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MORRISTOWN HAMBLEN HOSPITAL ASSOCIATION 908 W 4TH NORTH ST MORRISTOWN, TN 37814 March 30, 2017
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility policy review, medical record review, and interviews, the facility failed to promptly report an alleged incident of sexual abuse for 1 patient (#1) of 5 patients reviewed for abuse.

The findings included:

Review of facility policy "...Alleged Assault or Abuse of Patient Receiving Services..." last revised July 2016, revealed "...all staff have a duty to immediately report any witnessed, suspected, or alleged physical, sexual or verbal abuse to the manager/supervisor...if there is an allegation that a patient has been assaulted or abuse, always treat it seriously...if the alleged perpetrator is a staff member...they must not have any further contact with the alleged victim..."

Medical record review revealed Patient #1 was admitted to the facility on [DATE] for diagnosis of Chest Pain and Altered Mental Status. Continued review revealed the patient was transferred to the facility's behavioral health unit on 3/14/17 with a diagnosis of Dementia with Behaviors.

Medical record review of a Physician's Progress Report dated 3/20/17 revealed "...she is in dining room enjoying activities...she slept all night. However yesterday accused a male RN [Registered Nurse] of fondling her left breast during an assessment. She also believes there are dead bugs. Also believes that use of lice medicine at home has caused brain damage...family and RN staff talked at length about pts [patients] claims over weekend..."

Interview with the Quality Director (QD) and the Risk Manager (RM) on 3/28/17 at 3:00 PM, in the Quality office, confirmed the abuse policy must be followed and the accused employee would be removed from patient care until the investigation was complete. Continued interview revealed Patient #1 left the facility against medical advice (AMA) on 3/22/17 and presented to another hospital's emergency room (ED) with a complaint of Chest Pain. Further interview revealed "...[named second hospital] notified us...requesting a copy of her records here...the case manager on the unit received a call from them...she got the manager [Unit Manager] and they came to my [QD] office...we sent the chart to [named hospital]...the CNO [Chief Nursing Officer] at [named second hospital] then called our CNO to give her a heads up of an alleged rape by one of our nurses on a patient, saying she [Patient #1] had been penetrated...the UM [Unit Manager] said she wished they [Patient #1] would have told us, they had no clue anything was wrong...[informed] on Tuesday [3/21/17]...we released the chart and started our investigation...our investigation did not determine anything..."

Interview with the QD and RM on 3/29/17 at 1:10 PM, in the Quality office, revealed Registered Nurse (RN) #3 had been accused of fondling Patient #1's breast. Further interview revealed "...No one knew about this...he [RN #3] palpated [the resident's chest] for the pacemaker...it happened on admission...the son called [RN #2] on Saturday [3/19/17]...[RN #2] should have told someone...she [Patient #1] had already left before we found out...he [RN #3] was already off and the investigation was complete by the time he came back [to work]...[Patient #1] reported to the staff [RN #2] her breast was fondled...not reported to management...on 3/21 it was reported to a manager [2 days later]..." Continued interview confirmed "...[RN#2] should have filled out an occurrence report and didn't...she did not follow policy...she should have told the house supervisor...did not report it up...should have..."

Interview with RN #2 on 3/29/17 at 2:15 PM, in the office, confirmed she did not report the alleged incident to management and failed to follow facility policy.