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 an allegation of abuse was investigated and patients were protected from further potential abuse for one (1) of ten (10) sampled patients (Patient #1). On 11/21/16, Patient #1 reported to the facility's Risk Manager that Registered Nurse (RN) #2 (a contracted employee) had touched him/her inappropriately. Although the facility called the contract company and reported the allegation, RN #2 was not made aware that he was not to return to the facility and on 11/22/16 returned to work and made contact with Patient #1. In addition, interview with the facility's Risk Manager revealed the facility considered the allegation "a grievance" and failed to interview other employees or patients that RN #2 had cared for as part of an investigation of the allegation.

The findings include:

Review of a facility policy titled "Resolution of Patient Grievances and Complaints," dated 07/25/16, 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 "Suspected Child/Adult Neglect/Abuse," dated 02/06/16, revealed sexual assault was any unwanted sexual contact where verbal or physical force was used. The policy further revealed any employee suspected of abuse would receive appropriate work assignments to protect patients, staff, and visitors from further abuse. The policy indicated that action to ensure protection to patients, staff, and visitors was provided would include suspension from work or reassignment to a work area that did not involve patient contact. Continued review of the policy revealed when an allegation of abuse was reported the Administrator on call would be notified, and the Risk Management team would lead the investigation. The investigation was to consist of an interview with the person reporting the incident, interviews with any witnesses, an interview with the patient involved, review of the patient's medical record, interviews with other patients the alleged perpetrator had provided care to, and staff members having contact with the patient involved in the allegation.

Review of Patient #1's medical record revealed the facility admitted the patient on 11/05/16 with diagnoses including Diabetes Mellitus Type 2, Hypertension, Chronic Kidney Disease, and Congestive Heart Failure. Further review of the medical record revealed the facility discharged the patient on 11/23/16.

Review of facility documentation related to the allegation made by Patient #1 revealed the facility spoke with the patient, notified the contract agency that employed RN #2, and made a referral to Adult Protective Services.

Interview on 11/29/16 at 3:21 PM with RN #1 revealed Patient #1 reported to her on 11/21/16, that there "was a worker" in the dialysis department that the patient "was not fond of." The patient informed RN #1 that it was RN #2. The interview further revealed Patient #1 reported that when RN #2 placed the patient's blood pressure cuff on his/her arm, RN #2 "shook" the patient's breast and laughed about it. RN #1 stated she immediately reported the incident to the Lead Nurse.

Interview on 11/30/16 at 10:30 AM with RN #2 revealed the RN was providing dialysis services to Patient #1 on 11/21/16, and the patient appeared to be very drowsy and the patient's blood pressure was very low. The interview further revealed RN #2 informed Patient #1 he was going to adjust the blood pressure cuff on his/her arm. RN #2 stated he had to reposition the patient's breast to adjust the blood pressure cuff. RN #2 stated he was not made aware of the allegation or asked to leave the facility until after arriving for work on 11/22/16, and after having had a verbal interaction with Patient #1.

Interview on 11/29/16 at 11:54 AM with the facility Human Resources Director revealed he was made aware of the allegation on 11/21/16 and attempted to contact the agency that employed RN #2 to notify the agency of the allegation and inform the agency that the facility did not want RN #2 to return to the facility. However, the Administrator had the incorrect phone number for the contract agency, and RN #2 was not made aware that he was not to return to the facility.

Interview on 11/29/16 at 11:23 AM with the facility's Risk Manager and the Risk Management Director revealed they were made aware of the allegation and immediately interviewed Patient #1. The Risk Manager and the Director also stated the allegation was reported to the Human Resources Department so notification could be made to the contract agency that RN #2 was not to return to the facility. The interview further revealed no other staff was interviewed as part of the investigation. The interview further revealed that due to the facility being unable to "prove" the incident occurred, the facility had taken all required action to protect patients.

Interview on 11/29/16 at 12:01 PM with the Chief Nursing Officer (CNO) revealed the facility "thought" they had made the contract agency aware that RN #2 was not to return to the facility, not realizing they had contacted the wrong number. Subsequently, the facility took no further action to ensure that patients in the facility were not subjected to potential abuse by RN #2.