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Based on administrative staff interviews, policy manual review, incident report documentation and patient interviews, the facility staff failed to provide adequate monitoring and supervision to ensure patients were free of staff to patient physical abuse of a sexual nature. Two of two (#1, # 7) female patients, reported, post discharge, incidents of "sexual coercion" by a male staff member (Employee #1) with a known history to facility administrative staff of inappropriate communications with female patients.

Findings include:

The facility staff failed to provide adequate monitoring and supervision of patients to ensure patients were free of staff to patient physical abuse of a sexual nature.

~ Cross Reference 482.13(c)(3) Patients Rights - The patient has the right to be free from all forms of abuse and harassment.

~ Cross Reference 482.23(b)(3) - Nursing Services - A registered nurse must supervise and evaluate the nursing care for each patient.

Based on administrative staff interviews, policy manual review, incident report documentation and patient interviews, the facility staff failed to provide adequate monitoring and supervision to ensure patients were free of staff to patient physical abuse of a sexual nature. Two of two (#1 and # 7) female patients, reported, post discharge, incidents of "sexual coercion" by a male staff member (Employee #1) with a known history to facility administrative staff of inappropriate communications with female patients.

Findings include:

The facility staff failed to provide adequate monitoring and supervision of patients to ensure patients were free of staff to patient physical abuse of a sexual nature.

~ Cross Reference 482.13(c)(3) Patients Rights - The patient has the right to be free from all forms of abuse and harrassment.

Based on policy review, closed medical record review, patient, law enforcement and administrative staff interviews, and review of incident investigation documentation, the facility staff failed to provide adequate monitoring and supervision of patients to ensure patients were free of staff to patient physical abuse of a sexual nature. Two of two (#1, # 7) female patients reported, post discharge, incidents of "sexual coercion" by a male staff member (Employee #1) with a known history to facility administrative staff of inappropriate communications with female patients.

Findings include:

Policy review on 11/05/2015 revealed "Reporting and Investigating Patient Neglect, Abuse, and Exploitation" with an original date of May 08, 2013 and no review/revision date. Review of the policy revealed "Patients at [Name of hospital], are treated with dignity and respect, and have the right to be free from abuse, neglect or exploitation in any manner. If any abuse is suspected, alleged or observed, it is reported in accordance with this policy . . . 4. Investigating Procedures - A timely, thorough and objective investigation of all allegations of abuse, or neglect or exploitation will be initiated immediately. a. The complainant (the individual, who has allegedly been abused, neglected or exploited) will be provided reassurance and will be informed of the investigation process. b. The Risk Manager will be notified . . . The Patient Advocate must then communicate the event through a complaint resolution form to the patient/guardian. This will occur at the time the patient self-reports the alleged abuse, neglect or exploitation directly to the Patient Advocate. The Patient Advocate will then follow the steps outlined below in conjunction with the Risk Manager. - Notify the attending physician. - Notify the Director of Social Services or designee. - Notify the Department of Social Services (Adult or Child), if related to an external allegation of abuse and/or neglect. . . e. The investigation must include an interview of the complainant and request for statement from all employees, patients and others having knowledge of or involved in the incident. Staff members who fail to provide adequate, truthful information in a timely manner or engage in any breach of confidentiality regarding the investigation may have disciplinary action taken against them. . . 5. Investigation Report Completion The Report must be completed within five(5) working days from the date of the allegation. The following elements shall be included: a. A brief, clear description of the allegation with identification of the victim, suspect (s) and complainants, with the incident occurred and where. It should state the time of reporting. . . "

Telephone interview on 11/04/2015 at 1430 with Patient #1, a 45 year old female voluntarily admitted on 09/14/2015 with diagnoses including Bipolar Disorder and Suicidal Ideation and discharged to home on 09/23/2015, revealed the patient was at her out-patient therapist's office. The interview revealed the name of the alleged perpetrator. Per the interview, the patient had not shared the name of the alleged perpetrator with the local law enforcement detective. The Director of Risk Management, the Director of Nursing and the Chief Executive Officer were notified of the name of the alleged perpetrator on 11/04/2015 at 1705.

Telephone interview on 11/05/2015 at 1250 with Patient #7, a 43 year old female admitted 09/11/2015 with diagnoses including Bipolar Disorder and Post Traumatic Stress Disorder and discharged to home on 09/22/2015, revealed the patient had communicated with Patient #1. The interview revealed Patient #7 described the same alleged perpetrator as Patient #1 and stated "he raped me." Patient #7 stated she had not made contact with the hospital or law enforcement. Patient #7 was instructed to notify law enforcement and was provided with the telephone number for the local law enforcement detective. The Director of Risk Management, the Director of Nursing and the Chief Executive Officer were notified of the telephone interview on 11/05/2015 at 1325.

Interview on 11/03/2015 at 1030 with the Director of Risk Management and Quality (DRMQ) and the Director of Nursing (DON) revealed a local law enforcement detective had come to the hospital on 10/28/2015 and requested to view the video surveillance for September on the dates Patient #1 had received services. The interview revealed the detective had informed the DRMQ that Patient #1 had alleged sexual coercion by a staff member while an in-patient. The interview also revealed Patient #1 had alleged her roommate had also experienced staff to patient physical abuse of a sexual nature during the same time period. The interview revealed a chart audit was conducted on Patient #1 and Patient #7. The interview revealed the video surveillance is recorded for 15 - 30 days depending on unit activity. The DRMQ stated the detective was informed the most recent video surveillance available to be viewed was 09/29/2015 (six days after Patient #1 had been discharged). The interview revealed the house supervisors randomly review the video footage each 24 hour period. Per the interview, the detective offered no further information and informed the DRMQ he would be attending "training for the next couple of weeks" and would get back in touch with the DRMQ after the training.

Review of the incident report and documents presented as evidence of the hospital's investigation on 11/03-04/2015 revealed a chart audit had been conducted for Patient #1 and Patient #7 without evidence of a complaint or inappropriate sexual behavior. The review revealed no evidence Patients #1 and #7 had been contacted (5 days after being notified of the allegation). There was no evidence of personnel file reviews or interviews with patients or staff.

Review on 11/04/2015 of the "Senior Leadership Audit Tool - Observation Rounds Video Camera Review - Patient Observation Rounds Audit" sheets for September 11 through September 23, 2015 revealed no documentation of a Video Camera review by Senior Leadership.

Interview on 11/04/2015 at 1345 with the Director of Human Resources and DRMQ revealed there were no employees currently working that were listed on the Health Care Personnel Registry or had a positive finding on the North Carolina Sex Offender Registry. Review of personnel file for Employee #1 revealed a Final Written Warning with suspension dated 10/12/2015 with the following description: ". . . has received three patient complaints of a similar nature. The most recent complaint, made on Saturday, October 10, 2015, indicated that [name of Employee #1] made a female patient uncomfortable through his communication. While specific allegations made were not able to be substantiated, it was identified that [name of Employee #1] allowed a patient to enter a restricted area (laundry room) and remained in this restricted area with the patient with the door closed for over a minute. This act was in violation of the facilities rules on Therapeutic Boundaries

Interview on 11/05/2015 at 1640 with the DRMQ and DON revealed the House Supervisors are to conduct a Video Camera Review on each unit randomly on a daily basis. The interview revealed the DON had met with all the House Supervisors on 11/04/2015 and instructed the Video Camera Review is to be conducted randomly every 24 hours on each unit including weekends and holidays.

In summary,the facility staff failed to provide adequate monitoring and supervision of patients to ensure patients were free of staff to patient physical abuse of a sexual nature. Two of two (#1, # 7) female patients reported, post discharge, incidents of "sexual coercion" by a male staff member (Employee #1) with a known history to facility administrative staff of inappropriate communications with female patients.

Based on administrative staff interviews, policy manual review, incident report documentation and patient interviews, the facility staff failed to provide adequate monitoring and supervision to ensure patients were free of staff to patient physical abuse of a sexual nature. Two of two (#1 and # 7) female patients, reported, post discharge, incidents of "sexual coercion" by a male staff member (Employee #1) with a known history to facility administrative staff of inappropriate communications with female patients.

Findings include:

The facility staff failed to provide adequate monitoring and supervision of patients to ensure patients were free of staff to patient physical abuse of a sexual nature.

~ Cross Reference 482.13(c)(3) Patients Rights - The patient has the right to be free from all forms of abuse and harassment.

~ Cross Reference 482.23(b)(3) - Nursing Services - A registered nurse must supervise and evaluate the nursing care for each patient.

Based on policy review, closed medical record review, patient, law enforcement and administrative staff interviews, and review of incident investigation documentation, the facility staff failed to provide adequate monitoring and supervision of patients to ensure patients were free of staff to patient physical abuse of a sexual nature. Two of two (#1 and # 7) female patients reported, post discharge, incidents of "sexual coercion" by a male staff member (Employee #1) with a known history to facility administrative staff of inappropriate communications with female patients.

Findings include:

Policy review on 11/05/2015 revealed "Reporting and Investigating Patient Neglect, Abuse, and Exploitation" with an original date of May 08, 2013 and no review/revision date. Review of the policy revealed "Patients at [Name of hospital], are treated with dignity and respect, and have the right to be free from abuse, neglect or exploitation in any manner. If any abuse is suspected, alleged or observed, it is reported in accordance with this policy . . . 4. Investigating Procedures - A timely, thorough and objective investigation of all allegations of abuse, or neglect or exploitation will be initiated immediately. a. The complainant (the individual, who has allegedly been abused, neglected or exploited) will be provided reassurance and will be informed of the investigation process. b. The Risk Manager will be notified . . . The Patient Advocate must then communicate the event through a complaint resolution form to the patient/guardian. This will occur at the time the patient self-reports the alleged abuse, neglect or exploitation directly to the Patient Advocate. The Patient Advocate will then follow the steps outlined below in conjunction with the Risk Manager. - Notify the attending physician. - Notify the Director of Social Services or designee. - Notify the Department of Social Services (Adult or Child), if related to an external allegation of abuse and/or neglect. . . e. The investigation must include an interview of the complainant and request for statement from all employees, patients and others having knowledge of or involved in the incident. Staff members who fail to provide adequate, truthful information in a timely manner or engage in any breach of confidentiality regarding the investigation may have disciplinary action taken against them. . . 5. Investigation Report Completion The Report must be completed within five(5) working days from the date of the allegation. The following elements shall be included: a. A brief, clear description of the allegation with identification of the victim, suspect (s) and complainants, with the incident occurred and where. It should state the time of reporting. . . "

Telephone interview on 11/04/2015 at 1430 with Patient #1, a 45 year old female voluntarily admitted on 09/14/2015 with diagnoses including Bipolar Disorder and Suicidal Ideation and discharged to home on 09/23/2015, revealed the patient was at her out-patient therapist's office. The interview revealed the name of the alleged perpetrator. Per the interview, the patient had not shared the name of the alleged perpetrator with the local law enforcement detective. The Director of Risk Management, the Director of Nursing and the Chief Executive Officer were notified of the name of the alleged perpetrator on 11/04/2015 at 1705.

Telephone interview on 11/05/2015 at 1250 with Patient #7, a 43 year old female admitted 09/11/2015 with diagnoses including Bipolar Disorder and Post Traumatic Stress Disorder and discharged to home on 09/22/2015, revealed the patient had communicated with Patient #1. The interview revealed Patient #7 described the same alleged perpetrator as Patient #1 and stated "he raped me." Patient #7 stated she had not made contact with the hospital or law enforcement. Patient #7 was instructed to notify law enforcement and was provided with the telephone number for the local law enforcement detective. The Director of Risk Management, the Director of Nursing and the Chief Executive Officer were notified of the telephone interview on 11/05/2015 at 1325.

Interview on 11/03/2015 at 1030 with the Director of Risk Management and Quality (DRMQ) and the Director of Nursing (DON) revealed a local law enforcement detective had come to the hospital on 10/28/2015 and requested to view the video surveillance for September on the dates Patient #1 had received services. The interview revealed the detective had informed the DRMQ that Patient #1 had alleged sexual coercion by a staff member while an in-patient. The interview also revealed Patient #1 had alleged her roommate had also experienced staff to patient physical abuse of a sexual nature during the same time period. The interview revealed a chart audit was conducted on Patient #1 and Patient #7. The interview revealed the video surveillance is recorded for 15 - 30 days depending on unit activity. The DRMQ stated the detective was informed the most recent video surveillance available to be viewed was 09/29/2015 (six days after Patient #1 had been discharged). The interview revealed the house supervisors randomly review the video footage each 24 hour period. Per the interview, the detective offered no further information and informed the DRMQ he would be attending "training for the next couple of weeks" and would get back in touch with the DRMQ after the training.

Review of the incident report and documents presented as evidence of the hospital's investigation on 11/03-04/2015 revealed a chart audit had been conducted for Patient #1 and Patient #7 without evidence of a complaint or inappropriate sexual behavior. The review revealed no evidence Patients #1 and #7 had been contacted (5 days after being notified of the allegation). There was no evidence of personnel file reviews or interviews with patients or staff.

Review on 11/04/2015 of the "Senior Leadership Audit Tool - Observation Rounds Video Camera Review - Patient Observation Rounds Audit" sheets for September 11 through September 23, 2015 revealed no documentation of a Video Camera review by Senior Leadership.

Interview on 11/04/2015 at 1345 with the Director of Human Resources and DRMQ revealed there were no employees currently working that were listed on the Health Care Personnel Registry or had a positive finding on the North Carolina Sex Offender Registry. Review of personnel file for Employee #1 revealed a Final Written Warning with suspension dated 10/12/2015 with the following description: ". . . has received three patient complaints of a similar nature. The most recent complaint, made on Saturday, October 10, 2015, indicated that [name of Employee #1] made a female patient uncomfortable through his communication. While specific allegations made were not able to be substantiated, it was identified that [name of Employee #1] allowed a patient to enter a restricted area (laundry room) and remained in this restricted area with the patient with the door closed for over a minute. This act was in violation of the facilities rules on Therapeutic Boundaries

Interview on 11/05/2015 at 1640 with the DRMQ and DON revealed the House Supervisors are to conduct a Video Camera Review on each unit randomly on a daily basis. The interview revealed the DON had met with all the House Supervisors on 11/04/2015 and instructed the Video Camera Review is to be conducted randomly every 24 hours on each unit including weekends and holidays.

In summary,the facility staff failed to provide adequate monitoring and supervision of patients to ensure patients were free of staff to patient physical abuse of a sexual nature. Two of two (#1, # 7) female patients reported, post discharge, incidents of "sexual coercion" by a male staff member (Employee #1) with a known history to facility administrative staff of inappropriate communications with female patients.


Intake: NC00111678 ayc