Alameda Hospital

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 49983 Based on interview and record review, the facility failed to ensure 3 of 30 sampled patients (Patients 5, 8, and 9) were free from all forms of abuse. This failure occurred when: 1. Patients 5, 8, and 9 each reported allegations of sexual abuse that occurred during their physical therapy session. 2. The facility did not thoroughly investigate allegations of abuse for Patients 8 and 9. 3. The facility did not appropriately report allegations of abuse for Patients 5, 8, and 9 to the required agencies. This failure resulted in 3 patients experiencing physical, mental, and emotional anguish, and placed all patients in the facility at risk of experiencing abuse. Findings: During a record review of facility’s document titled, “Progress Notes”, dated 5/17/24, Patient 8 was a 22-year-old female with a diagnosis of complete tear of right Anterior Cruciate Ligament (ACL-ligament in the right knee). During a concurrent interview and record review on 12/3/25 at 11:08 a.m. with the Vice President of Rehabilitation Services (VPPT), facility’s document titled, “Reminder One”, dated 10/10/24 for Physical Therapist 1 (PT1) was reviewed. VPPT stated the document was the first level in the disciplinary action process for PT1. VPPT stated the document indicated on 5/17/24, Patient 8 reported she felt very uncomfortable and confused why PT1 touched her on the buttocks when she had a knee injury. During an interview on 12/3/25 at 2:29 p.m. with Patient Relations Manager (RM), RM stated incidents where a patient reports they were touched inappropriately should be reported to the Patient Safety department so that they can investigate, report to regulatory, and determine harm. RM stated the incident reported by Patient 8 on 5/15/24 was not reported to Patient Safety. During an interview on 12/3/25 at 2:29 p.m. with Patient Safety Director (PSD), PSD stated an incident where a patient reports that a staff member touched them in a way that made them feel uncomfortable should be reported to the Patient Safety Department. PSD stated the risk of not reporting to the Patient Safety Department was then the Patient Safety department would not investigate and there was a risk the regulatory department would not know or be involved. PSD further stated per facility’s policy titled, “Patient Complaints/Grievances”, this incident should have been reported to the Patient Safety Department. During an interview on 12/4/25 at 10:23 a.m. with Regulatory Affairs Manager (REG), REG stated Patient 8’s allegation she was touched on the buttocks in a way that made her feel very uncomfortable was not reported to the California Department of Public Health (CDPH). REG stated allegations of sexual assault should be reported to CDPH within 24 hours. REG stated there was no evidence a thorough investigation into Patient 8’s allegation was done by the facility. REG stated the risk of not reporting and investigating was it affected the patients and there was a mandatory requirement to report. During a review of facility’s document titled, “Physical Therapy Treatment”, dated 9/13/24, the document indicated Patient 9 had a diagnosis of left shoulder pain. During an interview on 12/3/25 at 11:08 a.m. with VPPT, facility’s document titled, “Reminder One”, dated 10/10/24 for PT1 was reviewed. VPPT stated the document indicated on 9/13/24, Patient 9 complained PT1 touched her on the buttocks in a way that was unexpected and made her feel uncomfortable. During an interview on 12/3/25 at 2:29 p.m. with Patient Relations Manager (RM), RM stated that incidents where a patient reports they were touched inappropriately should be reported to the Patient Safety department so they can investigate, report to regulatory, and determine harm. RM stated the incident reported by Patient 9 on 9/13/24 was not reported to the Patient Safety department. During an interview on 12/4/25 at 10:23 a.m. with Regulatory Affairs Manager (REG), REG stated the allegation made by Patient 9 was not reported to CDPH. REG stated allegations of sexual assault should be reported within 24 hours. REG stated there was no evidence that a thorough investigation was carried out by the facility. REG stated that the risk of not reporting and investigating was because it affected patients and there was a mandatory requirement to report. During a record review of facility’s document titled, “Physical Therapy”, dated 6/13/25, Patient 5 was evaluated for Achilles tendinopathy on 6/13/25 (a condition that involves pain and inflammation of the Achilles tendon, which is located in the ankle). During an interview on 12/2/25 at 1:33 p.m. with Physical Therapy Manager (PTM), PTM stated she observed Patient 5 leave the physical therapy area on 6/13/25 and noticed Patient 5 appeared upset. PTM stated she called Patient 5 on the telephone and Patient 5 reported she was not comfortable with how the PT1 touched her on the buttocks for her ankle injury, felt it was inappropriate, and she felt violated. During an interview on 12/3/25 at 10:24 a.m. with Physical Therapist 2 (PT2), PT2 stated it was part of physical therapy training to ask consent prior to touching patients. During an interview on 12/3/25 at 10:45 a.m. with Senior Employee Relations Consultant (CON), CON stated PT1 was terminated after their disciplinary process concluded that PT1 did not ask consent prior to touching Patient 5 on her buttocks. During an interview on 12/2/25 at 2:28 p.m. with Quality Improvement Manager (QUAL), QUAL stated the incident with Patient 5 happened on 6/13/25 and was reported to Patient Safety department on 6/26/25. During an interview on 12/2/25 at 2:35 p.m. with the Director of Patient Safety (PSD), PSD stated the expectation to report was to fill out a report to the Patient Safety department as soon as possible and before the employee leaves for their shift. During an interview on 12/4/25 at 10:23 a.m. with Regulatory Affairs Manager (REG), REG stated the incident with Patient 5 occurred on 6/13/25 and it was reported to CDPH on 7/1/25. REG stated this was too long, and allegations of sexual assault should be reported within 24 hours. During an interview on 12/3/25 at 10:04 a.m. with VPPT, VPPT stated she received a text message from PTM on 6/13/25 at 9:30 a.m. about a patient complaint. VPPT stated she met with PTM around 1:30 p.m. on 6/13/25 and PTM notified her that Patient 5 reported PT1 had touched her on her buttocks in a way that was inappropriate and she felt violated. VPPT also stated Patient 5 called the police to report the incident and the police came on 6/16/25. VPPT stated PT1 was suspended from work on Monday, June 16 at 2:00 p.m. due to the incident. In a record review of facility’s document titled, “ALH Physical Therapy Schedule”, dated 6/13/25 and 6/16/25, PT1 saw nine patients after Patient 5 reported being touched inappropriately on 6/13/25 at 9:00 a.m. and being suspended on 6/16/25 at 2:00 p.m. During a review of the facility’s policy titled, “Reporting Adverse Events/Sentinel Events, Attachment A”, dated 8/31/24, the policy indicated, “sexual assault of a patient, including allegations of sexual assault of a patient, ... shall be reported within 24 hours after detection.” During a review of the facility’s policy titled, “Patient Complaints/Grievances”, dated 9/2025, the policy indicated, “ ...Resolved and unresolved complaint details and supervisor/manager/director/or designee follow up actions should be entered into the electronic Safety Alert System (SAS), also known as MIDAS, as a Patient Relations event.”