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.

TEXAS COUNTY MEMORIAL HOSPITAL 1333 SAM HOUSTON BOULEVARD HOUSTON, MO 65483 July 23, 2020
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interview, record review, and policy review, the Governing Body failed to:
- Ensure the Chief Executive Officer (CEO) was responsible and accountable for the effective management of the entire hospital.
- Ensure adequate oversight of patient care related to the prevention, identification, and investigation of the allegations of abuse by two patients (#11 and #12).
- Ensure accountability occurred for the oversight of Staff M, Emergency Department (ED) Physician.
- Ensure the hospital conducted thorough investigations of abuse allegations per their zero tolerance patient abuse policy.

These failed practices placed all patients at risk for abuse and inappropriate behavior from Staff M, ED Physician. The hospital census was 11. The ED census was seven.

The severity and cumulative effect of these failed practices resulted in the hospital's non-compliance with 42 CFR 482.12 Condition of Participation: Governing Body, when the hospital failed to provide safe, quality health care, and failed to prevent patient abuse.

Refer to A-0057 for further details.
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and policy review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible and accountable for the effective management of the entire hospital, which included accountability for the effective oversight of one Emergency Department (ED) Physician, Staff M, when the CEO failed to ensure Staff M was removed from patient care, and failed to ensure a thorough investigation was completed, after two patients (#11 and #12) of two patients reviewed, alleged that Staff M touched them inappropriately and/or made inappropriate comments during their exam, when they presented to the ED for care and treatment.

This failed practice placed all patients at risk for abuse. The hospital census was 11. The ED census was seven.

Findings included:

1. Review of the hospital's document titled, "Bylaws," approved 09/24/15, showed the following directives for Article XVI - Code of Conduct:
- The protection of patients, employees and others in the hospital and the orderly operation of the medical staff and hospital were paramount concerns when incidents of inappropriate conduct, which included sexual harassment of employees, patients, other members of the medical staff and others, were addressed.
- Examples of "inappropriate conduct" included "sexual harassment," which was defined as any verbal and/or physical conduct of a sexual nature that was unwelcomed and offensive to those individuals who were subjected to it or who witnessed it.
- A disruptive practitioner was an individual who manifested conduct which adversely impacted the operation of the hospital, compromised or had the potential to compromise patient care. Such conduct could include sexual harassment to staff members and/or patients.
- A single incident of inappropriate conduct or a pattern of inappropriate conduct could be so unacceptable that immediate disciplinary action was required.
- Medical staff leadership and hospital administration would institute procedures that facilitated prompt reports of inappropriate conduct and prompt action as appropriate under the circumstances.

Review of the hospital's policy titled, "Zero Tolerance - Patient Abuse," dated 06/2015, showed that:
- The hospital would exercise a zero tolerance of verbal, sexual, physical and mental abuse by employees, family members, visitors or other patients.
- The intent of the policy was to protect patient health and safety and ensure that high quality care was provided to all.
- A system had been developed and implemented to identify, investigate, prevent and report any incident, or suspected incident of abuse, neglect, mistreatment, or misappropriation of patient property.
- Sexual Abuse included, but was not limited to sexual harassment, sexual coercion, or sexual assault.
- While an investigation would be conducted, the accused individual(s), or those suspected responsible for the abuse/neglect and who were employees of the hospital, would be placed on suspension pending the results of the investigation.

Review of the hospital's document titled, "Position Description and Standards of Performance - Chief Executive Officer," dated 12/2019, showed that under the general direction of the governing authority of the hospital (Board of Trustees), the (CEO) administered, directed and coordinated all activities and employees of the hospital to carry out its objectives in the provision of health care. The CEO also provided for personnel policies and practices that adequately supported sound patient care and services.

Review of Patient #12's ED record dated 06/18/20 at 6:07 PM, showed that the patient, a [AGE]-year-old male, presented with complaints of left leg pain.

During an interview on 07/20/20 at 4:54 PM, Staff D, Registered Nurse (RN), ED Nursing Director, stated that:
- When she triaged Patient #12, he asked which ED Physician was on and he verbalized that he did not want that "Pakistani" (Staff M, ED Physician) to care for him, because the last time the patient was in the ED (06/04/20), Staff M touched his thigh, told him that he was "handsome" and asked if he (Staff M) could touch the patient's beard.
- Patient #12 reported that he was married and "not that way."
- Patient #12 stated that he wanted to report the incident because he did not want Staff M, ED Physician, to be inappropriate with others, especially children.
- She reported the alleged inappropriate actions of Staff M, to the Chief Nursing Officer (CNO); however, the CNO did not give her direction to remove Staff M, from the ED until completion of the investigation. Staff M was allowed to continue to work and finished the remainder of his regularly scheduled night shift.
- She filled out an incident report and was informed by administrative staff that an investigation would take place.
- Human Resources was notified of the alleged inappropriate behavior of Staff M, toward Patient #12.

Review of Patient #11's ED record dated 07/02/20 at 7:28 PM, showed that the patient, a [AGE]-year-old male, presented with complaints of a cut on his right hip that resulted from an all-terrain vehicle (ATV) accident.

During an interview on 07/20/20 at 4:54 PM, Staff D, RN, ED Nursing Director, stated that:
- A [AGE]-year-old male presented to the ED because he had been involved in an ATV accident and required stitches to his hip.
- When an ED Technician went to assist the patient for discharge, he reported to the ED Technician that Staff M, ED Physician, had "spanked his butt" and "he was not that way."
- Patient #11 also reported to the ED Technician that Staff M asked him (Patient #11) if he liked milk because the patient had a "fat butt".
- The ED Technician reported that the patient's older sister was present and witnessed Staff M's physical and verbal interactions toward the patient and acknowledged what the patient reported.
- Staff I, Physician, Medical Director, had addressed with Staff M, the first allegation reported by Patient #12 and was in the process of investigating those allegations.
- The expectation was to remove the alleged perpetrator from patient care until completion of the investigation.

During an interview on 07/20/20 at 5:14 PM, Staff G, RN, Quality Director, stated that:
- Staff were to be removed from patient care pending the results of investigations when allegations of abuse/neglect occurred by staff to patients.
- Incident reports of alleged inappropriate behavior by physicians would go to Staff H, CEO.
- She would not be included in physician matters because Staff H was responsible for any issues concerned with medical staffs' conduct.
- Even if an alleged abuse/neglect allegation involved a physician, her expectation as the Quality Director would be that the physician would be removed from patient care pending results of the investigation.

During an interview on 07/20/20 at 5:48 PM, Staff I, Physician, Medical Director, stated that:
- There had recently been two allegations made by two different ED patients that Staff M had inappropriately touched them when Staff M cared for them.
- It would depend on the situation if an alleged perpetrator should be removed from patient care after allegations were made.
- All allegations needed to be taken seriously and investigated.

During an interview on 07/21/20 at 2:08 PM, Staff M, ED Physician, stated that he denied asking Patient #12 if he could touch his beard or that he stated to the patient that he was a handsome man, and stated that he did not "slap" Patient #11's "butt"; however, the patient's "butt" did "jiggle" when the patient laughed.

During an interview on 07/21/20 at 2:45 PM, Staff N, Unit Clerk, stated that:
- If a patient alleged that abuse or neglect occurred from a staff member, the staff member should be removed pending investigation.
- He had witnessed Staff M be inappropriate with male employees, and had even "smacked them on the ass" on several occasions.
- Staff M had never been held accountable for his poor behavior.

During an interview on 07/20/20 at 5:30 PM, Staff H, CEO, stated that:
- He acknowledged that Staff M, ED Physician, was a current employee of the hospital.
- He acknowledge that he had received two complaints related to Staff M's alleged inappropriate behavior toward two male patients that presented to the hospital's ED seeking care and treatment.
- He had not provided re-training/education to Staff M related to the alleged inappropriate behaviors reported by the two male patients.
- He had not provided re-training/education to other medical staff employed at the hospital related to the zero tolerance patient abuse policy.
- He followed the hospital's "By-Laws" under the section that addressed conduct when he addressed the two alleged incidents of inappropriate behaviors from the two patients with Staff M. Since Staff M was a physician, he (CEO) believed the By-Laws were the appropriate guidelines to follow and not the "nursing" policy related to patient abuse and neglect.

During an interview on 07/21/20 at 10:15 AM, Staff K, Physician, Board of Trustees Director, stated that:
- He received information about events that happened at the hospital regularly per either board meetings or memos.
- If an event occurred that was urgent, he would receive a phone call about the event.
- He had been informed of the allegations made against Staff M, ED Physician, and the allegations of inappropriate behaviors were discussed at the board meeting; however, he was not present at that meeting but had received notification of the allegations.
- His expectation for a thorough investigation would include interviews from all parties involved, for example, patients, visitors, and staff, and would also include any witness statements.
- He expected that the hospital's administration would be responsible for the investigation, the board would be informed, the hospital's policies and procedures would be followed and the alleged perpetrator would be removed depending on the severity of the allegation.
- The main focus was patient safety and staff should err on the side of safety and the benefit of doubt rests on the reporter.

The hospital failed to remove Staff M, ED Physician, on 06/18/20, after Patient #12 reported inappropriate conduct from Staff M that included touching, verbal comments and behaviors made during care/treatment while he was a patient in the ED. The hospital allowed Staff M to continue to work his scheduled night shifts in the ED. 14 days after the first allegation of inappropriate conduct, Patient #11, a [AGE]-year-old male, reported inappropriate conduct that was similar in nature to the allegation previously made by Patient #12. Failure to remove Staff M from direct patient care pending results of an investigation placed all patients that presented to the ED seeking care and treatment at risk when Staff M, ED Physician, was allowed to continue to work his scheduled night shifts.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview, record review and policy review, the hospital failed to:
- Follow their zero tolerance patient abuse policy in the handling of two separate abuse allegations.
- Remove Staff M, Emergency Department (ED) Physician, from patient care after one patient (#12) alleged that Staff M touched him inappropriately and made inappropriate comments to him during an exam.
- Remove Staff M from patient care after a second patient (#11) made allegations that were similar in nature to Patient #12.
- Complete a thorough investigation after two patients (#11 and #12) alleged that Staff M touched them inappropriately and made inappropriate comments during their exam.

These deficient practices resulted in the hospital's non-compliance with the specific requirements found under 42 CFR 482.12 Condition of Participation: Patient's Rights. The hospital census was 11. The ED census was seven.

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 07/20/20, after the survey team informed the hospital of the IJ, staff began to put together an immediate action plan in place that was sufficient to remove the IJ.

As of 07/22/20, the hospital provided an immediate action plan to remove the IJ when they implemented the following:
- Removal of Staff M from patient care pending a full investigation.
- Initiated a thorough investigation of the allegations made by two male patients (#11 and #12) according to the zero tolerance patient abuse policy.
- Education on the zero tolerance patient abuse policy, process for investigating, reporting, and the grievance process. Education would be provided in written and video format to all employees.
- Areas of patient care would be monitored for evidence of misconduct/abuse/neglect.
- Any evidence/reports of misconduct/abuse/neglect would be provided to and monitored by the Medical Executive Committee.

Refer to A-0144 and A-0145 for further details.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, record review and policy review, the hospital failed to remove Staff M, Emergency Department (ED) Physician, from patient care, after two patients (#11 and #12), of two patients reviewed, alleged that Staff M inappropriately touched and/or made inappropriate comments to them during an exam. Failure to remove a staff member from patient care after allegations of abuse, placed all patients at risk for abuse. The hospital census was 11. The ED census was seven.

Findings included:

1. Review of the hospital's policy titled, "Zero-Tolerance - Patient Abuse", revised 06/2015, showed that:
- All forms of abuse, neglect and harassment whether from staff, other patients or visitors was prohibited.
- A system had been developed and implemented to identify, investigate, prevent and report any incident, or suspected incident of abuse, neglect, mistreatment, or misappropriation of patient property.
- Sexual Abuse included, but was not limited to sexual harassment, sexual coercion, or sexual assault.
- The completed Patient Abuse/Neglect Report and written statements were to be forwarded to the Risk Manager prior to the completion of the work period that the report occurred.
- The supervisor would notify the Chief Nursing Officer (CNO) and/or Risk Manager of the report. The CNO and/or Risk Manager would notify the administrator.
- While an investigation was being conducted, the accused individual(s) would be placed on suspension pending the results of the investigation.

Review of Patient #12's medical record dated 06/04/20, showed that he was a [AGE] year-old male who presented to the ED with the chief complaint of stomach pain with no bowel movements.

Review of Patient #12's medical record dated 06/18/20, showed that he presented to the ED with a chief complaint of left leg pain.

Review of written statement by Staff L, RN, dated 06/19/20, showed that:
- Upon discharge (06/18/20 visit), Patient #12 stated he wanted to thank the female physician who treated him so that he wouldn't have to see that "foreign guy" again.
- Patient #12 stated that during a previous visit, Staff M "came on to him" and was very inappropriate.
- Patient #12 stated he didn't like the way Staff M touched "his balls" and that he was so uncomfortable that he left without his prescription.
- Patient #12 stated that he was "almost ready to hit him when he touched my beard."

During an interview on 07/21/20 at 11:15 AM, Staff L, RN, stated that:
- Patient #12 was seen in the ED in June (06/18/20).
- She went to discharge him and he began to talk to her about a previous visit (06/04/20) when Staff M, ED Physician, allegedly touched him "a bit more than necessary," asked if he could touch his beard, and told him that he was a "handsome" man.
- Patient #12 stated that he wanted to report the incident because he did not want Staff M to be inappropriate with others, especially children.
- She completed an incident report and gave it to Staff D, ED Director.

During an interview on 07/20/20 at 4:55 PM, Staff D, ED Director, stated that:
- She triaged Patient #12 on the night of 06/18/20 when he presented to the ED for treatment.
- Patient #12 expressed that he did not wish to be seen by Staff M, ED Physician, when questioned further, Patient #12 expressed that on a prior visit (06/04/20), Staff M had touched him on the thigh and made inappropriate verbal comments to him.
- She immediately reported the allegation to Staff E, CNO, and wrote up an incident report.
- The CNO did not give her direction to remove Staff M, from the ED.
- Staff M was allowed to continue to work and finished the remainder of his regularly scheduled night shift.
- She was informed by Staff H, Chief Executive Officer (CEO), that there would be a thorough investigation and that Human Resources (HR) would speak with Staff M, ED Physician, since this was a "he said, he said" incident.
- Staff M was not removed from patient care.
- Staff M was not suspended pending an investigation.
- She did not recall the exact policy related to patient abuse/neglect, however, the expectation would be to remove the alleged perpetrator from patient care until completion of the investigation.

During an interview on 07/20/20 at 5:30 PM, Staff H, CEO, stated that:
- He was informed of Patient #12's allegation on 06/19/20.
- Patient #12 had presented to the ED, had been in prior, and he was uncomfortable with the way Staff M touched his abdomen.
- Staff M was not suspended pending an investigation because he and Staff J, HR Director, were able to speak with Staff M prior to his next shift.
- Staff M adamantly denied any wrongdoing.

Review of Patient #11's medical record dated 07/02/20, showed that he was a [AGE]-year-old male who presented to the ED accompanied by his sister, and with complaints of multiple abrasions (an area of skin damaged by scraping) and a laceration (a deep cut or tear in skin) to the right hip.

During an interview on 07/21/20 at 11:15 AM, Staff L, RN, stated that:
- On 07/20/20, she triaged Patient #11, who came in for sutures (to medically sew skin together).
- When she and the technician entered the room to clean up the supplies and perform discharge vital signs, Patient #11 stated, "Look, I'm not gay, but that doctor kept touching my butt."
- She encouraged Patient #11 to file a formal complaint with administration.
- She immediately contacted Staff D and completed an incident report for Patient #11's allegation.
- She asked Staff D why Staff M was not removed from patient care because "if a nurse had these types of allegations they would have been."

During an interview on 07/20/20 at 4:55 PM, Staff D, ED Director, stated that:
- Patient #11, presented to the ED for treatment, "sometime in early July" and required sutures to the right hip.
- She was notified by the House Supervisor that Patient #11 reported that when Staff M was in the room to suture his injury he "spanked" his bare bottom and made "strange" and inappropriate comments.
- She immediately contacted Staff E, CNO, and Staff I, Medical Director, regarding the incident and was told it would be investigated.
- Staff M was not removed from patient care.
- Staff M was not suspended pending an investigation.

During an interview on 07/20/20 at 5:30 PM, Staff H, CEO, stated that:
- He was informed of Patient #11's allegation on 07/02/20.
- Patient #11 had stated to a nurse "I'm not gay" and that he was uncomfortable with the way Staff M "touched his butt".
- Staff M denied any wrongdoing, and stated that he only patted Patient #11's buttocks to get him to sit still during suturing.
- Staff M was not suspended pending an investigation.

During an interview on 07/20/20 at 5:48 PM, Staff I, Physician, Medical Director, stated that it would depend on the situation if an alleged perpetrator should be removed from patient care.

During an interview on 07/20/20 at 5:15 PM, Staff G, Quality Director, stated during an abuse/neglect investigation, the staff member in question should be removed from direct patient care and suspended, even if the allegations involved a physician.

Review of the ED physician call schedule for Staff M, ED Physician, showed that:
- He worked the remainder of his scheduled shift on 06/18/20, after the first allegation was reported.
- He worked 11 shifts between 06/19/20 and 07/01/20.
- He worked the remainder of his scheduled shift on 07/02/20, after the second allegation was reported.
- He worked 13 shifts between 07/03/20 and 07/20/20.

The hospital failed to follow their zero tolerance patient abuse policy when they failed to suspended Staff M following alleged staff-to-patient sexual misconduct. The hospital failed to recognize the seriousness of the allegations when they allowed Staff M to continue to work in patient care areas, which resulted in a second staff-to-patient sexual abuse allegation.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, policy review, and record review, the hospital failed to complete a thorough investigation after two patients (#11 and #12) of two patients reviewed, alleged that Staff M, Emergency Department (ED) Physician, had touched them inappropriately and/or made inappropriate comments to them during an exam. This failed practice placed all patients at risk for abuse. The hospital census was 11. The ED census was seven.

Findings included:

1. Review of the hospital's policy titled, "Zero-Tolerance Patient Abuse," revised 06/2015, showed that:
- All forms of abuse, neglect and harassment whether from staff, other patients or visitors was prohibited.
- A system had been developed and implemented to identify, investigate, prevent and report any incident, or suspected incident of abuse.
- Sexual Abuse included, but was not limited to, sexual harassment, sexual coercion, or sexual assault.
- The completed Patient Abuse/Neglect Report and written statements were to be forwarded to the Risk Manager prior to the completion of the work period that the report occurred.
- The Supervisor would notify the Chief Nursing Officer (CNO) and/or Risk Manager of the report. The CNO and/or Risk Manager would notify the Administrator.
- An investigation would be conducted.

Review of Patient #12's medical record dated 06/04/20, showed that he was a [AGE]-year-old male that presented to the ED with the chief complaint of stomach pain with no bowel movements.

Review of Patient #12's medical record dated 06/18/20 at 6:07 PM, showed that he presented to the ED with the chief complaint of left leg pain.

Review of the hospital's document titled, "Event Report," completed by Staff D, ED Director, dated 06/18/20, showed that:
- Patient #12 requested to not see "that Pakistani dude" and asked if there was another physician that could see him.
- Patient #12 stated that Staff M, ED Physician, "did not know shit and he hit on me".
- Patient #12 stated that Staff M touched his thigh while he sat on the bed next to him and asked if he could touch his beard.
- Patient #12 told Staff M he "was not like that."

Review of written statement by Staff L, RN, dated 06/19/20, showed that:
- Upon discharge, Patient #12 stated he wanted to thank the female physician who treated him so that he wouldn't have to see that "foreign guy" again.
- Patient #12 stated that during a previous visit, Staff M "came on to him" and was very inappropriate.
- Patient #12 stated he didn't like the way Staff M touched "his balls" and that he was so uncomfortable that he left without his prescription.
- Patient #12 stated that he was "almost ready to hit him when he touched my beard".

During an interview on 07/21/20 at 11:15 AM, Staff L, RN, stated that:
- Patient #12 was seen in the ED in June (06/18/20).
- She went to discharge him and he began to talk to her about a previous visit (06/04/20) when Staff M, ED Physician, allegedly touched him "a bit more than necessary", asked if he could touch his beard, and told him that he was a "handsome" man.
- Patient #12 stated that he wanted to report the incident because he did not want Staff M to be inappropriate with others, especially children.
- She encouraged Patient #12 to file a formal complaint with administration.
- She completed an incident report and gave it to Staff D, ED Director.

During an interview on 07/20/20 at 4:55 PM, Staff D, ED Director, stated that:
- She triaged Patient #12 on the night of 06/18/20, when he presented to the ED for treatment.
- Patient #12 expressed that he did not wish to be seen by Staff M, ED Physician, when questioned further, Patient #12 expressed that on a prior visit (06/04/20), Staff M touched him on the thigh and made inappropriate verbal comments to him.
- She immediately reported the allegation to Staff E, CNO, and completed an incident report.
- She was informed by Staff H, CEO, that a thorough investigation would be completed and that Human Resources (HR) would speak to Staff M, ED Physician, since this was a "he said, he said" incident.
- Human Resources was notified of the alleged inappropriate behavior of Staff M, toward Patient #12.

Review of the hospital's investigation dated 06/19/20, showed that the extent of the investigation into Patient #12's allegations, included an interview by Staff J, HR Director, with Staff M, ED Physician. Staff M denied any wrong doing.

2. Review of Patient #11's medical record dated 07/02/20, showed that he was a [AGE] year old male who presented to the ED accompanied by his sister, and with a chief complaint of multiple abrasions (an area of skin damaged by scraping) and a laceration (a deep cut or tear in skin) to the right hip.

Review of the hospital's document titled, "Event Report," dated 07/02/20, showed that Patient #11 felt uncomfortable with the way Staff M, ED Physician, spoke to him and repeatedly "patted his butt" when he sutured his wound. Patient #11 was informed about the grievance process and was told that a staff member from administration would follow-up with him.

During an interview on 07/21/20 at 11:15 AM, Staff L, RN, stated that:
- When she and the technician entered the room to clean up the supplies and perform discharge vital signs, Patient #11 stated, "Look, I'm not gay, but that doctor kept touching my butt."
- She encouraged Patient #11 to file a formal complaint with administration.
- She immediately contacted Staff D and completed an incident report for Patient #11's allegation.
- No one from administration ever interviewed her in regard to either incident.

During an interview on 07/20/20 at 4:55 PM, Staff D, ED Director, stated that:
- Patient #11, presented to the ED for treatment, "sometime in early July" and required sutures to the right hip.
- She was notified by the House Supervisor that Patient #11 reported that when Staff M was in the room to suture his injury he "spanked" his bare bottom and made "strange" and inappropriate comments.
- Patient #11 reported to a ED Technician that Staff M asked him (Patient #11) if he liked milk because the patient had a "fat butt".
- Patient #11's older sister was present and witnessed Staff M's physical and verbal interactions toward the patient and acknowledged what the patient reported.
- She immediately contacted Staff E, CNO, and Staff I, Medical Director, and reported the incident. She was told it would be investigated.

Review of the hospital's investigation dated 07/07/20, showed that the investigation regarding Patient #11's allegation, did not begin until five days after the allegation was reported, and included only an interview by Staff J, HR Director, and Staff H, CEO, with Staff M, ED Physician. Staff M denied any wrong doing.

During an interview on 07/20/20 at 3:30 PM, Staff D, ED Director, stated that investigations of abuse allegations would strictly be left up to administration.

During an interview on 07/20/20 at 5:15 PM, Staff G, Quality Director, stated that she was not normally involved in physician issues, those were handled by Staff H, CEO.

During an interview on 07/20/20 at 5:30 PM, Staff H, CEO, stated that:
- He was informed of Patient #12's allegation on 06/19/20.
- Patient #12 had presented to the ED, had been in prior, and he was uncomfortable with the way Staff M touched his abdomen.
- He and Staff J, HR Director, were able to speak with Staff M prior to his next shift.
- Staff M adamantly denied any wrongdoing.
- He and Staff J, felt that Staff M was credible so they determined the allegation was unfounded.
- He was informed of Patient #11's allegation on 07/02/20.
- Patient #11 had stated to a nurse, "I'm not gay," and that he was uncomfortable with the way Staff M "touched his butt."
- Staff M denied any wrongdoing, stated that he only patted Patient #11's buttocks to get him to sit still during suturing.
- Staff M denied any sexual wrongdoing.
- He felt that the allegations against Staff M were unfounded.

During an interview on 07/21/20 at 9:35 AM, Staff J, HR Director, stated that:
- She interviewed Staff M, ED Physician, after the first complaint.
- She and Staff H, CEO, spoke with Staff M after the second complaint.
- Neither she nor Staff H attempted to contact Patient #11 or Patient #12 for a formal statement regarding the allegations.
- This was the first time she had ever addressed this type of complaint in 10 years and she followed the same process that she followed with other investigations.
- She and Staff H did not feel as though Staff M made any sexual advancements on Patient #11 or Patient #12, that Staff M was sincere, and that the allegations were unfounded.

During an interview on 07/20/20 at 5:50 PM, Staff I, Medical Director, stated that:
- Recently there had been four complaints that involved Staff M. Two were from patients and the other two were from "low-level nurses."
- He was not involved in the investigation process since that was not his expertise. HR was involved due to unemployment laws.
- "Patient safety should always be the top priority."
- All allegations needed to be taken seriously and investigated.
- The best way to look at an allegation was to determine likelihood, and the best way to determine likelihood was to speak to the person that made the allegation as well as the person the complaint was made against.
- He was not made aware of the final outcome from HR in regard to Staff M.

During an interview on 07/21/20 at 2:45 PM, Staff N, Unit Clerk, stated that he had witnessed Staff M be inappropriate with male employees, he even smacked them on the "ass" on several occasions, but had never been held accountable for his poor behavior.

During an interview on 7/21/20 at 2:08 PM, Staff M, ED Physician, stated that:
- Patient #12 had abdominal pain so he performed an exam and also felt his thigh for pulses. The patient also complained of a sore throat so he examined the lymph nodes (small bean-shaped structure that is part of the body's immune system) in his neck, and in order to do so, he had to touch his beard.
- He denied asking Patient #12 if he could touch his beard or that he stated to the patient that he was a handsome man.
- He told Patient #11 to turn over so he could "sew up his butt."
- He did not "slap" Patient #11's "butt"; however, the patient's "butt" did "jiggle" when the patient laughed.
- He had no complaints in regard to his conduct since he obtained his license in 1999.
- He never had any disciplinary actions taken against him in any other positions.
- He never had any disciplinary actions taken against his license.

Review of Staff M, ED Physician's personnel file showed that:
- On 03/12/12, his position at another hospital was terminated due to "concern in regard to his clinical care" for two patients.
- On 08/14/14, the "State Board of Registration for the Healing Arts of Missouri" imposed a five-year probation on his medical license due to the incident that occurred on 03/12/12.
- In 09/2014, his privileges at another hospital were suspended for willful disregard and gross violation of the medical staff by-laws when he failed to promptly notify the hospital of his loss of privileges at another hospital.
- In 10/2014, his privileges at another hospital were suspended for misrepresentation on his application by when he omitted previously affiliated hospitals and denied his privileges were ever terminated.
-In 09/2015, according to the "State Board of Registration for the Healing Arts," Staff M violated his probation and settlement agreement when he made false statements to the Board and when he failed to disclose previous hospital discipline on both his 2013 and 2015 licensure renewal applications.

During an interview on 07/21/20 at 10:15 AM, Staff I, Chair of the Board of Trustees, stated that:
- The allegations of inappropriate behaviors against Staff M were discussed at a recent board meeting, and although he was not present at that meeting, he was notified about the allegations.
- His expectation would be that hospital administration would be responsible for the investigation, the board would be informed, the hospital's policies and procedures would be followed.
- The main focus during an investigation would be patient safety and the benefit of doubt rested on the person that made the allegation until proven otherwise.

The hospital failed to follow their zero tolerance patient abuse policy when they failed to thoroughly investigate allegations of staff-to-patient sexual abuse and based the investigation solely on Staff M's statements.