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.

This CONDITION is not met as evidenced by:

Based on interview, record review and review of facility policies and procedures, the facility failed to adequately investigate and report an allegation of sexual abuse for 1 of 1 patient (Patient #1) and to train their employees in the process of which department in the facility investigated reports of abuse.

Failure to adequately investigate and report an allegation of abuse puts patients and/or the public at risk for abuse.

Findings include:

1. The facility had a policy entitled "Clinical Risk Management Team", 2.2.10, revised 11/21/13. The policy read in part :The Clinical Risk Management Team (CRMT) is a group of WSH (Western State Hospital ) staff designated by the appointing authority to review all submitted reports alleging patient abuse and/or neglect and injuries of unknown origins and make recommendations. The CRMT provides recommendations to those charged with provding direct patient care".

2. Document review revealed they did not have a policy which defined the steps needed to be taken to investigate an allegation of abuse.

3. Review of Patient #1's medical record revealed on 10/17/2016 the patient disclosed to their therapist they had used former Staff #1's phone to take pictures of their breasts for Staff #1. The patient further disclosed Staff #1 had "brought in various food items" for the patient as well.

4. Review of facility documentation of the incident revealed the facility used a system called "Fuse Investigation Ticket System. The form had a ticket with a synopsis of when the call from the outside source was received at the facility. The ticket was dated 10/3/2016 no other information on the form provided.

5. On 10/31/2016 at 10:12 AM Staff #2 was interviewed. Staff #2 stated they received a phone call on 10/3/2016 from an outside source stating that Staff #1 had pictures of Patient #1 on their phone. Staff #2 stated the nature of the pictures was not disclosed to them. Staff #2 reported this information to their supervisor (Staff #3). Staff #2 added that they heard the employee immediately resigned from working at the facility on 10/3/2016 the same day the call came in to the facility.

6. On 10/31/2016 at 12:00 PM Staff #3 was interviewed. Staff #3 stated they received the phone call from Staff #2 on 10/3/2016 about the concern Staff #1 may have taken pictures of Patient #1. Staff #3 immediately took Staff #1 off the schedule for work. Staff #3 did not talk to Staff #1 about the allegation or the patient but stated he/she heard the employee quit the same day the phone call came in to the facility. Staff #3 stated they received communication from the Investigative Management Office (IMO) on 10/10/2016 to call the outside source that called in the allegations to get more details about the nature of the pictures. Staff #3 stated a phone call was made with another employee Staff #4.

7. On 10/31/2016 at 1:00 PM Staff #3 and #4 was interviewed. Staff #4 stated a phone call was made on 10/11/2016 by them and Staff #3 to the outside source that had called in the allegations on Staff #1. The individual disclosed the pictures on the phone were of Patient #1's breasts. Staff #4 stated then an email was sent to the IMO for investigation. Staff #3 stated they thought the IMO investigated all allegations of abuse.

8. On 10/28/2016 at 3:30 PM Staff #5 from the IMO was interviewed by phone. He/she stated the IMO did not do the investigations of abuse but rather they were handled by the CRMT. The CRMT would then make a report of the allegations to the IMO. He/she stated a referral was made to the local police department on 10/11/2016 about the allegations and the local police department accepted the referral on 10/24/2016 for investigation.

9. Review of the employee file for Staff #1 revealed a letter in their employee file dated 10/19/2016 which stated in part "You resigned from your position effective October 4, 2016 and your resignation was accepted on the same day. With your resignation, the investigation and any pending discipinary action by the agency have been suspended. Should you return to state service, the investigation will be reopened, and if the allegations are substantitated, and/or there are any findings, the appropriate level of action will be determined by the agency".

10. On 10/31/2016 at 1:10 PM Staff #6 and #7 were interviewed. They verified the above information. They stated because the employee quit the investigation was stopped. They stated the CRMT should have started the investigation and shared the results with IMO. The facility CRMT was going to start tracking and trending cases in the Quality Care Council. They further acknowledged staff needed education about the process of reporting to the CRMT rather than the IMO and about reporting to the department allegations of abuse..