Sanford Bemidji Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 40945 Based on interview and record review, the facility failed to protect patients, investigate an abuse allegation, and report an allegation to the state agency an allegation of staff to patient sexual abuse for 1 of 10 patients (P1) reviewed for patient rights. The hospital was informed by local law enforcement on 4/29/25 of a staff to patient sexual assault allegation and on 5/5/25 when law enforcement presented with a search warrant. As a result, the hospital was found out of compliance with the Condition of Participation Patient Rights at 42 CFR 482.13. An immediate jeopardy was issued at A-0145. See A-0145 for additional information. A standard level deficiency was issued at A-0117. See A-0117 for additional information.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 40945 Based on interview and document review, the hospital failed to protect and promote patient rights by issuing a patient bill of rights to 6 of 10 patients (P1, P2, P5, P6, P7, P9) reviewed for patient rights. Findings include: P1’s medical record identified an admission on 4/24/25, with discharge on 4/28/25. P1’s medical record lacked evidence P1 received the patient bill of rights. P2’s medical record identified an admission on 6/10/25 and was still a current patient. P2’s medical record indicated P2 received the patient bill of rights until 6/12/25. P5’s medical record identified an admission on 6/5/25 and was still a current patient. P5’s medical record indicated P5 received the patient bill of rights until 6/12/25. P6’s medical record identified an admission on 6/5/25 and was still a current patient. P2’s medical record indicated P6 received the patient bill of rights until 6/12/25. P7’s medical record identified an admission on 6/5/25, with discharge on 6/6/25. P7’s medical record lacked evidence P7 had received the patient bill of rights. P9’s medical record identified an admission on 6/5/25 and was still a current patient. P2’s medical record indicated P9 received the patient bill of rights until 6/12/25. During a medical record review, on 1/30/25 at 12:15 p.m., the director of quality improvement (QD)-A confirmed the above patient records did not have acknowledgement of receiving the patient bill of rights. During an interview on 6/12/25/25 at 3:34 p.m. the vice president of operations stated all patients are to be provided a copy of their patient bill of rights upon admission, serves to make sure they know their legal and ethical rights when they are at the hospital. Also to be part of their health care decision making. It also lets them know what the process is if they have a concern and how to elevate the concern. Expectation is the patient bill of rights is provided for all patients. The hospital policy titled Patient Rights and Responsibilities, dated 1/9/24, indicated the polices purpose is to assure that certain rights are preserved for all patients at Sandford Health facilities. To assure that each patient is informed of their rights and responsibilities as a patient. The patient rights are extended to all patients and will be respected by the medical staff and employees of Sanford. All patients will be provided a copy of the rights and responsibilities booklet upon admission to the 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: 40945 Based on interview and record review, the hospital failed to protect patients, investigate an abuse allegation, and report an allegation to the state agency an allegation of staff to patient sexual abuse for 1 of 10 patients (P1) reviewed for patient rights. The hospital was informed by local law enforcement on 4/29/25 of a staff to patient sexual assault allegation and on 5/5/25 when law enforcement presented with a search warrant. The immediate jeopardy began on 4/29/25, when the hospital failed to protect, investigate, and report an allegation of staff to patient sexual abuse when the hospital was informed by local law enforcement on 4/29/25 and 5/5/25 of an allegation of staff to patient sexual abuse. The Lead Accreditation Specialist, Chief Medical Officer, and Vice President of Operations was informed of the immediate jeopardy on 6/11/25 at 5:30 p.m. The immediate jeopardy was removed on 6/13/25 at 9:20 a.m. but noncompliance remained at a condition level. Findings include: A Vulnerable Adult Maltreatment Report dated 4/29/25 received by the state agency indicated on 4/29/25, at 4:06 p.m. family member (FM)-A reported to them P1 told her she was sexually abused by hospital staff on the third night of her hospitalization, which was 4/27/25. P1 told FM-A a hospital staff person entered her room, pulled up her nightgown and put a hand in her genital area and the incident was painful. P1 did not know who the hospital staff was because they were not wearing a name tag. FM-A informed the hospital, the medical provider, and nursing staff of the allegation who did not take the allegation seriously nor did the hospital investigation the allegation. P1’s medical record was reviewed. P1 was admitted to the hospital on 4/24/25 with a diagnosis of acute cystitis (inflammation of bladder) and urinary tract infection. P1 was treated with antibiotics and discharged back to a nursing home on 4/28/25. Review of a hospital report detailing the email which was sent out by security officer (SO)-A on 4/29/25, at 6:28 p.m. indicated a police officer came to the office today and stated they received a police report regarding P1’s abuse allegation of a hospital staff who came into P1’s room during the night and sexually assaulted P1 by grabbing P1 in the groin area. PD asked the hospital to investigate when the staff entered and left the room and that they would get a subpoena for video of the activity. The house supervisors and nursing staff on the unit were already aware of the allegation and stated P1 was confused and incontinent so there would be reason a staff person to be touching P1 to provide incontinent care. During an interview on 6/11/25, at 2:08 p.m. FM-A stated P1 reported she had been sexually assaulted by hospital staff on the third night of her hospitalization. FM-A immediately reported this to hospital including a nursing assistant (NA), registered nurse (RN) and medical provider (MD); however, all staff dismissed P1’s allegation. During an interview on 6/11/25, at 2:44 p.m. with Chief Medical Officer, Lead Accreditation Specialist and VP of operation, VP of operations stated on 4/29/25, a security officer had sent out an email indicating local police department had arrived at the hospital to initiate an investigation related to an allegation of sexual abuse. The email detailing the allegation of sexual assault went out to hospital leadership and risk management. No action was taken initiate to protect patients, investigate the allegation, or report to the allegation internally and externally to the state agency. On 5/5/25, local police department arrived on scene at the hospital to initiate a search warrant for video footage and medical records. No action was taken to protect patients, investigate the allegation, or report to the allegation internally and externally to the state agency. All nursing staff who provided care during P1’s hospital stay was still providing care for patients on the medical unit. No action was taken to protect patients, investigate the allegation, or report the allegation internally and externally to the state agency. Hospital’s Vulnerable Adult (VA) Maltreatment policy dated 2/2025, indicated the purpose of the policy included to provide direction and uniformity of action in properly reporting and recording cases of alleged or suspected abuse or neglect in compliance with state law and to provide direction and uniformity of action in properly reporting internal allegations of abuse or neglect by Sanford employees to patients/residents. The policy directed staff if a patient or their legally authorized representative claims they were abused, neglected, or harassed by a Sanford provider or staff member during care, please contact Patient Safety immediately. Hospitals Patient Rights and Responsibilities policy dated 10/9/2024, indicated the purpose of the policy included to assure that certain rights are preserved for all patients at Sanford Health facilities. Any patient who has a concern that their rights have not been respected shall be encouraged to voice these concerns to the caregiver and attempts shall be made to resolve the issue in the moment. If the issue is not resolved, please refer to the Enterprise Complaint and Grievance policy. The patient rights are extended to all patients and will be respected by the medical staff and employees of Sanford. The immediate jeopardy that began 4/29/25, was removed on 6/12/25, at 9:20 a.m. when it was verified by interview, and document review the hospital completed review of the Patient Rights, Adverse Event, and the Abuse and Neglect policies were reviewed, identified policy revisions completed, education was initiated on 6/11/25, by leadership for all locations with employees to validate understanding of mandated reporting requirements, reviewed annual computer-based education and deployed reports to leaders to ensure all staff complete required training. Education also included immediately following a patient report of an allegation of abuse, staff to intervene to remove the alleged perpetrator from providing patient care, communicate to care team/leadership to ensure an internal safety report has been filed and an investigation initiated, and a Mandated report filed to the State of Minnesota.”