The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on interview and record review, the hospital failed to ensure that systems to prevent and protect patients from abuse were implemented when an alleged abuse allegation regarding Patient 1's physician was reported. These systems failures include:

1. Staff A failed to report the observation of rough treatment of Patient 1 by Physician C in a timely manner.

2. The hospital failed to protect a potential universe of 22 other patients from rough treatment and/or abuse when they failed to remove Patient 1's physician (Physician C) from active duty in a timely manner.

3. The hospital failed to have a policy to direct staff and administration of how to protect the victim and other patients when alleged patient abuse was reported.

These failures had the potential for other patient's to be abused.


1. On 1/13/16 at 6:29 pm, the hospital reported a suspected dependent adult/elder abuse to the Department that read, "A mandated reporter witnessed Physician C provide assess of the above named victim (Patient 1) in a manner that reasonably appears to be inappropriate and possibly physical abuse."

On 2/17/16 at 11:45 am, the hospital Chief Executive Officer (CEO), the Chief Operating Officer (COO) and Administrative Staff D discussed the above report in more detail. On 1/11/16 at 5:42 pm, the COO, who is also covering the the Chief Nursing Officer role due to a resignation, received an e-mail from the ED Nurse Manager in which a forwarded message from Emergency Medical Services (EMS) Staff A reported that Physician C had treated Patient 1 rudely and roughly on 1/11/16 at approximately 7 am while examining him. An investigation was started on 1/12/16 by Administrative Staff E and ED Nurse Manager with staff on duty during the incident, and which revealed Staff B confirmed Staff A's report.

On 2/18/16 at 2:30 pm, the ED Manager stated she had received Staff A's e-mail at 3:55 pm on 1/11/16 (reporting alleged abuse concerns), and forwarded it to her superiors on 1/11/16 at 5:42 pm. On 1/12/16 at approximately 7 am, 24 hours later, the ED manager questioned Staff B about the alleged abuse incident. Staff B reported witnessing Physician C's interaction with Patient 1 which she described as rude and rough with Patient 1. When asked why Staff B had not reported the incident immediately, Staff 1 replied that she was hesitant to do so based to his past behavior directed at staff, and could not see that it was any different than what he has done in the past. The ED Manager stated she counseled Staff B on her duties as a mandated reporter and the need to report immediately.

On 3/10/16, Staff B's counseling record, dated 1/12/16, confirmed the above discussion.

On 2/17/16 at 11:45 am, COO acknowledged Staff B should have immediately reported the above incident with Patient 1.

The hospital policy "Elder or Dependent Adult Abuse, dated 2/11/14, read, "California law requires any care custodian or health practitioner to immediately file a report where that person, in the scope of his employment or in his professional capacity, .. Has observed an incident that "reasonably appears" to be physical abuse.... Hospital personnel who identify possible elder or dependent adult abuse should first ensure the safety of the elder or dependent adult, and then make the telephone and written reports (required State reporting - SOC 341) with the assistance of the Administrative House Supervisor or Case Management."

The hospital policy "Duty to Report Suspected Misconduct and Potential Compliance Issues" dated 7/18/14, read, "Persons are encouraged to report misconduct and potential compliance issues immediately to a direct supervisor or next supervisory level or up to and including the highest level of management."

2. On 2/18/16 at 12:04 pm, hospital electronic health record audits revealed that Physician C continued to admit, attend to, and operate on a possible universe of 22 patients in the hospital following the alleged abuse incident with Patient 1 and going on voluntary leave of absence on 1/13/16, over 2 days later.

On 6/2/16 at 12:30 pm, Administrative Staff F acknowledged that other patients were not protected from potentially being abused during the alleged abuse investigation when Physician C was allowed to attend to patients until he agreed to a voluntary leave of absence on 1/13/16.

The above abuse policy reads, "Reassure and protect patient through hospitalization ."

3. The above policy "Elder or Dependent Adult Abuse" did not contain guidance for what to do other than reporting when potential patient abuse was identified. The policy failed to include measures to protect the suspected abuse victim and other patients from staff identified as an alleged abuser while an investigation was conducted.

On 6/2/16 at 1:40 pm, Administrative Staff D acknowledged the policy did not contain sufficient guidance to protect patients following a report of suspected abuse.

The Center for Medicare and Medicaid Services Interpretive Guidelines provided the following suggested components as necessary for effective abuse protection:
o Prevent. A critical part of this system is that there are adequate staff on duty, especially during the evening, nighttime, weekends and holiday shifts, to take care of the individual needs of all patients.
o Screen. Persons with a record of abuse or neglect should not be hired or retained as employees.
o Identify. The hospital creates and maintains a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect.
o Train. The hospital, during its orientation program, and through an ongoing training program, provides all employees with information regarding abuse and neglect, and related reporting requirements, including prevention, intervention, and detection.
o Protect. The hospital must protect patients from abuse during investigation of any allegations of abuse or neglect or harassment.
o Investigate. The hospital ensures, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment.
o Report/Respond. The hospital must assure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law.