Larned State 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: 51768 Based on policy review, video review, record review, and interview, the Hospital failed to ensure the right to be free from all forms of abuse or harassment for 2 (Patient 1, and 3) of 10 sampled patients. The facility failed to ensure the protection of patients during an investigation of alleged abuse and/or failed to ensure an investigation of alleged abuse was conducted within the required time frame as required per facility policy for 3 (Patient 3, 5, 9) of 10 sampled patients. This deficient practice has the potential to negatively impact the health and well-being of any patient receiving services at the hospital. Findings Include: Review of a policy titled, “Abuse, Neglect, or Exploitation [ANE] of Residents or Patients,” dated 09/03/19, showed that residents/patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect and exploitation and that the hospital is to protect residents/patients from ANE from anyone, including staff members and other residents/patients. The policy went on to state that if an allegation of ANE occurs, the alleged perpetrator of the ANE will be immediately removed from the treatment area. All allegations, observations, or suspected cases of ANE will be investigated by the hospital. The investigative process includes the following: 1.The Risk Manager informs the Superintendent, Commissioner, Governance, Risk Management and Compliance Director, Legal Counsel, Program Director/Department Head, Director of Human Resources, and Unit Leader that an incident report alleging ANE has been received and assigns the incident to a primary investigator by the end of the day the allegation is received. The assigned investigator will complete a thorough investigation of the ANE allegation no later than twenty-one (21) days after receiving the incident report. If a thorough investigation is unable to be completed within 21 days after receiving the incident report, the investigator must send a written request to the Commissioner of State Hospitals/designee, with copies sent to the Governance, Risk Management, Compliance Director and Risk Manager for approval. If the allegation of ANE is confirmed, the case will be presented for Standard of Care Determination, corrective action, and minimization of future occurrence, and reported to the appropriate state and licensing agency if necessary. 2. The Program Director/Department Head monitors unit activities and/or develops corrective action plans deemed necessary as a result of the investigative findings. 3. The Director of Human Resources will consult with the Superintendent and Legal Counsel to determine what disciplinary actions, if required, will be taken for any employees involved. 4. The Social Worker will notify the resident/patient’s family, guardian or other person responsibly party of the ANE allegation and that the allegation has been reported, and an investigation will be conducted. This notification will be documented in the medical record. 5. Governance, Risk Management, and Compliance Director receives final investigative reports and is responsible to ensure the report is thorough and reviews all reports of confirmed cases of ANE. 6. The Superintendent will review all reports of alleged ANE and directs any recommended actions and disciplinary measures as indicated that will protect residents/patients from all forms of ANE. 7. The Risk Management Committee (RMC) reviews all cases of ANE and ensures all necessary actions were taken regarding the incidents, recommends whether or not a report should be made for a possible listing of the perpetrator on the abuse registry and makes the final Standard of Care determination as well as recommendations of ways to minimize future occurrences. Patient 1 Review of Patient 1’s discharge medical record showed an involuntary patient admitted on 09/25/25 with the diagnosis of altered mental status and attempted suicide. The record showed that Patient 1 reported an allegation of ANE on 10/08/25. Review of a progress note dated 10/08/25 at 6:44 AM showed that Staff J, Registered Nurse (RN), was informed about an incident in which Patient 1 reported that she had been raped by a male staff member who had entered her room. Review of the hospital’s surveillance video from 10/08/25 showed the following: 2:16 AM - 2:27 AM; Staff I, Mental Health and Developmental Disabilities Technician (MHDDT) (alleged perpetrator) entered Patient 1’s room (a duration of 11 minutes.) 2:25 AM; Patient 1 observed speaking to Staff J, RN. 2:36 AM - Staff I, MHDDT (alleged perpetrator), entered the nursing office and observed speaking to Staff J, RN. 2:45 AM - 3:00 AM; Staff I, MHDDT (alleged perpetrator) moves between multiple areas on the unit without direct supervision (duration of 15 minutes). The locations entered included areas that connect directly to patient care corridors. 3:22 AM - 3:25 AM; Staff I, MHDDT is escorted from the unit and out of the building. Between 2:00 AM and 3:20 AM, multiple Staff MHDDTs are observed walking around the unit and looking into patient rooms, performing rounds, and checking on patients in their rooms. Other patients can be seen in the hallway and talking to staff members during this time frame. During an interview on 10/22/25 at 9:20 AM, Staff J, RN, stated that he met and spoke with Staff I, MHDDT (alleged perpetrator) immediately following Patient 1’s allegation of sexual assault. Staff J went on to state that Staff I, MHDDT (alleged perpetrator), had admitted to his sexual conduct, asked who else was aware of the allegation, what would happen next, and pleaded for Staff J to help him. Staff J stated that he explained his obligation and responsibility to report the allegation and that he contacted supervisors and call security to respond to the unit. The hospital failed to ensure the safety of all patients that resided on the unit by allowing Staff I, MHDDT, to remain on the unit without direct supervision after an allegation of ANE was made. Patient 5 Review of Patient 5’s discharge medical record showed an involuntary patient admitted on 08/13/25 with the diagnosis of unspecified psychosis (a mental state that causes a disconnect from reality, often inducing symptoms of hallucination, delusions, and/or paranoia) and self-care failure (inability to take care of one’s daily needs.) The record showed that Patient 5 reported an allegation of ANE on 08/25/25. Review of a document titled, “Special Precautions Note,” dated 08/25/25 at 6:19 PM, showed that Patient 5 reported that a male staff member touched her inappropriately on her breasts and buttocks. Review of the hospital’s document titled “Risk Management Investigation Tool,” signed by the Department Head on 08/28/25, showed that Staff I, MHDDT, was identified as the alleged perpetrator in Patient 5’s allegation of ANE. The document went on to state that per the Assistant Superintendent and Director of Nursing, the decision was made to move Staff I, MHDDT off the unit in which Patient 5 resided. During an interview on 10/23/25 at 9:40 AM, Staff N, Assistant Risk Manager, confirmed that Staff I was moved to a different unit and was still allowed to perform patient care duties during the risk investigation. During an interview on 10/23/25 at 12:11 PM, Staff U, Commissioner, stated that it is the expectation that employees alleged of abuse, neglect, or exploitation, are not providing patient care while a thorough investigation is occurring. The hospital failed to implement its corrective action to ensure the safety of patients by allowing Staff I, MHDDT to continue providing patient care during an investigation of alleged ANE. Patient 9 Review of Patient 9’s discharged clinical record showed that Patient 9 was involuntarily admitted on 08/01/25. The record showed that Patient 9 reported an allegation of ANE on 08/23/25. Review of a progress note dated 08/23/25 showed that Patient 9 informed an MHDDT that a male staff member had entered her room “the other night” and had closed the door behind him. Patient 9 stated she had not reported the incident earlier because she felt staff would not believe her. Review of a provider note dated 08/23/25 at 8:56 PM showed that Patient 9 was interviewed about her report of alleged inappropriate sexual behavior against Staff F, MHDDT. Patient 9 had reported that Staff F had entered her room (date and time of incident unknown) and had shut the door behind him. Patient 9 went on to state that he [Staff F] was sitting close to her bed with his legs apart, “insinuating he wanted me to give him oral.” Patient 9 denied any physical contact between herself and Staff F. Patient 9’s orders were updated to female-only staff members. Review of Patient 9’s “Physician Order,” dated 08/23/25, showed, 1:1 at all times continuous, female staff only for 1:1. Pt has trauma hx [history].” Review of Patient 9’s “Observation Checks,” dated 08/25/25, showed that Staff F, MHDDT, sat 1:1 with Patient 9 (after an order was placed for female staff only) and documented checks for the following times: 08/25/2025 at 7:20 PM, sleeping in room 08/25/2025 at 7:34 PM, sleeping in room 08/25/2025 at 7:47 PM, sleeping in room 08/25/2025 at 8:01 PM, sleeping in room 08/25/2025 at 8:13 PM, sleeping in room Review of the investigation findings showed that the investigation was not reviewed, completed, and signed until 10/05/25, 10/09/25, and 10/15/25 (43 days after incident was reported.). During an interview on 10/23/25 at 9:40 AM, Staff O, Assistant Risk Manager, stated that the hospital received Patient 9’s allegation of ANE on 08/23/25. Staff O stated that the investigation has not been completed as of the date of this survey. Staff O stated other than an assessment completed by the on-call physician, no other corrective action has been taken. During an interview on 10/23/25 at 12:11 PM, Staff U, Commissioner, stated that it is his expectation that physician orders are followed. Staff U stated that placing Staff F, MHDDT, with Patient 9 was a problem and that Patient 9 should have been assigned only female staff. The hospital failed to complete an investigation for a reported allegation of ANE within 21 days as required per hospital policy and failed to ensure the prevention of further abuse/harassment to other patients by allowing Staff F, MHDDT to continue patient care after an allegation of ANE was made. Patient 3 Review of Patient 3’s discharged clinical record showed that Patient 3 was involuntarily admitted on 08/14/25. The record showed that Patient 3 reported an allegation of ANE on 09/02/25. Review of a progress note dated 09/03/25 showed that Patient 3 reported an allegation of ANE to Staff G, RN, and stated that he had been sexually assaulted by Staff F, MHDDT. Patient 3 stated that Staff F had performed fellatio on him. At the time of the survey, the Hospital was unable to provide documented evidence that an investigation of Patient 3’s allegation of ANE had been completed. During an interview on 10/21/25 at 1:01 PM, Staff M, Special Investigator, stated that Patient 3’s allegation is unsubstantiated at this time. During an interview on 10/23/25 at 9:40 AM, Staff O, Risk Manager Assistant, stated that the hospital received reports of Patient 3’s allegations on 09/03/25 and 09/11/25. Staff O stated that the investigation is not completed at this time. Staff O stated that corrective actions have not been determined and are still pending. The hospital failed to ensure that a complete and thorough investigation of Patient 3’s allegations was initiated within 21 days as required per Hospital policy. During an interview on 10/23/25 at 12:11 PM, Staff U stated that it is his expectation that all allegations of abuse, neglect, and exploitation are investigated within 30 days.”