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 interviews, review of the medical record, staffing schedules and policies and procedures, the hospital failed to initiate an investigation on 8/3/2012 when they were initially notified by the Department of Human Resources (DHR) about an allegation of sexual abuse by a former patient (Patient Identifier, PI # 1) and a current employee (Lead Mental Health Technician, MHT / Employee Identifier, EI # 3) . The hospital's investigation is documented as beginning 8/21/2012, 18 days after the hospital was notified of the abuse allegation. Furthermore, the accused employee was allowed to work with other patients prior to the conclusion of the hospital's investigation. The police were not notified of the abuse allegation until 8/23/2012, 20 days after the hospital was initially notified. The hospital also failed to immediately notify the Medical Director about the allegation per hospital policy and procedure. This deficient practice affected Patient Identifier (PI) # 1, one of ten sampled patients, but had the potential to affect all patients hospitalized after 8/3/2012.

Findings Include:

During an interview on 8/20/2012 at 1:30 PM, the Director of Nursing (DON) / Employee Identifier (EI ) # 1 stated she was contacted via telephone by DHR staff about two weeks ago regarding an allegation of abuse of a former patient. According to the DON, no written documentation was received from DHR, nor was the patient's name initially identified. However, the patient's name (PI # 1) was requested by the DON and it was provided by DHR. The DON said the hospital employee allegedly involved in the allegation was identified by name (Mental Health Technician/Employee Identifier # 3) by the DHR contact person. The DON stated the MHT/EI # 3, was interviewed by the hospital. The DON said, "There hasn't been any investigation other than the interview." No documentation was found in the grievance/complaint log regarding an abuse allegation related to Patient Identifier (PI) # 1 when reviewed by the surveyors. The DON verified she had not documented any information about the allegation and/or actions taken by the hospital after the hospital was notified by DHR on 8/3/2012 about the abuse allegation.

During an interview on 8/20/12 at 2:00 PM, the Administrator (EI # 2) was conferenced in via telephone by the DON. The Administrator said DHR provided no details about the abuse allegation. However, the accused employee (MHT/EI # 3) was interviewed and denied any knowledge about the allegation. According to the DON (EI # 1), the patient (PI # 1) "Reported something/somebody new everyday. We wrote it all down. Talked to involved staff and patient...Anything reported by a patient, we look into it. See if it happened." The DON also said she checked the schedule to make sure the accused employee wasn't working. The DON said she verified the employee was not working for the next four days.

During an interview with the Administrator (EI # 2) and the DON (EI # 1) on 8/21/12 at 9:45 AM, the Administrator said she was notified by the DON via telephone about the allegation of sexual abuse of a former patient (PI #1) by a hospital employee (MHT/EI # 3) by DHR on 8/3/2012. The Administrator (EI # 2) said the DON (EI # 1) asked DHR if the hospital could notify the MHT/EI # 3 about the allegation prior to DHR contact. DHR reportedly said the hospital could have five days to contact the employee according to the Administrator. The Administrator said she talked to the accused employee on 8/8/2012. The employee denied any sexually inappropriate behavior toward the patient (PI # 1). The Administrator (EI # 2) was asked if she documented the interview and she said no. The Administrator repeatedly stated DHR provided no details when DHR initially notified the hospital of the abuse allegation on 8/3/2012. Therefore, the Administrator said there was nothing to investigate.

According to the Administrator, the patient (PI # 1) made frequent grievances/complaints during the inpatient hospitalization . The Administrator described the patient (PI # 1) as "defiant." The Administrator stated she talked with PI # 1 about these allegations and the patient "denied everything." PI # 1 made an allegation that an employee (same employee accused of abuse by patient after discharge) grabbed her arm during inpatient hospitalization . The tapes were reviewed and the allegation was not substantiated. The Administrator said the tapes automatically re-record every 30 days.

The Administrator (EI # 2) said men are not allowed on the Girls Hall during shower time, except in the case of an altercation. If it is necessary for a male employee to be on the girls hall, he must be accompanied by female staff.

During the interview, the Administrator (EI # 2) said she received a written report today (8/21/2012) from DHR via e-mail regarding the allegation and read the report this morning. The Administrator was asked if she notified the Medical Director about the allegation and she responded, "No. I didn't want to damage the MHT's (EI # 3) reputation. Didn't have enough facts. "

A written report given to Surveyors by the Director of Nursing (DON)/ EI # 1 on 8/21/2012 documented, "On August 3, 2012, at approximately 3:55 PM, I received a call from (first name of DHR staff person) at the (Name of county in Alabama) DHR, who stated that a patient (PI # 1) had made sexual abuse allegations against one of our mental health techs. She revealed that the employee's name was (first and last name of employee, MHT/EI # 3) and the patient was in a (name of another state) hospital. She voiced that she didn't have any specific details about the allegations. I asked her who the patient was and she said it was (Name of patient/ PI # 1). She said they were not sure yet how or when they would interview the patient...I gave her (Name of employee accused of abuse/ MHT, EI # 3) as she requested. I asked her if we would get a chance to notify him first. She said yes...I reviewed the schedule to ensure employee (MHT/EI # 3) was not on for the weekend. The involved employee had been cancelled for the present day shift due to adjusted staffing needs. Employee (MHT/EI # 3) was not scheduled to work for the next four days. I immediately called (Name of Mental Health Technician (MHT) Supervisor/EI # 7) to make her aware of the situation and ensure she did not call the MHT in to work. I then contacted (Name of Administrator/ EI # 2) regarding the allegations and reviewed with her that he (EI # 3) was not scheduled for the next four days. She (Administrator) voiced that we would interview him the first of the week regarding allegations." This report was signed and dated 8/20/2012 by the DON (EI # 1).

During an interview on 8/21/2012 at 1:15 PM, Lead Mental Health Technician (MHT), Employee Identifier/ EI # 3 (employee accused of abuse) stated his regular shift is 7:00 AM to 7:00 PM. He was asked if he ever worked nights and he said no. According to the MHT the patient (PI # 1) did not like authority, cursed and lied during her hospitalization . The MHT (EI # 3) stated PI # 1's telephone call with her mother was ended early on one occasion (date unknown) because of the patient's (PI # 1) disrespectful language. PI # 1 reported the MHT's (EI # 3) action to the nurse on duty.

The MHT (EI # 3) was asked about the patients' shower schedule/process because it is related to the abuse allegation. The MHT denied working the night shift during shower time. The MHT also denied any sexually inappropriate behavior or talk, denied threatening and/or burning the patient with a cigarette and denied giving the patient cigarettes/drugs. The MHT (EI # 3) stated he walked the patient (PI # 1) to the hospital on one occasion.

On 8/21/2012 at 1:50 PM, the MHT (EI # 3) walked with a State Surveyor from Hospital # 1 to Hospital # 2 to retrace the route taken when he escorted PI # 1 to Hospital # 2 for an x-ray on 7/7/2012. According to the MHT, a direct route was taken from Hospital # 1 (hospital where PI # resided) to the Ambulatory Entrance of Hospital # 2 (Hospital with x-ray capability). The MHT denied touching or having any type of contact with the patient.

During an interview on 8/22/2012 at 11:35 AM, the Director of Therapeutic Services / Employee Identifier (EI) # 9 reported PI # 1 was disruptive, verbally aggressive, confrontational and defiant during group therapy on 7/7/2012. Patient Identifier (PI # 1) left group without permission. When PI # 1 was confronted and instructed by the MHT/EI # 3, to return to group, PI # 1 assumed a "defensive posture" towards the MHT. A memo written by the Director (EI # 9), dated 7/7/2012 regarding group therapy documents, "Name of patient (PI # 1) attempted to bow-up and become physically aggressive toward the lead tech (EI # 3)...Name of patient (PI # 1) later returned to group although her discontentment with the situation was obvious."

A review of the daily patient schedule revealed shower time begins at 8:00 PM. A review of the Daily Staffing/MHT Assignment Sheets revealed EI # 3/Lead Mental Health Tech worked night shift (during shower time at 8:00 PM) on the following dates when PI # 1 was in the hospital:
6/26/2012: 7:15 PM - 12:00 Midnight
7/10/2012: 7:15 PM - 1:55 AM
7/14/2012: 6:45 AM - 11:30 PM

According to the staffing sheets, the MHT (EI# 3) worked the following dates after the hospital was notified of the abuse allegation on 8/3/2012:

During an interview on 8/22/2012 at 4:40 PM, a Licensed Practical Nurse (LPN) / EI # 11, stated the patient (PI # 1) was overheard being disrespectful and profane during a telephone call with her mother on 7/7/2012. According to the LPN, the hospital policy is to ask the patient to stop or end the telephone call if necessary if the patient's behavior is inappropriate. PI # 1 became confrontational with the LPN when she (PI # 1) was asked to stop speaking disrespectfully during the telephone conversation. Reportedly, the patient cursed the LPN and got in the nurse's face. The LPN admitted calling the patient a name (slang word). Due to the patient's agitation, the LPN offered a prn (as needed) dose of oral Vistaril to the patient. The patient refused the oral medication and a Vistaril injection was administered by the LPN. The LPN described the patient as very agitated and disruptive. The LPN said she used her "judgement" that the intramuscular injection was indicated.

During a telephone interview on 8/22/2012 at 5:00 PM, the Medical Director/PI # 1's Attending Psychiatrist/ Employee Identifier (EI) # 6, was asked if he had been notified by hospital staff about the abuse allegation by a former patient. The physician said, "No. I don't think
that I heard about this until you (state surveyors) showed up."

On 8/23/2012 at 10:00 AM, the MHT Supervisor/ EI # 7, was asked to describe the hospital's process for the investigation of an allegation of abuse. According to the Supervisor, "Usually the accused person does not return until the investigation is over."

During a second interview on 8/23/2012 at 11:55 AM, the MHT Supervisor/ EI # 7 was asked when she was first notified about the abuse allegation. The Supervisor said, "Monday or Tuesday of this week." (8/20/2012, 8/21/2012).

EI # 3/ Lead MHT was interviewed a second time on 8/23/2012 at 3:10 PM to clarify questions about his work schedule. EI # 3 said he had forgotten that he worked on the night shift (7:00 PM to 7:00 AM) on several occasions when PI # 1 was hospitalized . The MHT stated he worked after 7:00 PM because three to four patients were on one to one observation and additional staff was needed. He denied being on the girls hall during shower time. The MHT/ EI # 3 was asked if he had been interviewed by the Administrator and/or the Director of Nursing (DON) about the allegation and he said, "Monday (8/20/12) she (Administrator's first name) asked me to come in...Needed to talk to me in person. She didn't interview me." The MHT said he met with DHR staff today. The MHT also said, "I think Ms. Administrator's first name) said Tuesday (8/21/12) I would have to be off the schedule until the investigation is complete."

A review of PI # 1's medical record reveals the patient was hospitalized from June 26, 2012 through July 14, 2012. The results of the lumbar spine x-ray, done at 2:21 PM on 7/7/2012 at Hospital # 2, "...appear normal."

Policy and Procedure Review:

1). Policy Title: Duty to Report Abuse/Neglect
Policy/Number: A100.512
Effective Date: 5/8/2008
Review Date: 6/2012

Policy: "All medical personnel are required by law to report any known or suspected child abuse or neglect under penalty of misdemeanor fine or sentence. (The Abused Child Act- Alabama Act 1124). This report is required whether abuse is alleged or confirmed in all situations which involves juveniles 18 years of age and younger...Any reports of known or suspected child abuse or neglect witnessed or reported to a staff member must be documented using the Incident Report Policy process as outlined in...Policy A100.402, Titled Incident Reports....

The report shall include, to the extent known by the reporter, the name, address, and age of the child...and the facts concerning the report..."

2). Title: Reporting Patient Abuse/Neglect
Policy Number: A100.501
Effective Date: 6/2008
Review Date: 6/2012

Policy: "Every employee of ... Hospital will act in a manner that is consistent with the mission, philosophy, and supporting policies of the members will demonstrate by personal and professional conduct an adherence to the values of:

Respect for the dignity of the individual whether patient, family... Provision of the highest quality and most appropriate services... Adherence to all applicable professional codes and practice guidelines.

1. Evidence of ethical practices will be noted in the following areas: A. This policy will be distributed each team member upon hire as part of the orientation process...
2. Any allegations of violations of this policy will be directed to the Director of Nursing or Director of Therapeutic Services and investigated and acted upon...

Mandatory Reporting:
All hospitals...doctors, social workers...nurses and mental health professionals, or any other person called upon to render aid or medical assistance to any child, when the child is known or suspected to be a victim of child abuse or neglect, shall be required to report to a duly constituted authority."

3). Title: Incident Management
Policy Number: A100.413
Effective Date: 8/2009
Review Date: 7/19/2012

Policy: It shall be the policy of Hospital # 1 to establish and maintain an Incident Management System, as a component of the Hospital's Improvement Plan, in order to promote an environment that is caring, free from harm and respectful of patient's rights.

Purpose: To describe the responsibilities staff in managing incidents including: identification, classification, reporting, investigation and implementing actions to eliminate and prevent reoccurrence of incidents that pose a risk of harm to patients.

Definitions: ...

1. Abuse: An employee...acts or incites another to act, in a manner that willfully, intentionally, or recklessly causes or may cause pain, physical, or emotional injury to a patient.

2. A. Physical Abuse: Any assault by an employee...upon a patient including: hitting, kicking, pinching, slapping, or otherwise striking a patient or using excessive force regardless of whether injury results.

B. Sexual Abuse: Any sexual misconduct with a patient by an employee or agent (on or off duty) including: sexual intercourse, touching...and/or incitement of a patient to engage in any form of sexual activity with another patient or person.

C. Verbal Abuse: Verbal conduct by an employee...that demeans a patient or could be reasonably expected to cause shame, ridicule, embarrassment or emotional distress including using abusive, obscene or derogatory language, teasing, or taunting a patient...

A. Reporting of incidents: To ensure proper and timely reporting of incidents the following procedures shall be adhered to:

1. Immediately upon discovering or having knowledge of an incident, the staff person shall ensure the patient's health and safety...and make a verbal report to the Charge Nurse on duty.

2. The staff member shall complete an Incident Report Form and give to his/her Charge Nurse within one hour.

3. The Charge Nurse, upon notification, should go to the scene and immediately ensure any necessary first aid/or medical treatment has been provided...The Medical Director or his/her designee should also be notified...

5. The Quality Assurance Coordinator/Director of Nursing shall review the incident report and begin the Incident Report Quality Worksheet.

A. If the incident involves allegations of abuse...determine whether accused staff person should be removed from direct patient care or suspended pending the completion of the investigation...

8. If a formal investigation is warranted, commence the investigation immediately...
A. Commence the collection of testimonial evidence as soon as practical. Conduct interviews with all potential witnesses, including the alleged victim....
C. Obtain written statements, as needed, from all witnesses and or persons with knowledge of incident.
D. Complete thorough investigative report within four include:
1. Summary of the initial incident report.
2. Description of the investigative process.
3. Summary of evidence.
4. Conclusions....

9. The Incident Report and any other relevant documents will be reviewed by the Medical Director and Administrator for action...

12. Incidents rising to the level of Sentinel Event will be reported to the Board of Directors. Notifications shall also be given to external agencies of the incident, investigative findings and actions, including the following agencies as indicated: County DHR, Alabama Department of Public Health...and local law enforcement agencies..."

A facsimile, received from and documented by the Hospital Administrator on 8/24/2012, revealed the following information:

8/21/2012 - 9:30 AM: "(Name of DHR employee)...called to tell me she had just received the patient's statement from...DHR...would e-mail the complaint letter to me immediately and I began (Name of Hospital's) formal investigation..."