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 clinical record review, policy and procedure review and interview, it was determined the Facility failed to provide documentation that all allegations of abuse were investigated and patients were protected from abuse during an investigation for 1 (#2) of 10 (#1-10) clinical records reviewed. The facility could not assure patients were protected from abuse. The failed practice affected Patient #2 and would likely affect all patients at the Facility. The findings follow:

A. Patient #2 was admitted to the facility on [DATE]. Review of Physician progress note dated 12/16/13 at 0930 on 12/30/13 revealed this statement "Pt (Patient) with severe delusions of persecution & paranoia of staff and peers. Patient said he was "sodomized this A.M." med (medical) consult ordered."

1) Nursing Progress Note 12/14/13 at 1730 stated "Became very agitated mid afternoon stating he was sodomized by Nursing Staff on admission. Calling relatives telling them he has been abused. Has refused medication 1:1 with patient. Listened, processed gave support." Received call from (named) cousin stating that sexual abuse occurred to (named) when he was in prison many years ago and he gets it confused with current occurrences when he does not take his prescribed medication."

2) Physician Progress Note 12/17/13 at 0915 documented "Very paranoid of staff, peers and friends. Reports "I was sodomized by 3 men and an 8 foot tall woman here".

3) Social Services note dated 12/16/13 at 0840 stated "Patient reports that he was sodomized when he got to this hospital. He did not give any names, but requests a physician examination. This writer passed this along to the Charge Nurse and Physician. The Physician is writing an order for patient to be physically examined by Physician. The patient continues to be extremely paranoid and delusional."

4) A medical consultation was completed on 12/16/13. The subjective data stated "I was asked by Dr.(named) to evaluate this patient who reports a history of rectal trauma recently." The History of present illness stated "The patient is a [AGE] year old gentleman with a history of chronic schizophrenia. He reports to his Psychiatrist that he has had rectal trauma and is having rectal pain. He reports "somebody did something they shouldn't have", but he refuses to elaborate. He reports that he has passed blood and has some rectal irritation and has reported sodomy to the staff in the past. He reports no difficulty with bowel movements at this time and no melena is reported." The rectal exam stated "shows normal perianal tissue with no evidence of tearing or severe hemorrhoidal irritation noted. No obvious fissures noted." The Impression stated "Likely delusional thoughts. I have recommened he follow up with his primary physician to schedule endoscopy at his earliest convenience."

B. The Director of Nursing and Administrator were interviewed on 12/30/13 at 1200 and stated they were not aware of any allegations or investigations of abuse for the patient. At 1230 on 12/30/13, the Director of Nursing stated she did recall the allegations. She stated she could not recall if she was contacted via e-mail or how. Stated she viewed the camera on 12/16/13 "from midnight to early am and two women worked. I looked at the video. No men were there." Stated she did not document any portion of the investigation. She confirmed she did not interview staff "because I didn't know what time it happened because the patient said this morning".

C. Review of facility policy "Patient Abuse/Neglect", HR 102 provided 12/30/13 at 1340 revealed: "Complaints of patient neglect and/or abuse: An employee who hears from a patient or visitor or observes a potential case of patient neglect and/or abuse will immediately report it to their Supervisor or Hospital Manager. A Healthcare Peer Review (HPR) Report must also be completed regarding the incident." The Hospital shall investigate the incident as soon as possible. Depending upon the circumstances, the Hospital may immediately suspend an employee pending an internal investigation." "Any employee who fails to report an incident of patient neglect and/or abuse may be subject to disciplinary action up to and including immediate employment termination. Any Supervisor who receives information, written or oral of alleged patient neglect and or abuse and fails to respond may be subject to disciplinary action up to and including employment termination."

D. The findings were confirmed by the Director of Nursing in an interview on 12/30/13 at 1340.