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THE RIDGE BEHAVIORAL HEALTH SYSTEM 3050 RIO DOSA DRIVE LEXINGTON, KY Jan. 31, 2018
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on interview, medical record review, review of the facility's policy, and review of the Kentucky Revised Statute (KRS) 209.030, it was determined the facility failed to report an allegation of sexual abuse by a facility employee towards a patient to state agencies. This effected one (1) of ten (10) sampled patients (Patient #4).

The findings include:

Review of the facility's policy, titled Abuse Reporting: Adult, effective 06/1989 and revised 12/2016, revealed failure to report adult abuse, neglect or exploitation to the Cabinet for Human Resources was a Class B Misdemeanor. Continued review revealed, it was essential facility staff protect adults in accordance with KRS 209.030 and to make appropriate referrals to the Cabinet for Human Resources. Further review revealed, the criteria for identification of a potential victim of abuse was: 1) any report given by the patient that physical or sexual abuse had taken place 2) observation of bruises, lacerations or broken bones leading staff to suspect abuse 3) if the patient exhibit signs and/or symptoms of sexual abuse such as nightmares, flashbacks and other Post Traumatic Stress Disorder (PTSD) symptoms. Further review revealed, any staff member who observes or receives a report of an adult being abused, or has reason to suspect that an adult has been abused, neglected, or exploited must report this information immediately to the Unit Charge Nurse and Department Manager or Nursing House Supervisor and Protective Services should also be contacted. Additional review revealed, the Director of Risk Management or designee would notify the Cabinet for Human Resources - Licensure and Regulation if internal investigation indicated it was warranted.

Review of KRS 209.030(2) revealed the following: any person, including but not limited to, physician, law enforcement officer, nurse, social worker, cabinet personnel, coroner, medical examiner, alternate care facility employee, or caretaker, having reasonable cause to suspect that an adult has suffered abuse, neglect, or exploitation, shall report or cause reports to be made in accordance with the provisions of this chapter.

Review of KRS 209.030(3), revealed the following: an oral or written report shall be made immediately to the cabinet upon knowledge of suspected abuse, neglect, or exploitation of an adult.

Review of Patient #4's medical record revealed, the facility admitted the resident on 01/07/18 with diagnoses to include: Bipolar Disorder I with Chronic Lithium use, Stage Three (3) Renal Disease, Coronary Artery Disease, Dyslipididemia, and Hypertension.

Interview with Registered Nurse (RN) #5, on 01/30/18 at 11:30 AM, revealed Patient #4 had reported to him that he/she was being raped by a Mental Health Associate. Continued interview revealed, he did not report the allegation, per the facility policy and state law, since he was sure it had not happened because the patient had been delusional and had hallucinations and he believed there was no way the rape had occurred. Further interview revealed, he should have immediately reported the allegation of the abuse to Administration per the facility policy and state law for further investigation.

Interview on 01/31/18 at 1:02 PM with the Director of Risk Management revealed she was not notified of Patient #1's allegation of sexual abuse at the time of the allegation. Continued interview revealed, all allegations of abuse were taken seriously and the facility did initiate an investigation immediately after being notified by Adult Protective Services (APS) of the allegation. Continued interview revealed, all allegations of abuse should be reported by staff to Administration and state agencies per the facility's policy and state law.

Interview with the Director of Staff Development & Performance Improvement, on 01/31/18 at 1:16 PM, revealed no one should assume abuse did not occur and every allegation was taken seriously and an investigation should have been initiated and completed. Further interview revealed, all allegations of abuse should be reported per the facility policy and state law.

Interview with the Chief Nursing Officer (CNO), on 01/31/18 at 2:49 PM, revealed Patient #1's allegation of sexual abuse was not immediately reported to Administration or state agencies per the facility's policy. Continued interview revealed, when she was notified of the allegation, she immediately initiated an investigation, suspended the alleged perpetrator and reported the allegation per the facility policy. Continued interview revealed, her expectation was for all allegations of abuse to be reported by staff to Administration and state agencies per the facility's policy.

Interview with the Chief Executive Officer (CEO), on 01/31/18 at 3:22 PM, revealed Patient
#1's allegation of sexual abuse was not immediately reported to Administration or state agencies per the facility's policy. Continued interview revealed, she was not notified of the allegation of sexual abuse until the CNO notified her on 01/30/18. Further interview revealed, it was her expectation that all allegations of abuse be reported by staff to Administration per the facility's policy to ensure the safety of all patients.