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Based on interview, record review, and review of the facility policy, it was determined the facility failed to promptly remove an alleged perpetrator from patient care, and notify the physician, after a patient allegation of abuse for one (1) of eleven (11) sampled patients, Patient #1.

The findings include:

Review of the facility's policy, Abuse and Neglect, dated July 2016, revealed the facility would notify the physician regarding a patient's allegation of suspected neglect/abuse.

Review of the facility's policy, Alleged Patient Abuse by an Employee, dated August 2016, revealed the facility would remove the employee from patient contact, and if warranted, suspend the employee pending further investigation.

Review of a facility Abuse Investigation, not dated, revealed Patient #1 notified staff between 9:30 PM and 9:45 PM on 04/13/17, that an employee sexually assaulted him/her. The House Manager interviewed the patient at 10:00 PM and the patient informed her that Personal Care Assistant (PCA) #3 had assaulted him/her. The House Manager left the patient's room at 10:10 PM and located the alleged perpetrator, PCA #3, and directed him to have no contact with Patient #1. The House Manager questioned the patient again for validity of the information provided. The House Manager called PCA #3 to the office at 11:20 PM and questioned him regarding the allegation. PCA #3 was relieved of duty and left the facility at 11:32 PM, one and one half (1 ½) hours after Patient #1 made staff aware of the allegation.

Review of Patient #1's closed clinical record revealed the facility admitted the patient on 04/10/17, with diagnoses of Chronic Obstructive Pulmonary Disease, Pneumonia, and Legally Blind from Macular Degeneration.

Review of Patient #1's Nursing Documentation, for 04/14/17, revealed no evidence of physician notification on 04/14/17, regarding Patient #1's abuse allegation.

Review of a physician's Daily Progress Note, dated 04/15/17 at 12:54 PM, revealed Patient #1's physician had assessed the patient's cough and shortness of breath, and the patient reported to the physician that a PCA had sexually abused him/her on the evening of 04/14/17.

Telephone interview attempted with Patient #1's physician, on 06/20/17 at 3:15 PM and 4:15 PM, but the physician was not available and did not return surveyor telephone calls.

Interview with Registered Nurse (RN) #4, on 06/20/17 at 12:00 PM, revealed she received an allegation of sexual abuse from Patient #1 on 04/14/17. She stated after receiving the allegation, she reported it to the House Supervisor who interviewed the patient and the PCA, so she thought the House Supervisor had notified the physician of the allegation of abuse. She stated if physician notification did not occur promptly, patient care needs would not be met. According to RN #4, interview with the patient revealed PCA #3 was the alleged perpetrator and the House Manger instructed the PCA not to go back into Patient #1's room. However, the PCA continued to take care of his other patients. She stated allowing PCA #3 to continue caring for other patients could put them at risk for abuse. RN #4 revealed she received abuse training yearly.

Interview with the House Manager, on 06/20/17 at 2:00 PM, revealed RN #4 notified her of Patient #1's allegation of abuse and she went to interview the patient around 10:00 PM on 04/14/17. She stated the patient provided her with a description of the alleged perpetrator and she determined PCA #3 fit the description and instructed him to stay away from Patient #1. However, he could continue to provide care to his other patients. The House Manager stated she contacted the facility's Risk Manager, who instructed her to ask the patient additional questions. The House Manager revealed after asking the patient the additional questions, PCA #3 was sent home. She stated around 11:30 PM, one and one half (1 ½) hours after Patient #1 made the allegation, she informed PCA #3 he was relieved of duty. She stated not relieving PCA #3 immediately from duty could put other patients at risk for abuse.

Interview with the Medical Surgical Unit Manager (MSUM), on 06/20/17 at 4:20 PM, revealed it was her expectation, and facility policy and procedure, for staff to notify a patient's physician of an allegation of abuse. She stated physician notification was important in order to receive further direction to meet the needs of the patient. The MSUM stated the facility policy required immediate suspension, or keep an employee from contact with patients, when an allegation of abuse was made against them. She revealed she thought the House Manager had put the alleged perpetrator in the office to wait while the initial investigation took place. According to the MSUM, not putting the alleged perpetrator in the office put other patients at risk for abuse.

Interview with PCA #3, on 06/20/17 at 11:36 AM, revealed the House Manger instructed him not to enter Patient #1's room while they investigated a complaint. He stated he continued to take care of his other patients until they called him into the office and relieved him of duty.

Interview with the Chief Nursing Officer (CNO), on 06/20/17 at 4:10 PM, revealed the facility policy and procedure required nursing staff to notify physicians if their patients made an allegation of abuse. He stated physician notification allowed the physician to direct the care of the patient to meet their needs. Continued interview revealed it was his understanding that the House Manager had immediately suspended PCA #3 after Patient #1's abuse allegation and not doing so, put other patients at risk for abuse.

Interview with the Chief Executive Officer CEO (CEO), on 06/20/17 at 4:35 PM, revealed he received a briefing on Patient #1's abuse allegation; however, he did not know that PCA #3 was not immediately suspended, nor the physician contacted regarding the abuse allegation. He stated the facility's policies directed staff to complete these tasks in order to meet patient needs.

Based on interview and record review, it was determined the facility failed to re-assess a patient after an allegation of sexual abuse for one (1) of eleven (11) sampled patients, Patient #1.

The findings include:

Review of the facility's Registered Nurse Position Description, dated October 2015, revealed a Registered Nurse (RN) implemented the nursing process for each patient assigned to his/her care. The RN also provided an ongoing assessment as indicated by the patient's status, and policies and procedures.

Review of a facility Abuse Investigation, not dated, revealed Patient #1 notified staff between 9:30 PM and 9:45 PM on 04/13/17, that an employee sexually assaulted him/her.

Review of Patient #1's closed clinical record revealed the facility admitted the patient on 04/10/17, with diagnoses of Chronic Obstructive Pulmonary Disease, Pneumonia, and Legally Blind from Macular Degeneration.

Review of Patient #1's Nursing Documentation revealed no evidence that nursing staff re-assessed Patient #1 after the allegation of sexual abuse on 04/14/17.

Interview with RN #4, on 06/20/17 at 12:00 PM, revealed she questioned Patient #1 after he/she made the sexual abuse allegation; however, she did not do a head to toe assessment or take vital signs. She stated she did not do a complete re-assessment of the patient and should have. RN #4 stated Patient #1's allegation of sexual abuse shocked her and she was not thinking. She revealed she kept reassuring the patient he/she was safe and to call staff if he/she needed anything. RN #4 stated performing a re-assessment was important because it revealed the physical and emotional care needs of the patient.

Interview with the House Manager, on 06/20/17 at 2:00 PM, revealed she did not do a re-assessment of Patient #1's condition after he/she made the allegation of sexual abuse because it was the responsibility of the primary care nurse. She stated re-assessing the patient after an incident was important for the ongoing physical and emotional needs of the patient.

Interview with the Medical Surgical Unit Manager (MSUM), on 06/20/17 at 4:20 PM, revealed it was her expectation that nursing staff re-assess patients after an allegation of abuse. She stated the primary care nurse assigned to the patient was responsible for re-assessing the patient. The MSUM stated patient care required ongoing re-assessments in order to meet the needs of the patient.

Interview with the Chief Nursing Officer (CNO), on 06/20/17 at 4:10 PM, revealed it was his expectation that nursing staff perform re-assessments of patients in order to determine care needs. He stated after an allegation of abuse, the nurse should perform a head to toe assessment, otherwise the patient's physical and emotional needs would not be met.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to revise patient care plans to address emotional care needs after an allegation of abuse for one (1) of eleven (11) sampled patients, Patient #1.

The findings include:

Review of the facility's policy, Multidisciplinary Plan of Care, dated March 2016, revealed the plan of care should be initiated as soon as possible after admission, describe patient goals, address the physiological and psychosocial factors, be consistent with the attending physician's plan for medical care, and be revised as the patient's care needs change.

Review of a facility Abuse Investigation, not dated, revealed Patient #1 notified staff between 9:30 PM and 9:45 PM on 04/13/17, that an employee sexually assaulted him/her.

Review of Patient #1's closed clinical record revealed the facility admitted the patient on 04/10/17, with diagnoses of Chronic Obstructive Pulmonary Disease, Pneumonia, and Legally Blind from Macular Degeneration.

Review of Patient #1's Care Plan, initiated 04/10/17, revealed nursing staff did not revise the care plan to address the emotional needs of the patient after the allegation of sexual abuse. The care plan had a problem/goal of Psychosocial Response to Interventions and Coping Mechanisms; however, there were no interventions listed.

Interview with Registered Nurse (RN) #4, on 06/20/17 at 12:00 PM, revealed the care plan provided nursing staff direction for patient care. She stated she did not revise Patient #1's care plan after the patient made an allegation of abuse because she was too busy and forgot. RN #4 stated Patient #1 was upset about the incident and she reassured the patient he/she was safe and the alleged perpetrator would not be back in his/her room. However, no other interventions other than reassurance were provided. She stated in order to address the patient's emotional needs; the care plan must be revised.

Interview with the House Manager, on 06/20/17 at 2:00 PM, revealed she did not update Patient #1's care plan because it was the responsibility of the nurse in charge of the patient's care. She stated Patient #1's nurse should have revised the care plan with interventions to meet the patient's emotional care needs.

Interview with the Medical Surgical Unit Manager (MSUM), on 06/20/17 at 4:20 PM, revealed it was her expectation for the nurse in charge of the patient's care to update the care plan. She stated she had not reviewed Patient #1's clinical record after the allegation of abuse to determine if the chart was complete and the care plan revised. She stated the care plan directed nursing care and if not revised, patient care needs would not be met.

Interview with the Chief Nursing Officer (CNO), on 06/20/17 at 4:10 PM, revealed it was his expectation that nursing staff update the care plan when a patient's status changed. He stated after Patient #1's allegation of abuse, he/she was upset and the care plan should have been revised in order for nursing staff to meet the patient's needs.