HospitalInspections.org

Based on record review and interview, the facility failed to protect patients from further abuse while an investigation was ongoing, failed to thoroughly investigate allegations of abuse, and failed to educate staff on the need for immediate reporting of abuse, in response to 2 of 2 Caregiver Misconduct Incident Reports reviewed (Patient (Pt) #1, Pt #2), in a total sample of 3 incident reports reviewed.

Findings include:

The facility failed to protect patients from further abuse when 1 of 1 employees accused of abuse (Paramedic A) worked providing direct patient care while the investigation was still ongoing. SEE TAG A-0145.

The facility did not fully investigate alleged incidents of abuse by interviewing all staff and patients who might have provided insight into the allegation per facility policy. SEE TAG A-0145

In response to allegations of abuse, the facility created draft policy/workflow that did not require immediate reporting of abuse by staff or managers. SEE TAG A-0145

Based on record review and interview, the facility failed to protect patients from further abuse while an investigation was ongoing, failed to thoroughly investigate allegations of abuse, and failed to educate staff on the need for immediate reporting of abuse, in response to 2 of 2 Caregiver Misconduct Incident Reports reviewed (Patient (Pt) #1, Pt #2), in a total sample of 3 incident reports reviewed.

Findings Include:

Review of policy and procedure #14653861 titled, "Reporting and Investigating Caregiver Misconduct" last reviewed 11/2023 revealed the following:
-"Immediately upon learning of any allegations of potential caregiver misconduct, staff must take the necessary steps to protect all patients from possible subsequent incidents of mistreatment or injury by taking the following steps: 1. Take steps necessary to ensure the safety of patients. Notify your immediate leader using the chain of command. Leader is to immediately reach out to HR (Human Resources) to consult regarding investigative leave for the accused employee from patient contact or responsibility. This may include removing the individual from patient care contact or responsibilities, additional supervision or monitoring of the patient and/or the accused, an alternative work assignment, review of the care plan with appropriate interventions as necessary, and suspension of the accused if deemed appropriate...Any employee witnessing alleged or actual misconduct is required to report this occurrence immediately to leader or supervising authority. (Failure to report abuse subjects the employee to disciplinary action.) ...All alleged violations involving caregiver misconduct must be thoroughly investigated and documented. A thorough investigation is conducted by the operational leader, Risk, and/or Compliance and may include ...2. Interviewing individual(s) (includes staff, visitors, patients, patient's relatives, etc.) who may be able to provide insight into the allegation .... It is recommended that interviews should be conducted with two individuals and that a signed statement is completed by any employee who is part of the investigation..."

Review of the "Misconduct Incident Report" submitted to the Department of Health Services on 04/11/2024 at 8:42 AM by Risk Manager E, revealed that on Friday 04/05/2024 (no time) Pt #1 notified hospital staff about an incident that occurred on Wednesday 03/27/2024 at 4:00 PM while Pt #1 was in the Emergency Department (ED). Per the Incident Summary, "(Pt #1) presented to the Emergency Department with head and chest pain, so they were giving (Pt #1) medications to lessen the pain which she said made her weak and tired. Patient reported that the staff member (Paramedic A) came in the room at one point and closed the door and pulled the curtains. (Paramedic A) then started to remove the EKG (electrocardiogram) pads and (Pt #1) felt (Paramedic A) fondled her left breast...(Paramedic A) then started to put his hand down (Pt #1's) panties."

Review of the "Misconduct Incident Report" submitted to the Department of Health Services on 04/11/2024 at 8:44 AM by Risk Manager E, revealed that on Saturday 04/06/2024 (1 day after 1st alleged incident) Pt #2 notified hospital staff about an incident that occurred on Friday 04/05/2024 at 3:00 PM while Pt #2 was in the ED. Per the Incident Summary, "(Pt #2) stated staff member (Paramedic A) administered (Pt #2) Dilaudid for her pain and she became 'loopy'. (Pt #2) stated that (Paramedic A) pulled down her gown and asked (Pt #2) if she had her leopard print bra on and then fondled (Pt #2's) breast." Per Incident Report, "Patient self reported this incident to the entity, as she felt it was very wrong. (Pt #2) also subsequently filed a report with law enforcement."

Review of Event SBARC (Situation, Background, Assessment, Recommendation, Communication) email sent to leadership staff from Risk Manager E on 04/08/2024 at 10:29 AM, with a subject line "...Alleged Caregiver Misconduct Emergency Department" revealed the following:
- "4/5/24: Patient 1 called Patient Experience and reported concerns. Patient Experience immediately notified Compliance and Risk to initiate further fact-finding."
- "4/5/24: Nursing leaders and Human Resources collaborated to discuss steps to be undertaken to ensure patient safety throughout investigation.
- "4/6/24: Patient 2 called and spoke to ED Manager and reported concerns."
- "4/8/24: Multidisciplinary team convened to discuss plan for investigation, including placing the staff member on administrative leave pending investigation."

Review of Paramedic A's Timecard revealed that Paramedic A worked in the ED/Urgent Care on 04/05/2024 (day staff was notified of incident) beginning at 3:58 PM and punched out at 8:31 PM (worked 4 hours 33 minutes).

Review of "Corrective Action Form" dated 04/09/2024 (no time) revealed, "On 04/09/2024 a multidisciplinary team met to discuss the complaints and determine if these complaints fall under the definition of Caregiver Misconduct. The caregiver misconduct review meeting resulted in substantiated caregiver misconduct. A Misconduct Incident Report will be submitted to DQA (Division of Quality Assurance) as well as a report submitted to the licensing body...we have decided to terminate (Paramedic A's) employment with (hospital) effective immediately."

Per interview with ED Manager D on 04/24/2024 beginning at 11:03 AM, Patient Experience was notified of Pt #1's sexual assault allegations on Friday 04/05/2024 at 2:00 PM. ED Manager D stated that she/he confirmed that Paramedic A was not scheduled to work on 04/05/2024 and consequently, scheduled a meeting with HR and leadership to discuss the plan for investigation for Monday 04/08/2024. ED Manager D stated that there was a staff call-in the evening of 04/05/2025 and Paramedic A picked up unscheduled hours in the ED. ED Manager D stated that the charge nurse was not aware of the alleged incident and allowed Paramedic A to work. ED Manager D stated that Paramedic A worked in the ED after hospital staff was made aware of the allegations against Paramedic A; ED Manager D stated that Paramedic A should not have worked. Per ED Manager D, HR and Manager D met with Paramedic A on Monday 04/08/2024 and placed Paramedic A on leave pending an investigation; Paramedic A was subsequently terminated on 04/09/2024.

Review of facility investigation reports revealed that the facility did not interview other staff and patients present in the ED on the dates of the alleged incidents per facility policy. Staff who worked with Patients 1 and 2 on the dates in question were not interviewed to determine if they witnessed anything out of the ordinary or if they noticed any change in the patients' condition or demeanor after the alleged incidents and prior to discharge from the ED.

Per interview with ED Manager D on 04/24/2024 beginning at 11:03 AM, based on the investigation there were no witnesses during the alleged incidents to interview so staff interviewed the two complainants (Pt #1 and Pt #2) and Paramedic A, who denied the allegations. Per ED Manager D, there were no complaints about Paramedic A from the ED staff on the dates in question. The incidents were not reported by patient #1 or patient #2 until after they left the ED. ED Manager D stated that there were no other staff or patient interviews conducted.

Per interview with Chief Nursing Officer (CNO) B on 04/24/2024 beginning at 11:30 AM, CNO B stated that the leadership team did identify a "gap" in reporting and have made revisions to the workflow for reporting of Caregiver Misconduct to ensure "tighter timeline" for staff removal from work in regards to 24 hour departments. Per CNO B, the Caregiver Misconduct reporting workflow revision is still in "draft form" and has not yet been rolled out to staff.

Review of "Caregiver Misconduct Process Steps," Draft Workflow (undated) revealed, "Staff member/provider observes or is made aware of alleged caregiver misconduct (abuse, neglect or misappropriation of property)...Staff member/provider follows chain of command for notifying one-up as soon as possible after the perceived misconduct...Department/unit leader notified as soon as possible..."

The draft policy does not call for immediate reporting by staff of perceived/observed caregiver misconduct but indicates reports to be made "as soon as possible." This could result in a delay in reporting and in the protection of patients from further abuse.