HospitalInspections.org

Based on document review and interview, it was determined for 2 of 2 (Pt. #1 and Pt. #11) patients with a reported allegation of inappropriate touching by the hospital staff, the Hospital failed to protect the patients from alleged abuse, thus putting other vulnerable patients at a serious risk for further potential sexual abuse. Refer to deficiency at A-145. As a result, it was determined that the Condition of Participation for Patient Rights 482.13 was not in compliance.

1. The Hospital failed to protect the patients from the alleged sexual abuse. See deficiency at A-145.

The immediate jeopardy (IJ) began on 4/4/17 when the patient alleged inappropriate touching by a staff member. An initial plan was put in place to protect the patients; however, an additional complaint was filed within 3 days after the plan was implemented. This indicated the plan was not comprehensive enough and patients remain at risk.

An IJ was announced on 4/12/17 8:45 AM, during a meeting, to the Hospital President and Chief Quality Officer. The immediate jeopardy was not removed by the survey exit date of 4/12/17.

Based on document review and interview, it was determined for 2 of 2 (Pt. #1 and #11) patients with a reported allegation of inappropriate touching by the hospital staff, the Hospital failed to protect the patients from the alleged sexual abuse.

Findings include:

1. The Hospital policy titled, "Abuse or Neglect of Patients (8/2014)" was reviewed on 4/10/17. The policy included, "Patients at Hospital, especially those who are elderly and at a greater risk for mental or physical disability, are vulnerable to possible abuse... The safety of patients is one of the highest priorities..."

2. The clinical record of Pt. #1 was reviewed on 4/10/17. Pt. #1 was a 69 year old female admitted on 3/21/17 with the diagnoses of chronic obstructive pulmonary disease (COPD) and pneumonia, requiring high flow rates of oxygen. The history and physical dated 3/21/17 at 9:39 PM included, "Has a history of intracerebral hemorrhage with sequelae (condition which is a consequence of a previous event) seizures after a motor vehicle accident, in which she suffered blunt head trauma. Currently, she is alert and oriented". The clinical record lacked inclusion of any allegation made by Pt. #1 or her daughter.

The hospital's internal incident report about Pt. #1 dated 4/4/17 at 8:13 PM was reviewed on 4/10/17. The report included that Pt. #1's daughter had requested to speak with someone about an incident that had occurred the previous night (4/3/17). The daughter informed the supervisor that a male staff member had come to clean Pt. #1 up, but Pt. #1 did not need cleaning. The staff proceeded to clean Pt. #1 in "ways that were inappropriate".

The Psychologist (MD#1) working with Pt. #1 was interviewed on 4/10/17 at 12:35 PM. MD#1 stated that Pt. #1 was inconsistent when telling her about the alleged abuse. First Pt. #1 told MD#1 that staff had put her under the bed and said she was scared and then said they put her under the bed twice and it was OK; however Pt. #1 began to cry and said "he knew I had an accident - I knew I didn't". MD#1 stated, "My impression is the patient was visibly upset and tearful. I believe the patient perceived something happened between the patient and staff that made the patient respond this way. She was responding like a victim of something".

The investigation team - Administration (Chief Quality Officer - E#7, Vice President of Human Resources - E#8, Chief Nursing Officer - E#9, Manager Patient/Family Relations - E#10, Vice President Business - E#11 and Vice President Risk - E#12) were all interviewed together on 4/10/17 at 1:00 PM. They described the investigation as follows: ...
8. Conducted call light review of Pt. #1's room. Established that the call light had been pulled out of the wall and turned off the majority of the night shift on 4/3/17 (8:41 PM - 6:44 AM). This information is not scientific, but is a starting point.

The Clinical Supervisor (E#13) on duty 4/5/17 day shift was interviewed on 4/11/17 at 8:45 AM. E#13 stated that at approximately 6:30 PM, Pt. #1's daughter came to the hospital and told her there was more to the story. E#13 stated, "The daughter told me that our staff not only touched her mother inappropriately, but put his hand inside her vagina, then came back later and did it again.

3. The clinical record of Pt. #11 was reviewed on 4/12/17. Pt. #11 was a 74 year old female admitted on 4/8/17 with the diagnoses of status post cardiac arrest with anoxic (lack of oxygen) brain injury requiring weaning (removing) from mechanical ventilator (breathing machine). The Psychologist's mental status exam dated 4/10/17 at 3:05 PM (exam conducted at 8:30 AM) included, "Awake, disoriented. Oriented to person and place (not time)". The clinical record lacked inclusion of any allegation made by Pt. #11 or her nephew.

The hospital's internal incident report about Pt. #11 dated 4/10/17 at 3:12 PM included an allegation that a male staff member had inappropriately inserted a finger into the patient's vagina. The allegation was later denied.

4. During an interview on 4/11/17 at approximately 10:00 AM, the Chief Quality Officer (E#7) and the Vice President of Risk (E#12) stated, "Both allegations are being taken seriously and are being investigated".

Based on document review and interview it was determined, for 2 of 5 (Pt. #9 and #10) clinical records reviewed for restraints, the Hospital failed to ensure patients were monitored every 2 hours while in restraints as required.

Findings include:

1. Policy entitled "Restraint Use" (revised 1/23/17), reviewed on 4/11/17, indicated "Procedure: G. Assessment and Reassessment ...2. The patients' physical status and needs are monitored and assessed by the RN (Registered Nurse) at a minimum of every two hours...I. Documentation of Care Provided to the Patients in Restraints...2. Documentation of Care...c. The RN will document the patient's assessment, safety care provided and outcomes in 2-hour increments while the restraint order is in effect."

2. On 4/11/17 at approximately 10:00 AM the clinical record of Pt. #9 was reviewed. Pt. #9 was a 69 year old female admitted on 4/4/17 with a diagnosis of Respiratory Failure. Pt. #9's clinical record contained physician's orders for restraints dated 4/6/17 at 7:09 AM and daily for soft limb restraint of the right and left upper extremity and 4 side rails.

The Nurse "Restraint Assessment" lacked documentation of an assessment every 2 hours as required on the following days:
-4/6/17 "Time Period 5:30 AM to 7:30 AM"
-4/9/17 "Time Period 3:30 AM to 5:30 AM"

3. On 4/11/17 at approximately 10:40 AM the clinical record of Pt. #10 was reviewed. Pt . #10 was a 67 year old male admitted on 3/25/17 with a diagnosis of Respiratory Failure. Pt. #10's clinical record contained a physician's order dated 3/27/17 at 8:00 AM for the use of 4 side rails.

The Nurse "Restraint Assessment" lacked documentation of an assessment every 2 hours as required on 3/25/17 from the time period of 9:30 AM to 11:30 AM.

4. On 4/11/17 at approximately 10:42 AM the findings were discussed with the Quality Coordinator (E #3) and the Nurse Manager of the "C-wing" and "B-2" (E #4). E #3 stated the nurses are required to document their restraint assessment in 2 hours intervals.