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.

METROPOLITAN ST LOUIS PSYCHIATRIC CTR 5351 DELMAR BOULEVARD SAINT LOUIS, MO 63112 Feb. 27, 2020
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview, record review, and policy review, the hospital failed to prevent one staff (K, Metropolitan St. Louis Psychiatric Center [Metro Psych] Custodial Worker I), from working in patient care areas, after an allegation of sexual abuse was made against Staff K by one Hospital B patient (#24), where Staff K provided contracted services. This resulted in a second allegation of sexual abuse by one Hospital B patient (#25) and a third allegation of similar sexual abuse by one Metro Psych patient (#5), refer to A-0144. The hospital also failed to adequately identify and investigate the allegations against Staff K of sexual abuse by the two Hospital B patients (#24 and #25), and failed to provide documentation of investigation of a third allegation of sexual abuse by Metro Psych patient (#5), refer to A-0145.

These deficient practices resulted in the hospital's non-compliance with specific requirements found under the Condition of Participation: Patient's Rights. The hospital census was 50.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 02/27/20, after the survey team informed the hospital of the IJ, the staff created educational tools, began educating all staff, and implemented interventions to protect the patients.

As of 02/27/20, at the time of the survey exit, the hospital had provided an immediate action plan sufficient to remove the IJ and implemented the following:
- Effective immediately, all employees would have a new Family Care Safety Registry screen (background screening process for abuse/neglect) completed. If any staff member had a disqualifying offensive, they would be placed on administrative absence until their future employment status was determined;
- Immediately, all employees would have a new Family Care Safety registry screen completed on their anniversary month of hire. If any staff member had a disqualifying offence, they would be placed on administrative absence until their future employment status was determined;
- The Director of Psychiatric Facilities completed immediate education to the Chief Operating Officer (COO) and Quality Management Director on the inquiry and investigation process;
- Immediate education of all Department Managers on Abuse and Neglect. This in-service included discussion of the appropriate response to allegations of Abuse and Neglect which required an immediate report to the COO or designee;
- Immediate contract amendment between Metro Psych and Hospital B, that any Metro Psych employee allegation at Hospital B must be reported immediately and in writing to the Metro Psych COO or designee. An Eastern Region investigator would be included in all Hospital B investigations. The final investigation report from Hospital B would include details of the allegation. A Metro Psych inquiry would be completed on the allegation. Any abuse and neglect allegations would be unsubstantiated before the staff member returned to work;
- Immediate education of Human Resources staff, housekeeping supervisors, and dietary supervisors if an allegation or complaint investigation was made at Hospital B, the accused staff was not to have any patient contact. The staff member could not have patient contact in any patient areas until a written report determined the allegation was unsubstantiated and was received by the COO or designee.
- Immediate education of all current Metro Psych employees on Abuse and Neglect on the Missouri Employee Learning System (MELs). The MELs course included information that outlined appropriate response to allegations of abuse and neglect which required an immediate report to the COO or designee; and
- Immediately implemented weekly employee misconduct allegation meetings. The COO would facilitate the meeting and discuss any allegations within the hospital.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on interview, record review, and policy review, the hospital failed to ensure vulnerable patients were provided a safe environment, when hospital leadership was informed that one staff member (Staff K), who provided contracted services for Metropolitan St. Louis Psychiatric Center (Metro Psych, surveyed hospital) within Hospital B patient care areas, was alleged by two patients (#24 and #25) of similar acts of sexual abuse. Hospital B terminated Staff K's contracted services after the second allegation, and Metro Psych allowed him to continue to work in patient care areas, which resulted in a third sexual abuse allegation of similar nature by one patient (#5). These failures had the potential to place all patients at risk for their safety and allowed potential abuse by staff to occur. The hospital census was 50.

Findings included:

1. Review of the hospital's policy, "Employee Misconduct Definitions and Procedures: State Operated Facilities," dated 06/28/17, showed that employee misconduct included an inappropriate relationship with a consumer, and pending completion of the employee misconduct review, the COO could place the staff member on administrative leave with pay or assign them to work in an area away from consumer contact, if available.

During an interview on 02/24/20, at 3:15 PM, Staff A, Chief Operating Officer (COO), stated that Metro Psych had a contract with Hospital B, which included that Hospital B leased two units (patient care areas) as a separate entity within Metro Psych, and that Metro Psych provided daily housekeeping services to those patient care areas.

Record review of the undated document titled, "Patient Safety & Quality Department Event Summary," showed that Hospital B Patient #24 reported that on 08/11/19, Staff K, Custodial Worker I, showed her a pornographic video on his cell phone, placed his hand in his pants, said he had not been with a woman before and asked for a sex act.

Review of a hospital provided document titled, "Individual Schedule Report," dated 08/11/19 through 02/20/20, along with concurrent interview with Staff B, Quality Management Director, showed the following work schedule and timeline for Staff K:
- On 08/14/19, Hospital B notified Metro Psych of a sexual abuse allegation against Staff K, made by Hospital B Patient #24.
- Between 08/15/19 and 09/15/19, Staff K was reassigned (areas of assigned work not documented) to work at Metro Psych (Hospital B requested that Staff K not return to work at that time).
- On 09/16/19, Staff K returned to work at Hospital B (areas of assigned work not documented), and continued to work there through 09/29/19.
- On 09/29/19, Hospital B notified Metro Psych of a second sexual abuse allegation against Staff K, made by Hospital B Patient #25.
- Between 09/30/19 and 01/23/20, Staff K was reassigned to work in Metro Psych, because he was not allowed to return to work in Hospital B patient care areas.
- On 01/23/20, a third sexual abuse allegation was reported to Metro Psych against Staff K, made by Metro Psych Patient #5 (Staff Kwas no longer allowed to work after the third allegation).
- On 01/29/20, Staff K was placed on administrative leave.
- On 02/20/20, Staff K was terminated from employment.

During an interview on 02/26/20, at 2:45 PM, Staff C, Personnel Analyst II, stated that on the morning of 08/15/19, she and Staff D, Housekeeping Supervisor, were made aware of the allegations Hospital B Patient #24 had made against Staff K.

During an interview on 02/25/20, at 11:55 AM, Staff D, Housekeeping Supervisor, stated that she immediately notified Staff O, Chief Financial Officer (CFO), that allegations had been made against Staff K.

Review of an untitled and undated hospital provided document, showed that on 08/15/19, Staff K, was reassigned to work at Metro Psych in Human Resources (non-patient care area), until he returned to work at Hospital B on 09/16/19.

During an interview on 02/26/20, at 2:45 PM, Staff C, Personnel Analyst II, stated that on 09/30/19, she was notified by Hospital B that there had been a second allegation of sexual abuse made against Staff K by Hospital B Patient #25, who alleged that on 09/29/19, Staff K had asked the patient to "suck his dick." Staff C stated that she immediately reported the allegation to Staff A, COO.

During an interview on 02/26/20 at 1:55 PM, Staff B, Quality Management Director, stated that the second allegation against Staff K was a mirrored image to the first allegation against Staff K.

Review of hospital provided emails dated 09/30/19, from 10:24 AM to 12:23 PM, showed the following staff from Metro Psych were notified and aware that Hospital B removed Staff K from work on Hospital B's unit, due to a second allegation of sexual abuse:
- Staff D, Housekeeping Supervisor;
- Staff O, CFO;
- Staff C, Personnel Analyst II;
- Staff E, Human Resources Director; and
- Staff A, COO.

During an interview on 02/25/20, at 11:55 AM, Staff D, Housekeeping Supervisor, stated that Staff K was reassigned to work at Metro Psych (patient care units) until he was terminated from employment.

Review of a hospital provided letter dated 02/10/20, showed that:
- On 01/23/20, Staff K was observed on video to have entered Patient #5's room twice without any legitimate reason.
- The video showed that Staff K did not enter any other patient's room.
- Shortly after Staff K entered Patient #5's room twice, the patient found a letter on her bed that asked, "Do you suck dick?"
- This was a violation of the Employee Misconduct policy, as a result of inappropriate interpersonal staff/consumer relationships.
- On 02/10/20, Staff K signed acknowledgment of receipt of termination letter.

The hospital failed to protect patients when they allowed Staff K to continue to work in patient care areas after repeated, similar allegations of sexual abuse, placing all patients at risk for abuse.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on interview, record review and policy review, the hospital failed to investigate allegations of staff to patient sexual abuse made by two patients (#24 and #25) of two allegations of abuse reported, which occurred at Hospital B. The allegations involved Staff K, Custodial Worker I, employee of Metropolitan St. Louis Psychiatric Center (Metro Psych), who provided contracted services to Hospital B's patient care areas. Due to the lack of investigation, the hospital failed to prevent allegations of staff to patient sexual abuse made by one Metro Psych patient (#5). These failures had the potential to place all patients in the hospital at risk for their safety and allowed for continued abuse by staff. The hospital census was 50.

Findings Included:

1. Review of the hospital's policy titled, "Abuse and Neglect Definitions, Investigation Procedures and Penalties," dated 08/28/18, showed:
- The definition for sexual abuse included promotion or observation for sexual purpose any activity or performance that involved patients. Any play, motion pictures, photography, dance or other visual or written representation is included.
-The department director and the heads of the hospital or designees, upon receipt of any complaint or discovery of unknown injury, shall conduct an inquiry to determine whether there was reasonable cause to believe that any prohibited conduct had occurred.
- The investigations unit would process and investigate all complaints when there is reasonable cause to believe that abuse had occurred.
- Complaints shall be immediately reported to the head of the hospital or their designee.
- Persons who fail to report complaints of known or suspected incidents of abuse or neglect are subject to discipline, criminal prosecution or both.

Review of the hospital's policy, "Investigation Procedures," dated 08/28/18, showed the following definitions and direction:
- Sexual Abuse included but was not limited to promoting or observing for sexual purpose any activity or performance that involved consumers in any play, motion picture, photography, dance, or other visual or written representation.
- Inquiry was a process used by the Chief Operating Officer (COO) or designee to gather facts that surrounded an event or complaint to determine if there was reasonable cause to believe that physical, sexual or verbal abuse, or neglect had occurred.
- The COO or designee upon receipt of any complaint should conduct an inquiry to determine whether there was reasonable cause to believe that any prohibited conduct had occurred.
- Investigation was a process used by the investigations unit to gather facts that surrounded an event once it was determined that there was reasonable cause to believe that physical, sexual or verbal abuse, or neglect had occurred.
- If there was reasonable cause to believe that physical, sexual or verbal abuse had occurred, the COO or designee should immediately refer the complaint to the investigations unit to initiate an investigation.

Review of the hospital's policy, "Employee Misconduct Definitions and Procedures: State Operated Facilities," dated 06/28/17, showed the following definitions and direction:
- Employee Misconduct included an inappropriate relationship with a consumer.
- The COO documented all complaints of employee misconduct on the department Events Management and Tracking (EMT, electronic system for documenting and communicating information related to investigations, to involved individuals) form within 24-hours and completed a review of the incident within 10 working days.
- Pending completion of the employee misconduct review, the COO could place the staff member on administrative leave with pay or assign them to work in an area away from consumer contact, if available.
- If the facts gathered suggested abuse or neglect, the COO or designee would comply with the requirements of the hospital's Investigation Procedures policy within 24-hours.

Review of the hospital provided document titled, "Individual Schedule Report," dated 08/11/19 through 02/20/20, and concurrent interview on 02/26/20, at 1:55 PM with Staff B, Quality Management Director, showed the following work schedule and timeline for Metro Psych Staff K, Custodial Worker I:
- On 08/14/19, Hospital B notified Metro Psych of a sexual abuse allegation against Staff K, made by Hospital B Patient #24.
- Between 08/15/19 and 09/15/19, Staff K was reassigned (area of work not documented).to work at Metro Psych (Hospital B did not want Staff K to return at that time).
- On 09/16/19, Staff K returned to work at Hospital B, and continued to work there through 09/29/19.
- On 09/29/19, Hospital B notified Metro Psych of a second sexual abuse allegation against Staff K, made by Hospital B Patient #25.
- Between 09/30/19 and 01/23/20, Staff K was reassigned to work in Metro Psych patient care areas. Hospital B would not allow Staff K to return to work at Hospital B.
- On 01/23/20, a third sexual abuse allegation was reported to Metro Psych against Staff K, by Metro Psych Patient #5 (Staff K was no longer allowed to work at Metro Psych after the third allegation).
- On 01/29/20 Staff K was placed on administrative leave pending investigation.
- On 02/20/20, Staff K was terminated from employment.

During an interview on 02/24/20 at 3:15 PM, Staff A, COO, stated that:
- Metro Psych had a contract with Hospital B.
- The contract included that Hospital B leased two units (floor space) as a separate entity within Metro Psych, and Metro Psych provided daily housekeeping to Hospital B.
- Metro Psych did not conduct an investigation into the sexual abuse allegations that Hospital B Patient #24 made against Metro Psych Staff K.

During an interview on 02/26/20, at 2:45 PM, Staff C, Personnel Analyst II, stated that on the morning of 08/15/19, she and Staff D, Housekeeping Supervisor, were made aware of Hospital B Patient #24's sexual abuse allegations against Staff K.

During an interview on 02/25/20, at 11:55 AM, Staff D, Housekeeping Supervisor, stated that she immediately notified Staff O, Chief Financial Officer (CFO), that allegations had been made against Staff K.

During an interview on 02/26/20 at 4:10 PM, Staff O, CFO, stated that:
- In 08/2019 Staff D, Housekeeping Supervisor, was under her direct supervision.
- Staff D told her there was an issue with one of the Metro Psych staff members that worked at Hospital B.
- She assumed it was a minor issue as Staff D did not tell her it was serious and she "just forgot about it."
- Staff D told her the Supervisor for Hospital B did not think it was a serious issue.

Review of an untitled and undated hospital provided document, showed that on 08/15/19, Staff K, was reassigned to work at Metro Psych in Human Resources (non-patient care area), until he returned to work at Hospital B on 09/16/19.

During an interview on 02/25/20 at 10:23 AM, Staff A, COO, stated that she contacted Staff W, Department of Mental Health (DMH, a licensing entity of Metro Psych) Investigator, and was advised that because Patient #24 was a patient at Hospital B, it did not fall under the authority of the DMH to investigate, and an investigation was not completed.

During an interview on 02/25/20 at 10:00 AM, Staff B, Quality Management Director, stated that Staff E, Human Resources Director, reviewed and advised, after consultation with with Staff V, Legal Department, that Metro Psych had no grounds to terminate Staff K, or not allow him to continue to work. Staff E stated they had no documentation of the allegations made by Patient #24.

During an interview on 02/26/20, at 2:45 PM, Staff C, Personnel Analyst II, stated that on 09/30/19, she was notified by Hospital B that there had been a second allegation of sexual abuse against Staff K, made by Hospital B Patient #25, who alleged that on 09/29/19, Staff K had asked the patient to "suck his dick." Staff C stated that she immediately reported the allegation to Staff A, COO.

During an interview on 02/26/20 at 1:55 PM, Staff B, Quality Management Director, stated that the second allegation against Staff K was a mirrored image to the first allegation against Staff K.

Review of hospital provided emails dated 09/30/19, from 10:24 AM to 12:23 PM, showed the following staff from Metro Psych were notified and aware that Hospital B removed Staff K from work on Hospital B's unit due to a second allegation of sexual abuse:
- Staff D, Housekeeping Supervisor;
- Staff O, Chief Financial Officer (CFO);
- Staff C, Personnel Analyst II;
- Staff E, Human Resources Director; and
- Staff A, COO.

During an interview on 02/26/20 at 4:10 PM, Staff O, CFO, stated that on 09/30/19, there was an email that stated Staff K was not allowed to work in Hospital B. She did not know what the allegations were, but stated that Staff K had been disciplined before for poor job performance.

During an interview on 02/26/20, at 2:45 PM, Staff C, Personnel Analyst II, stated that DMH investigators did not get involved with the first or second allegation of sexual abuse. Staff C stated that they did not feel there was any point to conduct an investigation.

During a telephone interview on 02/27/20 at 8:15 AM, Staff W, DMH Investigator, stated that she had no EMT information and no knowledge of the allegations for 08/15/19 and 09/29/19, against Staff K.

During an interview on 02/25/20, at 11:55 AM, Staff D, Housekeeping Supervisor, stated that Staff K was reassigned to work at Metro Psych (patient care units).

Review of a hospital provided letter dated 02/10/20, showed that:
- On 01/23/20, Staff K was observed on video to have entered Patient #5's room twice without any legitimate reason.
- The video showed that Staff K did not enter any other patient's room.
- Shortly after Staff K entered Patient #5's room twice, the patient found a letter on her bed that asked, "Do you suck dick?"
- This was a violation of the Employee Misconduct policy, as a result of inappropriate interpersonal staff/consumer relationships.
- On 02/10/20, Staff K signed acknowledgment of receipt of termination letter.

Although requested, a copy of the inquiry and/or investigation related to the third allegation against Staff K, was not provided.

During an interview on 02/26/20 at 3:29 PM, Staff E, Human Resource Director, stated that prior to 02/25/20, he was unaware of the issues with Staff K, and that if an issue happened within Metro Psych, they would investigate.

The hospital failed to follow their own policies and procedures when they failed to complete investigations of alleged staff-to-patient sexual abuse and failed to implement immediate measures to remove Staff K from patient care areas. The hospital failed to recognize the seriousness of the allegations when they allowed Staff K to continue to work in patient care areas, which resulted in the sexual abuse of other patients.