HospitalInspections.org

Based on record review and interview, the hospital failed to meet the requirement for the Condition of Participation of Patient Rights as evidenced by:


1. Failing to ensure patients were free from all forms of abuse or harassment as evidenced by failure of the hospital to 1) immediately and thoroughly perform an investigation of alleged patient sexual abuse, 2) ensure that the patient was transferred and examined at the closest Emergency Department per hospital policy, and 3) report the abuse allegation to the Louisiana Department of Health for 1 of 1 (Patient #1) patient abuse allegations reviewed in a total sample of 5 patients. (See findings in Tag A-145)


2. Failing to ensure the prompt resolution of patient grievances and effective operation of the grievance process as evidenced by failing to ensure a patient's allegation of sexual abuse was promptly and thoroughly investigated and written notice provided to the patient's representative for 1 (Patient #1) of 3 patients (Patient #1, R1, R2) reviewed for grievances. (See findings in A-122)

Based on record review and interview, the hospital failed to ensure the prompt resolution of patient grievances and effective operation of the grievance process. This deficient practice was evidenced by failing to ensure a patient's allegation of sexual abuse was promptly and thoroughly investigated and written notice provided to the patient's representative for 1 (Patient #1) of 3 patients (Patient #1, R1, R2) reviewed for grievances.
Findings:

Review of the hospital's policy titled "Grievance, Patient/Family", Policy 001-05-002.8, presented as current policy by S2Director of Quality Management, revealed in part that any grievance involving situations or practices that place the patient in immediate danger are resolved as soon as possible and the Quality/Risk Manager is notified immediately. The policy further stated that the patient or patient representative will be given a written response within 7 days of the grievance notification. If the grievance is still in the process of being resolved, this will be communicated in the notification as well as an anticipated date of resolution.

Review of Patient #1's nurses notes dated 06/04/16 at 9:00 p.m., written by S3RN, revealed that while administering routine meds to patient, family states that patient is upset and has written down the cause; upon inspection of patient's notebook, family showed this nurse where patient wrote that she had been "raped". Charge nurse immediately notified.

Review of Patient #1's nurses notes dated 06/04/16 at 9:00 p.m., written by S3Charge Nurse, revealed patient reported she was raped by a black male named ____ (first name written) during a bed bath. Patient also writes "penetrated" by "penis" when specific questions asked.

On 06/08/16 at 9:15 a.m., interview with S2Director of Quality Management revealed that on the night of 06/04/16, S3Charge Nurse called her and told her that Patient #1 had written down that she had been raped. She stated that she immediately came to the hospital and talked to the family. She stated that the patient was on a ventilator but could communicate by writing in her notebook. S2Director of Quality Management further stated that the patient wrote down that a black man in scrubs had raped her. The family stated that thru communicating with the patient, they thought the incident happened on the evening of 06/02/16 or 06/03/16.

Further interview with S2Director of Quality Management on 06/08/16 at 9:30 a.m. revealed that she had determined that there were four black males who worked the evening shift on 06/02/16 and 06/03/16, but none had the name that the patient had written down. When asked if she had interviewed these four employees, she stated that she had only interviewed two of them, on 06/06/16. When asked if she had interviewed any other staff who was working the evening shift on 06/02/16 and 06/03/16, she stated no.

On 06/13/16 at 11:30 a.m., when S2Director of Quality Management was asked if a written response had been sent to Patient #1's representative in response to the grievance, she stated that she had typed up a letter, but the hospital attorney was currently reviewing it. She further confirmed that a response letter had not been sent to the patient's representative within 7 days of the grievance notification (which occurred on 06/04/16), as stated in the hospital's grievance policy. At this time, S2Director of Quality Management revealed that the investigation had not been completed.

On 06/13/16 at 2:00 p.m., interview with S1Administrator confirmed that the hospital had not conducted the investigation regarding Patient #1's sexual abuse allegation in a timely manner. He confirmed that attempts to interview all staff who worked on the evening shift of 06/02/16 and 06/03/16 (when the alleged incident occurred) should have been immediately initiated; but as of this date, all staff had not been interviewed. He further stated that a written response to the grievance filed by Patient #1's family had not been sent to the family, as indicated in the hospital's grievance policy.

Based on record reviews and interviews, the hospital failed to ensure patients were free from all forms of abuse or harassment as evidenced by failure of the hospital to 1) immediately and thoroughly perform an investigation of alleged patient sexual abuse, 2) ensure that the patient was transferred and examined at the closest Emergency Department per hospital policy, and 3) report the abuse allegation to the Louisiana Department of Health for 1 of 1 (#1) patient abuse allegations reviewed in a total sample of 5 patients.
Findings:

Review of the hospital policy titled "Abuse, Neglect, Assault Alleged or Suspected", Policy 001-01-035.8, presented as current policy by S2Director of Quality Management, revealed in part that all accusations of physical, emotional, or psychological abuse of any patient necessitate immediate action. It is the policy of the hospital to provide appropriate psychosocial counseling and immediate follow-up medical care in a hospital-based Emergency Department to persons suspected of sustaining sexual assault. If sexual assault, physical abuse, or psychological/verbal abuse, or neglect is stated, suspected or identified, the facility will take the following actions: 1) immediately assure patient safety, 2) notify the Nurse Executive or Nursing Supervisor and Quality/Risk Manager, who will in turn notify the following persons or agencies: (a) Attending physician. The attending physician will assess the patient and document all findings such as bruises, reddened areas, abrasions, etc in the patient's medical record. The attending physician assessment should not delay the transfer of the patient to the closest Emergency Department.....(d) State Department of Health or corresponding state agency. In cases of suspected sexual assault, stabilize and transfer the patient to the closest Emergency Department designated as the community health care facility for treating sexual assault victims and for treatment and specimen collection by qualified forensic personnel.

Review of the medical record for Patient #1 revealed she was admitted to the hospital from an acute care hospital on 03/15/16 with diagnoses including end stage renal disease, diabetes mellitus, chronic obstructive pulmonary disease and congestive heart failure. Further review revealed patient was ventilator dependent and was on a Diprovan medication drip with bilateral hands restrained.

Review of Patient #1's nurses notes dated 06/04/16 at 9:00 p.m., written by S3RN, revealed that while administering routine meds to patient, family states that patient is upset and has written down the cause; upon inspection of patient's notebook, family showed this nurse where patient wrote that she had been "raped". Charge nurse immediately notified.

Review of Patient #1's nurses notes dated 06/04/16 at 9:00 p.m., written by S3Charge Nurse, revealed patient reported she was raped by a black male named _____ (first name written) during a bed bath. Patient also writes "penetrated" by "penis" when specific questions asked. Further review of the nurses notes revealed at 9:15 p.m., nursing supervisor notified and at 9:40 p.m., police on floor making report. At 10:30 p.m., the note revealed that the patient's husband wants to keep patient at this hospital, but requests no care be given by males, and that no staff enter room alone.

The next note was dated 06/05/16 at 12:00 a.m., stating that patient was resting quietly and call bell in easy reach. Family at bedside.

On 06/08/16 at 9:15 a.m., interview with S2Director of Quality Management revealed that on the night of 06/04/16, S3Charge Nurse called her and told her that Patient #1 had written down that she had been raped. She stated that she immediately came to the hospital and talked to the family. She stated that the patient was on a ventilator but could communicate by writing in her notebook. S2Director of Quality Management further stated that the patient wrote down that a black man in scrubs had raped her. The family stated that thru communicating with the patient, they thought the incident happened on the evening of 06/02/16 or 06/03/16. Further interview with S2Director of Quality Management revealed that the patient's family called the police and they came the hospital that night, but no sexual assault exam was performed by the police. She further stated that she was unsure if the police interviewed any staff of the hospital. S2Director of Quality Management further stated that staff was informed that night by S1Administrator not to provide care alone to the patient, but in pairs.

Review of the police report dated 06/04/16 at 9:30 p.m. revealed that Patient #1 "advised that she was sexually assaulted" at the hospital. The report further stated that no arrests were made at that time and the incident was pending.

Further interview with S2Director of Quality Management on 06/08/16 at 9:30 a.m. revealed that she had determined that there were four black males who worked the evening shift on 06/02/16 and 06/03/16, but none had the name that the patient had written down. These four employees included one CNA, who was assigned to Patient #1 on 06/02/16, and three environmental services employees. When asked if she had interviewed these four employees, she stated that she had only interviewed two of them on 06/06/16 (the CNA and one of the environmental services workers). When asked if she had interviewed any other staff who was working the evening shift on 06/02/16 and 06/03/16, she stated no. When asked if she had reported this alleged sexual abuse allegation to the Louisiana Department of Health, she stated that she had questioned the hospital's attorney regarding the reporting process, but the attorney had not gotten back in touch with her. S2Director of Quality Management confirmed she was unsure of the requirement regarding abuse reporting.

Interview with S5CNO on 06/08/16 at 10:30 a.m., revealed that S3Charge Nurse called him on the night of 06/06/16 regarding Patient #1's allegation of sexual abuse. He stated that he informed S3Charge Nurse not to allow any staff to go into the patient's room alone. S5CNO also stated that since the patient was on Diprovan, it was a possibility that the patient could have been in and out of consciousness during care and dreamed that the incident really happened.

On 06/09/16 at 12:00 p.m., interview with S3Charge Nurse confirmed that Patient #1 communicated with him by writing on 06/04/16 that she was raped. He stated that the patient seemed to be in her right state of mind that night. He further revealed that he called the patient's physician and left a message for him but the patient was not examined by a physician on that night. He further stated that he did not perform an assessment on the patient that night related to her allegation of sexual abuse.

On 06/09/16 at 12:40 p.m., interview with S4RN revealed that she was Patient #1's nurse on the evening of 06/04/16. She stated that the patient had written down in her notebook that she had been raped. When asked if she had performed any type of assessment on the patient related to the allegation of sexual abuse, she stated no.

On 06/09/16 at 2:30 p.m., when S2Director of Quality Management was asked if the patient was examined by her attending physician on the night of the allegation (06/04/16) or sent to the Emergency Department per hospital policy, she stated no. She further confirmed that the patient was not examined by a physician until two days later, on 06/06/16. When asked if she was assessed by any staff on the evening of 06/04/16 regarding her allegation of sexual abuse, she stated that she thought S3Charge Nurse had examined her.

Review of the progress note written by S6MD, Patient #1's physician, dated 06/06/16 at 8:25 a.m., revealed that the patient "did have an issue over the weekend with the patient seeming to be upset and made a suggestion that perhaps, some sexual molestation has occurred". The note further revealed that "There seems to be no effect on her current health except over the weekend, there was some difficulty with her emotional state, perhaps related to this incident or perhaps some hallucination associated with her Diprovan and chronic critical state."

Review of the progress note written by S6MD, dated 06/06/16 at 8:00 p.m., revealed that the patient's family informed him that the patient had not had a rape exam performed yet. The progress note further revealed that the physician performed an exam of introitus externally only. No concerns were noted by the physician.

On 06/13/16 at 2:00 p.m., interview with S1Administrator confirmed that the hospital had not conducted the investigation regarding Patient #1's sexual abuse allegation in a timely manner. He confirmed that attempts to interview all staff who worked on the evening shift of 06/02/16 and 06/03/16 (when the alleged incident occurred) should have been immediately initiated; but as of this date, all staff had not been interviewed. He stated that a thorough investigation had not been conducted. He further confirmed that hospital policy stated that the patient should have been sent to a hospital-licensed Emergency Department to be examined, but that did not occur. S1Administrator also confirmed that the Louisiana Department of Health was not notified of this alleged sexual abuse incident. S1Administrator further stated that due to the patient being on Diprovan, he thought the patient may have had a dream regarding this incident, and thought it actually occurred.