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.

Findings include:

1) Based on a review of facility documentation, medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure patients received care in a safe setting for four incidents reviewed involving the same employee (EMP11).

Cross reference with:
482.13 Patient Rights(c)(2) The patient has the right to receive care in a safe setting.
Based on a review of facility documentation, medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure patients received care in a safe setting for four incidents involving the same employee (EMP11).

Findings include:

Review of facility policy "Corrective Action Effective date 9/1/2015 ... A. Violation - A violation is defined as any behavior by an employee which conflicts with organization policies, procedures, organization rules and regulations, applicable local, state and federal laws or otherwise violates organization values. ... The supervisor is also responsible for following the established procedure when issuing disciplinary action, notifying Human Resources of any performance/behavior problems which exist and for documenting disciplinary actions. ... Human Resources is responsible for providing consultation regarding any employee's performance/behavior problems, reviewing disciplinary actions for consistency in application and for assisting, when appropriate, with the investigation and analysis of the violation. Human Resources may serve as a liaison between an employee and a supervisor or between supervisors of different departments. ... A. Disciplinary Procedure ... 1. Investigation. a. The supervisor shall promptly commence a fair and impartial investigation to verify and suspected, reported or observed violation. B. The supervisor shall develop a complete knowledge and documentation of the facts. c. The supervisor will interview potential witness as appropriate. ... 3. Analyzing the Disciplinary Problem. a. The supervisor analyzes the disciplinary problem and reviews the seriousness of the problem, frequency and nature of the problem. B. An employee's entire performance and disciplinary record should be reviewed as a whole when determining the appropriate level of discipline. C. The supervisor should notify Human Resources of the outcome of the investigation and recommended level of discipline to ensure consistency for serious or repeated violations."

Review of the "Standards of Conduct CORP-HR-049" policy reviewed July 2, 2016, revealed, "Standards of Conduct - Guidelines ... A. Employees shall follow and abide by the organization Values, code of ethics and Standards of conduct. The following list is an example of violations of the code of conduct and is not to be considered all inclusive. 1. Deliberate inattention to patient care, or deliberately engaging in any conduct detrimental to patient care. ...10. Engaging in any behaviors or activities that are disruptive to the operations of the organization and/or creates a work environment that is disruptive including but not limited to...sexually suggestive or explicit, degrading or racially/ethically/religiously slurring, degrading jokes or comments, physical threats, unwanted touching, obscene gestures ...or any behavior that is deemed to be intimidating or harassing."

Review of facility policy "Patient Bill of Rights and Responsibilities," last Revised September 2014, revealed "It is the purpose of this policy of patients' rights and responsibilities to promote the interest and well-being of the patients of all departments of the Hospital. ... 1. A patient has the right to respectful care given by competent personnel, in a safe environment, which includes consideration of psychosocial, spiritual and cultural issues, as well as, personal values, beliefs, and preferences."

Review of facility policy and procedure "Patient Abuse and Neglect," last revised June 2016, revealed "The purpose of this policy is to set forth guidelines to follow where there is suspected patient abuse and neglect while the patient is receiving care, treatment, and services. These guidelines reflect the Centers for Medicare and Medicaid (CMS) Conditions of Participation and The Joint Commission Standards. ... Abuse: intentional mistreatment or the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish ... Abuse can be mental, physical, or sexual. Exploitation: taking unjust advantage of another for one's own advantage or benefit. ... All allegations of patient abuse and neglect will be investigated at the direction of legal counsel. Investigations will be thorough, credible and timely."

1. Review of facility documentation revealed "Safety/Security Event ... Event Date 04-16-2016 ... approximately 1050 am spoke with pt (patient) at her request in her room she stated male na (nursing assistant) [EMP11] came to her room in morning got her vs (vital signs) then asked if she was cold due to only having a light blanket on na then touched pt back stating 'no youre warm' when walking towards bathroom na ask if she had underwear on he could not see panty lines. While watching tv pt mentioned to na about having dry skin na replied 'he has been known to give a mean massage' returned with lotion 'do you want me to massage lotion on you it would be quick he was the only one on the unit now' pt stated no she was ok. NA stated 'he would be working again tonight' I informed charge nurse she spoke with psychiatrist also nursing supervisor informed and unit manager informed. ... Spoke with HOA (hospital administrator on call), who was aware of report and Admin [administrator] is aware. NA was moved off unit. Will follow-up with PSO (patient safety office)... although alleged behavior was inappropriate, there was no allegation of abuse, sexual contact. ... Findings of investigation did not indicate need for disciplinary action against the employee (EMP11)."

2. Review of facility documentation "Current Summary Multiple Issues Feedback ... Date of Notification 05-12-2016 ...l Patient called the grievance line today reporting that a ' young blond RN ' male employee placed his hands on her buttocks and breasts on twenty separate occasions during her seven day admission ... She reported telling him three times to stop. After prompt for example, she spoke of this staff person being in her room to wake her in the morning when he touched her and him touching her while taking her vital signs. She did not know his name and did not recall specific dates or times of instances. She did not report these occurrences during her stay. When asked what prevented her from reporting during her stay she said she didn't know if he would retaliate. She said he did not threaten her if she reported. ... Patient was interviewed by telephone and involved staff member was interviewed in person. Reported occurrence aslo[sic] discussed with Medical Director. Employee (EMP11) denied any inappropriate contact with patient and there was no evidence to support patient's allegation of inappropriate contact. Investigation considered complete and closed."

3. Review of facility documentation "Safety/Security Event ... Event Date 07-22-2016 ... reported that male nurse aide (EMP11) ... had been in patient's room and kept her from entering the room by pushing the door. ... The patient reported that he penetrated her vagina with his fingers on two occasions. The patient said she did not report this to any staff when this occurred."

4. Review of MR4 on July 28, 2016, revealed, "He [EMP11] would come in the mornings and smack our ... to wake us up ... He stood there and watched me shave everywhere .... I ' ll get you real coffee, go get naked ... tell me when ... I can pop in."

Interview with EMP3 on July 27, 2016, at approximately 1:55 PM confirmed the above findings when asked if it was the same employee for the four events revealed "Yes, the events are the same person [Employee EMP11]."

Interview with EMP6 on July 27, 2016, at approximately 1:55 PM revealed "There were occurrences reports put out on ... They were fully investigated and unfounded. I do an investigation in consultation with HR. ... when we met with ... we consulted with legal and followed up with employee that any further incident would be taken seriously."
Based on review of policies, medical records (MR) and other facility documents, and staff interview (EMP), it was determined the facility failed to follow their established policies and procedures related to the documentation of unusual patient events for one of four patient records reviewed (MR4).

Findings include:

Review of the "Documentation" policy reviewed June 2013 revealed, "14. Any unusual occurrence...should be documented in the Medical Record."

Review of the "Patient Abuse and Neglect" policy revised June 2016 revealed, "All allegations of patient abuse and neglect will be entered into the appropriate patient safety event reporting system as soon as possible. All investigative steps will be documented. ...In an objective fashion, the medical record will contain the allegations (in the patient's words if possible), the measures taken to protect the patient from further abuse and neglect, and diagnostic and treatment interventions."

Review of the "Occurrence Reporting" policy reviewed September 2014 revealed, "Definition: Occurrence - any event that is not consistent with routine patient care or hospital procedure which either has or could have resulted in injury or loss to a patient or visitor, or which may give rise to a claim against the hospital, an employee or a member of the medical staff... The occurrence report serves as a factual account of an event or near miss. It is a means of bringing necessary information to the attention of designated persons who are responsible for appropriate follow-up. ...The person who discovers, witnesses, or receives the report of the event completes the on-line Occurrence Report form..."

1. During an interview on July 26, 2016, at approximately 9:45AM, EMP5 confirmed that on July 22, 2016, he/she received information from MR4 alleging an inappropriate staff/patient interaction had taken place on the nursing unit the prior day (July 21, 2016).

2. On July 27, 2016, at approximately 1:00 PM a review of requested patient occurrence reports revealed there was no occurrence report related to the above described interaction.

3. On July 28, 2016, at approximately 11:00 AM review of MR4 revealed no documentation related to the alleged inappropriate patient/staff interaction described above.

On July 28, 2016, at approximately 11:50 AM EMP3 confirmed there was no occurrence report related the above mentioned allegation of inappropriate staff/patient interaction and there was no documentation in the patient's medical record either.