HospitalInspections.org

Based on observation, interview, policy review and document review, the Critical Access Hospital (CAH) failed to ensure an allegation of abuse was thoroughly investigated to include a physical examination by the physician following an allegation of abuse for one patient (Patient 1) of three patients reviewed and failed to implement and provide staff education on written policies and procedures that prohibit and prevent abuse, neglect, and exploitation (ANE) following the alleged abuse. This deficient practice has the potential to place patients at risk for abuse, neglect, or exploitation leading to emotional and/or physical harm to all patients receiving treatment at this facility.


Findings Include:


Review of an undated document titled, "Swingbed Patient Rights," showed, " ...4. Each patient has the right to be free of mental, verbal, sexual, and physical abuse, corporal punishment, involuntary seclusion, and free of chemical and (except in emergencies) physical restraints except as authorized by the physician in writing for a specified and limited period of time, or when necessary to protect the patient from injury to self or others ..."


Review of a policy titled, "Physical Abuse to Patients," dated 06/2002, showed, " ...Reporting of physical abuse to patients in Sumner County Hospital Dist. #1 Swing Bed Program will be done in accordance with the Kansas Department of Health guidelines ...1. The patient should be seen by a physician promptly. 2. The Director of Nurses shall be notified immediately. If unavailable, the RN [Registered Nurse] Supervisor from the Acute Care Section of the facility shall be contacted so that an additional assessment may be made ...4. Complete incident report form accurately and completely including description of incident, including all details; patient vital signs, full names, addresses, and telephone numbers of all witnesses; and if available, physician's comments. 5. The Director of Nurses or the Administrator will contact the "Bureau of Long-Term Care" at the Kansas Department of Health by dialing 1-800-842-0078. This must be done regardless of how minor the incident may appear. If the Director of Nurses and the Administrator are unavailable, the RN Supervisor shall contact the Kansas Department of Health."


Review of Patient 1's medical record showed she was directly admitted to the Intermediate Care Unit on 07/23/15. The History and Physical present in admission record showed the reason for admission was advancing dementia and inability to provide own self-care.

Observation on 10/26/21 at 10:00 AM, showed Patient 1 was non-verbal, immobile with contractures (a condition of shortening and hardening of muscles, tendons, or other tissue) and requires complete assistance with activities of daily living.


Review of the facility investigative report dated 12/30/20 showed that Staff A, Chief Executive Officer (CEO) was notified at approximately 9:50 AM, by the facility Director of Nursing (DON) of an allegation of sexual assault to Patient 1 by Staff G, Housekeeping. The incident was witnessed by Staff E, RN who notified the DON and provided a written statement describing the incident. The report showed Staff G was brought in by the CEO for explanation at 10:35 AM. The allegations of abuse and protocols were discussed with Staff G, and Staff G voluntarily resigned.


During a phone interview on 10/26/21 at 1:10 PM, Staff E, RN stated that she entered Patient 1's room, and Staff G, Housekeeping, was standing between the bed and the window, his hand was in Patient 1's gown with his hand on her breast. When she entered, he removed his hand, picked up the broom or mop that was resting on the bed rails, and continued to clean and hum. Staff E stated that she reported the incident to the charge nurse, who then directed her to report the incident to Staff A, CEO. Staff E stated that she was not aware if Staff B, Medical Director, performed an examination on Patient 1 after the incident was reported.


During an interview on 10/27/21 at 8:00 AM, Staff B, Medical Director stated that he did not perform a physical exam on Patient 1 after being told of the sexual abuse allegation. Staff B stated, "I did not perform a physical exam of the patient. From what I was told the individual was fondling the patient's breast. If that is what happened, not a lot of evidence would be available to prove or disprove that. I was not involved after the initial allegation was reported to me."


During an interview on 10/26/21 at 3:35 PM, Staff D, Housekeeping Supervisor, stated that since the incident the facility requires two members of housekeeping staff in any patient room if the patient is of the opposite sex and if at all possible, cleaning of the patient rooms will be done at times when the patient is not present. Staff D stated that no new policies have been implemented regarding the new procedure and no documentation has been put in place to measure compliance of new procedures.


During an interview on 10/26/21 at 4:56 PM, Staff C, Risk Manager, stated, " ..."I know that we have to report to KDHE, APS, and depending on what it is, the police if there has been harm to the patient. A nursing exam will be done on each patient. There was not an exam done on the patient, I don't know why." Staff C, Risk Manager confirmed that that due to the patient not being examined after the alleged abuse, the facility could not confirm if any further abuse/injury was sustained by Patient 1 ..." When asked what the requirements are for an abuse/grievance investigation, Staff C, Risk Manager was not able to provide an answer. When asked what training is provided to the employees in regard to ANE, Staff C, Risk Manager, stated, "We have struggled to come up with any information for you. I don't recall that we have had any education of any type given to employees regarding ANE."