directors's supervisor regarding completion of an incident report, a report was not completed regarding the patient's allegation, and the director stated, "(supervisor) said (the allegation) would be handled internally."

Telephone interview with the risk manager on May 25, 2010, at 1:48 p.m., revealed the risk manager was unaware of Patient #1's allegation of inappropriate touching by Physical Therapist #1 until May 12, 2010.


Medical record review of a physician's order for Patient #2 dated November 3, 2008, revealed, "Eval & Tx." Medical record review of a Physical Therapy Evaluation dated December 1, 2008, revealed, "...29-year-old...originally injured...approximately 2001...2 months later...was assaulted by...stepfather...knocked against a railing, striking the right and back side of...neck...Today the patient received...soft tissue massage approximately 10 minutes to the upper back and cervical region..." Medical record review of physical therapy progress notes dated December 3 and 10, 2008, revealed the patient was treated by Physical Therapist #1.

Interview with the director of rehab on May 12, 2010, from 11:32 p.m. to 12:20 p.m., in the director's office, revealed a second allegation of inappropriate touching regarding Physical Therapist #1 was made late in 2008, and the allegation was made by Patient #2's mother. He stated, "...call from...mother...(Patient #2) just received therapy here had called her distraught and crying. Mother angry upset...(Patient #2) said...was in a closed door room with (Physical Therapist #1) prone on stomach...pulled clothing down below knees...believe (Physical Therapist #1) was alleged to have massaged back and buttocks...called (supervisor) at the time, left a message...filled out incident reports...Both (supervisor and rehab director) met with (Physical Therapist #1) the next morning...(Physical Therapist #1) was placed on administrative leave until further notice...After that (supervisor, rehab director, and two risk managers) met with (Patient #2) within a week...don't remember how many weeks (Physical Therapist #1) was on administrative leave. During that time other issue (first allegation) was brought up...returned to work with restrictions...required to attend mandatory hospital sponsored education on communication with patients. Not allowed to see any new or existing patients, treated males only. Those guidelines established by (supervisor) in HR (human resources)." Continued interview revealed the director's supervisor at the time of Patient #1 and Patient #2's allegations was no longer employed at the facility.

Telephone interview with Patient #2 on May 18, 2010, at 4:00 p.m., revealed Physical Therapist #1 provided treatment on December 10, 2008, and the patient stated, "...(Physical Therapist #1) said, 'I'm going to roll your pants down so I can reach your hip area or bones. Then he reached, pulled my pants approximately to (the) bend in my knees, closer to knees than buttocks, put jelly on me, massaged my rear end...I was in shock. Not one word was said. I was not sure if this was therapy...massaged back and rear end five to seven minutes. After that he pulled my pants and panties up. He directed me to leave the building. I asked my boyfriend if a PT should pull your pants down. He said no and I called my mom. She called and talked to (director of rehab) same day..." Continued interview revealed the director set up a meeting between the patient and four facility staff on December 15, 2008, and the patient stated, "...I've had two years to think about this. I consider it sexual assault. Another lady had complained about him. I didn't know until end of hearing when his license was suspended that there were other women...He abused his license in the worst way..."


Review of investigation documentation provided by the facility and dated December 11, 2008, revealed, "Complaints (Physician or Employee Related Events)...(Patient #2's) mother...called at approximately 5:30 PM on 12/10/08 to speak with me and report a complaint...(Patient #2) came home today after...4:30 PT appt (appointment) hysterical and crying. Stated (Physical Therapist #1) had...in a treatment room by themselves...pulled...pants/sweats down...massaged...buttocks...(patient) stated...felt violated and molested...mother demanded that this situation be addressed..."


Interview with the director of rehab on May 12, 2010, from 11:32 a.m. to 12:20 p.m., in the director's office, revealed a third allegation was made regarding Physical Therapist #1 in February, 2009, and the allegation was reported to the director by Physical Therapist #2, a therapist unaffiliated with the facility. The director stated, "(Physical Therapist #2) had (Patient #3) in his clinic who had received treatment here in fall of 2008, and shared with therapist interaction here of inappropriate, no specifics, of sexual nature. I asked if...had given therapist's name and it was (Physical Therapist #1). I asked (Physical Therapist #2)...if we could contact (Patient #3)...and it was okay. That same day I called (facility)...and said something needed to be done...was placed on administrative leave until we could get a hold of the patient...(Patient #3) described the incident...the next day we terminated him...no allegations since he was terminated..."

Medical record review of a PT Evaluation for Patient #3 dated September 9, 2008, revealed, "31-year-old...with a diagnosis of neck and shoulder pain...Plan: ...modalities - ultrasound, moist heat and massage..." Medical record review of physical therapy progress notes dated September 11, 16, 23, 25, 26, and 30, 2009, and October 2, 14, and 16, 2008, revealed the patient was treated by Physical Therapist #1. Medical record review of a physical therapy discharge note dated January 16, 2009, revealed, "Pt (patient) has not returned...Will D/C (discharge)."

Telephone interview with Patient #3 on May 12, 2010, from 10:20 a.m. until 10:58 a.m., revealed Physical Therapist #1 was the patient's therapist, and the patient stated "...(treatment) always behind closed doors. Second or third visit he handed me a gown, did not leave the room. He was behind me and held the gown out for me. Didn't voice anything until I was asked to lay on the table. Thought it was odd to be asked to lay on my back (when) all problems (were) behind me. He began to massage down between my breasts under the breasts all the way down the side to my rib cage. I asked what was the point in that...explanation was cartilage in rib cage and could release pressure from neck and shoulders...have a sister who's undergoing massage therapy classes and I told her what had happened. It hurt. He was rough. He didn't touch my nipples. (Sister) explained cartilage could release pressure..." Continued interview revealed the patient was later treated by two different therapists (females at the facility) and the patient stated, "Neither asked me to lay on my back...I mentioned it to them. It was different. (Physical Therapist #1) was massaging between my breasts. Their reactions was just, 'Hmm.' The only place...dug deep was my breasts...The last visit with (Physical Therapist #1)...was doing massage...while I was on table my gown slipped and exposed my breasts. He said, 'I don't want to embarrass you or anything but you have very beautiful breasts.' I shot up like a cannon. I couldn't say anything. It was like he completely flipped out and said, 'This is your last treatment'...I told my doctor I would not go back there. I told him what had occurred and he said, 'You don't need to be going back there...I felt like I had a major meltdown in (Physical Therapist #2's) office. He said, 'You have been victimized.' I gave statement to (facility)...was told he had been reprimanded before...They told me there had been other complaints. A man contacted me and told me that he had been found working someplace else and asked if I was willing to go to court. I don't want to do that unless absolutely necessary, don't want to see him...I don't want (Physical Therapist #1) to do this to another human being. It makes you feel so gross...I asked (director of rehab) anonymously...I told him (director of rehab) a PT (physical therapist) worked there I felt was inappropriately touching me in a closed room...said would check into it. He didn't ask for my name or anything."

Review of facility abuse policies provided on May 12, 2010, revealed policies addressed intervention for victims of domestic abuse and infants. Telephone interview with the risk manager on May 25, 2010, at 1:48 p.m., revealed the facility had no policy regarding abuse by employees.

Personnel file review on May 25, 2010, of an e-mail from a risk manager to facility's administrative personnel and legal counsel dated December 11, 2008, revealed the risk manager's notification regarding Patient #2's mother's complaint regarding December 10, 2008, and included, "...Another concerning issue was brought up against this therapist approximately 6-8 weeks ago. A 31 year old patient requested to speak with the PT Director regarding the "normal" treatment for a herniated disc in...neck....proceeded to share with him that...therapist (Physical Therapist #1) made contact and massaged around...breast/chest area, indicating he was also "free" with his hands...requested...treatment be transferred to another therapist...A third possible occurrence, although details were not provided, involved a patient calling...requesting a change in therapist. The patient provided no comment other than...did not want to continue seeing (Physical Therapist #1). According to (supervisor) and (rehab director), there have been no previous issues..." Continued review revealed Physical Therapist #1 was disciplined on December 28, 2008, and included, "...lack of effective communication with patients regarding treatment plan and implementation of that plan...No copy of 11-4-08 oral warning..." Continued personnel file review revealed a report regarding a meeting of facility staff and Patient #3, dated February 24, 2009, and included, "...During...third visit...ask (Patient #3) to lie on...back and remove...arms from gown...completely exposed...began squeezing on...breasts very hard while pulling them up until it felt very uncomfortable...I don't mean to embarrass you, but you have very beautiful breasts...shared...experience with (Physical Therapist #2) who immediately advised...(director of rehab) would want to know of this occurrence...Soon thereafter, the investigation into this event began which led to (Patient #3) coming in to speak with us on 2/24/09." Continued review revealed, "Separation Notice...Last Employed: From: 01/11/1993 to 02/25/09...Reason for Separation: Discharge...explain the circumstances of this separation: Involuntary Termination - inappropriate conduct involving patient care..."

Review of the Tennessee Board of Physical Therapy's disciplinary action report dated December, 2009, revealed, "Licensee: (Physical Therapist #1)...Violation: Providing substandard care; engaging in sexual and ethical misconduct with patients Action: License summarily suspended."

Telephone interview with Physical Therapist #1 on May 13, 2010, at 12:07 p.m., revealed the therapist had a board hearing scheduled on May 14, 2010, and he did not want to discuss the matter before speaking with his attorney.

Telephone interview with an attorney for Office of General Counsel on May 18, 2010, at 12:45 p.m., revealed a board hearing was held on May 14, 2010, and the attorney stated, "They (board) found he (Physical Therapist #1) violated the act (statute governing the practice of occupational and physical therapy in Tennessee). Ordered probation with the stipulation he can only work if another PT is on duty and agreement of employer to submit quarterly reports. The board was not clear on which witnesses to believe. They declined to find he was sexually inappropriate with two who testified (Patient #1, Patient #2)..."

Interview with a risk manager on May 12, 2010, at 3:50 p.m., in a conference room, revealed the facility had no incident reports regarding Patient #1 or Patient #3.

Interview with the Chief Operations Officer on May 13, 2010, at 11:27 a.m., in a conference room, revealed the physical therapy department was under his supervision, and he was unaware of Patient #1's allegation regarding Physical Therapist #1.

Interview with the director of Human Resources on May 12, 2010, at 5:10 p.m., in a conference room, revealed Patient #3 met with facility staff, and she stated, "...as...went through story was so much like (Patient #2)...When we met with (Physical Therapist #1) he was told we had two allegations...gave no response...We would never known of first allegation except looking at personnel file regarding oral warning..." Continued interview confirmed the facility failed to protect Patient's # 1, #2, and #3 from abuse by Physical Therapist #1 and she stated, "If we'd known about (Patient #1) (Physical Therapist #1) would have been gone."


C/O: #24824

Based on medical record review, review of investigative documentation provided by the facility, facility policy review, personnel file review, review of physical therapy board documentation, and interview, the facility failed to protect three patients (#1, #2, #3) of five sampled patients from inappropriate sexual touching at the facility's outpatient rehabilitation center.

The findings included:

Medical record review of a physician's order for Patient #1 dated October 7, 2008, revealed, "Eval and Tx (evaluate and treat) moist heat...electrical stimulation...traction." Medical record review of physical therapy progress notes dated October 21, 23, 29, and 31, 2008, revealed the patient was treated by Physical Therapist #1.

Medical record review of a physician's order for Patient #2 dated November 3, 2008, revealed, "Eval & Tx." Medical record review of physical therapy progress notes dated December 3 and 10, 2008, revealed the patient was treated by Physical Therapist #1.

Telephone interview with Patient #2 on May 18, 2010, at 4:00 p.m., revealed Physical Therapist #1 inappropriately touched the patient during treatment on December 10, 2008.

Medical record review of a physical therapy evaluation for Patient #3 dated September 9, 2008, revealed, "31-year-old...with a diagnosis of neck and shoulder pain." Medical record review of physical therapy progress notes dated September 11, 16, 23, 25, 26, and 30, 2008, and October 2, 14, and 16, 2008, revealed the patient was treated by Physical Therapist #1.

Telephone interview with Patient #3 on May 12, 2010, from 10:20 a.m. until 10:58 a.m., revealed Physical Therapist #1 inappropriately touched the patient and made inappropriate sexual comments during treatments at the facility.

Interview with the director of the facility's outpatient rehabilitation center on May 12, 2010, from 11:32 a.m. through 12:20 p.m., in the director's office, revealed the facility had complaints regarding Physical Therapist #1 in the fall of 2008, into the winter of 2009, from three female patients, sampled patient #1, #2, and #3. Continued interview revealed each complaint concerned allegations of inappropriate sexual touching and/or comments by Physical Therapist #1 during treatment at the facility.

Interview with the risk manager on May 12, 2010, at 3:50 p.m., in a conference room, revealed the facility had no incident reports regarding Patient #1 or Patient #3's allegations. Telephone interview with the risk manager on May 25, 2010, at 1:48 p.m., revealed the risk manager was unaware of Patient #1's allegation of inappropriate touching by Physical Therapist #1 until May 12, 2010.

Review of investigation documentation provided by the facility and dated December 11, 2008, revealed Patient #2's mother reported an allegation of inappropriate touching by Physical Therapist #1.

Review of facility abuse policies provided on May 12, 2010, revealed policies addressed intervention for victims of domestic abuse and infants. Telephone interview with the risk manager on May 25, 2010, at 1:48 p.m., revealed the facility had no policy regarding abuse by employees.

Personnel file review on May 25, 2010, revealed, "Separation Notice...Last Employed: From: 01/11/1993 to 02/25/09...Reason for Separation: Discharge...explain the circumstances of this separation: Involuntary Termination - inappropriate conduct involving patient care..."

Review of the Tennessee Board of Physical Therapy's disciplinary action report dated December, 2009, revealed, "Licensee: (Physical Therapist #1)...Violation: Providing substandard care; engaging in sexual and ethical misconduct with patients Action: License summarily suspended."

Telephone interview with Physical Therapist #1 on May 13, 2010, at 12:07 p.m., revealed the therapist had a board hearing scheduled on May 14, 2010, and he did not want to discuss the matter before speaking with his attorney.

Interview with the director of Human Resources on May 12, 2010, at 5:10 p.m., in a conference room, confirmed the facility failed to protect Patient's # 1, #2, and #3 from inappropriate sexual touching and/or comments by Physical Therapist #1 and she stated, "If we'd known about (Patient #1) (Physical Therapist #1) would have been gone."

Refer to A0115.

C/O: #24824

Based on medical record review, review of medical literature, review of investigative documentation provided by the facility, review of the facility's falls policy, and interview, the facility failed to provide adequate numbers of nursing personnel to provide the care required for one patient (#6) of seven sampled patients.

The findings included:

Patient #6 was admitted to the facility on September 12, 2009, with diagnoses including Osteoporosis, Urinary Tract Infection, and Breast Cancer with Metastasis to the Liver and Spine. Medical record review revealed the patient was eighty-three years of age. Medical record review of a flowsheet dated September 12, 2009, at 7:10 p.m., revealed, "...Fall Risk Screen Score>=25...protocol initiated..." Medical record review of a care plan dated September 12, 2009, revealed,"Potential for falls secondary to fall risk score of greater than 10...Visual checks of patient every 30 minutes...Instruct patient to call for assistance...Instruct patient to sit on side of bed for a couple of minutes before standing...Evaluate medication for sedating ability..." Medical record review of a flowsheet dated September 13, 2009, at 9:30 p.m., revealed, "...Safety Patient Checks q1h (every hour)..." Medical record review of the Medication Administration Record dated September 14, 2009, revealed Lorazepam (anti-anxiety medication) 0.25 milligram was administered at 12:27 a.m. and Oxycodone-Acetaminophen (narcotic pain relief medication) 5-325 milligram was administered at 1:27 a.m. Medical record review revealed no documentation regarding nursing intervention for the patient on September 14, 2009, between the time the medication was administered at 1:27 a.m. until 4:25 a.m.

Review of medication literature revealed, "...most frequent adverse reaction...lorazepam was sedation...weakness...unsteadiness. The incidence of sedation and unsteadiness increased with age...other adverse reactions...drowsiness...memory impairment, confusion..." Review of medication literature revealed, "...The most frequently observed non-serious adverse reactions (oxycodone) included lightheadedness, dizziness, drowsiness or sedation...seem to be more prominent in ambulatory (walking)...patients..."

Medical record review revealed of a nurse's note dated September 14, 2009, at 4:25 a.m., revealed, "Tech answering bed alarm walked in room to find pt (patient) in the floor. Nurse called out of another pt's room to assess pt. C/O (complained of) left hip pain radiating down to left knee. Pt states...was getting dressed for a doctor's appointment." Medical record review of a physician's order dated September 14, 2009, revealed, "...x-ray to left hip asap (as soon as possible)..." Medical record review of an x-ray dated September 14, 2009, revealed, "...mildly displaced intertrochanteric fracture of the left femur..." Medical record review revealed no documentation of nursing intervention between 1:27 a.m. and 4:25 a.m. Medical record review of a discharge summary dated September 19, 2009, revealed, "...got up one night during the hospitalization and had a fall. As a result of the fall...suffered a fracture...able to be discharged to skilled nursing facility..."

Review of a falls policy dated May 8, 2008, revealed,"...purpose of this policy is to prevent falls...in patients identified to be at risk. These precautions are implemented by utitilizing the high fall risk protocol...A score of 25 or greater indicates the patient MUST be put on the High Risk Protocol...Once the score is 25 or greater, the patient does not have to be scored again and will remain on the fall protocol until discharge...High Risk Fall Protocol...Designated Safety Rounding..."

Review of the facility's investigative documentation dated September 14, 2009, revealed, "Description of occurrence:...@3:00 a.m...pt ambulated to bathroom with tech (technician) in pt's room...@4:20 a.m. bed alarm called to nurse's station once again. Tech walked in and found pt sitting in floor on left side of bed...pt. had been confused throughout the night...found...sitting in the floor...pt confused denies falling...RN (registered nurse) was in another pt's room in the bathroom, couldn't leave pt. on fall precautions...How could this fall have been prevented? could have called family to come and sit with pt. Decreased pt load, lower acuity. At the time of fall we had 26 patients total and only 5 not considered high fall risk on bed alarm...What will you do in the future to address...cause of this fall? Have patient's family stay with pt."

Interview with a risk manager on May 13, 2010, at approximately 1:30 p.m., in a conference room, revealed the risk manager was unable to provide documentation of nursing intervention for the patient on September 14, 2009, between 3:00 a.m. and 4:25 a.m. Continued interview confirmed the facility failed to adequately staff 4 East to prevent a fall resulting in a fractured femur for Patient #6 on September 14, 2009.

C/O: #24027