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Based on review of the facility grievance documentation, policies and procedures, and interviews, it was determined the facility failed to investigate and document a complaint of sexual molestation.

Findings include:

Refer to A 0120 and A 0122.

Based on review of facility policies and procedures, grievance documentation, Patient Safety Events documentation for unit 3ST, and interviews it was determined Huntsville Hospital failed to follow its policies and procedures to investigate, review and provide to the complainant a prompt resolution of his/her complaint of alleged sexual molestation by a facility staff member.

This deficient practice affected one of four grievances reviewed, and did affect Patient Identifier (PI) # 1, and had the potential to negatively affect all patients admitted to the facility.

Findings include:

Facility Policy: Patient/Visitor Complaints & Grievances
Policy Number: ADM.037.15
Revision Date: 9/8/22

I. Purpose:

...This policy has been developed to establish Huntsville Hospital (HH) Health System's process for receiving, investigating, and resolving patients...complaints and grievances....

II. Policy:

...All patients and guests should be assured that their complaints will be investigated and resolved in a prompt, reasonable and consistent manner.

III. Procedure:

...B. Grievance Resolution Process:

The hospital must review, investigate, and resolve each patient's grievance within a reasonable time frame ...

...2. Investigate the concerns in order to determine the most appropriate resolution...

a. All allegations of abuse, neglect, or endangerment of a patient should be reviewed and investigated immediately given the seriousness of the allegations and the potential for harm to the patient, and then the patient should be notified that the hospital is still working to resolve the issue. The patient...should also be given an anticipated time frame for resolution in all cases alleging abuse, neglect, and endangerment of a patient...

...5. A complaint or grievance is considered resolved when:

a. The patient...is satisfied with the actions taken...or satisfied with the response...

Facility Policy: Patient Abuse and Neglect by a Staff Member
Policy Number: PCI.100.03
Revision Date: 9/8/22

I. Purpose/Guideline:

...7. Report/Respond. The hospital must assure that any incidents of abuse...are reported and analyzed, and the appropriate corrective, remedial, or disciplinary action occurs, in accordance with applicable local, state, or federal law.

III. Procedure:

A. If an allegation of abuse or neglect has been made by a patient against an employee...Actions are taken...Immediate medical, nursing, and psycho-social assessments are performed. The providers who perform the assessments enter findings in the medical record.

...VI. Documentation:

A. Allegations or patient abuse are considered unusual occurrences and are entered into the safety event tracking system via a Patient Safety Clinical event for reporting, follow-up, tracking, and trending. The manager or department head must confirm that the incident is entered as a Clinical Event Report.

1. PI # 1 was admitted to Huntsville Hospital's orthopedic unit, Sivley Tower (3ST) on 10/21/22 with a diagnosis of Infection of Prosthetic Right Knee Joint and discharged on 11/5/22.

In a phone interview with PI # 1 on 11/30/22 at 12:37 PM, PI # 1 confirmed he/she reported to his/her assigned nurse, Employee Identifier (EI) # 3, Licensed Practical Nurse (LPN) he/she had been sexually molested during bathing on 10/26/22 by EI # 4, Registered Nurse (RN). PI # 1 also stated the charge nurse, EI # 2 RN, came in and, "took everything down," and stated, "the boss of all the nurses" (EI # 1 RN 3ST Unit Manager) came to his doorway and stated he/she would be back later to talk with him/her. PI # 1 stated no one ever came back to discuss anything with him/her.

An interview conducted on 12/1/22 at 8:37 AM with EI # 3confirmed he/she received a complaint on 10/26/22 from PI # 1 of being sexually molested while being bathed that afternoon by EI # 4, RN. EI # 3 further stated he/she reported the complaint to the unit manager (EI # 1).

Review of PI # 1's medical record (MR) revealed there was no documentation of his/her allegation of sexual molestation by a staff member nor any responsive actions taken by the facility upon receiving the allegation.

Review of the Grievance Summary Report data from January 1, 2022 to November 28 2022, revealed no documentation of PI # 1's allegation of sexual molestation by a staff member on 10/26/22.

Review of the facility's Patient Safety Event Report for the 3ST unit dated 10/15/22 to 11/28/22 revealed there was no Safety Event Report documented of PI # 1's allegation of sexual molestation by a staff member.

An interview conducted 12/1/22 at 11:42 AM with EI # 1, 3ST Unit Manager, confirmed he/she was made aware of PI # 1's complaint about, "aggressive bathing," performed by EI # 4, and that PI # 1 did not understand why EI # 4 gave him/her his bath when EI # 4 was not assigned to him/her.

The facility failed to respond to an allegation of sexual molestation by a staff member and failed to follow its policies and procedures for investigation and documentation of reports of abuse.

Based on review of facility policies and procedures, grievance documentation, recorded data from the Radio Frequency Identification Device (RFID), and interviews it was determined Huntsville Hospital failed to follow its policies and procedures and investigate a patient report of alleged sexual molestation by a facility staff member.

This deficient practice affected one of four grievances reviewed, and did affect Patient Identifier (PI) # 1, and had the potential to negatively affect all patients admitted to the facility.

Findings include:

Facility Policy: Patient/Visitor Complaints & Grievances
Policy Number: ADM.037.15
Revision Date: 9/8/22

I. Purpose:

...This policy has been developed to establish Huntsville Hospital (HH) Health System's process for receiving, investigating, and resolving patients...complaints and grievances....

II. Policy:

...All patients and guests should be assured that their complaints will be investigated and resolved in a prompt, reasonable and consistent manner.

III. Procedure:

...B. Grievance Resolution Process:

The hospital must review, investigate, and resolve each patient's grievance within a reasonable time frame ...

...2. Investigate the concerns in order to determine the most appropriate resolution...

a. All allegations of abuse, neglect, or endangerment of a patient should be reviewed and investigated immediately given the seriousness of the allegations and the potential for harm to the patient, and then the patient should be notified that the hospital is still working to resolve the issue. The patient...should also be given an anticipated time frame for resolution in all cases alleging abuse, neglect, and endangerment of a patient...

...5. A complaint or grievance is considered resolved when:

a. The patient...is satisfied with the actions taken...or satisfied with the response...

Facility Policy: Patient Abuse and Neglect by a Staff Member
Policy Number: PCI.100.03
Revision Date: 9/8/22

I. Purpose/Guideline:

...7. Report/Respond. The hospital must assure that any incidents of abuse...are reported and analyzed, and the appropriate corrective, remedial, or disciplinary action occurs, in accordance with applicable local, state, or federal law.

III. Procedure:

A. If an allegation of abuse or neglect has been made by a patient against an employee...Actions are taken...Immediate medical, nursing, and psycho-social assessments are performed. The providers who perform the assessments enter findings in the medical record.

...VI. Documentation:

A. Allegations or patient abuse are considered unusual occurrences and are entered into the safety event tracking system via a Patient Safety Clinical event for reporting, follow-up, tracking, and trending. The manager or department head must confirm that the incident is entered as a Clinical Event Report.

1. PI # 1 was admitted to Huntsville Hospital's orthopedic unit, Sivley Tower (3ST) on 10/21/22 with a diagnosis of Infection of Prosthetic Right Knee Joint and discharged on 11/5/22.

An interview conducted 11/30/22 at 12:37 PM with PI # 1 confirmed he/she reported to his/her assigned nurse, Employee Identifier (EI) # 3, Licensed Practical Nurse (LPN) he/she had been sexually molested during bathing on 10/26/22 by EI # 4, Registered Nurse (RN). PI # 1 also stated the charge nurse, EI # 2 RN, came in and, "took everything down," and stated the "boss of all the nurses" (EI # 1 RN 3ST Unit Manager) came to his doorway and stated he/she would be back later to talk with him/her. PI # 1 stated no one ever came back to discuss anything with him/her.

Review of PI # 1's medical record (MR) revealed there was no documentation of his/her allegation of sexual molestation by a staff member nor any responsive actions taken by the facility upon receiving the allegation.

Review of recorded data from the facility's Nurse Call System confirmed EI # 4 was in PI # 1's hospital room on 10/26/22 from 1:55 PM to 2:28 PM, a total of 32 minutes.

Review of the facility's Grievance Summary Report data from January 1, 2022 to November 28 2022, revealed no documentation of PI # 1's allegation of sexual molestation by a staff member.

In an interview conducted 11/29/22 at 10:15 AM with EI # 6, Director of Patient Experience and Advocacy, EI # 6 confirmed there was no documentation of the grievance, and no documentation of an investigation or response to PI # 1.

An interview conducted on 12/1/22 at 8:37 AM with EI # 3 confirmed PI # 1 had reported to him/her, "He/she felt molested when being bathed by (EI # 4)." EI # 3 confirmed he/she did not document an incident/occurrence report of the allegation.
EI # 3 also confirmed he/she reported the allegation of sexual molestation to EI # 1, RN Unit Manager on 3ST on 10/26/22.

An interview conducted 12/1/22 at 11:42 AM with EI # 1 confirmed he/she was made aware of PI # 1's complaint about, "aggressive bathing," performed by EI # 4, and that PI # 1 did not understand why EI # 4 gave him/her his bath when EI # 4 was not assigned to him/her.

The facility failed to respond to a patient complaint of sexual molestation and follow its policies and procedures for investigation and documentation of abuse allegations.

Based on review of medical records (MR), facility policy and procedure, Grievance Summary documentation, Patient Safety Event Reports, and interviews it was determined the facility failed to ensure nursing staff investigated and documented a patient report of abuse as directed per policy.

This deficient practice affected one of four grievances reviewed, and did affect Patient Identifier (PI) # 1, and had the potential to negatively affect all patients admitted to the facility.

Findings include:

Refer to to A 0392.

Based on review of medical records (MR), facility policy and procedure, Grievance Summary documentation, Patient Safety Event Reports, and interviews it was determined the facility failed to ensure nursing staff responded to a patient complaint of abuse and:

1. Performed an immediate medical, nursing, and psycho-social assessment upon receipt of a patient allegation of sexual molestation by a staff member as directed by the facility policy.

2. Notified the Patient Advocate or designee as directed.

3. Documented the complaint in the facility complaint and grievance tracking database.

4. Documented a Patient Safety Clinical Event Report as directed in the policy.

This deficient practice affected one of four grievances reviewed, and did affect Patient Identifier (PI) # 1, and had the potential to negatively affect all patients admitted to the facility.

Findings include:

Facility Policy: Patient Abuse and Neglect by a Staff Member
Policy Number: PCI.100.03
Revision Date: 9/8/22

I. Purpose/Guideline:

A. To establish procedures for staff to report and respond to all abuse...allegations made by a patient against any HH (Huntsville Hospital) Health System employee...The following components are suggested by CMS for effective abuse protection:

...6. Investigate. The hospital ensures, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment.

7. Report/Respond. The hospital must assure that any incidents of abuse...are reported and analyzed, and the appropriate corrective, remedial, or disciplinary action occurs, in accordance with applicable local, state, or federal law.

II. Definitions:

...F. Sexual Abuse for purposes of this policy includes:

Any sexual contact involving a patient or any sexual contact that is encouraged or allowed by a caregiver. Examples include...inappropriate touching and fondling...penetration (or attempted penetration) of anus or mouth by penis, fingers, or other objects.

III. Procedure:

A. If an allegation of abuse or neglect has been made by a patient against an employee...Actions are taken...Immediate medical, nursing, and psycho-social assessments are performed. The providers who perform the assessments enter findings in the medical record. An allegation of abuse against an employee is considered a grievance and should follow the Patient Complaint and Grievance Policy by immediately contacting the Service Line VP, Service Line Administrator, Unit Director, and Customer Service.

IV. Notification Procedure:

A. Incidents of actual or suspected neglect or abuse is to be reported and investigated using this process as a general guideline.

...4. A Patient Safety Clinical Event report is entered into the safety event tracking database.

5. The Service Line VP or department head immediately notifies Risk Management of the allegation of patient abuse.

6. The Patient Advocate or designee is notified as soon as possible by Service Line VP or Department Head...

VI. Documentation:

A. Allegations or patient abuse are considered unusual occurrences and are entered into the safety event tracking system via a Patient Safety Clinical event for reporting, follow-up, tracking, and trending...

1. PI # 1 was admitted to Huntsville Hospital's orthopedic unit, Sivley Tower (3ST) on 10/21/22 with a diagnosis of Infection of Prosthetic Right Knee Joint and discharged on 11/5/22.

An interview conducted on 11/30/22 at 12:37 PM with PI # 1 confirmed he/she reported to his/her nurse (Employee Identifier # 3, Licensed Practical Nurse) on 10/26/22 that he/she had been molested by the nurse giving him/her a bath that day.

An interview conducted on 12/1/22 at 8:37 AM with Employee Identifier (EI) # 3, Licensed Practical Nurse (LPN) confirmed he/she received a complaint 10/26/22 from PI # 1 of being sexually molested while being bathed that afternoon by EI # 4, Registered Nurse (RN). EI # 3 further stated he/she reported the complaint to the unit manager (EI # 1). EI # 3 also confirmed during the interview he/she did not document an incident/occurrence report of the allegation.

An interview conducted on 12/1/22 at 11:42 with EI # 1, Unit Manager, confirmed he/she was notified of PI # 1's complaint allegation on 10/26/22. EI # 1 further confirmed he/she did not investigate or document the allegations.

Review of PI # 1's MR revealed no documentation an immediate medical, nursing, and psycho-social assessment was performed on 10/26/22 after his/her allegation of sexual molestation by a staff member as directed by policy.

Review of the facility's Grievance Summary Report data from January 1, 2022 to November 28, 2022 revealed no documentation of PI # 1's allegation of sexual molestation by a staff member on 10/26/22.

An interview was conducted on 11/29/22 at 10:15 AM with EI # 6, Director of Patient Experience and Advocacy who confirmed the Advocacy Department had not been notified of PI # 1's complaint allegation of sexual molestation by a staff member, and also confirmed there was no documentation of the grievance, and no documentation of an investigation or response to PI # 1.

Review of the facility's Patient Safety Event Reports for the 3ST unit dated 10/15/22 to 11/28/22 revealed no Safety Event Report documented of PI # 1's allegation of sexual molestation by a staff member.

An allegation of sexual molestation was conveyed to three nursing staff members and no investigation was conducted.