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.

CUMBERLAND HALL 270 WALTON WAY HOPKINSVILLE, KY Aug. 24, 2012
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interviews, record reviews, and review of the facility's policy and procedures, it was determined the facility failed to ensure one of 12 sampled patients (Patient #12) was protected from two staff members who inappropriately groped the patients breasts during a conversation. Patient #12 had a prior history of sexual abuse by a family member and the staff's inappropriate touching of the patient's breasts caused, according to the patients psychiatrist's, a decline or regression in the patient's condition. This incident caused the patient to relive a prior sexual abuse experience from the patient's childhood. Review of the facility's"Therapeutic Boundaries" policy and procedures revealed all interactions between staff and patients should be appropriate and therapeutic at all times. Review of the facility's "Patient Right's" policy and procedures revealed the patient has the right to be free from all forms of abuse or harassment. Review of the patients medical record and the facility's investigative report revealed the patient reported the incident to staff members, that two Mental Health Technicians (MHT) groped his breasts during a conversation about weight loss. Afterward, the patient verbalized feelings of anxiety and felt violated and experienced nightmares and sleeplessness due to the patient reliving his/her past sexual abuse. This incident was witnessed by several staff and other patients and was not reported until the following day.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews, record reviews, review of the facility's policy and procedures, it was determined the facility failed to ensure one of twelve sampled patients (Patient #12) was afforded protection for the patient's emotional health and safety. Additionally, the facility failed to ensure consideration was given to the patients respect and dignity to promote a emotionally safe environment related to two Mental Health Technicians (MHT #1 & #2) who groped Patient #12's breasts and who a history of past sexual abuse and a fear of being touched, all of which occurred during a conversation at the nurses station in view of other patients and staff. This incident was not reported by the staff who witnessed the sexual abuse and was not reported or investigated by the facility until the following day.

Findings include:

Review of the facility's policy and procedures for "Therapeutic Boundaries" revealed, all interactions between staff and patients should be appropriate and therapeutic at all times. Any staff who becomes aware of a boundary violation must report this immediately to any of the following individuals; Supervisor, Director of Clinical Services, Chief Executive Office, Medical Director, and Patient Advocate.
Staff interactions with patients should always take place with the patient's best interest in mind. Review of the facility's policy and procedures for "Patient Right's" revealed, it is the policy of the hospital to ensure protection and support of fundamental human, civil, constitutional, and statutory rights of each person served by the hospital insofar as is within the reasonable capabilities and limitations of the hospital and consistent with treatment. The hospital will protect and promote each patients rights and the patient has the right to be free from all forms of abuse or harassment.

A interview with Risk Management/Performance Review Director, on 08/23/12 at 4:05 PM, revealed staff receive boundary trainings and they are aware of patient's personal boundaries, they are taught not to touch patients unless for treatments or for the use of a restraint. Staff should never touch the patients, even if the patient gave permission, touching the patient's breasts was inappropriate, staff should have never touched the patient, this behavior does not follow the hospital's policies and procedures.

A review of the facility's "Healthstream Learning Center" training system revealed MHT #1 had completed a therapeutic boundaries training on 07/23/12 and MHT #2 completed therapeutic boundaries training on 06/28/12 and both staff were considered competent in understanding what constituted appropriate and therapeutic interactions between patients and staff.

A interview with Director of Nursing (DON), on 08/24/12 at 5:00 PM, revealed we do not touch patient's breasts, we do not touch patients in that manner. Staff should have recognized immediately that touching a patient's breasts was inappropriate and reported this behavior immediately to their supervisor. She further stated, staff should have recognized this behavior was inappropriate, they all have boundaries training and both staff members named in the allegation had received boundaries training and are long term employees and know better.

A review of Patient #12's medical record revealed the patient was admitted to the facility on [DATE] with self reported thoughts of self harm and with a history of family abuse and Major Depression without Psychotic Features. Review of nursing progress note dated 08/18/12 at 9:30 PM (late entry note) revealed, the patient reported on 08/17/12 at 9:30 PM two staff members put their hands on the patient without his/her permission, and the incident occurred on 08/16/12 at 9:00 PM, the patient was re-assured by staff that he/she was safe because the two staff members had been sent home pending an investigation. Review of a therapy note dated 08/18/12 at 3:46 PM revealed, the patient to describe the incident by saying that the Mental Health Technician (MHT) grabbed his/her breasts and this triggered memories of the patient's father molesting him/her as a child. The patient further stated, he/she did not like to be touched and touching "freaks" the patient out. The therapist noted that she reported this allegation to the Police Department. Additional nursing progress note, dated 08/18/12 at 12:00 PM, revealed the patient to complain of severe anxiety related to his/her recent allegation against staff. The patient reported feeling unsafe in the hospital and was contemplating signing out against medical advice.

A interview with Patient #12, on 08/23/12 at 8:45 AM, revealed the patient was standing at the nurses' station on 08/16/12 having a conversation with staff about his/her weight loss and the patient made a comment about breast size and the need for a breast reduction, then staff, both (MHT's #1 and #2,) each grabbed a breast and started "feeling them." The patient reported he/she was upset and did not want to be touched because it reminded the patient of the sexual abuse the patient experienced as a child. The patient complains of nightmares and reports he/she has regressed since this incident has occurred. The patient reported the incident to another staff (MHT #3) immediately after the incident occurred but the staff member failed to report the patient's allegation of sexual abuse to anyone.

An interview with the patient's Psychiatrist, on 08/14/12 at 9:30 AM, revealed the patient's condition initially regressed and what the staff did to the patient was unacceptable, the patient was abused by his/her father at the age of nine and the patient has experienced nightmares and had difficulty sleeping since this incident. The patient has been reliving his/her past trauma of sexual abuse due to the inappropriate touching by staff.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record reviews, review of the facility's policy and procedures, and facility's investigations it was determined the facility failed to ensure that patients are free from all forms of abuse, neglect, or harassment related to failure for one Mental Health Technician (MHT) to immediately report an allegation of sexual abuse reported to the MHT #3 by one patient of twelve sampled patients (Patient #12). Additionally, the hospital failed to thoroughly investigate allegations of abuse, neglect or harassment and assure that any incidents of abuse, neglect or harassment are reported and analyzed, and appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal laws for three of the twelve sampled patients (Patients #1, #2, and #3 ) and one patient outside the sample (Patient #13)

Findings include:

A review of the facility's policy and procedures on "Abuse, Neglect and/or Harassment" (Review date 12/2011) revealed all hospital employees are trained in the prevention, identification, and reporting procedures for suspected patient abuse, neglect, and harassment. The hospital protects patients from abuse during investigation of all allegations by removing employees suspected of abuse, neglect, or harassment from all patient care areas immediately following the allegation, during the investigation, and until the incident has been either "substantiated" or "unsubstantiated." Suspected incidents of patient abuse, neglect, or harassment are reported (either verbally or in writing,) to the Charge Nurse or Nurse Supervisor and will receive immediate attention and response. The Charge Nurse or Nurse Supervisor assesses the situation, takes appropriate action to secure patient safety. The Director of Compliance and/or Patient Advocate will complete an objective investigation on the incident to include interviews with persons making the complaint, and any patients,staff members, visitors, or other witnessing or having knowledge of the complaint. Any material evidence available will be gathered and considered in the investigation.

A review of Patient #12's medical record revealed the patient was admitted to the facility on [DATE] with self reported thoughts of self harm and with a history of family abuse and Major Depression without Psychotic Features. Review of nursing progress note dated 08/18/12 at 9:30 PM (late entry note) revealed, the patient reported on 08/17/12 at 9:30 PM two staff members put their hands on the patient without his/her permission, and the incident occurred on 08/16/12 at 9:00 PM, the patient was re-assured by staff that he/she was safe because the two staff members had been sent home pending an investigation. Review of a therapy note dated 08/18/12 at 3:46 PM revealed, the patient to describe the incident by saying that the Mental Health Technician (MHT) grabbed his/her breasts and this triggered memories of the patient's father molesting him/her as a child. The patient further stated, he/she did not like to be touched and touching "freaks" the patient out. The therapist noted that she reported this allegation to the Police Department. Another nursing progress note, dated 08/18/12 at 12:00 PM, revealed the patient to complain of severe anxiety related to his/her recent allegation against staff. The patient reported feeling unsafe in the hospital and was contemplating signing out against medical advice.

A interview with Patient #12, on 08/23/12 at 8:45 AM, revealed the patient told a MHT #3 on 08/16/12 at 9:00 PM, that two staff members (MHT #1 and #2) had grabbed the patients breasts and started feeling them, and the patient became upset and did want staff touching his/her body due to personal boundary issues.

A interview with MHT #3, on 08/23/12 at 2:45 PM, revealed, Patient #12 reported to her on 08/16/12 at 8:00 PM that MHT #1 and #2 both groped the patients chest and the patient was upset and had a panicked look when reporting this information to her. The MHT #3 stated, she did not tell anyone of the patient's allegation of sexual abuse because she forgot. MHT #3 was a new hire and had a recent abuse/neglect training provided by the hospital on [DATE].

A interview with the Director of Nursing, on 08/24/12 At 2:45 PM, revealed she would have expected the MHT #3, to have report the allegation of sexual abuse immediately, but the MHT stated she forgot to tell anyone about the patient's allegation of sexual abuse, and she failed to follow her training and the facility's policy/procedures for abuse/neglect.

A interview with Risk Management Director, on 08/23/12 at 4:05 PM, revealed he would have expected the MHT #3, to have reported the allegation of sexual abuse by patient #12, immediately to her supervisor, so that a investigation could be immediately started, and the staff involved could be sent home. He further stated, the MHT had recently been inserviced on abuse/neglect since she was a new hire.

A review of the hospitals "New Employee Orientation Checklist" dated 07/11/12 revealed MHT #3 had been inserviced on patient abuse/neglect for safety/risk management compliance.

A review of hospital's abuse/neglect investigation dated 07/24/12 by the Risk Management/Performance Improvement Director, revealed an allegation of a male adolescent being allowed by staff to enter a female adolescent's room unsupervised and to identify Patient #2 and Patient #3 as the alleged adolescents who cohorted, the review of the hospital's investigation revealed only patients #1, #2 and #3 were interviewed, to make a determination if the allegation was substantiated or unsubstantiated.

A review of another hospital investigation related to staff boundaries, dated 08/09/12 revealed only patients #1 and #2 and MHT #4 all named in the allegation, plus one therapist was interviewed to make a determination if the allegation was substantiated or unsubstantiated.

A review of another hospital investigation of the allegation of physical abuse dated 05/30/12 involving Patient #13 revealed that only Patient #13 and MHT #1 were interviewed to make the determination if the allegation was substantiated or unsubstantiated.

A interview with Risk Management/Performance Improvement Director, on 08/17 12 at 10:15 AM, revealed that he based a lot of his investigation on watching videos, however, some of the units do not have functioning cameras. He stated, that he usually just gathers a few facts and then turns the investigation over to Department for Community Based Services (DCBS) to make a determination. He further stated, that he only does a "brief investigation."

A interview with the hospital's Chief Executive Officer, on 08/22/12 at 8:45 AM, revealed he would have expected the Risk Management/Performance Improvement Director to complete a thorough investigation related to any allegations of abuse/neglect and that all parties meaning staff, visitors, and other witnesses having knowledge of the complaint involved in the allegation should have been interviewed as per the hospitals policy.