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Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights.

Findings include:

1. The hospital failed to ensure staff filed and ensured staff were trained in the recognition and reporting of allegations of abuse. See deficiency at A-145 A.

2. The hospital failed to notify the state within the required 24 hours timeframe. See deficiency cited at A-145 B.

3. The hospital failed to follow policy and suspend staff alleged of abuse until investigation was completed. See deficiency cited at A-145 C.

4. The hospital failed to ensure that a patient was monitored while in restraints. See deficiency cited at A-175.

A. Based on document review and interview, it was determined in 1 of 1 (Pt #1) abuse allegation records, the hospital failed to ensure staff were trained in the recognition and reporting of an allegation of abuse. This has the potential to affect all patients who are serviced by the facility.

1. On 11/08/23 at approximately 10:00 AM, the policy titled, "Allegations of Abuse/Neglect (revised 06/05/2023)" was reviewed. The policy stated, "... VI. Prevention: All clinical and non-clinical staff must be trained on the prevention of abuse/neglect. The hospital:... 3. Provide continuing education to staff as appropriate on such topics as:... What constitutes abuse/neglect..."

2. A review of the incident report was conducted on 11/07/23 at approximately 2:00 PM. The "CALM" Report stated, "Concerns: General Care, Patient Safety ... Action Taken: ... 0800 (11/4) Asked to come to patient room in 119. (family members) and patient still very upset over the incident from Friday. Pt stated to me '(E #4) shook me." ... Pt now saying (Pt #1's) right hand is numb and (Pt #1's) can't push (Pt #1's) call light .... AOC (Administrator On Call - E #7) called and reported ..."

3. An interview was conducted with RN (E #6) on 11/08/23 at 1:40 PM. When asked what training (E #6) has received on abuse, E #6 stated, "I don't know if we've ever had specific training on abuse. We've been told to follow chain of command with complaints."

4. An interview was conducted with the Director of Facilities Management (Administrator on call when the incident was reported - E #7) on 11/07/23 at 2:15 PM. When asked what training (E #7) has received on abuse, E #7 stated, "Nothing really as far as abuse goes. I received a call Saturday morning. The charge nurse made mention of rough handling/shook. Family stated they were going to call the state on Monday. I didn't follow up with them. I didn't know what to say to the family. I was the AOC."

5. On 11/09/23 at approximately 10:00 AM the abuse training/education was reviewed for E #6 and E #7. E #6's abuse training was dated 01/05/22 and E #7's abuse training was dated 11/08/21.

6. On 11/08/23 at approximately 10:30 AM, an interview was conducted with the Director of Quality and Risk (E #2). E #2 stated, "We do training during employee orientation. It is my understanding the clinical and case management staff are assigned annual abuse training. Clinical AOC's will get it pushed out annually. The non-clinical personnel (Director of Human Resources, Director of Facilities Management, Controller, Director of Quality and Risk, Chief Executive Officer, and Business Development Director) do not get the annual training pushed out to them. They will get training every 2 years per the regulation. We have not completed it yet but will be doing it soon."

B. Based on document review and interview, it was determined in 1 of 1 (Pt #1) abuse allegation records, the hospital failed to notify the state within the required 24 hours timeframe. This has the potential to affect all patients who are serviced by the facility.

1. A review of Illinois licensure regulations related to abuse reporting was reviewed on 10/25/23 at approximately 10:00 AM. "Title 77, SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES; PART 250 HOSPITAL LICENSING REQUIREMENTS
SECTION 250.260 PATIENTS' RIGHTS; Section 250.260 Patients' Rights" stated. "5) Upon receiving a report under subsection (c)(3), the hospital shall submit the report to the Department within 24 hours after obtaining such report."

2. A review of the incident report was conducted on 11/07/23 at approximately 2:00 PM. The "CALM" Report stated, "Concerns: General Care, Patient Safety ... Description: stated (Pt #1) asked to use the bathroom and the nurse that answered the light wasn't compassionate, didn't give (Pt #1) instructions on how to safely transfer, told (Pt #1) doesn't listen, and was rough placing (Pt #1) in (Pt #1's) wheelchair and walked out. (Pt #1) vocalized (Pt #1) doesn't want (E #4) on (Pt #1's) care team (entered by RN - E #5 on 11/3 at 10:02 AM) .... Action Taken: ... 0800 (11/4) Asked to come to patient room in 119. (family members) and patient still very upset over the incident from Friday. Pt stated to me '(E #4) shook me." ... Pt now saying (Pt #1's) right hand is numb and (Pt #1's) can't push (Pt #1's) call light .... AOC (Administrator On Call - E #7) called an reported ... The report lacked documentation of notification of IDPH.

3. On 11/08/23 at approximately 10:30 AM, an interview was conducted with the Director of Quality and Risk (E #2). E #2 stated, "We have not notified IDPH. The staff didn't recognize the complaint as an abuse allegation." When asked if the incident is an allegation of abuse, E #2 stated, "On Monday, I had not decided if it was an abuse allegation. I feel like I have to say yes with what I know from interviews. I would say yes as I don't have enough information to say no. We will notify IDPH now."


C . Based on document review and interview, it was determined in 1 of 1 (Pt #1) patients' abuse allegation records reviewed who were involved in altercations, the hospital failed to follow policy and suspend staff alleged of abuse until investigation was completed. This has the potential to affect all patients who are serviced by the facility.

1. On 11/08/23 at approximately 10:00 AM, the policy titled, "Allegations of Abuse/Neglect (revised 06/05/2023)" was reviewed. The policy stated, "... Policy ... II. Un-witnessed Report of Abuse ... 3. The patient must be .... C. secured from harm by taking any additional necessary actions to ensure the patient's safety and welfare, including, but not limited to ... ii. reassigning staff and/or suspending accused staff pending investigation..."

2. A review of the incident report was conducted on 11/07/23 at approximately 2:00 PM. The "CALM" Report stated, " ... 0800 (11/4) Asked to come to patient room in 119. (family members) and patient still very upset over the incident from Friday (11/3). Pt stated to me '(E #4) shook me." ... Pt now saying (Pt #1's) right hand is numb and (Pt #1's) can't push (Pt #1's) call light .... AOC (Administrator On Call - E #7) called an reported ..."

3. On 11/08/23 at approximately 10:30 AM, an interview was conducted with the Director of Quality and Risk (E #2). E #2 stated, (E #4 worked on Sunday (11/5) and was to work today. We have taken (E #4) off the schedule."

Based on document review and interview, it was determined that for 1 of 1 patients' (Pt. #10) clinical records reviewed regarding use of restraints the hospital failed to ensure that a patient was monitored while in restraints, as required.

Findings include:

1. On 11/9/2023, the Hospital's policy titled, "Use of Restraints" (Reviewed 9/11/202312/13/22)" was reviewed. The policy stated, "Every two hour monitoring through observation interaction, direct examination. Monitoring is to include, level of distress/agitation, mental status, cognitive function, vital signs (as appropriate) hydration, nutrition, elimination needs and positioning needs/RANGE OF MOTION."

2. On 11/8/2023 the clinical record of Pt. #10 was reviewed and included the following.
- Pt. #10 was admitted to the hospital on 7/25/2023 with diagnoses of "left occipital cerebrovascular accident with hemorrhagic conversion." Order for a Restraint Medical Surgical dated 8/2/2023 at 8:47 AM. unaware of physical limitations, bed enclosure. Pt #10's clinical record lack the required every two hour monitoring on 8/2/2023 5:33 PM until 7:00 AM on 8/3/2023,

3. On 11/8/2023 and interview was conducted with the Director of Quality and Risk (E #2). E #2 reviewed the restraint documentation recorded in Pt #1's clinical record. E #1 agreed with the above findings, regarding the lack of required documentation.