HospitalInspections.org

Based on review of hospital policies, review of facility documents, and staff interviews, it was determined that the hospital failed to provide a safe environment (A 0144) and have mechanisms/methods in place that ensure patients are protected from of all forms of abuse, neglect, or harassment as evidenced by the failure to remove a staff member following an allegation of sexual abuse to multiple patients and failing to develop adequate policies to address the protection of patients (A 0145). This failure resulted in an Immediate Jeopardy, posing the potential for serious risk of harm to all patients.

Findings are as follows:

The hospital administration received an anonymous letter on 7/9/2024 alleging a staff member at the Zambarano Unit of Eleanor Slater Hospital engaged in sexual exploitation of hospital patients. This letter identified a specific staff member by name as the alleged perpetrator. The allegation was also reported to the State Agency (SA). Upon the SA investigation, which began onsite at the hospital on the morning of 7/11/2024, it was identified that the hospital had not informed, interviewed or removed the alleged staff member from performing patient care for which she was still providing on 7/10/2024 and 7/11/2024. Additionally, they had not started interviews with hospital staff or patients.

On 7/11/2024 a finding which constituted an Immediate Jeopardy (IJ) was identified under 42 CFR 482.13 A-0115 Condition of Participation: Patient Rights.
-The hospital failed to provide a safe environment for vulnerable patients (A-0144).
-The hospital failed to protect patients by removal of the alleged perpetrator who was still providing direct patient care for 2 days following notification of the allegation, as well as the failure to begin an immediate investigation once the hospital was aware of the alleged incident on 7/9/2024 (A-0145).

On 7/16/2024 an audit was completed by the state surveyor and the Immediate Plan of Correction was verified as fully implemented by verifying policy changes, observations, review of education provided, and interviews with the staff who received the education. As of 7/16/2024 the IJ was removed.





45769

Based on review of hospital policies, and staff interviews, it was determined that the hospital failed to provide a safe environment and have mechanisms/methods in place that ensure patients are protected from of all forms of abuse, neglect, or harassment as evidenced by the failure to remove a staff member following an allegation of sexual abuse to multiple patients.

Findings are as follows:

A facility reported allegation of abuse was submitted to the Rhode Island Department of Health on 7/9/2024, stating the Chief Executive Officer (CEO) of the hospital received an anonymous letter on 7/9/2024 alleging a staff member at the Zambarano Unit of Eleanor Slater Hospital engaged in sexual exploitation of hospital patients by taking pictures of patient's genitals with their cell phone over the last eight years. This letter identified Staff A, Nursing Assistant, by name as the alleged perpetrator.

Findings are as follows:

The hospital's policy entitled, "Abuse and Neglect-Guidelines for Screening and Intervention," which was last approved on 3/2022 states in part,
"II. POLICY: ...
2. All staff at the ESH are responsible to report actual or suspected cases of abuse and/or neglect. The hospital is responsible to evaluate all allegations, observations and suspected cases of neglect, exploitation, and abuse.
3. Staff suspecting abuse or neglect must report suspicions to his/her supervisor. The supervisor is responsible for initiating appropriate actions including notifying his/her supervisor and administration.
4. The Administrator of Risk Management is responsible to notify applicable licensing bodies and authorities within 24 hours..."

The hospital's "Patient Rights and Responsibilities" policy, last approved on 3/2022, states, in part,
IV: Policy Statement Pertaining to Patients' Rights
1. The patient shall be treated with dignity and respect, [and] afforded considerate and respectful care ...

31. The patient has the right to be free from neglect, exploitation, verbal, mental, physical, and sexual abuse."

During an interview on 7/11/2024 at approximately 10:30 AM with the Human Resource Manager, she stated that she was made aware of the allegation on 7/10/2024 and was at the facility to begin the investigation on 7/11/2024.

She acknowledged that the employee had not been placed on leave, nor had they been removed from the patient care areas. The Human Resource Manager stated that it is not the hospital's current practice to place the staff out on a leave, unless the allegation is of "a serious nature". She was then asked if she considered this allegation to be serious and she responded that "she did, however there were no specifics regarding when, where and which patients were photographed."

During an interview on 7/11/2024 with the Chief Nursing Officer (CNO), at approximately 10:45 AM, she confirmed that the accused staff member worked on the day shift 7/10/2024 and was currently working today (7/11/2024) providing patient care.

During interviews on 7/11/2024 at 10:50 AM, with the Risk Manager, CNO, and the Human Resource Manager, they reported that the accused employee was not aware of the alleged allegation and no interviews had been conducted with the accused staff member, current hospital staff or patients regarding the alleged allegation.

45769

Based on policy review, record review, and staff interviews it has been determined the hospital failed to protect patients by failure to remove a Certified Nurse assistant (C.N.A.) who was alleged to engage in sexual exploitation of patients, and immediately investigate an allegation of sexual abuse. Additionally, the hospital's policy failed to identify effective components necessary to protect patients from abuse, neglect, and mistreatment.

Findings are as follows:

A facility reported allegation of abuse was submitted to the Rhode Island Department of Health on July 9, 2024, alleging a staff member at the Zambarano Unit of Eleanor Slater Hospital engaged in sexual exploitation of hospital patients by taking pictures of patient's genitals.

Following the hospital becoming aware of the alleged abuse on 7/9/2024, the hospital failed to immediately notify the alleged staff member and remove them from patient care. The hospital also failed to begin a timely investigation which was not started until after the state surveyor arrived onsite on 7/11/2024.

Review of the hospital's policy entitled, "Abuse and Neglect-Guidelines for Screening and Intervention," which was last approved on 3/2022 states in part,
"II. POLICY: ...
2. All staff at the ESH are responsible to report actual or suspected cases of abuse and/or neglect. The hospital is responsible to evaluate all allegations, observations and suspected cases of neglect, exploitation, and abuse.

Further review of the current policy entitled, "Abuse and Neglect-Guidelines for Screening and Intervention," dated 3/2022, identifies no mechanism to protect the patients from abuse, neglect or mistreatment following an allegation.

During an interview on 7/11/2024 at approximately 10:30 AM with the Human Resources Manager, she acknowledged that the employee had not been placed on leave, nor had they been removed from the patient care areas. She stated that it is not the hospital's current practice to place the staff out on a leave, unless the allegation is of "a serious nature". She was then asked if she considered this allegation to be serious and she responded that "she did, however there were no specifics regarding when, where and which patients were photographed."

During an interview on 7/11/2024 with the Chief Nursing Officer (CNO), at approximately 10:45 AM, she confirmed that the accused staff member worked on the day shift 7/10/2024 and was currently working today (7/11/2024) providing patient care.

During interviews on 7/11/2024 at 10:50 AM with the Risk Manager, CNO, and Human Resource Manager, they reported that the accused employee was not aware of the alleged allegation and no interviews had been conducted with the accused staff member, current hospital staff or patients regarding the alleged allegation.