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 interview and record review, the hospital failed to protect patient's rights to be free from all forms of abuse or harassment. When there was an allegation of sexual assault, which involved a certified nursing assistant (CNA), the hospital did not initiate their investigation and the CNA was not suspended in a timely manner, and the governing body did not discuss about the incident. These failures had the potential to miss opportunities for the hospital to maintain or improve a safe environment for patients.


1. Review of a local newspaper, dated 9/3/19, indicated CNA A was charged with sexually assaulting Patient 1 in late March 2019 and certified nursing assistant A (CNA A) was arrested.

On 9/4/19, the Department received a faxed report regarding the incident from the hospital.

During an interview with the Human Resources Director (HRD) on 10/2/19 at 11:35 a.m., she stated Patient 1 was brought in the emergency department and discharged to a crisis center on 3/30/19. On 3/30/19, a staff from the crisis center called a charge nurse in the hospital's emergency room and stated Patient 1 told them she was raped by CNA A in the restroom at the emergency room . The HRD stated the hospital's internal investigation started on 4/29/19, CNA A was suspended on 8/20/19, and arrested on 8/30/19.

Review of the hospital's policy, "Abuse, Neglect and Violence" dated 1/23/19, indicated staff are to report allegations of abuse to authorities/agencies as required or permitted by law or regulation.

2. During an interview with the quality and risk management director (QRMD) on 10/3/19 at 1:20 p.m., she stated she was aware of the allegation CNA A sexually assaulted Patient 1 when the facility staff reported the incident to human resources on 3/30/19. The QRMD stated the hospital's governing body did not discuss the alleged incident of sexual assault.

During an interview with the chief executive officer (CEO) on 10/3/19 at 1:14 p.m., the CEO reviewed the governing body's minutes from March 2019 to September 2019, and stated there was no evidence the governing body discussed the allegation of sexual assault.

During an interview with the CEO and the QRMD on 10/3/19 at 1:35 p.m., both CEO and QRMD stated the hospital's governing body should have discussed, addressed, analyzed, and took an action for the alleged sexual assault.

Review of the facility's policy, "Board of Director Bylaws Review" dated 1/23/19, indicated the facility board (governing body) is responsible for "...ongoing quality assessment, performance improvement, patient safety and utilization management activities...assuring that quality and patient safety issues are addressed and resolved appropriately..."