HospitalInspections.org

Based on document review and interview, it was determined that the Hospital failed to protect and promote patient's rights by failing to ensure appropriate steps were taken regarding a patient's allegations of abuse. This potentially places any patient in the Hospital at risk for serious harm, serious injury or serious impairment. As a result, the Condition of Participation 42 CFR 482.13, was not in compliance.

Findings include:

1. The Hospital failed to ensure patients were free from all forms of abuse by failing to follow the response and notification processes for allegations of abuse. See deficiency A-145.

The Immediate Jeopardy (IJ) began on 5/10/2023 due to the Hospital's failure to ensure a patient was free from all forms of abuse by failing to follow measures in accordance with policy and procedure regarding allegation of abuse. The IJ was identified on 6/29/2023 at 42 CFR 482.13, Patient Rights. The IJ and was announced on 6/29/2023 at 12:15 PM, during a meeting with the the Chief Executive Officer, Chief Medical Officer, Chief Financial Officer, Director of Admissions, and Lead Therapist. The IJ was not removed by the survey exit date of 7/03/2023.

Based on document review and interview, it was determined that for 1 of 2 (Pt. #1) clinical records reviewed for allegation of abuse, the Hospital failed to ensure that patient was free from all forms of abuse by failing to follow the response and notification processes for allegations of abuse. This has the likelihood to cause serious harm to any patient admitted in the Hospital.

Findings include:

1. The Hospital's policy titled, "Abuse and Neglect" (06/2022) included: " ...It is the policy of the Hospital that any staff who ... suspect a patient has been abused physically ... will report to the appropriate authority IMMEDIATELY. This includes ... staff-to-patient ... This suspicion may be based upon verbal report ... physical evidence ... which provides reasonable belief that a patient may have been or may become a victim ... Procedure. 1. Staff who ... suspect the patient has been abused either physically ... will report such abuse to the Administrator on Call (AOC) IMMEDIATELY and complete (an) incident report ... 2 ... If the allegation of abuse is made against staff, the Administrator on Call will notify the police. Upon receiving the incident report, the Director of Risk Management will file a report with the Illinois Department of Health within 24 hours of initial report ...4 ... a. the staff member shall be notified of the allegation and suspended from duty, pending results of the investigation ...Under no circumstances will the alleged perpetrator remain on any patient care unit ... 8. Investigation. Reports of Abuse ...will be thoroughly investigated by the Risk Manager ...within 24 hours of the initial report. All internal review findings shall be documented and filed ...and made available to the Department of Health upon request ..."

2. An email communication from DCFS (Department of Children and Family Services) to the Hospital on 6/15/2023 included, " ...(E #1/Director of Operations) was involved in a physical altercation with (Pt. #1) ...(Pt. #1) was on the unit in an anxious state not following directives when (E#1/Director of Operations) pushed (Pt. #1) which resulted in a verbal altercation that escalated into a physical altercation between (Pt. #1) and (E #1). (E #1) slammed (Pt. #1) on to the floor and fought with him until staff broke them up ..."

3. The Hospital's Incident Report for Pt. #1 on 5/10/2023 included, " ... At approximately 11:00 AM ... Patient Attacked Staff ... Placed on Visuals, Verbal De-escalation ...was injury observed-Yes abrasion on right elbow ..."

4. On 6/26/2023, the clinical record for Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital's 5th floor Adolescence Boys Unit with a diagnosis of intermittent explosive disorder/outbursts of anger and/or violence:

- On 5/10/2023, E #13's (Registered Nurse) Progress Note included, " ... (Pt. #1) was told by staff (E #15/Behavioral Health Associate) to move away and give peer some privacy ... (Pt. #1) was escorted to dayroom by staff (E #1 and E #15). (Pt. #1) became combative during escort, punched staff (E #1). (Pt. #1) reported pain in the right elbow related to staff (E #1 and E #15) escort event, small abrasion noted on right elbow as well. ROM (range of motion) intact, no evident swelling or deformity at this time ..."

-On 5/11/2023, MD #1's (Chief Medical Officer) Psychiatry Progress Note included, "(Pt. #1) has small bruise in his right elbow ..."

5. On 06/27/2023 at approximately 10:06 AM, an interview was conducted with MD #1 (Chief Medical Officer/Pt. #1's Psychiatrist). MD #1 stated that Pt. #1 reported to (MD #1) during Pt. #1's hospitalization in May 2023 that a staff abused Pt. #1. MD #1 did not recall if he reported Pt. 1#'s allegation to Administration.

6. On 06/27/2023 at approximately 11:35 AM, E #14 (Director of Quality and Risk Management) ... E #14 stated that there has been no incident or follow-up/investigation regarding Pt. #1's allegation of staff to patient abuse.

7. On 06/28/2023 at approximately 1:30 PM, an interview was conducted with E #11 (Chief Executive Officer). E #11 stated that the following has not occurred: an investigation regarding Pt. #1's allegation of abuse, notification of police, nor staff suspension. E #11 stated E #1 continues to work within the Hospital's units, including responding to patient behavioral emergencies.

Based on document review and interview, it was determined that for 1 of 3 (Pt. #1) clinical records reviewed regarding use of restraints, the Hospital failed to ensure that the staff obtained a physician's order for the application of physical restraints.

Findings include:

1. On 6/26/2023, the Hospital's "Restraint" policy, dated 6/2022, was reviewed and included, " ...1. Restraint means the use of manual method, physical or mechanical device that immobilizes or reduces the ability of a patient to move his arms, legs, body or head freely ...2. Restraint may only be used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety ...Definitions: Physical restraint includes manual measures approved by CPI (Crisis Prevention Institute) to limit or restrict body movement. Holding a patient who is not cooperative with receiving a medication through injection and/or approved CPI holds is considered a physical restraint ...Procedure: 1. ...the attending physician/covering practitioner will be contacted during the initiation of restraint or immediately after ...2. The order shall indicate the reason and maximum duration of restraint."

2. On 6/26/2023, the clinical record for Pt. #1 was reviewed. On 4/20/2023, Pt. #1 was admitted with a diagnosis of intermittent explosive disorder/outbursts of anger and/or violence. The clinical record included:

-On 5/5/2023, at 10:29 PM and 11:42 PM, a physical hold was applied to Pt. #1 due to aggressive and threatening behavior towards staff. An order for the physical hold was not obtained.

-On 5/6/2023, at 12:14 AM, a physical hold was applied to Pt. #1 due to aggressive behavior towards staff. An order for the application physical hold was not obtained.

-On 5/10/2023, at approximately 11:00 AM, a physical hold was applied to Pt. #1 due to Pt. #1 punching staff. An order for application of physical hold was not obtained.

3. On 6/27/2023, at approximately 10:49 AM, an interview was conducted with E #9 (Chief Nursing Officer). E #9 stated that a physical hold is considered a restraint and an order is required. E #9 could not provide documentation that an order for the physical hold was obtained.