HospitalInspections.org

A. Based on document review and interview, it was determined that for 1 of 2 (Pt. #2) patient records reviewed for abuse allegations, the Hospital failed to ensure that the patient had the right to be free from all forms of abuse by failing to conduct a thorough abuse investigation.

Findings include:

1. The Hospital's policy titled, "Patient Abuse by Employees" (effective 1/14/2022) was reviewed on 8/9/2022 and required, "It is the policy of the Hospital that no patient shall be mistreated or abused in any way by an employee... Hospital Investigation: All allegations of patient abuse are investigated.... Human Resources, Risk Management, and the COO or designee are each responsible for maintaining documentation of all allegations of abuse, neglect or assault; the specifics of reported allegations; the specific steps taken by law enforcement and other appropriate authorities; the results of the investigation; and any investigations conducted by external agencies..."

2. The clinical record of Pt. #2 was reviewed on 8/8/2022. Pt. #2 was transferred from an outside hospital (OSH) and admitted to the Hospital's 7 West (7W) Intensive Care Unit (ICU) on 8/6/2021, at approximately 10:34 PM, with a diagnosis of left neck abscess and acute respiratory failure. Nursing, Physician, and Social Worker Notes were reviewed and indicated that Pt. #2 made an allegation of sexual abuse on the evening of 8/10/2022. The Discharge Summary, dated 8/13/2021 at 2:38 PM, included, " ...Patient was extubated following IR (Interventional Radiology) procedure and upon extubation, stated that she had been raped while in the hospital. Patient reported sexual assault incident while traveling from inpatient room (7W) to IR Suite on 8/10 in which she was sexually assaulted by two male staff members ..."

3. All documentation related to Pt. #2's allegations of abuse was requested from the Hospital on 8/8/2022, at approximately 9:04 AM. A Safety Event Report, dated 8/10/2021, was provided on 8/8/2022 at approximately 12:07 PM by the Director of Accreditation and Clinical Compliance (E#19). The Safety Event Report filed for Pt. #2's allegation of sexual assault was reviewed on 8/9/2022 and indicated that the event was reported on 8/10/2021 at 9:20 PM by the 7W Charge Nurse (E#4). The report included, "Patient who is intubated wrote in front of her 2 relatives that she was raped. Nursing supervisor and University Police informed and came and interviewed involved staff ... Referred issue to another department [University/Hospital] Police ..." The report included one note sent by the University/Hospital Police Department stating, "[Police] was notified of possible Criminal Sexual Assault that occurred [at Hospital] by a patient who is on 7W. Patient states that it occurred in an unknown location in the hospital between 7 and 10 August 2021. With numerous inconsistencies in the story and upon learning that she was heavily sedated, the preliminary investigation was stopped. [Police] will continue the investigation once the patient is medically cleared." The report did not include any details of steps taken by the Hospital (separate entity from the University/Hospital Police Department) to investigate the allegation of assault/abuse.

4. Any additional supporting documentation regarding the Hospital's actions in response to Pt. #2's allegations/incident was requested from E#19 on 8/8/2022, at approximately 12:30 PM. On 8/8/2022, at approximately 2:00 PM, E#19 stated that the incident report provided had all the documentation for this particular case. No additional documentation was provided.

5. A telephone interview was conducted with the Senior Director of Risk Management & Patient Safety (E#1) on 8/9/2022, at approximately 9:30 AM. E#1 stated that the patient had a conversation with the Unit Director (E#7) and other nursing staff alleging sexual assault by 2 male staff. E#1 stated that the patient was heavily sedated and the story she gave was quite vague. E#1 stated, "We worked with the police and provided any information that was requested." When asked if there was documentation/evidence of what steps the Hospital took to investigate the allegation, E#1 stated that the investigation was referred to the University/Hospital Police Department. E#1 stated that there were issues/inconsistencies with the dates and account of what happened and therefore it was "very vague from a risk management standpoint." E#1 stated that formal interviews were not documented. When asked if video was available for this incident, E#1 stated that there are no cameras inside the patient rooms. When referring to cameras in the hallway, E#1 stated that video review would be something the Hospital would do to investigate allegations; however, did not recall if video had been looked at by the Hospital staff. E#1 stated, "We've done it in the past."

6. A telephone interview with University/Hospital Police Department (PD) Officer (Z#5) was conducted on 8/10/2022, at approximately 2:22 PM. Z#5 stated that the University/Hospital Police PD conducts investigations of any crimes that are committed on the University/Hospital property. Z#5 stated that the PD is a separate entity from the Hospital itself and has jurisdiction and authority to conduct criminal investigations that fall within the boundary lines of the University/Hospital. The Hospital does not have authority over the University/Hospital PD and clarified that the Hospital has their own security staff. Z#5 stated that the PD conducts their own independent investigation, separate from the Hospital's and does not disclose information regarding the investigation if it is still in progress. Z#5 stated, "The Hospital conducts their own investigation independently and we don't make recommendations for them."


B. Based on document review and interview, it was determined that for 1 of 2 abuse allegations reviewed (Pt. #2), the Hospital failed to ensure that a mechanism/method to track and analyze incidents of alleged patient abuse was in place to ensure patients are free of all forms of abuse, neglect, or harassment.

Findings include:

1. The Hospital's policy titled, "Patient Safety Event Reporting Process" (effective 8/5/2021), was reviewed on 8/9/2022 and required, "The Hospital maintains an electronic and verbal Patient Safety Event Reporting System that all staff may access for the purpose of reporting a patient safety event....The intent of the event reporting process at the Hospital is to identify opportunities to improve patient safety by analyzing root causes of patient safety events and implementing systems and operational changes for improvement... the Risk Management and Patient Safety Department will trend the data and use these as opportunities for process improvement..."

2. The clinical record of Pt. #2 was reviewed on 8/8/2022. Pt. #2 was transferred from an outside hospital (OSH) and admitted to the Hospital's 7 West (7W) Intensive Care Unit (ICU) on 8/6/2021, at approximately 10:34 PM, with a diagnosis of left neck abscess and acute respiratory failure. Nursing, Physician, and Social Worker Notes were reviewed and indicated that on 8/10/2022, Pt. #2 made an allegation of sexual abuse by hospital staff.

3. A Safety Event Report was filed for Pt. #2's allegation of sexual assault on 8/10/2022. The report included, "Patient who is intubated wrote in front of her 2 relatives that she was raped."

4. A log of allegations of patient abuse was requested on 8/8/2022, at approximately 9:00 AM. On 8/10/2022, a list of the Hospital's allegations of patient abuse by staff was provided by the Director of Accreditation & Clinical Compliance (E#19). The list included 4 events; however, did not include Pt. #2's allegation of abuse.

5. A telephone interview was conducted with the Senior Director of Risk Management (E#1) on 8/10/2022, at approximately 11:45 AM. E#1 stated that the category for patient safety events is selected by the reporter when the incident is filed. E#1 stated that sometimes the appropriate category is not selected and therefore the log provided of patient assaults by staff may not include all reports of patient abuse. E#1 stated that generally Risk Management will change the category if caught during review. E#1 stated that the only way to find other possible patient abuse events would be to take the time to individually go through each event and read the details. E#1 stated that there was no way to generate a report that would include ALL patient abuse allegations, if any were filed under a different category.

6. An interview was conducted with Senior Risk Manager (E#26) on 8/10/2022, at approximately 3:00 PM. E#26 demonstrated how to conduct a search for patient assaults by staff. E#26 stated that sexual abuse allegations (such as in Pt. #2's case) should have been filed under "Assault by staff" however, it was filed under "Other" instead. E#26 stated that it was the Risk Manager's oversight in this case. E#26 could not be certain if there were any other allegations of patient abuse filed under different categories. When asked how the Hospital would be able to ensure accurate tracking of patient abuse allegations (in order to analyze for trends), E#26 stated that this is something they will need to figure out. E#26 stated that it was ultimately up to the Risk Manager to assign to correct event category.