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 review of policies and procedures, hospital documents, and medical records, and interviews with hospital staff, the hospital failed to ensure patients received care in a safe setting and according to hospital policies. Review of hospital documentation concerning an allegation of possible sexual abuse did not demonstrate the hospital investigated, analyzed and implemented changes to the processes/policies and procedures and environment to ensure a safe setting for patients and staff.


1. Patient #1 was placed on one-to-one (1:1) observation on 02/16/2012 at 1345 and remained on this until discharged on [DATE] at 0040 (actually left the hospital at 0130).

2. The hospital's policy concerning 1:1 observation, PI-142, with a review/revised date of 10/2011 recorded, "Staff must be within an arm's length away from (the) patient at all times." The policy required "same sex staff must monitor" during times of sleeping, restroom use, and showering.

3. The hospital did not follow its policy to ensure patient safety. According to the monitoring sheets, a male staff was assigned to monitor Patient #1, a female, on the day-shift (0700 to 1500) for both 02/16 and 17/2012. With the exception of documentation at 1430 on 02/16/2012 by a female staff member, all day shift documentation for both days was recorded by the male staff. On 02/17/2012, the staff member documented the patient was in her room from 0700 through 1115 and 1230 through 1515. Documentation in the record did not demonstrate other individuals were present in the patient's room. (Review of Patient #3's, Patient #1's roommate, medical record for 02/17/2012, same time period did not show Patient #3 was in the room for any extended period of time.) The male staff documented the patient was sleeping in the room multiple times. The patient later alleged sexual abuse by the staff member.

4. Review of staffing sheets showed the hospital had coverage to place a female staff member to provide 1:1 observation of the patient on the day shift on 02/17/2012.

5. Hospital documents provided did not demonstrate the hospital had developed and instituted corrective actions to ensure staff and patients would not be placed in this compromising situation again.
a. The form entitled, "Intensive Analysis", with no date of the meeting, only documented that the administrator on call would be notified if a "staff of opposite sex" was placed as the staff assigned to provide 1:1 coverage.

b. The Quality committee meeting minutes for 03/13/2012 recorded:
i. That holds/restraints for the increased for the prior month, but the minutes did not reflect an analysis of this information or a corrective plan to reduce the number of needed restraints. Staff A stated, during the exit conference on the afternoon of 04/23/2012, that the overall number had decreased since the previous quarter.
ii. Documentation of an allegation of abuse on 02/17/2012. The minutes did not contain analysis of the causative factors, review of the hospital processes/policies and procedures and determination if any of the hospital established procedures needed corrective actions/changes to ensure a safe setting/environment for staff and patients.
Based on review of policies and procedures, hospital documents, personnel file and medical records, and interviews with hospital staff, the hospital failed to follow its policy to ensure abuse did not occur. For one of one patient (Patient #1) who alleged abuse by a hospital staff member, the hospital staff did not follow the hospital's procedure when allegations of abuse by staff occurred.


1. The hospital's policy, RI-105, with a review/revise date of 08/2011 and 03/2012, stipulated all cases of reported abuse would be investigated and resolved. The policy documents the Compliance Officer or designee in conjunction with the Director of Clinical Services and Director of Nursing will initiate preliminary investigation.

2. Review of hospital documents and medical records documented Patient #1 reported to nursing staff that a staff member had touch the patient inappropriately/had sexual contact with the patient. The hospital's records documented the policy specified individuals were notified and the staff member (who was not present at the time of the allegation) was placed on administrative leave.

3. The hospital provided no evidence an investigation of the allegation was performed. Only the written statements by the staff present at the time the Patient #1 made know the allegation of sexual abuse was provided. The material did not contain interviews with other staff and patients present on the unit at the time of the alleged occurrence, including Patient #1's roommate and the alleged perpetrator. The written summary by the only staff present on the unit during the time of the alleged incident only wrote about what Patient #1 told her about the alleged incident.

4. When the surveyors ask Staff B, on the afternoon of 04/23/2012, about investigating the reported allegation, she stated that the hospital's lawyer had investigated and she had reported the occurrence to the required authorities. No documentation of investigation was provided.

5. The hospital's policy stipulated that "if the investigation has resulted in personnel action against an employee, the written documentation concerning the investigation will be placed in the employee's personnel file." According to Staff A and B action was taken concerning Staff D, but review of the personnel file did not demonstrate the policy was followed. The personnel file contained not documentation of the investigation.
Based on review of medical records and hospital documents, the hospital failed to ensure the registered nurse (RN) supervised the nursing care for each patient, followed established policies and procedures and standards of care and assigned staff accordingly. This occurred for one of one patient (Patient #1), who was placed on one-to-one (1:1) observation, monitored by opposite sex staff, and whose medical record was reviewed.


The hospital's policy concerning 1:1 observation, PI-142, with a review/revised date of 10/2011 recorded, "Staff must be within an arm's length away from (the) patient at all times." The policy required "same sex staff must monitor" during times of sleeping, restroom use, and showering.

1. The supervising RN/Campus Supervisor did not supervise nursing staff to ensure staff and Patient #1 was provided care in a safe setting.
a. The staffing sheet for 02/17/2012 for the day shift (0700 to 1500) showed the adult unit was staffed with one female RN, one female licensed practical nurse (LPN), one female mental health tech (MHT) who was "shadowing" and one male MHT. The census for the unit was nine with only one patient on 1:1 observation, a female. The Campus Supervisor did not ensure a female was assigned to monitor the female 1:1 patient.
b. Staff B told the surveyors on the afternoon of 02/23/2012 that the female MHT that had been pulled to monitor the patient had called and stated she would not be at work and that was the reason why the male had been assigned to be in close contact with the patient at all times. The surveyors requested the Supervisor Reports to assure contacts were attempted to try to locate another female to provide 1:1 observation and/or the supervisor was advised a male was assigned to monitor a female patient and was involved in the decision to allow this practice, but none was provided.

2. The RN on the unit did not supervise staff and the care provided to ensure policies and procedures were followed and safe care in a safe setting was provided to Patient #1 on 02/17/2012 on the day shift.
a. According to Patient #1's medical record, with the exception of a shift summary, only a male MHT charted on the patient for the time period of 0700 to 1500. The medical record documented the patient spent most of the shift, from 0700 to 1115 and 1230 to 1500 in her room. The male MHT documented multiple entries that the patient was asleep for extended periods of time on the observation sheet.
b. Review of the medical record of the patient's roommate, Patient #3, documented Patient #3 stayed in other areas of the unit, not in the room with Patient #1 and the male MHT.
c. The patient later reported inappropriate behavior by the male MHT toward her.