Regency Hospital of Minneapolis LLC

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48040 Based on interview and document review, the hospital failed to ensure appropriate measures were implemented to ensure patient protection after an allegation of staff to a female patient sexual abuse was verbalized by 1 of 1 patient (P1) who reported sexual abuse by staff during the provision of care. The facility failed to implement a thorough investigation into the allegation and the alleged perpetrator continued to provide unsupervised patient care. As 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.”

“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: 48040 Based on interview and document review, the hospital failed to ensure appropriate measures were implemented to ensure patient protection after an allegation of staff to a female patient sexual abuse was verbalized by 1 of 1 patient (P1) who reported sexual abuse by staff during the provision of care. The hospital’s failures resulted in immediate jeopardy (IJ) that had the potential to affect all female patients receiving care within the hospital. The immediate jeopardy began on 3/22/26, when law enforcement (LE)-A informed the nurse supervisor that a male staff member placed his hands directly onto R1’s genitals and the facility failed to implement a thorough investigation into the allegation and the alleged perpetrator continued to provide unsupervised patient care placing other female patients at risk for sexual abuse. The Chief Nurse Officer (CNO) and the Chief Executive Officer (CEO) were informed of the immediate jeopardy on 3/27/26 at 1:23 p.m. The immediate jeopardy was removed on 3/30/26 at 2:10 p.m., but the hospital remained out of compliance with the CoP of Patient’s Rights at 42 CFR 482.13. Findings include: P1’s admission record dated 1/30/26, indicated P1’s diagnoses included acute encephalopathy, acute respiratory with hypoxia and borderline personality disorder. P1’s medical record dated 1/30/26 identified she was confused and delusional and required assistance of one for toileting prior to the incident and two staff with mechanical lift for transfers. During an interview on 3/25/26 at 1:58 p.m., a registered nurse (RN)-C stated she and the alleged perpetrator (AP)-1 were providing care to P1 on 3/21/26 when P1 became agitated, began yelling, and required restraint. RN-C reported during this episode, P1 stated not to “restrain her” because her brother used to “tie her up to rape her” which RN-C reported to RN-A. RN-C explained she was standing at P1’s doorway when a family member (FM)-A who was visiting at the time, attempted to calm P1. RN-C also stated FM-A did not report P1’s sexual abuse allegation to her on 3/21/26. During an interview on 3/26/26 at 2:39 p.m. FM-A stated was visiting P1 on Saturday 3/21/26, during the visit P1 told her she was raped while at the hospital. FM-A explained she did not report the allegation to the staff on 3/21/26 because, in her view, it “would not make any sense” as she believed staff could potentially be among the alleged perpetrators. FM-A called the police on 3/22/26 initially for overall concern of P1’s safety and to report P1’s sexual abuse allegation. During an interview on 3/25/26 at 11:22 a.m., P1 stated she was sexually abused by a male nursing staff, on day shift during the weekend of 3/21/26 into 3/22/26. P1 was not able to report on a specific day or time. P1 described the AP was African American male and was not able to articulate any other characteristics. P1 described the alleged assault as rough with the inability to articulate any further details of the alleged assault. P1 reported the incident to a family member (FM)-A then she told LE-A who was onsite on Sunday 3/22/26 after lunch at 1:20 p.m. Police report dated 3/22/26 12:19 p.m., indicated P1 reported sexual assault to FM-A on Saturday 3/21/26 and LE-A came onsite to interview P1. AP placed his hands directly onto her genitals while saying he “knew what a woman needs and could meet those needs.” P1 reported no penetration. P1 reported AP’s name was “Do or Dow” then “Lip,” was black male in his 20’s. The report indicated LE-A had reported to the nurse supervisor the information at the conclusion of the interview. On 3/24/26 at 9:19 a.m. LE-B received a call from RN-B. The summary of conversation with the nurse included, AP name was “Lip” described as black male, bald or short hair, and tall, wearing all black. RN-B reported to LE-B no nurses wear black, and no staff match that description. The case remained open. During an interview on 3/25/26 at 2:47 a.m., RN-A stated LE-A reported P1’s sexual abuse allegation to her on 3/22/26. On the same day, RN-A then followed-up with P1’s sexual abuse allegation by changing her care plan to be female caregivers only with two staff at all times. RN-A stated she identified two males staff members (AP-1 and AP-2) who provided nursing care to P1 from 3/20/26 through 3/22/26 and AP-1 was P1’s caregiver when she received the report about P1’s sexual abuse allegation. RN-A did not remove AP-1 from the schedule that evening but reassigned AP-1 to care for different patients including female patients, on the same unit, but restricted AP-1 from providing care to P1. RN-A explained she did not do anything to protect other patients, she did not offer a SANE (Sexual Assault Nurse Examiner) exam, did not interview P1 to obtain additional information about the AP, and did not interview other patients on the unit P1 resided. RN-A just focused on protecting P1 by updating P1’s care plan to reflect two staff at all times during cares and explained when P1 required personal hygiene, staff were to use the “female caregivers only”. RN-A stated on the same day (3/22/26), she reported the allegation to RN-B, the nurse manager of the unit. RN-A did not report the allegation to the State Agency (SA) on 3/22/26 nor obtained a case number from the police. During an interview on 3/25/26 at 3:46 p.m., RN-B stated RN-A told her and the chief nurse officer (CNO) on 3/22/26 about P1’s sexual abuse allegation via text message between 2:00 p.m. or 3:00 p.m. and she was directed to follow the abuse policy protocol by protecting P1. RN-B stated she attempted to talk to LE-B on 3/23/26 to get more information but she could not reach the officer. On 3/23/26, one day after the allegation, she was able to talk to P1 who confirmed a male nursing staff, an African American, on the weekend of 3/21/25 to 3/22/26, assaulted her. RN-B stated they had identified three African American male staff who had worked with P1 during that time frame, however the names and description P1 provided did not match the staff members. RN-B stated AP-1 and AP-2 were not suspended; they were still working in the unit but not caring for P1 anymore. RN-B indicated she confirmed P1’s care plan had been updated to reflect female caregivers. P1 was not given SANE exam or assessment. RN-B reported no education was provided to the staff to timely report an allegation of abuse to the State Agency (SA) and/or the police nor was the education provided for protocols on immediately implementing patient protections after an allegation of abuse was made. P1’s Incident Report Event summary, entered on 3/24/26, included an event identified as a staff-to-patient “sexual abuse allegation” with no visible harm noted. The description of the event indicated a report of a potential abuse allegation had been made to the law enforcement. The report further indicated the matter was escalated and the hospital initiated the abuse allegation process in accordance with hospital policy. Staff involved in P1’s care were identified, statements were requested, and clinical documentation was being reviewed as part of the ongoing investigation. During an interview on 3/25/26 at 4:20 p.m., the CNO stated RN-A sent a group text message to RN-B and herself regarding P1’s sexual allegation reported by LE-A onsite where P1 alleged she was inappropriately touched by a male staff member over the weekend. CNO explained RN-A knew the abuse policy and her job was to keep P1 safe since nobody fit the description provided or had names like “Do, Dow or Lip”. CNO stated RN-A did not initiate an investigation but updated P1’s care plan to be only female with two staff at all times. On 3/26/26 at 10:56 a.m. the director of risk management (RM)-A stated he was not made aware of the allegation until 3/24/26 after police came onsite to talk to P1. RM-A’s team initiated the internal investigation which consisted of identifying staff involved in P1’s care, statements were requested, and clinical documentation related to P1’s care was being reviewed as part of the investigation. RM-A stated they had determined P1’s description of African American male did not fit the description of any staff including the three African American males who worked on the unit and conceding to a male staff was assigned to P1 on 3/20/26, 3/21/26 and 3/22/26. RM-A stated they did not have enough information to suspend any staff per P1’s descriptions. RM-A stated the allegation was so challenging because there was no AP that matched the description of a particular male “African American.” RM-A stated they have not reported the allegation to the SA because he thought the police already did it and did not want to create a duplicate. RM-A stated RN-B reported to him that the police had opened an investigation but did not have the case number yet. RM-A explained P1 was confused and vague in her sexual abuse allegation, so the only thing they had focus on was her safety and her care plan was updated to be female caregivers only, but he did not think whether something should be done to protect other residents. On 3/25/26 at 1:26 p.m. AP-1 stated he provided care to P1 on the day shifts of 3/21/26 and 3/22/26. He was giving P1 cares when she said to him “did you see him from the window” but there was nobody there. AP-1 explained P1 seemed confused during cares, and he reported to RN-C. AP-1 stated P1 was not the only female patient he cared for on 3/21/26 and 3/22/26. AP-1 stated he did not sexually abuse or touch P1 inappropriately. AP-1 stated he was reassigned to care for different patients on 3/22/26 in the unit. RN-A was the only person who talked to him on 3/22/26 about P1’s care plan changed to only two female staff at all times. AP-1 confirmed he was not suspended but continued to work in the unit with other female patients unsupervised on 3/22/26, 3/23/26, 3/24/26 and 3/25/26. AP-1 stated no education was provided to him at this time. During an interview on 3/26/26 at 9:19 a.m., AP-2 stated he provided cares to P1 on 3/20/26 and P1 did not complain or raise concerns about anything. AP-2 reported he did work over the weekend on 3/21/26 to 3/22/26 on the day shift but did not care for P1. AP-2 explained he did not know anything about law enforcement present on Sunday 3/22/26. AP-2 stated it was reported during a huddle in morning that P1 was now female only with two staff at all times on Monday 3/23/26. AP-2 stated he continued caring for other patients including female patients on 3/22/26, 3/23/26, and 3/24/26 when he was asked to write a statement about care he provided to P1 on 3/20/26 which he did and gave it to the nurse manager RN-B. AP-2 confirmed he was not suspended but continued to work in the unit on 3/22/26, 3/23/26, 3/24/26 and 3/26/26. AP-2 stated no education was provided to him at this time. During an interview on 3/26/26 at 2:18 p.m., the administrator stated he was made aware of the sexual abuse allegation on Monday,3/23/26 by the CNO. The administrator stated when the allegation was reported to the staff, RN-A put interventions in place to make sure P1 was safe but claimed that they did not think other patients’ safety was a concern at that time and just pointed out to what they have done so far. The administrator stated P1 had been at the hospital for 55 days and this was the first time she had made a sexual abuse allegation against a staff member. He explained that his expectation was when staff received a sexual abuse allegation, they had to protect the patient and if they have identified AP, he/she should be removed from the schedule pending a thorough investigation. He claimed the police unsubstantiated the investigation which was rejected by LE-B during an interview on 3/26/26 at 3:10 p.m. reporting that he had not spoken to any hospital staff that the case was unsubstantiated. Facility Abuse and Neglect policy dated 1/1/24 identified five points of Protection of patients: Any allegation of abuse or neglect must result in removal of the patient from potential of further abuse. Any employee involved in such an accusation will be placed on administrative leave and instructed not to come to the hospital until the investigation is completed and the matter resolved. The CEO or designee will begin the investigation with the advice and counsel of the Corporate Legal and Human Resources Departments. All relevant State and local laws related. The immediate jeopardy that began on 3/20/26, was removed on 3/30/26, when it was verified by interview and document review the hospital conducted a thorough investigation. Additionally, the hospital provided educational handouts to be reviewed and signed off by nursing and therapy staff within a tracking log before their next scheduled shift. Practice changes include Vulnerable Adult (VA) & Child Maltreatment reports of abuse need to be filed immediately following the event. Staff to initiate immediate protection measures such ensuring immediate safety of the patient, suspending suspected team members, interviewing, and assessing the patient (consider SANE). Also, staff have to file VA or Child Maltreatment report, notify team members and/or patient representative if needed, and reassess all patients in contact with suspected team members.”