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TENNOVA HEALTHCARE 900 EAST OAK HILL AVENUE KNOXVILLE, TN 37917 Oct. 11, 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, review of a facility investigation, and interview, the facility failed to follow facility policy during an investigation of alleged abuse for 1 patient (#1) of 4 patients reviewed for abuse.

The findings included:

Review of the facility policy "Detection of Abuse, Abandonment, Neglect or Exploitation Policy" dated 7/5/17 revealed "...protect patients real or perceived abuse...during the time of the investigation of the incident...the patient will be protected from any additional incidents of abuse...if the alleged abuse is a staff member...when it is an allegation of a determined serious nature...the employee should be sent home with pay pending an administrative investigation..."

Medical record review revealed Patient #1 was a [AGE] year old female admitted to the facility on [DATE] with a diagnosis of Peritoneal Abscess. Continued review revealed the patient was discharged from the facility on 9/28/17.

Review of a facility Investigation dated 9/26/17 at 10:00 AM revealed the facility conducted an interview Registered Nurse (RN) #1, on 9/26/17 at 10:00 AM. Further review revealed "...Around 7:20 PM [Patient #1] called out for pain medication [named nurse] got her pain medication and went in the room and gave it to her...[Patient #1] did not mention anything about [perpetrator] at that time...around 8:30 pm [named nurse] performed a dressing change and assessment on [Patient #1]...[Patient #1] told [named nurse] that she felt dirty and would like to get cleaned up so she could sleep better...[named nurse] went and got the stuff ready for her to be able to bath herself...Around 9:00 PM [named nurse] was getting ready to walk out the door when [Patient #1] said there is something I need to tell you...[Patient #1]...told [named nurse]...did not want the short African American dietary worker back in her room...[named nurse] stated that she would take care of that and started to leave the room...[Patient #1] stated I need to tell you something else too...told her [named nurse] that he [dietary worker] had made sexual advances...did not elaborate on what that exactly meant...only told [named nurse] that she did not want to get him trouble...patient was not in any distress and did not seem upset...she was calm...told [Patient #1] that she would have the House Supervisor come talk to her...called the House Supervisor...she [House Supervisor] told her [named nurse] that the ED was on 'alert' status and she [House Supervisor] was in the ED helping...would be up to talk to patient as soon as she was done...House Supervisor arrived sometime after 11:00 pm..."

Review of a facility Investigation dated 9/26/17 at 11:00 am revealed the Risk Manager and the 3rd Central Unit Manager conducted an interview with Patient #1 on 9/26/17. Continued review revealed "...[Patient #1] states that [dietary worker/perpetrator]...delivered her dinner tray around 6:00 PM and said that she looked familiar and asked if he could come back later and talk to her. She told him yes...he came back around 6:30 PM...[Patient #1] states...[Perpetrator] took her hand and placed it on his penis...started masturbating...he grabbed her head and put his penis in her mouth and ejaculated...[Perpetrator] told her he would come back later after he got off from work...she told him she was going to sleep...she thinks he came back around 10:00 PM because someone knocked on her door but never came in...[Patient #1] states...saw her nurse...around 9:00 PM and that is when she told her what had happened to her...stated that she decided that he was not going to get away with sexually abusing her..."

Review of a facility investigation dated 9/27/17 at 9:18 AM revealed the Dietary Worker/Perpetrator was terminated from employment on 9/26/17 for "...gross misconduct..."

Review of the facility Investigation dated 10/2/17 at 12:00 AM revealed a time sheet for the employee dated 9/25/17. Continued review revealed "...[Perpetrator]...work date 9/25/17...start time 4:31 PM...wrk [work]...meal...unpaid-hour...start time...6:24 PM...meal...unpaid-hour...end time...7:19 PM...wrk...end time...9:59 PM..." Continued review revealed the Perpetrator was not sent home by the facility and continued to work 59 minutes after the alleged incident occurred.

Interview with 3rd Central Unit Manager, on 10/10/17 at 11:04 AM, in the conference room, revealed "...I was told there was a sexual assault report from the patient [Patient #1]...went with...Risk Manager to visit the patient the next day...the patient stated a dietary employee came and delivered her tray...[Perpetrator] spoke with her for a few moments and told her he would come back later...he came back between 6:30-6:45 PM...they had a conversation...she [Patient #1] said it was nice to talk to someone...they talked about her son and her girlfriend...she said the conversation turned more sexual and he showed her pictures of his private parts...she [Patient #1] said 'all of a sudden I looked over and his pants were down'...she said he took her hand and had her help and she just laid with her hand there and let him do what he wanted to do...she went into shock and she didn't really know how to respond to him...as he [perpetrator] got close to climax he grabbed her head and pulled it down and stuck his penis in her mouth and ejaculated in her mouth...the patient said no one came to her room for 2 hours but I know my nurse went in to give her medicine at 7:35 [PM]...we moved her to another room and made her a no info patient to make her feel safe...she was afraid he would come back..."

Telephone interview with RN #2, House Supervisor, on 10/10/17 at 3:00 PM revealed "...I was the house supervisor...I received a phone call from staff...she [nurse] had concerns about a dietary employee who delivered trays...he [perpetrator] had made some sexual advances...I was in the ED and couldn't go right then...[later on] went to go talk with her [Patient #1]...she [Patient #1] told me a gentleman came in to deliver tray [meal tray]...he [perpetrator] recognized her...they had a conversation and he had to delivery meal trays and asked if he could come back...she said yes...he came back...sat down in chair...started reminiscing...shared some interest...he showed her a picture on his phone of his genitals...put his mouth on her breast...I stopped the interview...I told her we may reach out to law enforcement...I asked her did she want us to...she said yes...I told her I would contact the Administrator...I contacted the Administrator...she...wanted to reach out to Risk Management...she [Administrator] called me back...she said yes to proceed and contact Law Enforcement...I reached out to security for them to contact Law Enforcement...after I first spoke with patient...I went down to the cafeteria and no one was in the cafeteria...he [perpetrator] was gone..."

Interview with Nursing Assistant (NA) #1 on 10/11/17 at 7:30 AM in the conference room revealed "...me and [RN #1] were taking care of [Patient #1] the night this happened...the dietary guy [perpetrator] came back and saw her about 10:00 PM...I almost got up to stop it but he came right back out [of Patient #1's room]...I told [RN #1]]...the Charge Nurse...and the Detective...he [perpetrator] was here about 4-5 minutes..."

Telephone interview with the perpetrator on 10/11/17 at 12:54 PM revealed "...ma'am to be truthful we [perpetrator and Patient #1] had a conversation...I hadn't seen her since high school...I asked her if I could come back to see her...she said yes...we were catching up...we were talking about sex...she showed me her private [genitalia] area...I showed her a picture [on cell phone] of my privates...she didn't say no...she played with my privates...she never said no or never tried to pull away or push me away...I was wrong doing it at the work place..." Continued interview revealed "...I clocked out...I came back to check on her...I walked by the nurses' station...I knocked twice on her door...she didn't answer and I went on my way..."

Interview with the Director of Nursing and the Quality Director on 10/11/17 at 2:35 PM, in the conference room, confirmed the facility failed to send the employee home after they were aware of the alleged incident and the facility failed to follow facility policy.