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 document review and interview, it was determined, for 1 of 1 Patient (Pt. #1) allegedly sexually abused, the Hospital failed to ensure immediate action was taken to protect the patient from potential abuse.

Findings include:

1. On 4/26/17 at 8:55 AM, Hospital policy titled, "Patient's Rights and Responsibilities", approved 2/17/15, was reviewed. The policy required, "Personal Safety: The patient has the right to expect personal safety insofar as the Hospital practices and the environment are concerned. Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect, exploitation and corporal punishment... Refusal of Treatment: The patient may refuse treatment to the extent permitted by law"

2. On 4/24/17 at 10:30 AM, Hospital policy titled, "Occurrence/ Investigative Reports", approved 2/2016, was reviewed. The policy required, General Instructions: 1. The occurrence report is to be initiated by the individual identifying the occurrence and entered into the Occurrence Reporting System (within 24 hours of the occurrence or its discovery).

3. On 4/24/17 at 10:20 AM, Pt. #1's clinical record was reviewed. Pt. #1 was a [AGE] year old female, admitted on [DATE], with a diagnosis of ventral hernia without obstruction or gangrene. A nursing note on 3/10/17 at 8:30 PM, included, "Informed by patient's nurse ... to speak with the patient. Patient informed me she did not want CA [Clinical Associate] [E #1] to care for her. When I asked her what happened patient stated she had an issue with a CA caring for her yesterday. Patient stated the CA came in to see if she was clean. The patient stated she told the CA she would take care of the lower part, referring to her genitalia, and he could check her Foley. Patient stated CA insisted on checking her to see if she soiled her bed pad and proceeded to do so even after she insisted, repeatedly, she would do it herself..."

4. On 4/25/17 at 9:30 AM, an interview was conducted with the Registered Nurse/ 5 East Assistant Manager (E #4) who wrote the nursing note on 3/10/17 at 8:30 PM. E #4 stated that she wanted to discuss the event with the 5 East Unit Manager and with Human Resources. E #4 did not call a House Supervisor, initiate an incident report, relocate Pt. #1, or remove E #1 from duty, pending investigation.

5. Twenty hours after E #4 discovery of Pt. #1's allegation, a House Supervisor note on 3/11/17 at 4:40 PM included, " ... spoke with patient about being inappropriately touched... As CA was emptying Foley catheter patient told CA that she would take care of her care down there and she pulled covers up more. The CA grabbed the covers and she stated she told him again, 'No'. CA proceeded to spread her legs, and fondled her... Patient stated that she was scared that he was going to come back ...". Following this second discovery, an incident report was initiated. E #1 was suspended, pending investigation, and Pt. #1 was relocated to 4 West.

6. On 4/26/17 at 12:15 PM, a "Record of Coaching and Counseling" dated 3/13/17 related to E #4 was reviewed. The document addressed E #4's responsibility to inform the House Manager of the patient's complaints. The document did not address E #4's failure to complete an occurrence report for an abuse allgegation.