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.

COLUMBIA MEMORIAL HOSPITAL 71 PROSPECT AVENUE HUDSON, NY 12534 Dec. 16, 2014
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and record review the hospital failed to protect a patient who reported a sexual relationship with a nurse at the patient's nursing home. Specifically, hospital staff failed to conduct a timely and thorough investigation of the patient's report. Additionally, hospital staff failed to ensure the patient was not discharged back to the nursing home, or was visited by the nursing home staff, from the date of the report (12/5/14) until the date of discharge (12/9/14).
Findings:
See 482.13 (c)(2) and 482.13 (c)(3)
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on interview and record review the hospital failed to ensure the patient was not discharged to the nursing home (NH) where the patient was allegedly engaged in a sexual relationship with a nurse. Also, the hospital failed to ensure supervised visitation, if the alleged abuser had visited the patient, during the hospital admission.

Findings:

Based on interview of facility staff the following information was obtained. On the afternoon of 12/5/14 housekeeping staff was cleaning the bed of a discharged patient in a semiprivate room. The patient in the other bed told the housekeeper she had a new boyfriend. The housekeeper had seen the patient on prior admissions and knew the patient was a nursing home (NH) resident. The patient stated a male NH nursing supervisor rubs her breasts and legs. The housekeeper told the patient that the NH nurse should not be touching the patient. The patient said that she liked what the nurse was doing and she was not going to report him to the NH.

The hospital housekeeper reported the conversation to a patient care aide, who reported the conversation to a social worker. The social worker sought out the housekeeper and gathered information regarding the conversation with the patient. The social worker then took the information to the Director of Social Services that same afternoon.

The Director of Social Services met with the Director of Housekeeping and the housekeeper on 12/9/14 at 9:15 am. The housekeeper was interviewed by the Director of Social Services (Director) regarding the statements made by the patient. In addition to the previous information, the patient had also told the housekeeper she was upset that the NH supervisor had not called to find out how she was doing. The patient planned to get an apartment and give the NH supervisor her phone number.

The Director reported the patient's statements to the Vice President of Patient Safety and Risk on 12/9/14. At 10 am the Director was also notified by Social Services staff that an order had been written for the patient to be discharged to the NH. On 12/9/14 the Director notified the NH Administrator of the patient's statements. Within an hour of the notification, the patient was discharged from the hospital back to the NH.

On 12/12/14 the patient's medical record was reviewed during the onsite investigation. The record contains a "Discharge Planning Assessment and Readmission Risk Assessment" and a "Discharge Note". Progress and nursing notes were also reviewed. The patient's record does not have any notations regarding a concern for sexual abuse at the patient ' s home (NH). The record does not contain any notations to prevent the discharge of the patient back to the NH or prevent unsupervised visitation by NH staff.

On 12/12/14 at 12:30 pm the Director of Social Services and Vice President of Patient Safety and Risk were interviewed. The Director discussed the process to assess all admitted patients for discharge needs, and the process used to document discharge planning information. The Director also provided information on the hospital policy for patients who allege abuse in their home.

The Director stated the patient had not been interviewed. The Director reviewed the patient's medical record and confirmed there was no documentation regarding the patient's statement. The Director provided a copy of handwritten notes from the housekeeper's interview. The Director and the Vice President stated there were no other records related to this patient's statement.

On 12/16/14 a follow up telephone interview was conducted with the Director. The Director was asked if the patient's record contained any documentation which would have prevented discharge, or visitation by the alleged perpetrator, between 12/5/14 and 12/9/14. The Director confirmed there were no notes in the patient record to prevent discharge to the NH or prevent visitation by the alleged perpetrator.

Facility policies and procedures were reviewed during the onsite. "Reporting Suspected Abuse/Mistreatment of Patients", effective 03/04, was reviewed. The policy report states patients will be protected from harm during the investigation of abuse. If the allegation involves family or a visitor, the visitor is not permitted to have unsupervised visits with the patient.

Hospital staff failed to ensure the patient was safe from potential continued abuse. The medical record did not contain any notations to protect the patient from further abuse. Social Service staff did not take any steps to prevent the patient's discharge to the nursing home, or prevent visitation by the alleged abuser, from 12/5/14 to 12/9/14. The nursing home administrator was made aware of the patient's statement on 12/9/14, shortly before the patient was discharged from the hospital and returned to the nursing home. Hospital staff failed to follow patient abuse policies which require protection of the patient.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on interview and record review the hospital failed to conduct a timely and thorough investigation of a patient's report of sexual abuse. During a hospital admission the patient stated she was engaged in a sexual relationship with a nurse at the nursing home (NH) where she lived. Hospital staff also failed to follow policies which require the investigation of suspected patient abuse.

Findings:

Based on interview of facility staff the following information was obtained. On the afternoon of 12/5/14 housekeeping staff was cleaning the bed of a discharged patient in a semiprivate room. The patient in the other bed told the housekeeper she had a new boyfriend. The housekeeper had seen the patient on prior admissions and knew the patient was a nursing home (NH) resident. The patient stated a male NH nursing supervisor rubs her breasts and legs. The housekeeper told the patient that the NH nurse should not be touching the patient. The patient said that she liked what the nurse was doing and she was not going to report him to the NH.

The hospital housekeeper reported the conversation to a patient care aide, who reported the conversation to a social worker. The social worker sought out the housekeeper and gathered information regarding the conversation with the patient. The social worker then took the information to the Director of Social Services that same afternoon.

On 12/9/14 at 9:15 am the Director of Social Services (Director) interviewed the regarding the statements made by the patient. In addition to the previous information, the patient had also told the housekeeper she was upset that the NH supervisor had not called to find out how she was doing. The patient planned to get an apartment and give the NH supervisor her phone number.

The Director reported the patient's statements to the Vice President of Patient Safety and Risk on 12/9/14. At 10 am the Director was also notified by Social Services staff that an order had been written for the patient to be discharged to the NH. On 12/9/14 the Director notified the NH Administrator of the patient's statements. Within an hour of the notification, the patient was discharged from the hospital back to the NH.

Facility policies and procedures were reviewed during the onsite on 12/12/14. "Reporting Suspected Abuse/Mistreatment of Patients", effective 03/04, requires staff to report suspected abuse. The policy states all reports of abuse will be promptly and thoroughly investigated. Department Directors are obligated to investigate suspected or reported abuse, as well as complete an Incident Report. The policy states individuals involved will be interviewed, and witness will sign and date a written report. Incident Reports are to be filed with Risk Management, and staff conducting the investigation are to consult with hospital executive staff on a daily basis regarding the findings and progress of the investigation. The policy also states that the investigation will be completed in a timely manner and "as quickly as possible". The Incident Report is to be forwarded to executive staff no more than 7 days after the abuse was reported. The policy report states patients will be protected from harm during the investigation of abuse. If the allegation involves family or a visitor, the visitor is not permitted to have unsupervised visits with the patient.

"Recognizing and Reporting Elder Abuse/Neglect", effective 3/99, was also reviewed. The purpose of the policy is to provide hospital staff with criteria to recognize elder abuse and/or neglect. The policy states if staff suspect a patient is the victim of elder abuse, the abuse should be reported. Additionally, a mental status exam and psychosocial assessment should be performed. The policy states the abuse should be reported to the hospital's Social Work/Case Management department, administrator on call and the local Department of Social Services, Protective Services for Adults.

On 12/12/14 at 12:30 pm the Director of Social Services and Vice President of Patient Safety and Risk was interviewed. The Director discussed the process to assess all admitted patients for discharge needs, and the process used to document discharge planning information. The Director also provided information on the hospital policy for patients who allege abuse in their home.

The Director was then asked specifically about the patient report of sexual abuse by a NH supervisor. She relayed the sequence of events noted above. The Director said no one from the hospital had interviewed the patient. The Director reviewed the patient's medical record and confirmed there was no documentation regarding the patient's statement. The Director provided a copy of handwritten notes from the housekeeper's interview. The Director and the Vice President stated there were no other records related to this patient's statement.

Based on interview and record review the hospital failed to conduct a timely and thorough investigation of a patient allegation of sexual abuse. Hospital staff were made aware of the allegation on 12/5/14. Hospital staff did not take any action regarding the allegation until 12/9/14. The hospital staff failed to follow patient abuse policies which require prompt and thorough investigation, and reporting.