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 that the facility did not comply with the Condition of Participation for Patient Rights. This was evident by the facility's failure to effectively implement the facility's "Chain of Command" and "Assault" Policies following patient's allegations of sexual abuse.

This placed all patients at risk for not having sexual assault allegations immediately investigated.

See citations: Tag A 145.

Based on document review and staff interview, in two (2) of two (2) medical records reviewed, it was determined that the facility failed to protect patients from potential abuse. Specifically, staff did not escalate patient allegations of sexual assault and the process for resolution of this allegation was not followed. (Patient #1, Patient #2).

This placed all patients at risk for potential abuse.


Review of the medical record for patient #1 revealed: on 01/11/16 at 10:57 PM, patient #1 was admitted to the hospital for right shoulder/upper back pain. The medical screening examination was successfully completed by Staff #1 (Emergency Department Attending Physician) and the patient's course of treatment included diagnostic studies for chest x-ray and pain management. On 01/12/16 at 6:00 AM she was discharged home.

During interview on 1/21/16 at 1:55 PM, Staff #2 (Physician Assistant) stated patient #1 complained of being sexually abused by Staff #1, on 01/12/16 at approximately 2 AM. "Staff #1 had ordered morphine for the patient as she was in pain. The nurse gave the morphine and we were letting her sleep. The nurse came to me some time after that and asked me to go in to see the patient because the patient was very drowsy and saying something about the attending doctor (Staff #1). When the nurse and I went into the room together the patient asked to speak with me alone and the nurse left the room. The patient said " your boss (Staff #1) is an (expletive used), he was in here masturbating next to me and then I felt his semen on my face." I said to the patient what do you want me to do? Do you want me to report this? She said "no, keep it between you and me and don't tell anybody. Promise me." So, I didn't tell anyone because the patient made me promise not to say anything. I let her know if she should change her mind while still in the hospital or when she got home later, if the patient should decide to make this a police matter, she should call the police and make a report with them. I did not tell anyone in the hospital or let anyone know what she said to me because I kept her promise and respected her wishes. This was around 2 to 3 AM, and at that time, I gave her discharge papers because she said she was ready to go. She seemed very tired. She was alert and oriented, just very drowsy, so I left her to sleep. She left around 6 AM but I didn't see her leave."

Review of the facility patient complaint log identified a sexual assault allegation intake, dated 01/15/16 (Patient #2).

Review of Quality Management document, dated 01/15/16, revealed that on 09/22/15, patient #2 complained that a staff sexually abused her (touched her inappropriately).

Review of the patient's medical record (MR#2) revealed: Patient presented to the emergency department (ED) on 9/22/15 at 10:04 PM, with chief complaint Upper Respiratory Infection (URI). Physical exam was done by Staff #1(Emergency Department Attending Physician) at 10:18 PM; all systems reviewed with no significant findings. Patient was discharged at 11:23 PM.

Interview on 1/21/16 at 4:00 PM, Staff #4 (Social Worker) stated, " On or around September 28th 2015, an employee from an out patient facility reported patient #2 made a verbal complaint that she was sexually assaulted/abused by a staff member at the Mount Sinai facility. The information about the call was shared (verbal) with his supervisor." Staff #4 went on to state that on 1/15/16, a call was received from the out patient facility reporting that the patient who made the allegation in September saw the physician in the news and identified him as the physician she reported that fondled her breast. This was then reported to Patient Relations."

Interview on 1/22/16 at 11:25 AM, Staff #5 (Supervisor), stated he was "made aware of this allegation in late September 2015." Staff #5 stated there is no documentation of these events.

Staff #4 and Staff #5 were notified on 09/28/15 of an allegation of sexual abuse, which occurred on 09/22/15, the allegation was not investigated at the time of the alleged occurrence.

Review of the policy titled, "Assault Policy and Procedures Subject No. GPP-513," last revised 6/14, documented:
"II. A. Any employee or physician who witness or becomes aware of an alleged assault must immediately notify the Clinical Director and Nurse Manager. If the incident occurs during the evening or on the weekend, the Administrator on Call must be notified."
" II. C. Risk Management must be immediately notified at extension XX or through the Risk management person on call. Risk Management will then conduct an initial evaluation of the allegation and direct the investigation thereafter."
" IV. E. A comprehensive investigation report shall be prepared, including a summary of the investigation, written accounts of all interviews, detailed chronology of events and any conclusions, as well as documentation that the steps in the process have been followed."

These findings were reviewed and confirmed in interviews with facility Administrators including the Chief Medical Officer, on 01/21 and 01/22/16.