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 interviews, record review, and review of the facility's policies, it was determined the facility failed to ensure that an allegation of abuse for one (1) of ten (10) sampled patients (Patient #1) was investigated and that patients were protected from further potential abuse. On 06/16/17, the nursing facility where Patient #1 resided reported to the facility's Social Worker that Patient #1 alleged that a male entered the patient's hospital room and raped the patient when he/she was a patient at the facility. The Social Worker transferred the phone call from the nursing home representative to the Risk Manager; however, the Risk Manager was not working on 06/16/17 and never received the report. The Social Worker took no further action to ensure the allegation was investigated and took no action to ensure patients were protected from further potential abuse. When the Risk Manager was made aware of the allegation on 06/22/17, she determined that the allegation did not require an investigation because Patient #1 was confused and had an altered mental status.

The findings include:

Review of a facility policy titled "Patient Grievance Policy," dated July 2010, revealed a grievance was a written or verbal complaint made to the hospital by a patient or the patient's representative regarding the patient's care and/or treatment. The policy further revealed that allegations of abuse or neglect were considered grievances and should be reviewed promptly given the seriousness of the allegation and the potential for harm to the patients.

Review of a facility policy titled "Abuse/Neglect/Exploitation of Patients," dated March 2016, revealed abuse was defined as willful infliction, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. The policy stated abuse may be physical, sexual, or verbal in nature. According to the policy, patients would be protected from further abuse during the investigation of any allegation of abuse, neglect, or mistreatment. According to the facility's policy, if a staff member was identified or accused of an act of abuse, neglect, harassment, or exploitation, the employee would be reassigned to a non-patient care area or placed on leave until cleared of the allegation.

Review of the facility's policy titled "Patient Rights and Responsibilities," not dated, revealed the patient had the right to be free from verbal or physical abuse, negligence, and harassment while hospitalized .

Review of Patient #1's medical record revealed the facility admitted the patient on 06/11/17 with diagnoses including Urinary Tract Infection, Cerebral Vascular Accident (CVA) with left sided hemiparesis and dysphagia, Depression, Type II Diabetes Mellitus, and Altered Mental Status with [DIAGNOSES REDACTED]. The record revealed staff placed an indwelling urinary catheter on 06/11/17 and the patient was discharged on [DATE].

Interview with the Social Worker on 06/26/17 at 1:42 PM revealed she received a phone call from the nursing facility where Patient #1 resided on 06/16/17. The nursing facility informed the Social Worker that Patient #1 alleged he/she was raped while hospitalized . The Social Worker stated she was not qualified to investigate allegations of abuse so she transferred the phone call to the Risk Manager. Further interview revealed the Social Worker found out later that the Risk Manager was not working on 06/16/17, but assumed the nursing facility staff left a message for the Risk Manager. The Social Worker took no further action to ensure the allegation was reported and that patients were protected.

Interview with the Risk Manager on 06/26/17 at 2:02 PM revealed she was not working on 06/16/17. She stated she was not made aware of the allegation involving Patient #1 until 06/22/17 when Adult Protective Services (APS, a state agency) came to investigate the allegation. Further interview revealed at that time the Risk Manager looked at Patient #1's medical record and found that RN #1 removed Patient #1's indwelling urinary catheter prior to discharge and felt that due to the patient's confusion and altered mental status, the allegation did not warrant a formal investigation by the facility.

Review of nursing notes revealed RN #1 was the only male that provided care to Patient #1 during his/her hospital stay. Further review of nursing notes revealed RN #1 removed Patient #1's indwelling urinary catheter on 06/15/17.

Interview with RN #1 on 06/26/17 at 12:54 PM revealed he was not aware that Patient #1 made an allegation of abuse. He stated he cared for the patient on 06/15/17 and removed the patient's indwelling urinary catheter prior to his/her discharge from the facility. He stated he worked on the weekends and had not been notified by facility administrative staff that there was an investigation or that he could not provide patient care.

Interview with the Unit Manager on 06/26/17 at 2:15 PM revealed she was not aware of an allegation involving Patient #2 until APS came to the facility to investigate the complaint on 06/22/17. She further stated she did not know if an investigation had been performed for the allegation of rape.

Interview with the Community Chief Nursing Officer on 06/26/17 at 2:43 PM revealed she and other management staff made rounds daily and she spoke with patients and their family members to ensure patients were free from abuse. She further stated she reviewed incident reports daily to ensure any allegations were investigated. The Chief Nursing Officer stated she was not aware that the allegation of rape made by Patient #1 had not been investigated.