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, interview and record review, the facility failed to provide 1 of 1 patient (#1) alleging sexual abuse with a timely, through investigation, increasing the risk of abuse for all patients with sexual abuse allegations. Findings include:

Record Review:

Review of reports and records, on 3/18/13 from approximately 10:30 am - 4:30 pm, revealed:

1. An Incident Report dated 3/7/13 notes patient #1's statement, accusing one peer and several staff of sexual assault.
2. The 3/7/13 Incident Report states: "Pt. (patient) was examined by on call Dr."
3. There was no documentation identifying the "on call Dr." or any physician's note/report noting a physical examination of patient #1 on 3/7/13 in the patient's clinical record.
4. The 3/7/13 Incident Report notes that the Office of Recipient Rights (ORR) was informed of the incident.
5. Recipient Rights Advisor #2's investigation file revealed no interviews until 3/18/13. There were two , 1-2 sentence interviews dated 3/18/13 in the file.
6. A "Report Filed to Police Agency," dated 3/7/13, by facility Safety Officer #, states: "Dr. (#1) notified Safety that Wayne County SAFE had examined (patient #1) and determined that (patient #1's story was consistent." The report did not contain a "complete description of the allegation, including witness names" and did not document distribution of the report, required by policy #203.

Policy Review:

Policy review conducted on 3/18/13 revealed:

1. "Abuse and Neglect" # 203, effective 4/3/13, states: "Upon...receiving a report of suspected/alleged abuse/neglect incident or an apparent or suspected Rights violation...the patient shall be assessed for injuries and if apparent, a physician shall be immediately notified...The Physician: examines the patient for external injuries indicative of suspected sexual abuse (if alleged)."
2. "Abuse and Neglect" # 203, effective 4/3/13, does not state when abuse/neglect investigations will be initiated.
3. "Non-Discrimination, Patient Rights Protection, and Grievance Resolution" #223, states: ORR (Office of Recipient Rights) is responsible for investigating any potential patient rights violation." (ORR staff are on-site Monday-Fridays, on the day shift only.
4. "Abuse and Neglect: Definitions and Reporting" #203, effective 4/3/13, states: "Safety Director/Officer on-duty: "Completes WRPH Form "Report Filed to Police Agency" (WRPH-336) with a "complete description of the allegation, including witness names" and sends copies of the completed WRPH-336 to: Hospital Director, Chief of Clinical Affairs, Director of Nursing, Human Resources, ORR."


Interviews conducted on 3/18/13 revealed:

1. At approximately 10:50 am patient #1 was interviewed. The patient denied recall of this incident.
2. At approximately 3 pm the complainant's Supervisor at Adult Protective Services (APS) was interviewed. (The complainant was unavailable.) The APS Supervisor verified the complaint statements regarding observation of trauma to patient #1's vaginal and anal areas. The results of the rape kit were unavailable at this time.
3. At approximately 3:40 pm, the Acting Director of Nursing (ADON) was interviewed, verifying that patient #1's record contained no documentation of a physical examination by a physician on 3/7/13, as stated in the 3/7/13 Incident Report.
4. The ADON stated that the Unit Manager, absent on 3/18/13, had "some staff interview notes on her desk" in regard to this incident. (Policies do not state any supervisory nursing responsibility to investigate abuse/neglect allegations except: "If directed by the Hospital Director/Designee.")
5. At approximately 3:15 pm Recipient Rights Advisor (RRA) #2 was interviewed. RRA #2 stated that she typically works at this facility only 2 days per week. so "there was a delay in starting this investigation" (from 3/7/13 until 3/18/13).
6. At approximately 5 pm the Risk Manager/Compliance Officer verified that Office of Recipient Rights staff are not available to initiate abuse investigations on evenings, weekends or Holidays. Policies do not identity who is responsible at these times.
7. At approximately 12 noon the Fire and Safety Officer Supervisor verified that there was no documentation indicating that Safety Officer #1's report (form #336) documenting that "(Physician #1) notified Safety (Department) that Wayne County SAFE had examined (patient #1) and determined that (patient #1's) story was consistent" was distributed as required in policy #203 (above). The Supervisor stated that it should have been distributed and distribution documented.
8. The (above-336) report did not contain a complete description of the allegation, including witness names, per policy (above). This finding was verified by the Fire and Safety Officer Supervisor at approximately 12 noon.


1. There was insufficient evidence to substantiate either allegation. Although patient #1 had signs of physical trauma, there was insufficient evidence to draw conclusions regarding possible causes. The allegation that several staff were involved, including some from other shifts, and the patient's significant psychiatric impairment, were considered in determining this finding.
2. A Standard level citation was written at A-0145 regarding failure to initiate a timely and through investigation and follow policies and procedures for investigating the allegation.