HospitalInspections.org

a.
Based on medical record review, document review and interview, the facility failed to protect patients at risk for sexual abuse. Specifically, the facility failed to: (1) investigate an incident of a sexual assault allegation made by Patient #2; and (2) fully implement its sexual assault policy and procedure and implement measures to prevent further sexual assault. These failures were identified in two (2) of five (5) medical records reviewed from June 2021 to March 2023.

These failures placed all patients at increased safety risk.

Findings include:

The facility failed to: (a) investigate an allegation of sexual assault; and (b) implement corrective actions

See Tag A-0144 and A-0145.
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Based on medical record review, document review, and interview, the facility failed to ensure the protection of patients. Specifically, the facility failed to identify an allegation of potential abuse and to immediately remove staff from patient care pending a full investigation (Patient #2).

These failures placed all patients at increased risk of harm.

Findings include:

On 3/1/23, facility staff viewed a video at the Queens DA's office showing inappropriate touching of Patient #1's breast and vagina by Staff A on 5/4/22.

Patient #1 was a 47-year-old with a history of catatonic schizophrenia, chronic respiratory failure, dysphagia, and on trach to ventilator. The patient presented to the ED on 2/15/22, with a complaint of posterior scalp hematoma. She was admitted to the medicine unit for sepsis and ventilator associated pneumonia.

On 5/4/22 at 5:30 PM, RN documented: "Patient's PEG dislodged. PA made aware. As per PA will notify GI. Discharge held."

On 5/4/22 at 5:30 PM, Staff A's consult note documented: " ...Physical Exam- Gastrointestinal abdomen soft, nontender, nondistended, prior 20 French PEG replaced at bedside. Noted to be 2cm at the skin ...Rectal exam: No external hemorrhoids, no anal fissure, normal sphincter tone, no masses seen at the anus, no masses palpated in the rectal vault, brown stool ..."

At 6:39 PM, RN documented: "Peg replaced. Patient pending peg placement confirmation. Endorsed to night RN."

On 3/30/23, while conducting an onsite investigation into the alleged sexual abuse of Patient #1, the survey team was notified by Staff B (Chief Medical Officer) of another sexual abuse that occurred on 6/20/21 by Staff A.

Review of Patient #2's MR revealed a nursing note dated 6/21/21 at 04:41 AM, that stated the patient notified the nurse on 6/20/21 at 11:10 PM that on 6/20/21 at 9:30 PM, "An [race] doctor"... came and told her not to look and made her turn to her right side as he injected an unknown medication through her IV access in her left antecubital. Immediately after the injection, she fell asleep and when she woke up, the doctor was no longer in the room, she was in extreme pain to lower abdomen and the inability to sit up due to numbness.."

There was no scheduled or documented medication administration noted in the medical record by any doctor for the time reported by the patient. The nurse notified Pediatric and Surgical Residents on 6/20/21 at 11:14 PM.

Review of the NP (Nurse Practioner) note dated 6/21/2021 at 12:00 AM, revealed security tapes were reviewed and an individual in blue scrubs was seen entering the unit from the 4G stairwell and then entering the patient's room at 9:29 PM. The individual was then seen exiting patient's room and then exiting the unit at 9:48 PM through main unit doors. This staff was later identified by the patient as Staff A (GI Fellow), who had seen Patient #2 earlier in the day.

Review of Staff A's facility badge access identified that Staff A accessed the Pediatric facility stairwell on 6/20/21 at 9:32 PM, consistent with the patient's timeline of events.

Additional review of Staff A's badge access identified that after Patient #2 identified Staff A as the MD who injected her with an "unknown" medication, Staff A was in the facility on 6/21/21 at 10:34 AM, 12:20 PM, 12:28 PM, 1:50 PM, 3:04 PM, 3:25 PM, 4:00 PM and 5:34 PM; on 6/22/21 at 9:44 AM, 4:12 PM, 4:47 PM and 4:59 PM; and on 6/23/21 at 8:03 AM, 12:24 PM, 2:03 PM, 2:05 PM and 6:37 PM.

A list of Staff A's patients revealed Staff A consulted/assessed and or provided care for six (6) additional patients between 6/21/21 at 11:15 AM through 6/23/21 at 5:37 PM.

Facility document titled "Allegation of Physical/Sexual Abuse of Patient Policy", dated 2/24/20, states "it is strongly recommended that any employee identified or fitting the patient's description of the accused be suspended until the investigation is concluded."

The policy lacks instructions to "immediately" remove the accused from patient care or access pending the outcome of the investigation.

There is no documented evidence that Staff A was removed from patient care or that the facility investigated the patient's concern as an allegation of abuse after Patient #2 identified Staff A as the MD who injected her with an unknown medication.

These failures may have lead to the sexual abuse of Patient #1 by Staff A on 5/4/22.

Per interview with Staff B on 4/4/23 at 12:29 PM, Staff B acknowledged the facility did not investigate the patient complaint as an abuse allegation.

An Immediate jeopardy situation was identified on 04/04/2023 at 12:29 PM due to the facility's failure to protect patients at risk for sexual assault. Specifically, the facility failed to: (1) investigate an incident of a sexual assault allegation made by Patient #2; and (2) fully implement its sexual assault policy and procedure and implement measures to prevent further sexual assault.

The facility's executive leadership and administrators submitted an IJ Removal Plan on 4/4/23 at 10:30 PM which was found acceptable and included the following:

Patient complaints/Grievances Policy (#611-11) was revised to require that:
A verbal or written complaint alleging abuse, assault, neglect, patient harm, discrimination or hospital compliance with CoPs is considered a grievance.

Allegation of Physical/Sexual Abuse of Patient Policy (#99-012) was revised to include:
Policy applicability has been expanded to include Patient Services, in addition to Security Department. Patient Services will lead the investigation and interview the patient in the presence of a security staff.

-Before conduction interview or history and physical, the patient must be given a copy of the NYS Victims Bill of Rights.

-The patient will be assessed by a physician within 60 minutes and provided treatment to include laboratory testing.

-Any staff member or employee fitting the patient's description of the accused will be immediately placed off duty pending the completion of the investigation.

-Communication of any such incident will be escalated to hospital leadership and human resources.

-Any photo or video evidence collected during the course of the investigation will be preserved by the security department and retained for at least five (5) years.

Sexual assault and Treatment Policy (Policy # 6179-S8) was revised as follows:
The policy was expanded to include all areas outside of the ED.
-Contact a physician or mid-level provider to conduct an exam and a SAFE Nurse to conduct a forensic exam and evidence collection within 60 minutes on patients in all areas outside the ED.

-The Drug Facilitated Sexual Assault Kit must be completed within 120 hours of the assault
Expanded evaluation by mid-level practitioners of patients alleging sexual abuse in all areas outside the ED.

-If a Social Worker is not available to serve as the patient's advocate, with the patient's consent, the facility will offer other qualified providers including a SAFE examiner, physician, or mid-level provider.

-The role of the Social Worker was revised to require them to remain with the patient throughout their visit in the ED or inpatient, including during the interview by law enforcement and the forensic examination.

-The Social Worker cannot conduct any part of the medical or forensic exam or part of the chain of custody for the Sexual Offense Evidence Collection Kit or Drug Facilitated Sexual Assault Kit.

The IJ was removed on 04/06/23 at 5:50 PM by onsite verification of staff training and re-education to the revised policies.

Inservice began on all units while surveyors were onsite and was verified by interviews and attendance records.

Surveyors conducted interviews in 17 Inpatient and Outpatient Units. Interviews were conducted with several disciplines including Nursing, Administration, Physicians, Anesthesiologists, Dietary, and Environmental Services Staff. Interviews revealed that 100% of staff were knowledgeable on the revised policies and they were able to verbalize identification of a sexual assault complaint and how to respond per the facility revised policy. Interviews conducted with senior leadership confirmed that facility staff members that have not been in-serviced would be trained on the revised policies before the start of their shift.





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Based on medical record (MR) review, document review and interview, the facility failed to identify a complaint of sexual abuse of a patient and investigate the allegations.

These failures placed all patients at risk for potential abuse.

Findings include:

On 3/29/23 during an onsite allegation survey for the sexual assault of Patient #1, Staff B, Chief Medical Officer, reported to survey team that Patient #2 was identified as another sexual assault victim of Staff A, GI Fellow.

Review of the Patient #2's MR revealed an alert and oriented 19-year-old female admitted on 6/18/21 for abdominal pain.

On 6/21/2021 at 04:41 AM, RN documented that at 10:40 PM on 6/20/21, the patient complained of pain to her lower abdomen which she rated at 10 on a pain scale of 0 -10. The patient described the pain as if someone was "twisting and pulling her lower abdomen". The patient also stated, she was not able to move from a lying to sitting position because she felt "numb" which she demonstrated by her inability to sit up. The nurse administered Morphine at 10:48 PM.

Per the RN note, at 11:10 PM on 6/20/21, the patient notified the nurse that at 9:30PM "An [race] doctor ... came and told her not to look and made her turn to her right side as he injected an unknown medication thru her IV access in left antecubital. Immediately after injection, she fell asleep and when she woke up, the doctor was no longer in the room, she was in extreme pain to lower abdomen and the inability to sit up due to numbness ..."

Facility document titled "Sexual assault Treatment Policy", dated 08/20, states "If there is a concern for drug facilitated assault, then the Drug Facilitated Sexual Assault (DFSA) kit may be indicated and should be offered."

There was no documented evidence that the patient was offered a DFSA kit, or that the facility tested the patient's blood for unprescribed medications.

The "Sexual Assault Treatment Policy" also instructs staff to "contact SAFE examiner" and "facilitate examination ...".

The policy lacks instruction for the provision of the NYS "Victim's Bill of Rights" (VBOR) to patients prior to interview, history, and physical examination.

An MD note on 6/21/21 at 2:02 AM, revealed the patient was interviewed and examined by the Attending MD in the presence of the Senior Resident and Attending Surgeon. There was no documented evidence the patient was provided the VBOR as required.

The "Sexual Assault Treatment Policy" also instructs "In order to preserve evidence keep the patient dressed ...until the evaluation can begin by the Sexual Assault Forensic Exam (SAFE) Examiner, a physician or a mid-level provider."

On 6/21/21, the patient underwent an ERCP procedure and on 6/22/21, she was taken to the OR for a Cholecystectomy.

There was no collection of any evidence on 6/20/21 at the time of the allegation or 6/21/21 prior to any other procedure to prevent contamination and maintain chain of custody for any potential evidence.

A Pediatric Attending MD note, dated 6/23/21 at 4:48 PM, documented that the "full Medical team including Security, HR, Legal, Pt Services, Nursing Management, Nursing, Pediatric Attending, Peds Department Head, Social Work and Gastroenterology" had a meeting in Patient #2's room with the patient, her mother and Staff A (the accused GI Fellow)."

Per the Pediatric Attending MD note, Staff A told the patient that he came back to the patient's room on 6/20/21 at 9:30 PM to explain the surgical procedure to the patient's mother as requested by the patient earlier. The mother was not present at 9:30 PM. Staff A stated he used the language line to communicate with the patient because she did not speak English and Staff A did not speak Spanish.

Review of the facility Language Line call log revealed no record of the alleged call by Staff A on 6/20/21. There was no record of any Spanish Language calls between 6/20/21 at 10:23 AM and 6/23/21 at 2:49 PM for the facility.

The Pediatric Attending MD note also documented that the team "suggested" to Patient #2 that the patient was confused about the timeline of events due to the administration of Morphine for pain. However, the patient was able to identify Staff A by a picture as the physician who had seen her earlier in the day and the patient's statement that the (race) male doctor came into her room at 9:30 PM was verified on the Security Camera and consistent with the patient's timeline of the events.

A SAFE exam was ordered on 6/23/21, 69 hours after the initial allegation.

Per interview with Staff K (ED Staff SAFE Certified RN) on 4/3/23 at 10:00AM, Staff K stated she was not notified of Patient #2's allegation until 6/23/21, the same day she completed the examination of Patient #2. She added that the physician was supposed to offer and perform a drug kit for a drug assisted sexual assault.

Per interview with Staff M (Quality Manager) on 4/3/23 at 3:00 PM, the Security Office is responsible for investigations of allegations of abuse. The investigation report from the Security Office notes the incident occurred on 6/23/21 at 11:26 AM, two days after the initial allegation by Patient #2 that she was administered an unknown medication by Staff A. The incident ended on 6/23/21 at 2:45PM, almost 5 hours before the SAFE examination was provided at 7:40 PM.

There was no evidence Patient #2's allegation was treated and investigated as a potential Sexual Assault.

During interview on 4/4/23 at 12:29 PM, Staff B (Chief Medical Officer) acknowledged the findings.
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Based on medical record review, document review, and interview, the facility failed to utilize its hospital-wide quality assessment and performance improvement program to ensure serious patient incidents were identified, analyzed, and corrective actions implemented. These findings were identified in three (3) of five (5) medical records reviewed (Patient #1, #2 and #3).

These failures may have resulted in actual harm to patients.

Findings include:

On 3/1/23, the facility's legal team viewed a video in the DA's office of inappropriate touch of Patient #1 vagina and breasts by Staff A, a third year GI fellow.

During interview on 3/29/23 at 12:00 PM, Staff B (Chief Medical Officer) reported that the investigation of Staff A's sexual assault on Patient #1 was ongoing and there has not been a plan of correction implemented. Staff A was terminated on 1/12/23.

On 3/29/23, the Queens DA reported to the facility that Patient #2 was sexually assaulted by Staff A, GI Fellow on 6/20/21 prior to Patient #1's incident.

On 6/20/21, Patient #2 reported that Staff A injected medication through her intravenous line that put her to sleep immediately, and when she woke up, she felt numbness.

The complaint made by Patient #2 was not investigated as a sexual assault. The facility concluded that the patient was confused.

On 4/5/22, Patient #3 complained of inappropriate touch by a Radiology Technician (RT).
On 4/6/22, the facility sent the RT home pending investigation. The facility terminated RT's employment on 4/11/22.

There was no documented evidence the facility implemented an appropriate plan of correction.

Review of Quality Assessment and Performance Improvement (QAPI) minutes for March 2022 to March 2023 revealed there was no tracking, analysis, trending, and corrective actions implemented for complaints of sexual assault by Patient #1, Patient #2, and Patient #3.

See Tag 0286
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Based on medical record review, document review, and interview, the facility failed to utilize its hospital-wide Quality Assessment and Performance Improvement program to ensure that a serious patient incident was identified, investigated, analyzed, and corrective actions implemented. These findings were identified in three (3) of five (5) medical records reviewed from June 2021 to March 2023 (Patient #1, #2 and #3).

These failures may result in serious adverse outcome for patients.

Findings include:

On 3/1/23, facility staff viewed a video at the Queens District Attorney's (DA) office showing inappropriate touching of Patient #1's breast and vagina by Staff A on 5/4/22. The facility identified Staff A as a third year GI Fellow.

During onsite investigation on 3/29/23 at 12:00 PM, interview with Staff B, Chief Medical Officer, reported that the investigation of Patient #1 was initiated but had not been completed. The corrective actions were limited to re-educating the medical staff to the Chaperone Policy. The facility's policy titled "Use of Medical Chaperones for Examinations" (approved 9/2021) states: a) A chaperone is required for the following examinations:
I. Pelvic examinations
II. Examination of or involving the external genitalia
III. Examination of the female patient's breast(s)
IV. Rectal examinations.

Staff B added that Staff A was terminated on 1/12/23.

On 3/29/23, the Queens DA reported to the facility another incident in which Patient #2 was also identified to be sexually assaulted by Staff A on 6/20/21 prior to Patient #1.

Review of the investigation report for Patient #2 revealed on 6/20/21 at 10:40 PM, the patient filed a complaint with an RN stating that an [race] doctor arrived in her room and told her not to look and made her turn to her right side and injected medication through her intravenous line. Immediately after the injection, she fell asleep and when she woke up, the doctor was gone. She was in extreme pain in her lower abdomen and was unable to sit up due to numbness.

On 6/23/21, the facility's investigation of Patient #2's complaint concluded that she was confused. The facility failed to identify the complaint as a sexual assault allegation, conduct an appropriate and thorough investigation of the complaint, identify areas of improvement, and implement corrective actions.

Review of complaints and grievance logs identified on 4/5/2022 at 5:30 PM, Patient #3 complained that she was inappropriately touched by a Radiology Technician (RT). The patient stated that when she was in the exam room, the RT asked her to lay on the exam table and he asked her to place her hands to her side. The RT pulled her scrubs down to her C-5 spine and using two (2) fingers, he lifted her blouse up to her bra. The RT asked about a tattoo she had on her lower abdominal area. The RT kept putting gel on her abdomen and she felt that she was being "felt up with his bare hands."

On 4/6/22, the facility sent the RT home pending investigation. On 4/11/22, the facility terminated the RT.

There was no documented evidence of any proposed plan of correction to address the allegation of sexual abuse by staff.

Review of Quality Assessment and Performance Improvement (QAPI) minutes for March 2022 to March 2023 revealed there was no tracking, analysis, trending, and corrective actions implemented for complaints of sexual assault by Patient #1, Patient #2, and Patient #3.

During interview on 3/31/23 at 11:30 AM, Staff M, Quality Manager acknowledged the findings.
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