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MEMORIAL HERMANN NORTHEAST 18951 MEMORIAL NORTH HUMBLE, TX 77338 May 15, 2018
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on interview and record review patient right to receive care in a safe setting for Paitent #2 was not met as evidenced by failure to implement facility policy and procedure of investigating allegations of Abuse, Neglect and Sexual Abuse of patients.

Findings include:

Reported alleged sexual abuse by facility male employee on 5/2/18 to a Registered Nurse(RN) who failed to implement facility policy and providing for Patient #2 her Patient Right of a safe setting.

In an interview on 5/14/18 with Risk Manger, RN ID#51 at 1:30 pm she reported she was well acquainted with the reported allegations of sexual abuse from Patient ID#2. Asked by surveyor had she interviewed PCA#60 about the facility's procedure of not performing peri-care or change diapers on a patient of the opposite sex without another staff member of the same sex as patient being present? Nurse,#51 stated, "I had told him this back in February 2018, this was the second time I had to tell him". She further reported PCA#60 was aware of the procedure but reported to RN#51, that patient needed cleaning and no one was available to help. Nurse#51 reported she counseled him do not ever do that again without someone being with him. Was PCA#60 allowed to complete his shift there on the same Unit? To my knowledge yes. He was not removed? No, he remained and finished his shift on that Unit. Where you aware that nurse # 53 asked him to come back into the room of the Patient #2 to assist with a plug she could not get back into the wall? Yes, I was told that. Facility policy reads: that when an allegation of abuse is made reassignment is made, either patient is moved, or staff. Was Patient #2 moved to another location?, Response, "no". Was PCA#60 reassigned different patient or removed? She responded, "no".
RN #51 was asked by the surveyor at anytime did you notify the State, or local law enforcement to notify of the allegation of Sexual Abuse by a male employee of the hospital concerning Patient #2? RN, #51 reported that she did not call the police, or State in either Patient #1 or Patient #2 allegation of sexual abuse.

In a phone interview on 5/15/18 with Nurse ID#53, at 12:30pm was asked if she knew Patient ID#2, she reported she did. She reported that she was on the Unit as a Resource Nurse. She was there helping out the staff, but that Patient ID#2 was not her patient.
She reported that she entered the room on 5/2/18 of Patient#2 around 3:00pm and had been told by Patient #2 "man is not nice to me; he pushes me down to kiss me". Her lunch tray was there I tried to feed her a little bit of food. Her breast had been exposed, gown was off her shoulder. When I came out of the room I told PCA#60 , "do not go back into the room alone, and told him what she said. Again I heard her yelling, I went into Patient #2 room she (Patient#2)reported ," he open's legs and licks me". She was screaming he is mean and bad you can come in but he can't. I heard her screaming again I went into the room. During this visit the Patient #2 had pulled the plug out of the wall and I could not get it back in. I called for help, stepped in hall, asked PCA #60 to help me get it back into the wall. He walked in with me, Patient #2 said: "You are welcome he is not". He left the room. What happened next? I thought she was confused; she does have Dementia. I did tell PCA#60 do not go into the room alone at all. What time was this? Guess, sometime after 4:00pm? I did tell my Nurse Manager,ID#52 in the shift we needed to talk. What time did that happen, 4:30pm or so. Did you talk at that time, she repsonded, "no". We talked about the incident around 6:00pm or after. She(Nurse Manger#52) had been busy till then. Was PCA#60 on the Unit at that 6:00pm time? No, he finished his shift and left by the time we got to talk. What time would that have been; close to 6:00- 6:15pm. Did you tell anyone else about the incident with Patient #2? She reported (nurse #53) just PCA#60 and the bedside nurse, RN # 85. Nobody else, she stated, "no, well the Manager #52".

In a second interview with Nurse Manager ID#52 RN, on 5/15/18 at 1:30 involving Patient #2 she reported the following: She remembered the incident involving staff member PCA#60 and the allegation by Patient #2 of sexual assault. She further reported that at the nurse's station, around 4:30pm she was approached by RN #53 who was floating on the Unit as a Resource Nurse. She(RN#53) told her they needed to talk. RN #52 reported she had been interviewing a new hire and told nurse#53, as soon as she was done they would talk. Nurse #52 was asked by the surveyor, "was there a sense of urgency from Nurse #53 when she said we need to talk? Nurse #52 response was," no". Nurse Manager #52 reported she arrived back to the Unit about 5:45pm, approached RN#53 about 6:15pm. At that meeting Nurse#53 told Manager #52 about what Patient #2 had told her involving PCA #60. Patient #2 alleged that he threw her down and kissed her, then spread her legs and said he was going to lick her. Surveyor asked did nurse #53 report this to anybody else? She responded; "Yes, she told PCA#60 what the Patient #2 said and the bedside nurse #58". Surveyor asked nobody else? Not that I was aware of. What does your policy say if an allegation of abuse has been made by patient? Nurse 52 reported, reassure the patient, make them comfortable, notify my Director. Surveyor asked, are reassignments made if staff are involved? She reported, "yes". With Patient #1 PCA#60 was removed from the schedule till after that patient discharged from the facility. Was that the same procedure followed in Patient #2 allegation? Nurse #53 response was "no". Did he remain on the Unit and finish his shift, "yes". Was he then allowed to go back into Patient #2 room? RN#52 reported, yes, I suppose he could have. Did Nurse #53 tell you that she requested PCA#60 to accompany her into Patient #2 room to asssit with replacing a call light in the wall after she had been told of the allegation involving PCA#60? Yes, she did.

Record review of policy titled, "Investigation of Reported Abuse During an Encounter Policy", dated 09/19/2016 reads:
POLICY STATEMENT:
A person having reasonable cause to believe that any person may be/has been abused, neglected, or exploited during an encounter at facility shall report said abuse, neglect or exploitation without delay to the Hospital/Entity Chief Executive Officer (CEO) or designee (Operations Administration/ Immediate Supervisor) and the Risk Manager so an appropriate investigation can be conducted, to include necessary reports filed with the appropriate regulatory agencies.

Record review of policy titled: Investigation of Reported Abuse During An Encounter Procedure, dated: 10/06/2016 reads:
Procedure:
Responsible Party:
Employee Action
All employess must immediately notify the Operations
Administration (OA) or their immediate supervisor, in accordance with the Identifying and Reporting Victims of
Sexual Assualt/Physical Assualt...
A. a patient states that he/shr has been abuses eglectd or
exploited...
* If a co-worker or charge nuurse is notified first, that individual must "immediately" notify the OA/immediate supervisor.

Risk Manager Immediately notify(activate) Response Team...
A. Determine acuity/urgency of the issue annd idntify any
patient safety issues.
i. If the patient is currently in the facility, implement
measures to make patient safe while investigsation
is being conducted (i.e. reassign staff, move patient, etc.)


Record review of facility policy, titled" Reporting of Known or Suspected Abuse, Neglect and Exploitation of Elderly or Persons with Disabilities, dated, 05/03/2016 reads:
Policy Purpose: To identify and appropriately report the abuse, neglect, and exploitation of elderly or persons with disabilities.
POLICY STATEMENT:
1. In any case where there is a reason to believe an elderly or disabled person is being or has been abused, neglected, or exploited, the clinical staff must notify the appropriate law enforcement agency where the offense occurred.
2. In any case as described in statement 1 involving caretakers, family members or other individuals who have an ongoing relationship with the person, The Department of Family and Protective Services must be contacted.
3. Texas law requires that any person who believes an elderly or disabled person may be suspected of being abused, neglected, or exploited must report circumstances orally or in writing to the appropriate authorities.

Record review of policy titled, "Investigation of Reported Abuse During an Encounter Policy", dated 09/19/2018 reads:
POLICY STATEMENT:
A person having reasonable cause to believe that any person may be/has been abused, neglected, or exploited during an encounter at facility shall report said abuse, neglect or exploitation without delay to the Hospital/Entity Chief Executive Officer (CEO) or designee (Operations Administration/ Immediate Supervisor) and the Risk Manager so an appropriate investigation can be conducted, to include necessary reports filed with the appropriate regulatory agencies.

Record review of procedure titled, "Chaperone Procedure for Providing Intimate Care, dated 04/14/2016 reads:
PROCEDUR PURPOSE: To provide guidance related to use of a chaperone when providing care to a patient which involves intimate care, treatment or procedures with the opposite gender patient.
1. Intimate care may include, but is not limited to:
a. Bathing
b. Peri-care
c. Inserting a foley(catheter)
d. Diaper change ...
h. Toileting when personal touching is needed to provide hygiene
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on interview and record review the facility failed to protect, investigate, and adhere to policy in two (2) of (2) elderly patient's allegations of Abuse and Sexual assualt.

Findings include:

Facility failed to follow written policy and procedure for investigatin of allegations of Abuse, Neglect, and Sexual Abuse by failure to notify the State of the allegation of Pt. #1 Sexual Assualt allegation of 2/18/18 and Pt #2 allegation of Sexual Assualt on 5/2/18 by a male employee of the facility.

Facility failed to follow Policy and Procedure of notification to the local law enforcement and State of the allegation of sexual assualt of Pt ID #1.

Facility failed to provide an environment free from abuse or harrassment for Pt ID # 2 by failing to remove the alleged male Personal Care Attendant (PCA) from the Unit per facility policy or transfer Patient #2 to another area in the hospital.

Patient ID # 1

Interview on 5/14/18 at 11:30 am with RN Manager of 3rd floor ID#52 stated she did recall both Patient ID#1, Patient ID#2 and the allegations of sexual abuse by a male employee on her Unit, (Medical Surgical 3rd floor). She went on to report that Pt #1 alleged to RN #58 that she had been touched inappropriately in her genital area by a male attendant while cleaning her and changing a diaper. Nurse #58 also reported that the male employee had violated procedure of performing pericare on the opposite sex without another person of the patient's same sex in the room. Nurse #52 also reported that she remembered that Nurse ID # 58 told her she had not been using diapers on the patient, but pull ups during the shift and surprised to see the diaper on patient.
The employee did not work the next day and was then transferred for the next few days to another Unit untill Patient ID # 1 discharged , then he returned to the Medical Surgical Unit (3rd floor). To her knowledge he was allowed to continue to work but not her Unit.

Interview on 5/14/18 with Risk Manger ID #51 at 1:30 pm reported that she did not call the State to notify of the allegation of Sexual Abuse by a male employee of the hospital. RN # 51 also reported that she did not call the police, but that Patient ID #1's daughter had gone to Security desk day of the incident and requested the police be called . RN ID #51 stated, " I was called by the Security Desk day and told that the daughter insisted the police be called. It was at that time the police became aware of the alleged sexual assualt at daughters request and not the facility. Surveyor asked, "at anytime during the investigation did you initiate a call to the State or local law enforcement to alert them to the abuse allegation? Her,RN #51 response,"no I did not".
Nurse #51 reported that in her interview with the alleged male PCA#60 the following day; she specifcally told him about the procedure when performing intimate care on a patient of the opposite sex and that they are not to go alone. Was he aware of that procedure, she stated, " yes, he told me he knew to get someone, but patient needed to be cleaned up, so he did it".

Record review of facility policy, titled" Reporting of Known or Suspected Abuse, Neglect and Exploitation of Elderly or Persons with Disabilities, dated, 05/03/2016 reads:
Policy Purpose: To identify and appropriately report the abuse, neglect, and exploitation of elderly or persons with disabilities.
The Department of Aging and Disability Services Definitions:
6. ABUSE- Any act, failure to act or incitement to act, done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This includes verbal, sexual, mental/psychological or physical abuse, including corporal....
d. Sexual abuse - Any touching or exposure of the anus, breast, or any part of the genitals of the resident/patient without the voluntary, informed consent of the resident/patient and with the intent to arouse or gratify the sexual desire of any person and includes, but is not limited to, sexual harrassment, sexual coercion, or sexual assualt.

POLICY STATEMENT:
1. In any case where there is a reason to believe an elderly or disabled person is being or has been abused, neglected, or exploited, the clinical staff must notify the appropriate law enforcement agency where the offense occurred.
2. In any case as described in statement 1 involving caretakers, family members or other individuals who have an ongoing relationship with the person, The Department of Family and Protective Services must be contacted.
3. Texas law requires that any person who believes an elderly or disabled person may be suspected of being abused, neglected, or exploited must report circumstances orally or in writing to the appropriate authorities.

Record review of policy titled: Investigation of Reported Abuse During An Encounter Procedure, dated: 10/06/2016 reads:
Procedure:
Responsible Party:
Employee Action
All employess must immediately notify the Operations
Administration (OA) or their immediate supervisor, in accordance with the Identifying and Reporting Victims of
Sexual Assualt/Physical Assualt...
A. a patient states that he/shr has been abuses eglectd or
exploited...
* If a co-worker or charge nuurse is notified first, that individual must "immediately" notify the OA/immediate supervisor.

Risk Manager Immediately notify(activate) Response Team...
A. Determine acuity/urgency of the issue annd idntify any
patient safety issues.
i. If the patient is currently in the facility, implement
measures to make patient safe while investigsation
is being conducted (i.e. reassign staff, move patient, etc.)