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.

UNIVERSITY OF KANSAS HOSPITAL 4000 CAMBRIDGE STREET KANSAS CITY, KS 66160 Jan. 25, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, staff interviews, patient interviews, document review, and security video review the hospital failed to monitor staff to ensure they were providing care in a safe setting by appropriately following hospital policy and training for three of three Continuous Observation (CO) staff (Staff O, DD and GG) observed and one of one security videos observed of nursing staff (RN Staff W and RN Staff CC), (Refer to tag A-0144). The hospital failed to conduct a thorough investigation and take actions including education and monitoring for one of one report of staff (CO Staff O) to patient (Patient #1) sexual abuse and failed to ensure reporting to the State Agency in a timely manner (Refer to tag A-0145).

This systemic failure has the potential to create an unsafe patient care environment including the risk of serious injury, harm, impairment, or death.

At approximately 2:25 PM on 1/24/2018 after observations of CO staff performing their job duties it was identified that they failed to provide a safe environment for patient care. This was communicated to the Centers for Medicare and Medicaid Regional Office representative and it was determined to be an Immediate Jeopardy (IJ). Survey staff notified administrative staff members (Staff A) of the Immediate Jeopardy situation.

As of 1/25/2018 at 4:30 PM, the hospital had provided an immediate action plan sufficient to remove the IJ by implementing the following:

- Emergency Department Notification

Who: The Director of Emergency Services Met with all ED Supervisors and provided expectations for the CO staff.

- Educated all CO staff must provide constant observation of patients with no distractions, be positioned between the patient and the door with the door and/or curtain open, unless an intervention is being performed for patient privacy.

- Implement the new Maize Electronic Medical Record access audit process to ensure staff are not accessing areas of the medical record not necessary for their patient care role.

- Re-educating staff on current policies restricting medical record access to necessary areas for their patient care role.

- The Associate Chief Nursing Officer and Director of Accreditation and Regulatory Compliance met with the inpatient Nurse Managers, Nursing Administrative Coordinators and Nursing Directors to ensure all CO's hospital wide are positioned between the patient and the door with the door/and or curtain open, the CO must constantly observe the patient with no distractions.

- A member of the Regulatory Compliance team, Nurse, Patient Care Assistant, Nursing Assistant, Health care Technician will conduct observations to ensure policy compliance of Constant Observers. The observations will be conducted at least every two hours until the CO action plan is implemented. This includes all areas of the hospital.

- Hourly Safety/Intentional Rounding Checks conducted by a nursing leader from each unit to verify in real time that staff have performed rounding on each patient hourly. This will be completed every four hours until 100% compliance is achieved, then every eight hours until 100% compliance is achieved, and then once per shift 24/7 until the hospital is in compliance. This will be conducted in all areas of the hospital.


Findings include:


See further evidence at A-0144: The hospital failed to provide care in a safe setting by not monitoring and supervising their constant observation staff (CO Staff O, GG, and DD) and not monitoring an emergency department patient (Patient #1) at regular intervals.

See further evidence at A-0145: The hospital failed to prevent sexual abuse of a patient (Patient #1) by a staff member (CO Staff O), failed to report an allegation of abuse in a timely manner.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, staff interview, security video review, and document review the hospital failed to provide care in a manner which ensured patient safety for 1 of 3 patients, (Patient # 1), who were placed on Constant Observation (CO) and failed to ensure staff followed the Constant Observation Policy for three of three CO patients (Patients #1, #35 and #36) . This deficient practice places all patients placed on CO at risk for harm and injury.


Findings include:

- Patient #1's medical record review on 1/16/2018 revealed she was admitted on [DATE] at 9:56 PM with alcohol intoxication and complaint of homicidal ideation (thoughts of harming others) related to her history of schizophrenia with auditory hallucinations (hearing voices that are not real) that direct her to harm others. Patient #1 was placed on constant observation for her safety and protection. Emergency Department Tech Staff O was assigned to provide constant observation for Patient #1.

- Review of video footage provided by the hospital regarding Patient #1's Constant Observation on 1/17/2018 revealed the following information. The video start time on 11/17/2017 was 3:00 AM and stop time was 5:30 AM.

Video Start 3:00 AM, Patient #1's room identified as room #17 and nurse's station viewable from camera angle revealed the door closed and curtain pulled shut. The hospital failed to have the door open when the patient was under constant observation.

- Review of document titled "1-to-1 Observation Expectations" on 1/19/2018 directed: What is expected of the sitter: always keep the door open for safety.

Interview on 1/23/2018 at 11:11 AM, ED Director Staff L revealed: During constant observation the door should be open. If the door needs to be closed the curtain should be open.

3:03 - 3:06 AM - RN Staff W entered room #17. Review of medical record documentation revealed that Staff W administered the medication Zyprexa (used to treat certain mental/mood conditions such as schizophrenia and bipolar disorder and causes drowsiness).

3:08 - 3:42 AM- RN Staff W observed eating at the nurse's station that is located directly facing the patient's room. (Room #17). RN Staff W had visualization of Patient #1's room with the door closed and curtain pulled shut with a CO (Staff O) in place. RN Staff W failed to ensure the door was open and the CO Staff was safely placed between the patient's bed and the door.

- Review of document titled "1-to-1 Observation Expectations" on 1/19/2018 directed: What is expected of the sitter: Always place yourself between the door and the patient so that you can exit quickly if you need to call for help.

3:35 AM - A person identified by RN Staff K (member of the ED staff viewing the security video) as Patient #1's companion exits the room and is near the nurse's station and then returns to the room at 3:38 AM.

3:44 AM - The patient's companion exits the room leaving the area. The door and curtain remain closed to the room and the companion does not return.

3:54 AM- CO Staff O was identified by RN Staff K. Staff O was observed opening the sliding glass door from the inside of Patient #1's room.

3:55 AM - An unidentified female employee is seen walking down the hallway toward Staff O with a blanket. Staff O takes the blanket and reenters the room and closes the sliding glass door and curtain remains closed.

5:30 AM video footage ended. RN Staff W did not return to Patient #1's room for the 2 hours and 25 minutes after they administered the medication. RN Staff W failed to complete hourly rounding or to monitor the patient after medication administration to check to see if it had the desired effect or any side effects. RN Staff W did not intervene when Staff O was incorrectly performing their job duties (door and curtain closed, with computer in the room while doing a constant observation) nor did the on duty supervisor (Nursing Staff CC) monitor for compliance of nurse rounding or CO requirements.

- Review on 1/23/2018 of policy titled "Constant Observation" directed, RN Responsibilities: Check in with the Constant Observer often to ensure they know the standard of care for that patient. Update throughout the shift of any changes in patients orders or care.

Interview on 1/17/2018 at 2:25 PM, Nursing Shift Supervisor RN HH revealed the following information: We know there are changes to the patient's condition by our hourly rounding. Hourly rounding is completed by both nurses and techs; it's a joint responsibility. When there is a CO (constant observer) who is a tech, the nurse should still do the hourly rounding. At the very least, the CO tech should communicate with the nurse. The nurse is ultimately responsible for the hourly rounding getting done.

The hospital failed to provide any video footage after 5:30 AM on 11/17/2017.

Interview with Senior Director Staff C on 1/17/2018 indicated this was all the available footage of the patient encounter for Patient #1 that began at 9:56 PM on 11/16/2017 and ended at 7:18 AM on 11/17/2017.

The record showed that Patient #1 was discharged at 7:30 AM on 11/17/2017.

- Review on 1/16/2018 at 1:30 PM of KU Medical Center Police document revealed, Patient #1 filed a report on 11/17/2017 at 4:11 PM indicating an incident occurred at University of Kansas Hospital between 3:45 AM and 7:00 AM that morning. Page 2 of the document was not provided by the Police Department as they stated page 1 was the only document that was a matter of public record.

Interview with Patient #1 on 1/20/2018 at 4:45 PM, I went to the hospital that night (November 16, 2017) because I was planning to hurt myself or other people. I was given Zyprexa while in the ED. They said they were going to admit us and so [Patient #1's companion] went ahead and left. Staff O was on the right side of me facing the wall. The rails to the bed were up to keep me from falling out of the bed. Then he put his fingers on my genitals, then I shut down and didn't move. I tried pretending like it wasn't happening. Then I started to fall asleep again. I was so tired. Staff O told me to scoot up in the bed next to the rail. I only had a gown on because they had taken all my cloths and everything. Then he inserted his penis and went in and out a couple of times. Then he pulled out and said he couldn't finish. Then he covered me up with a blanket. I was scared and sedated and just laid there. Staff O was just so calm like he knew no one would come in. He acted like it wasn't the first time he had done it. I had a bad experience with reporting things, so I just told my companion when he got home from work.

- Review of Timeline - Report of Alleged Emergency Department (ED) Assault provided by Senior Director Staff C: 11/17/2017 1600 - KU PD receives report from a patient (Patient #1) of alleged rape by an ED staff person (Staff O) during the night of 11/17/2017, while she was a patient in the ED. Patient accompanied by KU PD to outside hospital (B) for Sexual Assault Nurse Examiner (SANE).

- Review on 1/24/2018 at 10:30 PM, Medical Record from hospital B (an acute care hospital located about 20 minutes away) revealed, Patient #1 arrived at the hospital on [DATE] at 8:26 PM. A sexual assault exam was performed. Patient #1 indicated she had been penetrated in the vagina by Staff O's fingers once and by Staff O's penis four to five times.

Interview on 1/17/2018 at 3:45 with Administrative Staff A revealed, Patient #1 went to security sometime around 5:00 PM on 11/17/2017. Staff A stated that while Patient #1 was at hospital B, KU Police reported that the patient had received a text message from Staff O, but they did not disclose the content of the text message to University of Kansas Hospital Staff. Staff A indicated at that point we were aware Staff O had accessed the patient's medical record information and used it.

- A Kansas City Star article dated 1/12/2018 read, Man in custody for alleged rape at KU hospital. A [AGE]-year-old man has been charged with committing a sexual assault in November at the University of Kansas Hospital in Kansas City, Kansas. Staff O is charged in Wyandotte County District Court with raping a victim who was unconscious or physically powerless. The alleged crime occurred on November 16, according to court records. The charge was filed December 14, and Staff O was booked into the Wyandotte County Detention Center on Tuesday. He is being held on a bond of $200,000 and is scheduled to appear in court on January 16.

- Review of employee records for Staff O revealed a hire date of 1/10/2017. Staff O received a written warning for hitting a female coworker on the bottom on 11/6/2017 (11 days prior to the alleged sexual assault), and was fired for allegedly raping a patient on 11/18/2017.

Interview on 1/23/2018 at 11:11 AM with ED Director Staff L said that he was involved in the internal investigation and was notified that Staff O had swatted one of the nurses on the butt. He said that his supervisor and the NAC (Nurse Administrative Coordinator) put Staff O on administrative leave. Staff O admitted it and we gave him a written warning. It was HR's recommendation to give him a written warning for a first offense. I could have pushed that. I did recommend termination initially.

The hospital did not notify the State Agency of the alleged sexual assault. The hospital notified the Centers for Medicare and Medicaid Services (CMS) about the alleged sexual assault on January 11, 2018 (55 days after the incident).

- Review of policy titled "Abuse Assessment Program: Key Components of Preventing, Protecting/Investigating, and Reporting Abuse in Patients and Employees" directed, Reporting/Responding: Maintain a policy which places accountability for mandatory reporting with all of the clinical care team with the Department of Case Management (Social Workers) to assure consistent expert reporting in accordance with State and Federal law.

K.S.A. 39-1431 (a) Any person who is licensed to practice any branch of the healing arts, the chief administrative officer of a medical care facility, a licensed social worker, a licensed professional nurse, a licensed practical nurse, a case manager, who has reasonable cause to believe that an adult is being or has been abused, neglected or exploited or is in need of protective services shall report, immediately from receipt of the information, such information or cause a report of such information to be made in any reasonable manner. Reports shall be made to the Kansas department for children and families during the normal working week days and hours of operation. Reports shall be made to law enforcement agencies during the time the Kansas department for children and families is not in operation.

Interview on 1/24/2018 at 9:30 AM with Administrative Staff A confirmed they were sent a link from the State Agency for reporting an incident, but stated they did not follow the link and provide the report. Staff A indicated they were unaware they needed to report to the state because they are a deemed facility accredited by The Joint Commission (TJC). Staff A stated they did report the incident to TJC on 12/14/2017 (27 days after being notified by local police of the alleged sexual assault).

The Staff (Staff O, RN Staff W, and Nursing Staff CC) did not provide constant observation as directed by hospital policy and procedure the night of the alleged sexual assault, and the hospital's investigation did not identify this failure as a contributing factor to the alleged sexual assault of Patient #1. Therefore, at the time of survey, Staff (DD, GG, ED Supervisor Staff FF, and unidentified RN) continue to provide constant observation in violation of the hospital's policy and procedure and continue to place patients at risk for injury, elopement, or abuse.

- Observation on 1/23/2018 at 9:38 AM of Continuous Observer (CO) Staff DD, revealed them acting as a CO for both Patient #35 (ED room 19) admitted for PCP withdrawal (agitation, seizures) and Patient #36 (ED room 20) admitted with suicide attempt. Staff DD was seated in a chair located in the hallway directly in front of both rooms, with a computer on wheels in front of him. Staff DD left their position to provide care for Patient # 35 and left Patient #36 unsupervised for approximately one minute. Even though nearly two months have passed since the alleged rape of Patient #1 by Staff O, the CO staff continue to perform their duties incorrectly by having access to a computer and are being assigned to watch two patients at the same time.

- Review of slide presentation titled, "1-to-1 Observation Expectations"; "What is expected of the Sitter" directed: continuous visual observation of the patient at all times, and should not have a computer or a WOW [workstation on wheels] in the room.

Interview on 1/23/2018 at 9:38 AM with CO Staff DD, they acknowledged that they often are assigned as a CO for two patients at one time. Staff DD stated, "I received CO training when I started here in the ED (5/16/2010). I have not received any training on CO since then."

- At 9:46 AM, CO Staff DD was relieved by CO Staff GG and began to provide continuous observation for both Patient #35 and #36. During handoff, unidentified RN and ED Supervisor Staff FF stood in front of Staff DD and Staff GG blocking the line of site between both of the CO staff members and the two patients for approximately one minute while providing information on unrelated patients. Even though nearly two months have passed since the alleged sexual assault of Patient #1 by Staff O, RN and Supervisory RN Staff continue to ignore the policies and procedures for CO staff to have continuous visual observation of the patient at all times and to have one to one observation of a singular patient at all times.

- Observation on 1/23/2018 at 9:47 AM of Staff GG, revealed them providing CO duties for Patient #36. Staff GG moved the chair and computer on wheels from the hallway into patient #36's room behind the partially pulled curtain which concealed the presence of a CO, and positioning themselves so the patient was nearest to the door. Even though nearly two months have passed since the alleged rape of Patient #1 by Staff O, The CO staff failed to follow the safety expectations by not placing themselves between the door and the patient and by having a WOW in the room. This deficient practice could allow patients to leave the room easily and places the CO at risk for not being able to get help quickly if the patient becomes violent.

Interview on 1/18/2018 at 10:00 AM and again on 1/23/2018 with Administrative Staff A, confirmed there has not been any formal training of all CO Staff assigned throughout the hospital nor has there been any monitoring of CO staff or Nursing staff to ensure compliance with hospital policies and training after it was identified they were not performing their job duties as required.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, staff interview, medical record review, security video review and document review the hospital failed to report an alleged sexual assault of a patient (Patient #1) by a staff member (Staff O) in a timely manner, they failed to identify issues around constant observation as a contributing factor of the alleged sexual assault, and failed to respond to the incident by providing education, training, and monitoring of their constant observation and nursing staff. This deficient practice places all patient at risk for abuse, neglect, and harassment.

Findings include:

- Patient #1's medical record review on 1/16/2018 revealed she was admitted on [DATE] at 9:56 PM with alcohol intoxication and complaint of homicidal ideation (thoughts of harming others) related to her history of schizophrenia with auditory hallucinations (hearing voices that are not real) that direct her to harm others. Patient #1 was placed on constant observation for her safety and protection. Emergency Department Tech Staff O was assigned to provide constant observation for Patient #1.

- Review of video footage provided by the hospital regarding Patient #1's Constant Observation on 1/17/2018 revealed the following information. The video start time on 11/17/2017 was 3:00 AM and stop time was 5:30 AM.

- Video Start 3:00 AM, Patient #1's room identified as room #17 and nurse's station viewable from camera angle revealed the door closed and curtain pulled shut. The hospital failed to have the curtain open when the door was closed, during constant observation of Patient #1.

- Review of document titled "1-to-1 Observation Expectations" on 1/19/2018 directed: What is expected of the sitter: always keep the door open for safety.

Interview on 1/23/2018 at 11:11 AM, ED Director Staff L revealed: During constant observation the door should be open. If the door needs to be closed the curtain should be open.

3:03- 3:06 AM - RN Staff W entered room #17. Review of medical record documentation revealed that Staff W administered the medication Zyprexa (used to treat certain mental/mood conditions such as schizophrenia and bipolar disorder and causes drowsiness).

3:08- 3:42 AM- RN Staff W observed eating at the nurse's station that is located directly facing the patient's room. (Room #17). RN Staff W had visualization of Patient #1's room with the door closed and curtain pulled shut with Staff O in place. RN Staff W failed to ensure the door was open and the Staff O was safely placed between the patient's bed and the door.

- Review of document titled "1-to-1 Observation Expectations" on 1/19/2018 directed: What is expected of the sitter: Always place yourself between the door and the patient so that you can exit quickly if you need to call for help.

3:35 AM - A person identified by RN Staff K (member of the ED staff viewing the security video) as Patient #1's companion exits the room and is near the nurse's station and then returns to the room at 3:38 AM.

3:44 AM - The patient's companion exits the room leaving the area. The door and curtain remain closed to the room and the companion does not return.

3:54 AM- Staff O was identified by RN Staff K. Staff O was observed opening the sliding glass door from the inside of Patient #1's room.

3:55 AM - An unidentified female employee is seen walking down the hallway toward Staff O with a blanket. Staff O takes the blanket and reenters the room and closes the sliding glass door and curtain remains closed.

5:30 AM video footage ended. RN Staff W did not return to Patient #1's room for the 2 hours and 25 minutes after they administered the medication. RN Staff W failed to complete hourly rounding or to monitor the patient after medication administration to check to see if it had the desired effect or any side effects. RN Staff W did not intervene when Staff O was incorrectly performing their job duties (door and curtain closed, with computer in the room while doing a constant observation) nor did the on duty supervisor (Nursing Staff CC) monitor for compliance of nurse rounding or CO requirements.

- Review on 1/23/2018 of policy titled "Constant Observation" directed, RN Responsibilities: Check in with the Constant Observer often to ensure they know the standard of care for that patient. Update throughout the shift of any changes in patients orders or care.

Interview on 1/17/2018 at 2:25 PM, Nursing Shift Supervisor RN HH revealed the following information: We know there are changes to the patient's condition by our hourly rounding. Hourly rounding is completed by both nurses and techs; it's a joint responsibility. When there is a CO (constant observer) who is a tech, the nurse should still do the hourly rounding. At the very least, the CO tech should communicate with the nurse. The nurse is ultimately responsible for the hourly rounding getting done.

The hospital failed to provide any video footage after 5:30 AM on 11/17/2017.

Interview on 1/17/2018, Senior Director Staff C indicated this was all the available footage of the patient encounter for Patient #1 that began at 9:56 PM on 11/16/2017 and ended at 7:18 AM on 11/17/2017.

The record showed that Patient #1 was discharged at 7:30 AM on 11/17/2017.

- Review on 1/16/2018 at 1:30 PM of KU Medical Center Police document revealed, Patient #1 filed a report on 11/17/2017 at 4:11 PM indicating an incident occurred at University of Kansas Hospital between 3:45 AM and 7:00 AM that morning. Page 2 of the document was not provided by the Police Department as they stated page 1 was the only document that was a matter of public record.

Interview with Patient #1 on 1/20/2018 at 4:45 PM, I went to the hospital that night (November 16, 2017) because I was planning to hurt myself or other people. I was given Zyprexa while in the ED. They said they were going to admit us and so [Patient #1's companion] went ahead and left. Staff O was on the right side of me facing the wall. The rails to the bed were up to keep me from falling out of the bed. Then he put his fingers on my genitals, then I shut down and didn't move. I tried pretending like it wasn't happening. Then I started to fall asleep again. I was so tired. Staff O told me to scoot up in the bed next to the rail. I only had a gown on because they had taken all my cloths and everything. Then he inserted his penis and went in and out a couple of times. Then he pulled out and said he couldn't finish. Then he covered me up with a blanket. I was scared and sedated and just laid there. Staff O was just so calm like he knew no one would come in. He acted like it wasn't the first time he had done it. I had a bad experience with reporting things, so I just told my companion when he got home from work.

- Review of Timeline - Report of Alleged Emergency Department (ED) Assault provided by Senior Director Staff C: 11/17/2017 1600 - KU PD receives report from a patient (Patient #1) of alleged rape by an ED staff person (Staff O) during the night of 11/17/2017, while she was a patient in the ED. Patient accompanied by KU PD to outside hospital (B) for Sexual Assault Nurse Examiner (SANE).

- Review on 1/24/2018 at 10:30 PM, Medical Record from hospital B (an acute care hospital located about 20 minutes away) revealed, Patient #1 arrived at the hospital on [DATE] at 8:26 PM. A sexual assault exam was performed. Patient #1 indicated she had been penetrated in the vagina by Staff O's fingers once and by Staff O's penis four to five times.

Interview on 1/17/2018 at 3:45 with Administrative Staff A revealed, Patient #1 went to security sometime around 5:00 PM on 11/17/2017. Staff A stated that while Patient #1 was at hospital B, KU Police reported that the patient had received a text message from Staff O, but they did not disclose the content of the text message to University of Kansas Hospital Staff. Staff A indicated at that point we were aware Staff O had accessed the patient's medical record information and used it.

- A Kansas City Star article dated 1/12/2018 read, Man in custody for alleged rape at KU hospital. A [AGE]-year-old man has been charged with committing a sexual assault in November at the University of Kansas Hospital in Kansas City, Kansas. Staff O is charged in Wyandotte County District Court with raping a victim who was unconscious or physically powerless. The alleged crime occurred on November 16, according to court records. The charge was filed December 14, and Staff O was booked into the Wyandotte County Detention Center on Tuesday. He is being held on a bond of $200,000 and is scheduled to appear in court on January 16.

- Review of employee records for Staff O revealed a hire date of 1/10/2017. Staff O received a written warning for hitting a female coworker on the bottom on 11/6/2017 (11 days prior to the alleged sexual assault), and was fired for allegedly raping a patient on 11/18/2017.

Interview on 1/23/2018 at 11:11 AM with ED Director Staff L said that he was involved in the internal investigation and was notified that Staff O had swatted one of the nurses on the butt. He said that his supervisor and the NAC (Nurse Administrative Coordinator) put Staff O on administrative leave. Staff O admitted it and we gave him a written warning. It was HR's recommendation to give him a written warning for a first offense. I could have pushed that. I did recommend termination initially.

The hospital did not notify the State Agency of the alleged sexual assault. The hospital notified the Centers for Medicare and Medicaid Services (CMS) about the alleged sexual assault on January 11, 2018 (55 days after the incident).

- Review of policy titled "Abuse Assessment Program: Key Components of Preventing, Protecting/Investigating, and Reporting Abuse in Patients and Employees" directed, Reporting/Responding: Maintain a policy which places accountability for mandatory reporting with all of the clinical care team with the Department of Case Management (Social Workers) to assure consistent expert reporting in accordance with State and Federal law.

K.S.A. 39-1431 (a) Any person who is licensed to practice any branch of the healing arts, the chief administrative officer of a medical care facility, a licensed social worker, a licensed professional nurse, a licensed practical nurse, a case manager, who has reasonable cause to believe that an adult is being or has been abused, neglected or exploited or is in need of protective services shall report, immediately from receipt of the information, such information or cause a report of such information to be made in any reasonable manner. Reports shall be made to the Kansas department for children and families during the normal working week days and hours of operation. Reports shall be made to law enforcement agencies during the time the Kansas department for children and families is not in operation.

Interview on 1/24/2018 at 9:30 AM with Administrative Staff A confirmed they were sent a link from the State Agency for reporting an incident, but stated they did not follow the link and provide the report. Staff A indicated they were unaware they needed to report to the state because they are a deemed facility accredited by The Joint Commission (TJC). Staff A stated they did report the incident to TJC on 12/14/2017 (27 days after being notified by local police of the alleged sexual assault).

The Staff (Staff O, RN Staff W, and Nursing Staff CC) did not provide constant observation as directed by hospital policy and procedure the night of the alleged sexual assault, and the hospital's investigation did not identify this failure as a contributing factor to the alleged sexual assault of Patient #1. Therefore, at the time of survey, Staff (DD, GG, ED Supervisor Staff FF, and unidentified RN) continue to provide constant observation in violation of the hospital's policy and procedure and continue to place patients at risk for abuse.

- Observation on 1/23/2018 at 9:38 AM of Continuous Observer (CO) Staff DD, revealed them acting as a CO for both Patient #35 (ED room 19) admitted for PCP withdrawal (agitation, seizures) and Patient #36 (ED room 20) admitted with suicide attempt. Staff DD was seated in a chair located in the hallway directly in front of both rooms, with a computer on wheels in front of him. Staff DD left their position to provide care for Patient # 35 and left Patient #36 unsupervised for approximately one minute. Even though nearly two months have passed since the alleged rape of Patient #1 by Staff O, the CO staff continue to perform their duties incorrectly by having access to a computer and are being assigned to watch two patients at the same time.

- Review of slide presentation titled, "1-to-1 Observation Expectations"; "What is expected of the Sitter" directed: continuous visual observation of the patient at all times, and should not have a computer or a WOW [workstation on wheels] in the room.

Interview on 1/23/2018 at 9:38 AM with CO Staff DD, they acknowledged that they often are assigned as a CO for two patients at one time. Staff DD stated, "I received CO training when I started here in the ED (5/16/2010). I have not received any training on CO since then."

- At 9:46 AM, CO Staff DD was relieved by CO Staff GG and began to provide continuous observation for both Patient #35 and #36. During handoff, unidentified RN and ED Supervisor Staff FF stood in front of Staff DD and Staff GG blocking the line of site between both of the CO staff members and the two patients for approximately one minute while providing information on unrelated patients. Even though nearly two months have passed since the alleged sexual assault of Patient #1 by Staff O, RN and Supervisory RN Staff continue to ignore the policies and procedures for CO staff to have continuous visual observation of the patient at all times and to have one to one observation of a singular patient at all times.

- Observation on 1/23/2018 at 9:47 AM of Staff GG, revealed them providing CO duties for Patient #36. Staff GG moved the chair and computer on wheels from the hallway into patient #36's room behind the partially pulled curtain which concealed the presence of a CO, and positioning themselves so the patient was nearest to the door. Even though nearly two months have passed since the alleged rape of Patient #1 by Staff O, The CO staff failed to follow the safety expectations by not placing themselves between the door and the patient and by having a WOW in the room. This deficient practice could allow patients to leave the room easily and places the CO at risk for not being able to get help quickly if the patient becomes violent.

Interview on 1/18/2018 at 10:00 AM and again on 1/23/2018 with Administrative Staff A, confirmed there has not been any formal training of all CO Staff assigned throughout the hospital nor has there been any monitoring of CO staff or Nursing staff to ensure compliance with hospital policies and training after it was identified they were not performing their job duties as required.