HospitalInspections.org

Based on document review and interview, it was determined that for 2 of 2 (Pt. #1 and Pt. #6) records reviewed for allegation of abuse, the Hospital failed to report the alleged abuse to the Illinois Department of Public Health, as required, to ensure patient is free from all forms of abuse.

Findings include:

1. On 9/19/2022, the clinical record for Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital on 7/21/2022 with a diagnosis of major depressive disorder. The attending psychiatrist's (MD #1) progress notes on 7/27/2022 included, " ... I (MD #1) discussed with risk-management allegations (Pt. #1) had against staff regarding incident that happened yesterday (7/26/2022). Unit staff involved in the incident has been removed from the unit until patient is discharged."

2. On 9/20/2022, the Hospital's complaint and grievance log from 6/1/2022 through 9/19/2022 was reviewed. The log included tracking forms regarding Pt. #1 and Pt. #6's complaints:

- The tracking form for Pt. #1 indicated that E #10 (Nurse Manager/House Supervisor) received a report on 7/27/2022 that Pt. #1 complained of being abused by staff. The report indicated that a staff allegedly grabbed Pt. #1 by her neck, slammed (Pt. #1) against the wall choking Pt. #1. The report also included that another staff tried to punch Pt. #1. The allegation of abuse was not reported to the Illinois Department of Public Health (IDPH).

- The tracking form for Pt. #6 indicated a complaint regarding physical abuse by staff. The tracking form indicated that Pt. #6 complained that a staff assaulted Pt. #6. The allegation of physical abuse was not reported to IDPH.

3. On 9/21/2022, the Hospital's policy titled, "Hospital Staff Responsibility for Patient, Visitor, and Employee Safety" (revised on 3/2021) was reviewed and included, "... Allegation of Patient Abuse. All allegations made by patients against Staff shall be dealt with in the following manner: Patient abuse allegations shall be managed according to the... IDPH... reporting guidelines..."

4. On 9/20/2022 at approximately 12:15 PM, an interview was conducted with E #1 (Chief Compliance Officer). E #1 stated that allegations of abuse is not reported to IDPH if the allegation is unsubstantiated within 24 hours of receiving the report. On 9/21/2022 at approximately 10:30 AM, findings were discussed with E #1. E #1 stated that Pt. #1 and Pt. #6's allegations of abuse were not reported to IDPH.