HospitalInspections.org

Based on document review and staff interviews, the Rehab hospital's administrative staff failed to follow their policy to ensure timely reporting of 1 of 1 incidents of possible sexual abuse (Patient #1) to the Department of Inspections and Appeals (DIA). Failure to recognize and report incidents of possible sexual abuse in a timely manner resulted in the administrative staff allowing 1 of 1 staff member (Patient Care Technician, PCT A) to continue to work with patients after PCT A committed a possible act of abuse. The hospital's administrative staff identified a census of 20 patients.

Findings included:

1. Review of the policy, "Abuse-Neglect, Suspected Reporting", effective 5/25/18, revealed in part, "Abuse/neglect is reported to the Iowa Department of Inspections and Appeals within 24 hours ... of the initial notification to the supervisor." The policy failed to include language requiring the rehab hospital staff to immediate protect the patients from any employee accused of abuse or neglect.


2. During an interview on 6/4/19 at 9:45 AM, Patient #1 stated PCT A had committed a potential act of abuse. Patient #1 told the Nurse Manager about the incident later that morning, as the Nurse Manager was investigating why Patient #1 fell during the night.


3. During an interview on 6/5/19 at 8:09 AM, the Nurse Manager revealed that on the morning of 5/20/19, the Patient #1 told the Nurse Manager about the incident between PCT A and Patient #1, which happened the night prior. The Nurse Manager verbally reported the incident to the Chief Clinical Officer and Director of Quality Management sometime between 10:45 - 11:00 AM, immediately after talking to Patient #1. The Nurse Manager then sent an email to Director of Quality Management documenting the incident.


5. During an interview on 6/4/19 at 3:30 PM, the Director of Quality Management first learned of incident from the Nurse Manager on 5/20/19 at approximately 9:30 AM. The Nurse Manager verbally relayed information to the Director of Quality Management and Chief Clinical Officer. The Director of Quality Management was initially still focused on the fact Patient #1 fell, and did not recognize the incident as potential abuse until the Director of Quality Management received the written summary of the incident from the Nurse Manager.

The Director of Quality Management began their investigation into the incident and attended in two conference calls about the incident on 5/21/19. The Director of Quality Management acknowledged they failed to suspend PCT A after Patient #1 accused PCT A of abuse, and allowed PCT A to work 1 shift.

The Director of Quality Management called the Department of Human Services (DHS, the incorrect state agency for hospital staff to report allegations of abuse) after hours hotline to report the incident between PCT A and Patient #1 on 5/21/19 at approximately 5:00 PM. The Director of Quality Management acknowledged they notified the DIA approximately 32 hours after the hospital staff became aware of Patient #1's allegation of abuse against PCT A.


6. Review of Rehab hospital's internal investigation showed, in part:

a. The Nurse Manager became aware of an allegation of abuse by PCT A from Patient #1 on 5/20/19, between 8:45 AM and 9:15 AM
b. The hospital's administrative staff began their investigation on 5/21/19 at 8:30 AM to 1:00 PM.
c. The hospital's administrative staff notified the DHS on 5/21/19 at 4:58 PM (approximately 32 hours after the hospital staff became aware of the incident).

Based on document review and staff interview, the Rehab hospital's administrative staff failed to update the visitation rights information to ensure staff informed each patient (or support person, where appropriate) of the right, subject to his or her consent, to receive the visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time. Failure to provide all patients with current visitation rights could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person when they are provided any type of care, services, or treatment modalities. The Rehab hospital identified a census of 20 patients on entrance.

Findings include:

1. Review of the hospital's policy, "Visitors," effective 5/25/18, revealed the Rehab hospital policy failed to include language that informed patients (or support person, where appropriate) of the right, subject to his or her consent, to receive the visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

2. Review of the "Patient Handbook," undated, revealed the Rehab hospital failed to include language that informed patients (or support person, where appropriate) of the right, subject to his or her consent, to receive the visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

3. During an interview on 6/3/19 at 3:30, the Director of Quality Management acknowledged the Rehab hospital's Visitor policy and Patient Handbook lacked the required language regarding visitation rights. The Director of Quality Management further confirmed the Rehab hospital did not distribute any other documents that included the required language for visitation rights to patients or post the information anywhere in the rehab hospital the required language for visitation rights.