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.

LEGACY EMANUEL MEDICAL CENTER 2801 N GANTENBEIN AVENUE PORTLAND, OR 97227 Oct. 2, 2013
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interviews, review of policies, procedures and other hospital documentation, and documentation of 3 of 10 medical records reviewed (Patients #5, 6, and 9), it was determined that the hospital failed to ensure that it protected and promoted each patient's right to receive care in a safe setting. The hospital failed to ensure that it had systems in place to prohibit and prevent sexual abuse, including conducting a thorough investigation of an allegation of sexual abuse.

Findings include:

1. Refer to the deficiency cited at Tag A 0119, Patient Rights: Review of Grievances, which reflects the failure of the hospital to ensure that their grievance policy was followed in order to protect patient's rights.

2. Refer to the deficiency cited at Tag A 0142, Patient Rights: Privacy and Safety, which reflects the failure of the hospital to ensure the patient's right to safe care.

3. Refer to the deficiency cited at Tag A 0145, Patient Rights: Free From Abuse/Harassment, which reflects the failure of the hospital to ensure the patient's right to be free of abuse.

This Condition level deficiency substantially limits the capacity of the hospital to protect patient's rights and to investigate an allegation of sexual abuse.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on interviews, review of complaint/grievance documentation and review of policies and procedures, it was determined the hospital failed to ensure that their grievance policies were followed in order to protect patients.

1. Review of a local media news article dated 07/11/2013 reflected the arrest of Employee 1 (E1), an emergency department (ED) nurse who worked at the hospital. The article reported that three victims had come forward alleging sexual abuse when they sought treatment at the hospital's ED. The article reported that E1 had been charged with first degree rape, first degree sodomy and sex abuse.

2. Review of Legacy Health policy titled "Patient Complaint Resolution," revised 09/2009 (in effect at the time the alleged incidents occurred), reflected on page 1, "2. Grievance: A written or verbal concern filed by a patient/the patient's designated representative to request the facility formally review a quality of care concern, abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation..." Page 5 reflected "5. All complaints received directly by Patient Relations will be documented and forwarded to the appropriate department/unit manager or other appropriate referral for investigation and follow-up..Grievance Management:..3. After having been notified of the grievance, the department/unit manager, or their designee, will contact the patient and/or family member to review the concern and bring to resolution...4. If the grievance represents an immediate and serious threat to patient health and safety, the initial grievance review will be expedited and appropriate corrective action instituted."

Review of Legacy Health policy titled "Actions to Correct Employee Performance or Conduct," last revised 01/2012, reflected "The purpose of this policy is to clarify ways of addressing job related performance or conduct through documented communication of problems and expectations for improvement...Any noncompliance with these standards must be corrected...3. Corrective action can be based on a single incident, continued instances, and/or overall performance or conduct. Separate progressive corrective actions are not required for each issue or incident...4...Managers must consult with an Employee Relations Consultant when written corrective action is being considered and before initiating termination. 5. All levels of corrective action should be documented in writing and the original signed document sent to Human Resources."

3. An interview with the ED Manager, Interviewee 5 (I5) conducted on 08/29/2013 at 1105 reflected "I talked to [Employee 1, the alleged perpetrator] about the allegations made by the patient [Patient #5]" during the patient's ED visit on 09/24/2012. I5 stated that E1 appeared to be confident and assured and that he/she denied the patient's allegations. I5 also stated that he/she did not talk directly to the complainants but he/she discussed patient complaints with employees involved in the care. When asked if he/she kept written documentation of the conversations, I5 stated "I don't keep notes of interviews, normally I just speak to the employees. I deal with the issue at the time...I don't remember if I talked to the doctor in this case but normally I do."

Five months later, another patient, P6, made similar allegations to a night charge nurse regarding E1's inappropriate sexual contact with him/her during an ED visit on 02/14/2013. I5 was informed of the incident via an e-mail message from the charge nurse. I5 discussed the case with the ED Director, I6, and the Director of Risk Management, I7, per policy. The decision was made to suspend E1 for 5 days; I5 stated he/she remained very concerned about E1 since he/she was ambivalent about the complaint. I5 admitted that he/she did not discuss the complaint with the patient. I5 also stated that he/she did not document the investigation of this complaint nor the discussion that he/she had with E1 per hospital policy.

4. Review of Legacy Health policy titled, "Critical Incident Notification and Management Plan Appendix A," last revised 03/2013, reflected "Effective situation management requires understanding of the 'whole picture': inclusive of, as the situation requires: Risk Management, Legacy Legal, Quality and Operational Leadership, Accreditation and Clinical Compliance, Public Relations. It is essential to know the facts when planning the course of action and particularly when communicating externally and coordinating information to a patient or family. A single point person and single written record of the incident aid effective management. The point person needs to be informed of all activities and developments to successfully ensure ongoing coordination and alignment."

During interviews on 08/28-29/2013, it was confirmed that when the hospital investigated the complaints, interviews were conducted by the ED Manager, Clinical Patient Safety Coordinator, Human Resources Manager, Director of Risk Management and the Patient Relations Specialist. Most interviews of patients and staff were conducted and documented within each department. However, the documentation was not shared between all management personnel per hospital policy.

In an interview with Human Resource personnel, I4, on 08/29/2013 at 1030, he/she stated "It's like that old game of telephone. [I10] filters the complaint and tells me what I need to know, then I do my part and tell [him/her] what [he/she] needs to know." When asked who is the one person who makes sure that all of the loose ends are caught, I4 stated "I think they have identified that as a problem with our process."

5. On 10/02/2013 at 0815 twenty-one employees (e.g. nurse management, registered nurse, certified nursing assistant, physical therapy assistant, housekeeping, respiratory therapy, security guard, and mental health therapist staff) were interviewed from various nursing units and patient care departments (e.g. ED, medical, surgical specialties, float pool and psychiatric units). None of the staff/managers interviewed could find a policy that provided guidance to protect patients during an investigation of abuse.

In response to a question regarding what the employee would do if a patient told them that they had been sexually or physically abused by an employee or provider in the hospital, 16 of 21 personnel stated they would report it to supervisory personnel.

In response to a question regarding employees knowledge of a policy or procedure that provided guidance related to their responsibilities, 16 of 21 personnel stated they would "look up the policy on the computer." When I30, a nurse manager, attempted to find the policy, he/she identified Legacy Health's policy titled "Managing Patient's Complaints and Grievances," then stated "I'm sure I'd get some direction from Risk Management."

In response to a question regarding the hospital's policy on protecting patient's during an investigation of abuse, one nurse manager stated "I don't know if there is a policy." He/she was unable to locate the policy on-line and stated, "No matter what I type into 'search' I cannot find anything about patient protection during an investigation."

Another manager looked unsuccessfully for a policy then said "I think removing them [alleged assailant] completely would be the best thing to do, to protect the patients until we can figure out what happened."

A staff nurse looked unsuccessfully for the policy then stated the policy ["Mandatory Reporting of Suspected Abuse,"] would be the "go to policy." After careful review, he/she stated that the policy did not address what to do if abuse occurred to a patient in the hospital by a staff person 'here at the hospital.'"

An ancillary staff member stated that the "Mandatory Reporting of Suspected Abuse" policy did not address what to do to protect the patient during an investigation of abuse by a staff member.

In response to a question regarding training related to this type of complaint, 12 of the 21 staff denied receiving any training related to abuse of patients by staff or providers. One nurse stated he/she had received training but, "None of the training addressed protecting patients during an investigation of abuse."

It was determined after multiple interviews that the hospital failed to establish a process for timely investigations of complaints regarding sexual abuse by staff or providers and had also failed to provide guidance to protect patients during the investigation of the incident.
VIOLATION: PATIENT RIGHTS: PRIVACY AND SAFETY Tag No: A0142
Based on interview, complaint documentation and review of policies and procedures, it was determined the hospital failed to ensure the patient's right to safe care. Although the hospital staff documented a patient expressed a complaint of inappropriate sexual contact, it failed to thoroughly investigate and implement its own policies and procedures to address the complaint in a timely manner that provided privacy and safety to the patient who filed the complaint.

Findings include:

1. Review of a Legacy Health policy titled "Patient Rights and Responsibilities," last revised 10/2012 reflected the following: "Patients are encouraged to voice all concerns without fear of retribution. If staff caring for the patient cannot resolve the patient's concern promptly, the issue is referred in accordance with Legacy policy." The policy further reflected "Staff are trained in the identification of abuse, neglect or harassment of patients and processes are in place to ensure timely reporting and response in keeping with Legacy policy, Mandatory Reporting of Suspected Abuse (900.2312) and applicable law."

2. Review of a Legacy Health policy titled "Harassment," last revised 10/2011 reflected "Sexual or other forms of harassment will not be tolerated by Legacy Health...Anyone receiving a complaint of harassment or who witnesses any behavior that violates this policy must report it immediately to a Human Resources representative." The policy further reflected "All complaints of harassment will be investigated promptly by a member of the Human Resources staff. The investigation will generally include interviews with the complaining employee, the alleged harasser and any witnesses as well as review of any relevant documents or information."

3. Review of the medical record of Patient #5 reflected the patient was admitted to the emergency department (ED) on 09/24/2012 at 1433 with a complaint of back and rib pain. The triage registered nurse (RN) documented the patient also needed a pelvic exam. The patient's assigned RN was Employee #1 (E1). The provider ordered labs and X-Rays at 1634 which were completed by 1649. The provider also ordered an analgesic to relieve pain and E1 medicated Patient #5 for pain at 1737. Shortly after receiving the pain medication and before 1758, Patient #5 spoke to a different RN informed the nurse that he/she had decided against having the pelvic exam.

The patient was discharged from the ED at 1809. As Patient #5 left, he/she spoke to E11, a hospital employee, stating that E1 made suggestive comments about his/her tattoo and told the patient "that turns me on." He/she also stated that E1 "started rubbing up against [him/her]." After the patient left, E11 wrote an e-mail to the ED manager and included E1 in the e-mail that described the patient's detailed complaint. As the patient left the ED, he/she complained to the front desk staff stating, "(E11) doesn't believe me, I will come back tomorrow." The following day, on 09/25/2013 Patient #5 called the hospital and filed a formal complaint regarding the inappropriate behavior of E1 while he/she was in the ED.

4. On 10/05/2012 a letter was sent to Patient #5 stating "We are unable to substantiate the specific allegations in your complaint. However, education to emergency department staff will be conducted." During the complaint investigation, the hospital neglected to reveal documentation of a thorough investigation of the allegation or staff interviews that were conducted before the letter was sent to Patient #5.

5. A review of the e-mail message sent to the ED manager from E11 reflected that E1 was also included in the e-mail that provided a thorough description of the complainant's concerns. By including the alleged assailant in the e-mail message, the hospital personnel effectively put the patient at risk for making the allegation. This action did not support the hospital's policy for Patient's Rights that encouraged patients "to voice all concerns without fear of retribution."

The hospital failed to provide documentation that reflected the hospital's effort to ensure the privacy and safety of a patient who filed a complaint against a staff nurse.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital staff interviews, documentation in 3 of 10 medical records (Record #s 5, 6, and 9)(P5 09/24/2012, P6 02/14/2013, P9 04/14/2013), and review of policies and procedures, it was determined the hospital failed to ensure the patient's right to be free of sexual abuse. The hospital failed to ensure that it had mechanisms and systems in place to prohibit and prevent such abuse. The hospital failed to protect patients after it had received allegations of sexual abuse and it failed to implement appropriate training and education to ensure that sexual abuse would not reoccur and patients were protected.

Findings include:

A. Review of medical record #5 reflected a [AGE] year old patient admitted on [DATE] at 1433 with a complaint of left rib pain which radiated to his/her left flank and back. The medical record reflected that Patient #5 denied dysuria but noted vaginal itching and discomfort." The provider ordered labs, X-Rays and an analgesic. The provider documented a planned vaginal exam when a female RN was available.

The patient's assigned RN, E1, documented that he/she medicated the patient for pain on 09/24/2012 at 1737 but neglected to document a pain assessment prior to treatment. This documentation was the last documentation by E1 on the patient's chart.

According to the medical record, the physician documented at 1758 "she has spoken with female nurse and decided against exam of her vaginal area."

1. A review of the employee file for E1 and an interview with a Human Resources representative, I4, on 09/28/2013 at 1430, revealed the file included an e-mail from a charge nurse, E11, to the ED manager, I5. The e-mail documented the patient's description of the inappropriate behavior of E1. It was noted that the e-mail was also sent to the alleged RN, E1. This action informed E1 that the patient had filed a formal complaint against him/her.

The e-mail described E1's suggestive comments about the patient's tattoo including the statement that he/she told the patient "that turns me on." Patient 5 also stated that E1 started rubbing up against him/her and touched his/her genitals.

The e-mail further stated that as Patient 5 left the ED, he/she complained to the front desk staff stating, "(E11) doesn't believe me, I will come back tomorrow." The following day, on 09/25/2012, Patient #5 called the hospital and filed a formal complaint regarding the inappropriate behavior of E1 while he/she was in the ED.

2. An interview with I5 on 08/29/2013 at 1105 revealed that he/she heard about this incident from the e-mail message sent to him/her by E11. I5 stated that he/she did not keep employee interview notes. I5's preference had been to resolve issues when they arose. In this case, I5 stated that "I talked to E1 and asked what happened, I spoke to E11 who said the patient's affect was 'different.' I didn't think the incident happened." I5 stated he felt that E1 was "confident and assured" during the interview. I5 did not remember interviewing the patient's physician or other ED staff who may have been present at the time.

I5 placed a call to Patient #5 the following day to clarify the incident. After speaking to Patient #5 and then to E1, I5 documented that he/she felt that E1 was a credible employee.

3. A letter was sent from I5 to Patient #5 on 10/05/2012 that stated "Consistent with our practices and policies, we promptly began an investigation. We interviewed the relevant witnesses, reviewed the necessary documents and verified the veracity of witness statements. We were unable to substantiate the specific allegations in your complaint."

B. Review of the medical record for Patient #6 reflected a [AGE] year old patient brought by ambulance to the ED on 02/14/2013 at 1841 with complaints of pelvic cramping and bleeding. The patient was assaulted in the morning and had been "punched and kicked in the stomach." He/she had experienced increased pain and cramping before ED admission. The physician documented a diagnosis of "incomplete miscarriage."

E1 was the RN who documented the first RN triage assessment and IV placement on 02/14/2013 at 1848.

1. An e-mail sent from an ED RN, E8, to the ED Manager on 02/14/2013 at 2043 documented the discussion E8 had with Patient #6 regarding the care he/she received from E1. The e-mail reflected, "At 2035 I was asked to go into pts room, that pt had a complaint to make about the staff last shift. I went into pts room, pt told me that she wanted to speak to a supervisor about some things that happened to her earlier during the last shift. Pt then told me that a male nurse with blue eyes had her go into the bathroom and stand up and checked her cervix. He then asked her to get undressed and into a gown. Pt then stated 'when he was checking my temperature he told me I had beautiful lips and that I looked like I could suck good dick.' Pt then states 'I just felt really unsafe.'"

2. An interview with I4 on 08/28/2013 at 1430, reflected Patient #6 also notified hospital security personnel, E12, of E1's actions. After talking to Patient #6, Security personnel documented "When we interviewed [Patient #6], the report we got from [E8] lined up with what [Patient #6] told us..." After receiving the complaint, the security officer contacted I10, the Clinical Patient Safety Coordinator.

During the interview, I4 reviewed notes documented in the file of E1. He/she documented "It seems unlikely that a male nurse would take such liberties with a female patient in the ED...The patient's report varies substantially from what was reported by E1." However, I4 also stated during the interview that he/she never had an employee with two complaints like this, let alone three.

3. An interview with I10, Clinical Patient Safety Coordinator, on 08/29/2013 at 0940, reflected that Human Resources personnel had conducted an investigation but had not been able to substantiate the complaint. The investigation consisted of an interview with the patient and the alleged RN suspect.

4. A letter was sent to P6 from I10 on 02/20/2013 that stated "I want to thank you for raising your concerns and to let you know that we take all patient complaints extremely seriously. We promptly conducted a thorough investigation. In the course of our investigation, we were unable to substantiate the specific allegations in your complaint." I10 stated that the letter was returned to the hospital with the following information, "Return to sender, not deliverable as addressed, unable to forward."

5. An interview with I5 conducted on 08/29/2013 at 1120, reflected that he/she called E1 several times regarding the investigation into the complaint of Patient #6. I5 stated that he/she discussed the issue with the ED physician, E8 and I4. I5 met with I6, the ED Director, and they agreed to suspend E1 from work for 5 days.

C. An interview with I4 on 08/2/2013 at 1430, reflected that administration requested a review of all employee files for E1 to determine if there had been similar complaints filed against E1. It was discovered at that time, that on 04/07/2006, a former Human Resources Consultant had documented a patient complaint against E1 stating that the male nurse had inappropriately touched the patient's genitals. The complaint was not validated at that time and was not filed in the Human Resources file per policy.

D. Review of medical record #9 reflected a [AGE] year old homeless patient who (MDS) dated [DATE] at 1547 requesting a prescription refill. The patient had recently been hit by a car and sustained a complicated fracture, he/she had been discharged approximately 9 -10 days earlier. Patient #9 resided in a extended-stay hotel but had called his/her adoptive parents and they had escorted the patient into the ED. The provider documented the patient also had a history of poly substance use.

Upon initial entrance to the ED, Patient #9 refused to speak to the provider. The adoptive parents stated they thought that he/she was having a psychiatric event. The provider decided to observe the patient in the ED and planned to obtain a psychiatric evaluation the following day. Following the evaluation, the patient was discharged on [DATE] at 1315. The patient was accompanied by his/her mother.

E1 was not assigned to this patient but he/she documented giving the patient oxyCONTIN SR 20 mg tab on 04/15/2013 at 0850 and oxyCODONE 5 mg PO on 04/15/2013 at 0852.

1. On 04/16/2013, I9, Patient Relations Specialist, received a notification on his/her pager. I9 returned the call to the [parent] of Patient #9 the following morning at 0745. The [parent] stated that he/she talked to the police regarding the behavior of one of the ED RNs.

I9 documented the following conversation he/she had with the patient's parent. "[Parent] came in Monday and pt was giddy and said a [male/female] RN was hitting on [patient]. [Parent] felt this was very inappropriate. Then pt said [the RN] asked [patient] for phone number and told [the patient] was beautiful. [Parent] just wanted to get [patient] home but knew what the RN did was wrong. They got pt home and then about 4-5 hours later that evening pt was crying and really upset. [Patient] told [parent] there was more about the nurse. Pt said [he/she] fondled [him/her]. Pt told [parent] that [his/her] thigh had an injuring (sp) on [his/her] right thigh from her previous accident. RN asked [patient] to stand up pt could not put weight on [his/her] right leg. RN said [he/she] wanted to compare [patient's] right buttocks to [patient's] left buttocks. Pt thought that was a little odd. Pt put weight on [his/her] right leg and it was painful and [patient] lean into the RN. RN put [his/her] arm around [patient] and started fondling [patient] and told [the patient] made [him/her] horny. Pt stopped [RN] from feeling [him/her]. RN asked pt what [he/she] would do for more oxy and tried to fondle [his/her] brea(s)t and talking about [his/her] breast. PT felt is (sp) was cool because this [RN] was paying attention to [him/her]. RN brought in oxy and sai(d)e what would you do for more and they agreed on oral sex. RN positioned [him/herself] with back to the door. [Patient] performed oral sex and then [RN] left the room. [Patient] called for the RN and [he/she] came back and [his/her] dem(e)anor had changed very professional. [Patient] asked for the additional oxy and [RN] said I will no longer be your RN I have been reassigned."

2. Review of hospital documentation reflected that security received a complaint from the patient's parent and notified Risk Management. That same day following a conference call between administrators, ED management team and Risk Management, a decision was made to suspend E1 pending a thorough investigation into the 04/16/2013 patient complaint. Between 04/16-17/2013, 10 ED staff were interviewed and a decision was made to terminate E1's employment. The State Board of Nursing was formally notified.

3. An interview with I6 on 08/29/2013 at 1205 reflected he/she was notified at home by the Director of Security regarding the 04/15/2013 complaint. A total of 10 ED staff were interviewed as part of the hospital's investigation of this complaint. I6 stated that he/she was intimately involved with the staff interviews and confirmed that none of the staff who were interviewed observed any suspicious or "odd" behavior by E1 toward patients.

E. The determination to terminate the employment of E1 was made after the third sexual abuse allegation was made against him/her within a seven month timeframe.

1. In a phone interview with I4 and I5 on 09/12/2013 at 1300, I4 reflected "The first allegation in September (2012) did not generate corrective action. E1 had a long history with us and no other complaints. We were unable to substantiate this complaint...The second complaint in February (2013) was when we learned of the prior complaint from 2006...Because there was no substantiation of the 2006 complaint it was kept in a general file in the ED. It was found in the...archived file by the previous employee relations consultant who was here...in a file for general stuff that happened in the ED."

I5 stated, "I did not know about the 2006 allegation when I spoke to [him/her] in February (2013) because I remember talking to [him/her] about one complaint being not uncommon, 2 complaints being uncommon and 3 complaints being unheard of."

The hospital failed to protect patients from abuse during it's investigation of allegations of abuse.