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.

ROSWELL PARK CANCER INSTITUTE ELM AND CARLTON STREETS BUFFALO, NY Dec. 29, 2014
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on medical record review, interview and document review, it was determined that the facility failed to investigate an inpatient complaint of potential sexual abuse of Patient #1. Patient #1 was not assessed and the alleged abuser was allowed to continue to provide care for other patients.

See Tag # :
0084- Contracted Services
0118- Patient Rights; Grievances
0145- Patient Rights; Free from abuse and harassment
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, interview and document review, the facility does not follow its grievance policies and procedures, specifically, it did not investigate an allegation of sexual abuse by Patient #1.

Findings Include:

Review of Patient #1 medical record from 12/1/14 to 12/12/14 revealed no evidence that on 12/10/14 the agency sitter was "swapped out" due to Staff # 19, CNA/Agency Sitter upsetting/agitating Patient #1, that Patient #1 made statements related to alleged sexual abuse, that the nursing staff did not examined Patient #1 or notified the nursing supervisor or that a physician was notified and examined Patient #1.

Review on 12/23/14 of the Patient Advocate Report dated 12/17/14 revealed the wife called indicating on Wednesday (12/10/14) she entered Patient #1 ' s room and his arms were over his head saying " get him out of here (the aide). " Patient #1 told the family that the aide licked his finger and stuck it in his butt while saying Allah is making him do it. On 12/18/14 at 3:50 PM a sexual abuse report given to public safety and legal was contacted who advised not to call the wife back. On 12/19/14 Staff # 15, Director of Patient Care Services was paged and indicated interviews were conducted and staff re-education on how to re-orientate neuro patients was provided. At 10:05 AM a message was left for the wife who called back and was not happy. She wants staff information (aide & agency) and public safety to call her back. No call was received from public safety. The wife was called and given the information. She was satisfied. Staff # 14, Risk Manager and Staff # 15, Director of Patient Care Services were emailed. This report is the only documentation provided by the facility related to the alleged sexual abuse investigation.

Interview on 12/22/14 at 1:35 PM with Staff # 2, Vice President & Chief Nursing officer revealed Patient #1 was moved to 7 East where he had sitters from the outside agency including Staff #19, CNA/Agency sitter. The wife alleged Patient #1 was pushed out of bed. There is no evidence he fell and the wife seemed fine. Staff switched out the agency aide (sitter) due to being chatty. We do have a complaint related to Allah and hands near rectum. Staff # 16, Patient Advocate and Nurse Manager concluded there was no evidence of abuse or that Patient #1 was pushed out of bed. No evidence was found to indicate a complaint regarding Patient #1 being pushed out of bed was filed or allegated sexual abuse was investigated and resolved.

Interview on 12/22/14 at 4:35 PM with Staff # 16, Patient Advocate revealed complaints are handwritten and then put into Quantros (incident report) at the end of the month. Response to a patient in writing can occur if a complaint is received in writing or if a complaint takes days to investigate. There is usually a 7 day response or will contact the patient. We try to handle complaints at point of service and don' t usually give a written response.

Interview on 12/22/14 at 1527 with Staff # 10, Nurse Manager of 7 East revealed on 12/10/14 during 1830 to 0730 shift, Staff # 17, RN on 7 East had Patient #1. In the morning after Staff # 17 ' s, shift, she told her Staff # 19, CNA/Agency Sitter was the sitter for Patient #1 and she didn't like the way he was acting around him. He talked too much. Patient #1 told Staff # 17, RN on 7 East that the sitter touched him and had his finger near his butt. Staff # 18, Nursing Supervisor switched sitters. She did not document her conversation with Staff #17, RN. Staff # 17, RN on 7 east did examine Patient #1' s body who did not have any bruising. No documentation of the examination was found. She did speak with Staff # 19, CNA/Agency Sitter (date unknown) asking him if he touched or forcibly held down Patient #1. He said no. She did not document her conversation with Staff #19, CNA/Agency Sitter. She emailed (12/11/14 at 0725) the other nursing indicating she didn't think Staff # 19, CNA/Agency Sitter fit well with neuro patients. Patient #1 was discharged on [DATE]. She received an email dated 12/15/14 on the following Tuesday (12/16/14) from the wife. She returned the wife' s call on 12/16/14 who asked why no one notified her Patient #1 fell . I told the wife he had a sitter at all times and theres a policy to notify the family of all falls even if just suspected. I did not fill out a Quantro (incident) Report.

Interview on 12/23/14 at 0805 with Staff # 17, RN on 7 East revealed Staff # 19, CNA/Agency Sitter was the sitter for Patient #1 the last 2 nights. The 3rd night (12/10/14) Staff # 19, CNA/Agency Sitter did not stay Patient #1. The sitter talks and talks, agitating Patient #1 who threw things at him and tried to get out of bed more. Patient #1 didn't want the sitter back in his room. Patient #1 mentioned that the sitter stuck his finger up his butt stating " He just can't keep his finger out of my ass. They are always giving me suppositories. " I spoke with Staff # 18, Nursing Supervisor who switched Staff # 19, CNA/Agency Sitter with another sitter who was in the next room. She does not remember if she told Staff # 18, Nursing Supervisor about the touching but did tell Staff # 21, Charge Nurse and Staff # 10, Nurse Manager that night. No documentation of the event was found in the medical record. No documentation of the patient complaint of the alleged sexual abuse was found.

Interview on 12/29/14 at 1:50 PM with Staff # 18, Nursing Supervisor revealed on 12/10/14 Patient #1 had a sitter in the room. Staff # 17, RN on 7 East did not feel comfortable with the sitter. The sitter was being too aggressive, holding and pushing Patient #1's legs when he was trying to get out of bed. We switched the sitters from the room next door. She did not document the event as she did not think anything of it. It is the staff nurses responsibility. Staff # 17, RN on 7 East did not tell her about any alleged abuse. Patient #1/family did not file a complaint on 12/10/14. She received a complaint after Patient #1 was discharged claiming Patient #1 was pushed out of bed. No evidence was found to indicate a complaint regarding Patient #1 being pushed out of bed was filed, investigated and resolved.

Review on 12/23/14 of the following policies related to alleged patient abuse received from Staff # 2, VP Chief Nursing Officer revealed the following:
- Policy "Patient Complaint of Service" effective 10/28/13 revealed all complaints regarding abuse, neglect or patient harm are grievances. Grievances about situations that endanger the patient, such as neglect or abuse shall be reviewed immediately. It is expected and to be reviewed and addressed within 24-48 hours. The risk manager is to be notified immediately of all such situations. Complaints and grievances shall be documented and entered into Quantros incident reporting system by the Patient Advocate office. A monthly report of complaints and grievances and resolution shall be provided to the Quality Improvement committee.

- Policy "Management of Serious Clinical Adverse Events" last revised 5/5/14 revealed any staff who becomes aware of or is involved in a serious event shall immediate notify the nursing supervisor who will promptly notify the Medical Director, Chief Nursing Officer, Chief Clinical Operations Officer and counsel for Risk Management. The Medical Director and Chief Nursing Officer will collaborate to stabilize the patient, provide necessary/appropriate care, ensure the safety of all other patients and evaluate the impact on the patient/family and provide support accordingly. The emergency management team will be notified within the first hour and shall convene with the first 24 hours.

- Review of policy "Occurrence Reporting" effective 8/27/12 revealed it is the responsibility of the facility associate who was directly involved or witnessed the incident to complete an incident report not later that the end of the shift. The facility supervisors are required to ensure all staff are familiar with this requirement. The incident reporting system is Quantros located on the Intranet. All patient incidents of a serious nature or appear to have potential liability are to be reported to the Counsel for Risk Management or the nursing supervisor after normal business hours. A physician must be notified of any occurrence involving actual or potential injury to the patient. Entries into the electronic reporting system are to be completed promptly. Documentation in the patient's medical record shall include the factual description of the occurrence, the patient's condition and the nurse and examining physician's examining notes. All occurrences should be reviewed and investigated by the department supervisor or charge person to determine the cause and corrective actions needed.

Interview on 12/23/14 at 2:50 PM with Staff # 2, VP and Chief Nursing Officer revealed there is a Patient Occurrence Report form or " I-2 " for staff to fill out for occurrences. Staff have not been utilizing this form but will be instructed to do so going forward. The form outline encompasses the following information related to an occurrence: patient demographics, occurrence type/date/time, and description of event, location, outcome, patient actions and staff actions. On the bottom of page #2 it directs the author to complete and forward to Risk Management by the end of the shift.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on medical record review, interview and document review, the facility failed to ensure patients are free from abuse, specifically, Patient #1 made allegations of sexual abuse and the facility continued to employ and utilize Staff #19 for other patients.

Findings Include:
Interview on 12/22/14 at 3:27 PM with Staff # 10, Nurse Manager of 7 East revealed on 12/10/14 during the 6:30 PM to 7:30 AM shift, Staff # 17, RN on 7 East was assigned to Patient #1. In the morning after Staff # 17's shift, she told her Staff # 19, CNA/Agency Sitter was the sitter and she didn't like the way he was acting around Patient #1. He talked too much which stimulates Neuro patients. Patient #1 told Staff # 17, RN on 7 East that the sitter touched him and had his finger near his butt. Staff # 18, Nursing Supervisor switched sitters. She did not document her conversation with Staff #17, RN. Staff # 17, RN on 7 East did examine Patient #1' s body and did not note any bruising. She did speak with Staff # 19, CNA/Agency Sitter (date unknown) asking him if he touched or forcibly held down Patient #1. He said no. She did not document her conversation with Staff #19, CNA/Agency Sitter. She emailed (12/11/14 at 7:25 AM) the other nursing supervisors indicating she didn' t think Staff # 19, CNA/Agency Sitter fit well with neuro patients. Staff # 15, Director of Patient Care Services called Staff # 37, Agency Staffing Assistant Manager a week later (12/17/14 at 3:00 PM) to inform them Staff # 19, CNA/Agency Sitter was no longer need as he "doesn't fit."

Interview on 12/22/14 at 4:15 PM with Staff # 15, Director of Patient Care Services revealed there was an allegation of a fall, that Patient #1 was pushed out of bed. She was helping Staff # 10, Nurse Manager 7 East interview staff and find out what happened. No fall occurred. We asked staff to look at Patient #1 for signs/symptoms of a fall but there was no evidence. I was informed by Staff #10, Nurse Manager 7 East that Staff # 19 talks a lot and does not honor neuro patients. Staff #19 was re-educated about talking. Initially we thought we would not have Staff # 19, CNA/Agency Sitter back but the other nursing supervisors didn' t have any complaints about him.

Interview on 12/23/14 at 8:05 AM with Staff # 17, RN on 7 East revealed Staff # 19, CNA/Agency Sitter was the sitter the last 2 nights. The 3rd night (12/10/14) Staff # 19, CNA/Agency Sitter did not stay with Patient #1. The sitter talks and talks, agitating Patient #1 who told him to "shut the hell up", threw things at him and tried to get out of bed. Patient #1 didn' t want the sitter back in his room. Patient #1 mentioned that the sitter stuck his finger up his butt stating "He just can't keep his finger out of my ass. They are always giving me suppositories." I spoke with Staff # 18, Nursing Supervisor who switched Staff # 19, CNA/Agency Sitter with another sitter who was in the next room. She does not remember if she told Staff # 18, Nursing Supervisor about the touching but did tell Staff # 21, Charge Nurse and Staff # 10, Nurse Manager that night. Patient #1 did not complain of being held down by the sitter.

Interview on 12/29/14 at 1:50 PM with Staff # 18, Nursing Supervisor revealed on 12/10/14 Patient #1 had a sitter in the room. Staff # 17, RN on 7 East did not feel comfortable with the sitter. The sitter was being too aggressive, holding and pushing Patient #1' s legs when he was trying to get out of bed. We switched the sitters from the room next door. She did not document the event as she did not think anything of it. It is the staff nurses responsibility. Staff # 17, RN on 7 East did not tell her about any alleged abuse.

Review on 12/23/14 of the Staffing Agency scheduled for December 2014 revealed Staff # 19, CNA/Agency Sitter worked the following 8 hours shifts at the facility:
- Day shift on 12/12/14.
- Evening shift on 12/8/14, 12/10/14 and 12/14/14.
- Night shift on 12/5/14 and 12/8/14.
12/14/14 was his last day at the facility. Staff # 15, Director of Patient Care Services emailed the Staffing Agency on 12/17/14 at 3:00 PM stating his services would no longer be needed.
Review of email dated 12/11/14 at 7:25 AM from Staff # 10, Nurse Manager of 7 East to "Nursing Supervisors" revealed she talked to Staff #19 on 7 East. He doesn't interact well with the patient population on 7 East, especially the neuro patients. He often adds to their agitation. If possible please don' t send him back to 7 East.
VIOLATION: CONTRACTED SERVICES Tag No: A0084
Based on interview, policy review and document review, the governing body does not have a mechanism to evaluate the quality of each contracted service, specifically agency sitters to ensure care is provided in a safe and effective manner. The facility does not:
1. Have an agency sitter job description indicating what tasks they can perform.
2. Staff #19 did not receive orientation and/or departmental training.
3. Have a protocol in place to notify the agency of unsatisfactory job performance or action taken to terminate services of a temporary healthcare personnel due to incompetence, negligence or misconduct.

Findings #1:

Review of the contract agreement between the Staffing Agency and the facility that commenced on 8/20/2011 revealed responsibilities of the facility include making final determinations of the suitability of the temporary healthcare personnel documented competencies and experience as presented by the Staffing Agency for the designated assignment.

Review on 12/23/14 of the personnel file for Staff # 19, CNA/Agency Sitter revealed there was no evidence found to indicate the facility has a job description and/or policy referencing duties/tasks required for agency sitters.

Interview on 12/22/14 at 3:27 PM with Staff # 10, Nurse Manager of 7 East revealed most agency sitters are CNA' s. They do not do patient care, toileting, bathing or feeding.

Interview on 12/22/14 at 4:15 PM with Staff # 15, Director of Patient Care Services revealed sitters are utilized for re-directing, safety or falls preventions for patients. Agency sitters are supposed to be CNA' s. The Staffing Agency coordinates sitter placements through the nursing supervisors. An agency sitter who is a CNA can toilet and feed patients with nursing direction.

Interview on 12/23/14 at 7:35 AM with Staff # 11, RN on 6 West revealed she usually does not know if a sitter is a CNA. Sitters are expected to toilet, feed, ambulate and provide personal care for patients. Sitters do not document on the patient.

Interview on 12/23/14 at 8:05 AM with Staff # 17, RN on 7 East revealed tasks assigned to agency sitters is dependent on their qualifications. Staff # 19, CNA/Agency Sitter will help staff but did not perform any tasks by himself. Nursing Supervisors inform nursing staff of the tasks the sitters can do.

Interview on 12/29/14 at 1:50 PM with Staff # 18, Nursing Supervisor revealed agency sitters may help feed or ambulate a patient. She knows sitters are not nurses but was unsure if they are aides.

Findings #2:

Review on 12/23/14 of the contract agreement between the Staffing Agency and the facility that commenced on 8/20/2011 revealed responsibilities of the facility which includes providing orientation, minimally, the review of policies and procedures regarding medication administration, documentation, patient rights, infection control and fire & safety.

Review on 12/2314 of policy "Orientation" effective 5/5/14 revealed all contract workers must participate in both an institutional orientation program (conducted by Human Resources) and a departmental orientation (conducted by department heads or designees) and shall be documented and completed as soon as possible upon arrival of the new hire. No evidence was found to indicate Staff #19, CNA/Agency sitter received institutional and departmental orientation.

Review on 12/23/14 of the "Abuse or Neglect" employee online training (no date available) revealed it is intended to introduce types of abuse that health care workers should recognize, specifically signs of abuse/abuser, assessment and referral of victims, reporting requirements and patient confidentiality and rights. All non-clinical staff who may play a critical role in identifying victims should receive general awareness training. If you witness or suspect abuse or neglect: take immediate action to protect/comfort the patient, ensure treatment, alert a supervisor, preserve evidence and complete report forms. All incidents of actual or suspected abuse or neglect are investigated. The facility has a policy to protect patients from abuse/neglect by staff or volunteers. Any employee accused of patient abuse or neglect will be informed of his or her rights.
No evidence was found to indicate Staff #19 receive this education.

Interview on 12/22/14 at 4:15 PM with Staff # 15, Director of Patient Care Services revealed she does not know what type of training or orientation the sitters receive. Competencies and evaluations are not provided by the facility.

Review on 12/23/14 of the personnel file for Staff # 19, CNA/Agency Sitter revealed no evidence to indicate he received facility orientation and departmental specific training.

Findings #3:

Review on 12/23/14 of the contract agreement between the Staffing Agency and the facility that commenced on 8/20/2011 revealed responsibilities of the facility include:
- To manage temporary healthcare personnel consistent with the facilities own policies and procedures and address any incident consistent with those policies. Promptly notify (within 24 hours) the agency of any unexpected incidents, errors and sentinel events that involve the temporary healthcare personnel.
- Promptly (within 24 hours) notify the agency of any unsatisfactory job performance or action taken to terminate services of a temporary healthcare personnel due to incompetence, negligence or misconduct.

Interview on 12/22/14 at 3:27 PM with Staff # 10, Nurse Manager of 7 East revealed on 12/10/14 during the 6:30 PM to 7:30 AM shift, Staff # 17, RN on 7 East was assigned to Patient #1. In the morning after Staff # 17 ' s, shift, she told her Staff # 19, CNA/Agency Sitter was the sitter and she didn' t like the way he was acting around Patient #1. He talked too much which stimulates Neuro patients and Patient #1 told Staff # 17, RN on 7 East that the sitter touched him and had his finger near his butt. Staff # 18, Nursing Supervisor switched sitters. She did speak with Staff # 19, CNA/Agency Sitter (date unknown) asking him if he touched or forcibly held down Patient #1. He said no. She did not document her conversation with Staff #19, CNA/Agency Sitter. She emailed (12/11/14 at 7:25 AM) the other nursing supervisors indicating she didn't think Staff # 19, CNA/Agency Sitter fit well with neuro patients. Staff # 15, Director of Patient Care services called Staff # 37, the Staffing Agency Assistant Manager a week later (12/17/14 at 3:00 PM) to inform her Staff # 19, CNA/Agency Sitter was no longer needed as he "doesn't fit."

An allegation of sexual abuse was lodged by Patient #1 on 12/10/14 to Staff #17, RN on 7 East. The facility and department of health both received a complaint of sexual abuse on 12/17/14. The Staffing Agency was notified that Staff #19's services were no longer needed on 12/17/14, however there is no evidence the agency was informed of allegation of sexual abuse.