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 observation, record and policy review and interview, it was determined that the facility failed to protect and promote the rights of patients as evidenced by: failure to follow policies to ensure that 2 of 4 current patients (#2 and #3) with abuse/neglect allegations received timely, through investigations and that appropriate remedial actions were taken (A-0145) and failure to establish a process for prompt resolution of patient grievances (A-0119), resulting in increased risk of harm from abuse or neglect and potential loss of grievance rights.
Based on observation and interview, the facility failed to provide patients with information on where to obtain complaint forms and file them resulting in the potential loss of grievance rights. Findings include:


During a tour of the facility on 10/29/12 from 10:15-10:30 am the following was noted and confirmed by Unit Manager #1.
1. Floors # 2 and 3 had no labeling on the Patient Rights Complaint box or information posted near the box regarding where to obtain a complaint form.
2. Floor 6 had a patient complaint box labeled as such but no complaint forms nearby or information on where to obtain them.


During a tour of the facility on 10/29/12 from 10:15-10:30 am Unit Manager #1 confirmed the above observations and stated that there should be labeled complaint boxes and instructions on where to get obtain complaint forms near to the boxes on all units.
Based on interview, policy and record review, it was determined that the facility failed to ensure that 2 of 4 patients with abuse or neglect complaints (#2 and #3) were free of abuse or neglect by failing to provide timely, through review of allegations and initiate remedial action according to facility policies. Findings include:

Patient #2:

On 10/18/12 nursing staff observed physical injuries on patient #2 vaginal area, buttocks and right upper thigh. When staff asked patient #2 how the injuries occurred, the patient stated that Resident Care Attendant (RCA) #1 sexually assaulted her in bed, approximately 1-2 weeks ago.


Abuse and Neglect: Definitions and Reporting, #203, issued 8/31/12, states:

A. 8." Immediate Supervisor: Assures that all records and other documentary or physical evidence are secured as necessary.
A. 12. Physician: Examines the patient for external injuries indicative of suspected sexual abuse (if alleged). If evidence of such is apparent, refers patient (and clothing worn at the time of the suspected/alleged abuse) to a local hospital for a sexual abuse evidence kit.
A. 15. Hospital Director/Designee: Reviews preliminary abuse/neglect allegations and takes all necessary actions to ensure the safety of patients. Instructs CNO (Chief Nursing Officer) for the Removal of staff suspected of abuse/neglect immediately from the patient care until either the ORR (Office of Recipient Rights) investigation is completed or there is notification from ORR that the allegation will not be substantiated.
B. 1. Director of Nursing: Assigns nursing supervisory staff to conduct an investigatory review and upon completion, submits to the Hospital Director/Designee for review and final approval."

Record Review:

From 10/29/12-10/30/12, record review revealed:

1. On 10/30/12 from 10 am-2 pm the following was confirmed during record review with the Performance Improvement/Utilization Review (PI/UR) Coordinator:

a. On 10/18/12 at 1 am a facility Incident Report documented that patient #2 had the following injuries: "right inner upper thigh and right posterior labia hematoma, no history of falls."
b. On 10/18/12 at 9:20 am a facility Incident Report by Unit Nurse #1 noted that patient # 2 stated: "I was raped...1-2 weeks (RCA #1)...."
c. On 10/18/12 at 10:00 am MD #1 documented: "Noted purplish/red contusion with induration on right lower labia; right inner/upper thigh' posteriorly up to rectum...."
d. A nursing progress note dated 10/18/12 at 1:48 pm, states: "RCA (Resident Care Attendant) informed to assist pt. (patient) with clean, appropriate clothing."
e. On 10/18/12 at 1:45 pm MD #1 documented: "will transfer patient to ER (emergency room ) for management. Allegation of Rape, Bruise on right inner thigh, right lower labia, complaint of bringing on (word?) vaginal area" and noted contact with a hospital ER physician.
f. MD #1's "Consultation or Referral Sheet," for communicating the physician's request for ER evaluation, that went with the patient to the ER, states: "history of schizophrenia; tendency to fall/lying on the floor (word?) secondary to Behavior...reported Raped by male; 1-2 weeks ago. Complaint of burning in the genitalia; noted contusion right lower labia; inner thigh; posterior thigh- for evaluation." There was no request for a rape kit.
g. At Annapolis hospital patient #2 received tests for : Chlamydia, Urinalysis, Trichomonas and Pregnancy and a urinalysis and routine pelvic exam. HIV testing was not done.
h. A rape kit was not administered and there was no documentation, from the facility or Annapolis hospital, that it was requested or considered.
i. Patient #2 was diagnosed with a Urinary Tract Infection by Annapolis hospital ER staff on 10/18/12.


1. On 10/29/12 at approximately 11:15 am, Unit Manager (UM) #3 stated that she was responsible for investigation of patient #2's 10/18/12 rape allegation for the nursing department. UM #2 stated that she did not have documentation of any completed interviews to investigate the allegation but had distributed a questionnaire to unit nursing staff.
2. On 10/30/12 at approximately 1:45 pm, Recipient Rights Officer (RRO) #1's documentation of the investigation of patient #2's 10/18/12 rape allegation was reviewed with RRO #1. RRO #1 stated that there is no requirement that possible witnesses to abuse allegations must be interviewed in a specific timeframe. RRO #1 stated that he had not yet interviewed unit staff with possible information relevant to this investigation. RRO #1 verified that the only documentation of interviews with patient #2 and nursing staff to date consisted of:
--one interview with patient #2, dated 10/18/12, stating: "(Unreadable) sleeping while it happened didn't wake up as he left he told her (unreadable) bruise on buttock and (RCA #1's name)"
--one interview with a staff member, Resident Care Attendant (RCA) #2, dated 10/18/12, that contained no questions relating to interactions between patient #2 and the alleged abuser (RCA #1).
3. The Annapolis ER Physician who treated patient #2 on 10/18/12 was not available for interview during this survey.
4. On 10/30/12 at approximately 3:30 pm the PI/UR Coordinator was queried regarding patient #2's clinical record and facility policy #203 A 12, referencing physician responsibility when there are "external injuries indicative of suspected sexual abuse (if alleged)." This policy (above) states that the physician: "refers patient (and clothing worn at the time of the suspected/alleged abuse) to a local hospital for a sexual abuse evidence kit." The PI/UR Coordinator confirmed that there was no documentation in patient #2's clinical record of staff asking the patient what she was wearing when the alleged assault occurred or of sending the patient's clothing or bed sheets to the hospital to be included in a sexual abuse evidence kit. Policy #203 also states that the facility physician will refer the patient to a local hospital "for a sexual abuse evidence kit." The PI/UR confirmed that there was no documentation in patient #2's record that a facility physician referred patient #2 to the hospital for a sexual abuse evidence kit.
5. On 10/30/12 at approximately 4:30 pm Psychiatrist #2, the Medical Director, commented on the facility physician's failure to refer patient #2 to a local hospital for a rape kit, per policy. Psychiatrist #2 stated that it was up to the emergency room physician to decide what tests were appropriate, not the referring physician.

Patient #3:

A facility Incident Report, dated 9/11/12, reports an incident that occurred on 9/3/12 involving an allegation of neglect of patient #3. The allegation was not reported to a nursing supervisor or the Office of Recipient Rights unit 9/11/12. Patient neglect was substantiated by the Office of Recipient Rights and the employee was allowed to return to work on 10/24/12. A Disciplinary hearing between the employee and Human Resources to discuss a possible written reprimand for work rule violations had not occurred.


"Incident Reporting," #201, approved 2/1/12, states:

A. "Any employee who witnesses, discovers, or is notified of an unusual incident, including allegations of abuse or neglect, shall take immediate action to protect and comfort any patients involved, assure the treatment of injuries as necessary, and shall immediately notify their supervisor."
B. "All unusual incidents shall be reported on Incident Report form (DCH-0044), no later than the end of the shift during which the incident was discovered."

"Substantiated Abuse/Neglect Remediation and Monitoring," #107, approved 6/9/11, states:

E. "The Department Director /Designee is responsible for assuring that employees returning to work after receiving discipline for a substantiated patient abuse/neglect allegation receive all remediation prior to resuming regular work activities."

Record Review:

From 10/29/12-10/30/12, record review revealed:

1. An Incident Report dated 9/11/12 states that on 9/3/12, RCA #3, "the assigned staff neglected to follow physician's orders to check on the patient every 15 minutes.'" The report noted that patient #3, "was on every 15 minute checks for assault, water intoxication and self safety and stealing from peers' rooms." The report notes a discrepancy in RCA #3's documentation, noting that patient checks were done every 30 minutes, and safety precautions ordered by patient #3's physician, required checks every 15 minutes.
2. Unit Manager #2 provided a handwritten note stating that RCA #3 worked on : 9/5, 9/6, 9/7, 9/9 and 9/10, 2012, before the incident was discovered.
3. On 10/12/12 Neglect of patient #2 on 9/3/12 was substantiated by RRO #2, in a "Report of Investigative Findings." This report notes that RN #2 had responsibility for identifying the discrepancy between the physician's order for 15 minute checks and RCA #3's documentation of doing checks every half hour. The report indicates that RN #2 asked RCA #3 to produce the checks form for review but that RCA #3 failed to comply. No further response by RN #2 was noted. The report contains the following statement by Psychiatrist #1: "staff's failure to monitor (patient #3) every 15 minutes could have placed him at risk of physical harm." RRO #2 recommended disciplinary action for RCA #3.
4. On 10/19/12 Unit Manager #2's "Investigative Summary" of this incident, concluded with recommendations for disciplinary action for RCA #3.
5. In a letter dated 10/22/12, the Human Resources Director informed RCA #3 of a Disciplinary Conference scheduled for 11/9/12. The letter states that work rule violations will be discussed at this conference that may result in disciplinary action.
6. On 10/24/12, Unit Manager #1 reviewed selected facility policies with RCA #3 but did not address work rule violations or disciplinary actions.
7. RCA #3 returned to work on 10/24/12.


1. On 10/30/12 at 10 am Unit Manager #2 confirmed the content of the Incident Report and nursing department documentation referenced above, including the "Investigative Summary" report and listing of dates in #2 (above).
2. On 10/30/12 at approximately 3:30 pm patient #3's recipient rights file was reviewed with (Recipient Rights Officer) RRO #1 and findings noted above were confirmed.
3. On 10/30/12 at approximately 3 pm Unit Manager #1 was asked why there was a delay between RCA #3's documenting of doing 30 minute checks rather than 15 minute checks in the precaution log (on 9/3/12) and completion of an Incident Report (on 9/11/12) and initiation of a neglect investigation. UM #1 responded that it occurred because "a supervisor needed to notice first." UM #1 stated that she did not know why the discrepancy in physician orders and RCA's documentation was not found by nursing staff responsible for patient #2 on the shift when it occurred.
4. The Director of Human Resources was not available for interview during this survey.
5. On 10/30/12 at approximately 11:15 am policy 107 (above) was reviewed with Human Resources Analyst (HRA) #1. HRA #1 was asked if it was against policy to allow RCA #3 to return to work before the disciplinary conference scheduled for 11/9/12 since there was a substantiated finding of patient neglect. HRA #1 stated that she was unaware of any policy prohibiting this practice.