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.

LANCASTER GENERAL HOSPITAL 555 NORTH DUKE STREET LANCASTER, PA 17602 Nov. 14, 2018
VIOLATION: GOVERNING BODY Tag No: A0043
Based on a review of facility policy and procedures, a review of facility documents and interviews with staff, it was determined the Governing Body failed to consistently implement the policies and procedures to ensure that patients were free from abuse.

As evidenced by the manner in which investigations of abuse were handled, the Governing Body failed in its responsibility to provide oversight to ensure the hospital's policies related to patient abuse, were consistently followed. The facility's policy, "Vulnerable Abuse", stated that staff should respond timely to allegations of abuse, perform a comprehensive investigation of all abuse allegations, and report the allegation to outside agencies. The Governing Body's failure to ensure that the policy was consistently followed, placed the patients of the facility at risk for abuse.

Interview with EMP1 on November 14, 2018, confirmed that the facility had not followed their abuse policy and reported the allegations as stated in the "Vulnerable Adult Abuse Policy."
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on a review of facility policy and procedures, facility documents, and interviews with staff, it was determined that the hospital's failure to follow established procedures to investigate and report allegations of abuse, placed patients at risk for abuse.

The governing body failed to ensure its medical staff was accountable to the governing body for the quality of care provided to patients and the conduct of the hospital. As evidenced by a review of facility documentation and interviews with staff, the medical staff failed to implement and monitor the approved Vulnerable Adult Abuse policy which placed patients at risk for abuse.

Interview with EMP1 on November 14, 2018, confirmed that the facility had not followed their abuse policy and reported the allegations as stated in the "Vulnerable Adult Abuse Policy."
VIOLATION: PATIENT RIGHTS Tag No: A0115
This condition is not met as evidenced by:

Based on the facility's failure to develop and implement a system which ensured that all allegations of abuse were reported timely and investigated as per policy, it was determined that the facility was not in compliance with the condition level regulation for patient rights.

Cross Reference:
482.13(c)(2) Patient Rights: Care in Safe Setting
482.13(c)(3) Patient Rights: Free from Abuse/harassment
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on a review of facility documents, medical records and staff interview, it was determined the facility failed to provide care in a safe setting by failing to investigate and report allegations of abuse.
As a result of the facility's report of alleged abuse of MR1, documentation of additional allegations since July 2017 was requested. Review of an additional three allegations revealed that none of the incidents had been reported to outside agencies as per the facility' s Vulnerable Adult Abuse Policy. The events are listed below:
Event 1. An investigation was started by the facility on September 12, 2018. A review of the facility documentation revealed "...The Patient was sleeping and states (the patient) woke up startled. Patient reported to the (nurse) that (the patient) found the ____ (title redacted) touching (the patient's) genitals while touching the employee's own genitals.

Event 2. An investigation was started by the facility on July 18, 2017. A review of the facility documentation revealed "Patient self reported on July 21, 2017 ... that ___ (title redacted) allegedly fondled (the patient's) genitals for 5 to 10 minutes while applying topical medication to a rash..."

Event 3. An investigation was started by the facility on June 7, 2018. A review of the facility documentation revealed "...Per patient while (the patient) was at the elevator bank the ... nurse caring for (the patient) grabbed and pulled (the patient) backwards...Patient was upset that ... nurse put hands on (the patient) in rough manner..."

Event 4. An investigation was started by the facility on August 7, 2017. A review of facility documentation revealed " Wife was visiting pt (patient) and became angry and began striking pt. The pt was able to restrain ...wife's hand and the staff immediately intervened."

A review of facility policy "Vulnerable Adult Abuse" revealed "Policy Statement: It is the policy of Lancaster General Health for its employees, personnel, and staff who care for patients and who have reasonable cause to suspect that a Vulnerable Adult is a victim of Abuse, Neglect, Exploitation, or abandonment to report such suspicion in accordance with this policy and Pennsylvania's Adult Protection Services Act...Definitions:...Abuse: The occurrence of one or more of the following acts:...3. Sexual Harassment. This term means unwelcome sexual advances, request for sexual favors, and other verbal or physical conduct of a sexual nature...5. Abuse between family or household...Such abuse means the occurrence of one or more of the following acts: (a) placing another in reasonable fear of imminent serious bodily injury: ...
Procedures: when an employee or staff member has reasonable cause to suspect that a Vulnerable Adult is a victim of Abuse, Neglect, Exploitation, or abandonment, the employee or staff member shall do the following: (a) If not a physician, auxiliary health care provider, nurse or departmental supervisor of the patient or the patient's care team, notify a member of the patient's care team directly, immediately. (b) The patient 's physician, auxiliary health care provider, or departmental supervisor shall immediately make an oral report to the Protective Services Hotline..." (d) within 48 hours after making the oral report to the Protective Services Hotline, work with the administrator to send a written report ...2. In addition, when the reporter has reasonable cause to suspect that the Vulnerable Adult is the victim of Sexual Abuse, .... the reporter shall do the following in addition to the steps outlined above: (a) immediately make an oral report to the local police. (b) immediately make an oral report to DHS by calling the mandatory abuse reporting line .... (c) within 48 hours after making the oral report to the local police and DHS, complete the form attached to this policy ....and send it to the local police " . B. Other Procedure: 1. The medical record shall reflect a careful assessment, evaluation, and summary of the injuries or other signs or symptoms of the suspected abuse. "
The facility failed to follow the " Vulnerable Adult Abuse " Policy. According to documentation in MR1, on September 12, 2018, the patient reported an incident to staff that occurred earlier that morning. The patient stated that an employee had touched the patient in a sexual nature. The patient indicated that the sound of a zipper and a snap from an elastic band was heard when the patient awoke to find the employee at the bedside. Staff responded to the allegation by reporting the incident internally and began the investigation. The facility failed to immediately report the allegation of abuse to the Protective Services Hotline and failed to file a written report of the incident to Protective Services; failed to file an oral report with the police and DHS and send the form utilized to document the investigation to the police and DHS within 48 hours. The facility also failed to document in the patient's medical record an assessment, evaluation, and summary of the injuries or other signs or symptoms of the suspected abuse. A review of the patient' s medical record revealed no documentation of the allegation and/or follow-up with the patient following report of the incident.
Interview with EMP2 on November 14, 2018, confirmed the facility's investigation of the incident lacked a detailed account of who interviewed the patient and employee and the order and the time that the interviews were conducted. Interview also revealed that the investigative team did not have all of the information collected through the interviews to review before making a decision that the incident was " unfounded ". Based on the result of the investigation, EMP3 was permitted to return to work and the allegation was never reported to Protective Services, local police, or DHS. On November 8, 2018, 57 days following the conclusion of the hospital ' s investigation, the local police came to the hospital unannounced and arrested the accused employee.
Interview conducted on November 14, 2018 with EMP1 revealed that Events 1 and 2 were reported to the Patient Safety Authority incorrectly as incidents. When the facility staff realized the errors, the events were upgraded to Infrastructure Failures. Further interview revealed that none of the events were reported to the appropriate authorities, as required, because the facility had done an investigation and the events were unfounded. Interview revealed that the facility failed to have a system in place which ensured that investigations were comprehensive, timely, and reported to outside agencies as stated by the Vulnerable Abuse Policy.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on a review of facility policy, facility documents and staff interview (EMP), it was determined facility staff failed to follow approved reporting requirements for allegations of sexual assault and suspected sexual assault for two events that occurred at the facility.

Event 1: An investigation was initiated by the facility on September 12, 2018. A review of the facility documentation revealed"...The Patient was sleeping and states he woke up startled". Patient reported to the nurse that a (staff member) was touching the patient's genitals. The allegation was not reported to the Department until November 12, 2018. Based on the facility's documentation, it was difficult to determine the series of events including what time the staff interviewed the patient related to Event 1 and how a determination was made that the incident was unfounded. Based on the final determination, the employee was permitted to return to work and the allegation was never reported to law enforcement and/or the state entity.

Event 2: An investigation was initiated by the facility on July 21, 2017. A review of the facility documentation revealed "Patient self reported"...that a (staff member) allegedly fondled the patient's genitals for 5 to 10 minutes while applying topical medication to a rash. The allegation was not reported to the Department until July 27, 2017.

Interview with EMP1 on November 14, 2018, at 3:00 PM confirmed that the allegations of abuse were not reported to outside entities as per the facility policy.