HospitalInspections.org

Based on reviews of records and staff interviews, the Governing Body failed to develop an effective monitoring mechanism to ensure the Chief Executive Officer managed the hospital in accordance with acceptable standards of practice.

The findings include ...

The Chief Executive Officer failed to:

A.Protect a patient's right to care in a safe setting (A-0144)

Based on record review, policy review, and staff interview, the hospital failed to protect a patient's right to care in a safe setting by failing to screen the background of an employee and act on discrepancies identified in the employee's background attestation prior to hire offer. Subsequently the employee was accused of sexual abuse of a patient (Patient#1).

The findings include ...

The Bridgepoint National Harbor policy entitled "Background Checks", last reviewed 04/16, showed that " ...violations of Bridgepoint policies, including providing false or misleading information used for any of the above background check, shall be handled in accordance with applicable Bridgepoint policies and procedures, which may include corrective action up to and including termination ..."

Patient #1 is a 61-year-old female admitted to the hospital on 06/29/18 with a history of Chronic Obstructive Pulmonary Disease (COPD). She was admitted from an acute care hospital for rehabilitation, and pain management.

On 09/05/18, the facility notified DC health of a sexual assault allegation. According to the report, Patient #1 reported the allegation to Employee #9, Physician on the evening of 08/31/18. She alleged that Employee #1, Patient Care technician, entered her room on 08/21/18, touched her leg and swiped his hand up her legs to her thighs and breast.

The surveyor conducted a face-to-face interview on 09/07/18 at 1:20 AM with Patient #1, regarding the allegations she made against Employee #1. She stated that she was familiar with Employee #1 from when she was a patient on another unit in the hospital. She explained that she is a self-care patient and doesn't require assistance from staff with her Activities of Daily Living (ADL's), and that Employee #1 had gotten her ice and water in the past while she was on the other unit. She stated that on the night of 08/21/18 she had just taken her night medications and was asleep. She went on to say that she was awakened by Employee #1 saying "all that is for me?" after which the alleged sexual assault occurred. She then stated that another employee entered her room, Employee #8, Patient Care Technician and asked Employee #1 what he was doing in the room to which he responded "that's my baby." After that, Employee #1 and Employee #8 left her room.

The surveyor conducted a telephone interview on 09/07/18 at 9:53 AM, with Employee #8. She stated that she provides minimal care for Patient #1. She stated that Patient #1 never reported sexual abuse to her. She went on to say that, she remembered on the night of 08/21/18 she walked into Patient #1's room and saw Employee #1 in the room. She asked him what he was doing in the room and he said "I'm here to see my baby." Employee #8 stated that she did not see Employee #1 do anything to Patient #1.

The surveyor conducted a telephone interview on 09/07/18 at 12:59 PM, with Employee #9, Physician. He stated that on 08/31/18, while seeing Patient #1, she said she was violated, that a gentleman who worked at the hospital fondled her from her private parts to her breasts. Employee #9 reported the allegation to the nursing supervisor. Thereafter, the police were notified and Employee #1 was removed from the schedule pending investigation.

The surveyor conducted a face-to-face interview on 09/07/18 at 10:27 AM, with Employee #1, in the presence of Employee #2, Union Representative, regarding his employment history and the allegation. Employee #1 stated that he was a Patient Care Technician at the hospital since May 2018 and that he works the night shift 7:00 PM to 7:00 AM. He said that his work history included working in a Trauma Burn Emergency Room, and that he was a Paramedic for many years. He stated that he had a Bachelor's Degree in Biology and was working towards a career as a Physician Assistant. He denied sexually assaulting Patient #1.

Review of the Human Resources Personnel File of Employee #1 revealed an employment application dated 4/10/18. On the application, Employee #1 wrote that he completed a Bachelor's degree in Biology in 2012 from a local university, and that he graduated from a local high school with a 3.70 grade point average (GPA), however, the dates of attendance were recorded as "(N/A) not applicable. Employee #1 attested to the accuracy of the content in the application by signature.

Review of the background check contained in the personnel file showed that Employee #1 attended the high school identified on his application but he did not graduate. Additionally, he obtained a High school Equivalency Certificate from the state of Texas in 1993, and did not graduate from a high school located in the District of Columbia, as stated on his application. There was no evidence of attendance at the local university and a baccalaureate degree in biology.

The surveyor conducted a face-to-face interview on 09/07/18 at 11:47 AM with Employee #5, Human Resources Coordinator, regarding the discrepancy in the information submitted on the employment application by Employee #1 and the information obtained from his background check. She stated that she was aware of the inaccuracies and through conversation with Employee #1 (prior to hire); he acknowledged that the information submitted was inaccurate.

Additionally, the personnel file revealed Employee #1 was offered employment prior to receipt of the criminal background check clearance as evidenced by a signed the job description and signed receipt of the hospital's abuse policy, both dated 4/13/18. The record revealed the Fingerprint-based Background Check was conducted on 4/23/18 and the results of eligibility was dated 5/2/18.

Employee #1 was hired in spite of documenting inaccuracies on his employment application and he was accused of sexual assault by a patient.

The surveyor conducted a face-to-face interview on 09/07/18 at 12:30 PM with Employee #10, Chief Clinical Officer, and Employee #4, Senior Director of Human Resources. Both employees acknowledged the findings.