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 hospital policy review, grievance file review and staff interview, the hospital failed to provide written notice of the resolution of a grievance for 1 of 3 grievances reviewed (#11).

The findings include:

Review of the hospital's "Patient Grievance Management Policy" reviewed/revised July 2015 revealed "...Patient Grievance is a written or verbal complaint (when the verbal complaint is about patient care and is not resolved at the time of the complaint by staff present or who can quickly be at the patient's location) by a patient, or the patient's representative, regarding (1) the patient's care, (2) abuse or neglect, (3) issues related to the fancily's compliance with the CMS Hospital Conditions of Participation (COP), or (4) a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489. ... Procedure ... 7. Within seven calendar days, the patient or complainant will be sent a follow-up letter by the appropriate administrator; or designee which addresses a resolution or notifies the patient that further investigation is required. The patient or complainant will be informed of the progress of an expected follow-up time to address the resolution and will be kept informed of the progress on a weekly basis. All grievances will be resolved as soon as possible with a goal of resolution within seven calendar days and the recommendation that it take no longer than 30 days. 8. In the resolution of the patient grievance, the administrator, or designee will provide the patient or complainant with written notice of the decision, the name of the appropriate contact person, the steps taken to investigate, the results of the grievance process, and the date of completion. ..."

Grievance file review on 09/09/2015 for Patient #11 revealed the patient's representative called the customer care line on 08/23/2015 at 2036 reporting care and patients' rights concerns. Review revealed an investigation was conducted and a verbal response was provided to the patient's representative on 08/27/2015. Review of the grievance file revealed no written notification had been sent regarding the grievance that was called to the facility on [DATE]. Review of the grievance file revealed the case was closed on 08/27/2015.

Interview on 09/10/2015 at 1035 with an administrative staff member revealed that she conducted the investigation related to the grievance. The staff member revealed there was no written response sent to the patient's representative. Interview confirmed the hospital's grievance policy was not followed.

Based on review of hospital policy, North Carolina Healthcare Personnel Registry website, medical record review, Care Event Reports, and staff interviews the facility failed to report suspected sexual abuse in 2 of 3 sampled patients (#14, #15).

Findings include:

Review of Hospital Policy Staff Guidelines for Patients Suspected of Being Harmed, Abused, Neglected or Exploited, revised 06/26/2014 revealed on page 3, 'If abuse is suspected or reported upon assessment/admission/during treatment to have occurred during the hospitalization and involved a (name of behavioral health hospital) staff member: Guidelines: A. refer back to notification of physicians, facility departments and supervisors and 1. Dismiss the staff member from duty until further investigation ...Some instances of substantiated abuse/neglect may be further reported, depending on the requirements mandated by the respective discipline's authority." NC Department of Health and Human Services Division of Health Service Regulation Health Care Personnel Registry Section is the discipline's authority in this investigation, (website: <>) revealed '...when certain allegations, (abuse allegations are included), are suspected involving unlicensed health care workers, health care employers are required to submit 24 hour and 5 day reports to the Health Care Personnel Registry (HCPR) Investigations Branch."
Review of August 2015 Care Event report revealed two incidents of patient (#14 and #15) reported sexual abuse by the same staff member. Review further revealed no evidence that HCPR was notified of the suspected abuse in either event.
1. Closed medical record review of Patient #14 revealed a [AGE] year old female admitted on [DATE] with an admitting diagnosis of borderline personality (severe mental illness with problems regulating emotions and thoughts, impulsive and reckless behavior, and unstable relationships with others). Pt. # 14 was involuntarily committed for suicidal ideations and a history of previous suicidal attempts. On 8/22/2014 at 1900 another Pt (# 15) reported to staff nurse that Pt #14 had told her she had sex with a staff member. Pt. # 14 verified that on 08/21/2015 at 1800, the event occurred with the staff member. An investigation was conducted by facility staff and a timeline was developed. Pt. # 14 was sent to the emergency department for an evaluation but declined a rape test and offers to call the police.
2. Closed medical record review of Patient #15 revealed a [AGE] year old female admitted on [DATE] with a diagnosis of Suicidal Ideation (intrusive thoughts about wanting to kill herself). On 08/20/2015 Pt. # 15 reported that the same staff member (as in the previous event with Pt. # 14) attempted to sexually abuse her but that she left the room and immediately reported this to staff. An investigation was conducted.
Interview with Nurse Manager for this facility on 09/09/2015 at 1400 revealed that she had notified the administrator and Chief Nursing Officer after being informed of the accusation as per their policy.
Interview with Administrator for this facility on 09/10/2015 at 1030 revealed that during the investigation for Patient #14, video surveillance revealed an additional female patient (not Patient #15) was alone in a room with the same staff member for 'longer than normal' and that "we have suspicions and are still concerned regarding the abuse by this staff member." A request regarding facility policy on external reporting for this abuse, Administrator stated there was "none" and that he was "not aware of any board to report to regarding their lingering suspicions for staff member for his role in Patient #14, #15 and another." The interview further revealed that the staff member was placed on an internal "do not rehire" list.
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