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 record review and and interviews the facility failed to identify opportunities for improvement and failed to take actions aimed at performance improvement related to timely reporting of allegations of sexual abuse for 1 of 4 incident reports sampled (patient #1).

The findings include:

A review was conducted of an incident report entered into the facility's electronic reporting system on 9/21/2020. The report addressed concerns voiced by staff member G, a safety sitter, involving patient #1 in which the sitter stated that at approximately 1930 (7:30 PM) on 9/20/2020, staff member F, a Patient Care Technician (PCT) had entered patient #1's room to take the patients vital signs. The sitter reported that the PCT stood very close to the patient's bed for what seemed to be a long time and kept bending down and whispering to the patient. She heard the patient say "magic touch" and reported that she could see the PCT's pants moving. She further reported that before the PCT left the room he kissed the resident on her forehead. At this time the sitter told the patient she was going to report the incident. The incident report indicated the staff member G had reported her concerns to the house supervisor immediately on 9/20/2020 approximately between 7:30PM and 8:00PM.

The incident report did not indicate the initial actions taken with PCT F.

A review was conducted of the timesheet for PCT F which revealed he continued to provide patient care following the allegation on 9/20/2020 and worked until 9/21/2020 at 6:23AM.

On 11/4/20 at approximately 12:53 PM, an interview was conducted with the Risk Manager and the Director of In-patient Nursing (DON) who reported they did not remember what actions had been taken but the DON said she believed the PCT (staff member F) was told not to enter the patients room and was given a new assignment.

On 11/5/20 at approximately 10:37 AM, a telephone interview was conducted with the House Supervisor, who was working on the night the incident occurred. During the interview she confirmed that PCT F was not questioned about the incident prior to the end of his shift and was allowed to provide patient care until the end of his shift the following morning, approximately 11 hours after the incident. The House Supervisor further confirmed that she did not attempt to notify the facility's leadership including risk management until the next morning (9/21/20) stating "I guess probably should have reached out to risk management that night".

On 11/05/2020 at approximately 2:07PM, an interview was conducted with the Executive Director for Clinical Safety and Excellence during which she stated that she first learned PCT F had continued to provide patient care following the allegation of abuse on 11/05/2020. She was asked if the facility had identified a need to address the reporting or investigation process which allowed the PCT to continue to work with patients for 11 hours after the allegation made by the sitter, she replied "I was not acutely aware that the event happened the night before. I made the assumption that the event had just happened, so it did not come to my attention that there was a lengthy time frame between the event and the reporting. I was not aware until today (11/5/20) that the event happened the night before. I did not know that the alleged perpetrator continued to provide patient care after the even was reported (by the sitter)". She further reported that the facility had not offered in-services or redirection for staff to ensure timeliness of reporting "There hasn't been anything done because this is a surprise to me. I have no explanation of how that happened".