HospitalInspections.org

Based on Record reviews and interviews, the facility failed to document that allegations of potential abuse were thoroughly investigated and safeguards put in place to assure the safety of 1 of 1 patient (Patient #1). The facility failed to ensure:

1.) A complete a thorough assessment of Patient #1 was conducted after she made any outcry of verbal sexual abuse.

2.) Document that a thorough investigation was completed into the alleged allegations.

3.) Document any interventions which were implemented to assure the safety of Patient #1.

Refer to A0145 for evidence of findings.

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Patient Rights.

Based on Record reviews and interviews, the facility failed to document that allegations of potential abuse were thoroughly investigated. Facility interdisciplinary staffs failed to document that a thorough investigation was completed, assessment and any interventions documented when patient #1 complained of verbal sexual harassment from another patient (Patient #2).

Findings include:

Record review of the facility incident reports, dated 8/19/18 revealed that The facility RN (Registered Nurse) Charge Nurse documented that patient #1 had reported that Patient #2 was verbally sexually harassing her, asking patient #1 for money and to have sexual encounters.

Record review of Patient #1's Interdisciplinary notes revealed that on 8/21/18 the social worker documented in part the following:
- " Patient also discussed and processed interpersonal that have occurred recently, and stated "I don't want to feel like I can't be safe here. I can't avoid (Peers) because it's such a small place, but at the same time I don't feel safe and that's not okay."

Further review of the Interdisciplinary notes revealed no evidence of documentation regarding an assessment and/or safety plan for Patient #1, or investigation into Patient #1's allegations of verbal sexual harassment.

Record review of the facility policy entitled: Investigating Abuse and Neglect, revised 06/18 revealed in part the following information:
- The reporting employee will initiate an Incident Report, summarizing in full all details of the occurrence.
- Nursing staff will make appropriate documentation in the patient's medical record as to the patient's condition and intervention.

Record Maintenance:
- The Risk Manager will organize a file for the case which will include:
- The original incident report
-Investigator's summary and accompanying evidence.
-Documented requests for action resulting from the findings and conclusion of the case.

In an interview conducted on 10/23/18 at 12:00 pm with the director of Quality Management and the Acting Hospital Administrator confirmed that there was no documentation of an assessment and/or safety plan for Patient #1, or that a thorough investigation took place regarding Patient #1's verbal sexual harassment complaints.