HospitalInspections.org

A. Based on document review and interview, it was determined for 2 of 3 (Pts #1 and #10) patients, reviewed for Department of Child and Family Services (DCFS) notifications/documentation, the Hospital failed to ensure DCFS was notified verbally of allegation(s) of abuse with confirmation in writing within 48 hours of verbal reporting.

Findings include:

1. The Hospital policy titled "Reporting Suspected Cases of Abuse, Neglect, or Exploitation" (revised 5/27/15 to reflect additions unrelated to areas cited in deficiency). The policy stated "V. B. 1. Cases of suspected abuse or neglect must be immediately reported to the Department of Child and Family Services... 2. These verbal reports must then be confirmed in writing on form CANTS 4 (7/80)... 3. The original CANTS 4 Form should be sent to the local DCFS office. A copy of all such forms should be retained in the medical records and a copy..."

2. Internal documentation was reviewed on 8/11/15 at approximately 2:20 PM. The documentation stated the following:
a. Pt #1 was admitted to the Hospital on 10/10/14 with the diagnosis Phimosis and underwent a Circumcision under general anesthesia administered by the Certified Registered Nurse Anesthetist (CRNA #1) under the supervision of Anesthesiologist (Anes) Medical Doctor (MD) (Anes MD #1).
b. Anes MD#1 was observed by two Registered Nurses (E#3 and E#4), a Certified Surgical Technician (E#5) and a Patient Care Technician (E#6) to "fondle" Pt #1's scrotum "for a few seconds" and then left the room.
c. Anes MD#1 had no reason to assess or touch Pt #1's scrotum.
d. After the surgery was completed, E#3 followed the chain of command in immediately notifying Administration. Administration immediately gathered all staff who had witnessed the event and Anes MD#1 for one on one interviews.
e. Anes MD#1 was placed on a 10 day Administrative leave and was asked to immediately leave the Hospital premises.
f. Anes MD#1 was required to undergo an evaluation by a Neurologist (MD#4) to ascertain a professional evaluation of Anes MD#1 and the allegation of witnessed abuse to Pt #1.

3. Pt #1's record was reviewed on 8/12/15 at approximately 1:20 PM, by the Director of Analytics and Accreditation (E#1). Pt #1 was admitted to the Hospital on 10/10/14 with the diagnosis Phimosis and underwent a Circumcision that day under general anesthesia. The record lacked documentation of verbal or written notification to DCFS concerning the allegation of staff witnessing Anes #1 "fondling" Pt #1's scrotum while under anesthesia.

4. E#1 presented an email on 8/12/15 at approximately 2:25 PM. The email was dated 10/10/15 at 5:39 PM from the Risk Manager (E#8) to the Chief Operating Officer (E#16) and stated "I made the call and filed the report... (a name and report number)... would be filed as a mandated caller/no report..."

5. An interview was conducted with E#1 on 8/12/15 at approximately 2:25 PM. E#1 verbally agreed Pt #1's record lacked documentation of the DCFS verbal and written confirmation of verbal reporting and that these were required to be documented in the patient record. When asked who the call was made to (what Department), what was reported, and who the report was on, in relation to the email, E#1 stated "It doesn't specifically say those things, but the day is the same as the allegation."

6. Pt #10's record was reviewed on 8/13/15 at approximately 11:15 AM. Pt #10 presented to the Emergency Department on 7/16/15 with the Chief Complaint of Alleged Sexual Assault. The record lacked documentation of verbal and written confirmation of verbal reporting to DCFS.

7. An interview was conducted with the Emergency Department Registered Nurse (E#13) on 8/13/15 at approximately 11:15 AM. E#13 reviewed the record of Pt #10 and verbally agreed the record lacked documentation of DCFS verbal and written notification of the alleged sexual assault and agreed this should be in the record.

B. Based on document review and interview, it was determined for 1 of 1 (Pt #1) patient, in which an allegation of abuse while under anesthesia was reported to Administration, the Hospital failed to ensure the allegation was reported to the Illinois Department of Public Health (IDPH) within 24 hours of the allegation of abuse report.

Findings include:

1. The Hospital policy titled "Reporting Suspected Cases of Abuse, Neglect, or Exploitation" (revised 5/27/15 to reflect additions unrelated to areas cited in deficiency) was reviewed on 8/11/15 at approximately 1:25 PM. The policy stated "IV. 5. Sexual Abuse of a Child occurs when a person responsible for the child's welfare commits any of the following acts: d. Sexual molestation such as sexual conduct with a child when such contact, touching, or interaction is used for arousal or gratification of sexual needs or desires. Examples include fondling a child... IX. Specific Procedures for Reporting Suspected Abuse of Patients/Visitors on (the Hospital) Property: A. No (the Hospital) administrator, agent, or employee or a member of its medical staff shall abuse, neglect, or exploit any (the Hospital) patient or visitor... D. Under no circumstances may an (the Hospital) internal review of an allegation of abuse replace an investigation of the allegation by IDPH. E. Upon receiving a report (the Hospital) designated administrator will submit the report to IDPH within 24 hours of obtaining such a report..."

2. Internal documentation was reviewed on 8/11/15 at approximately 2:20 PM. The documentation stated the following:
a. Pt #1 was admitted to the Hospital on 10/10/14 with the diagnosis Phimosis and underwent a Circumcision under general anesthesia administered by the Certified Registered Nurse Anesthetist (CRNA #1) under the supervision of Anesthesiologist (Anes) Medical Doctor (MD) (Anes MD #1).
b. Anes MD#1 was observed by two Registered Nurses (E#3 and E#4), a Certified Surgical Technician (E#7) and a Patient Care Technician (E#6) to touched Pt #1's scrotum "for a few seconds" and then left the room.
c. Anes MD#1 had no reason to assess or touch Pt #1's scrotum.
d. After the surgery was completed, E#3 followed the chain of command in immediately notifying Administration. Administration immediately gathered all staff who had witnessed the event and Anes MD#1 for one on one interviews.
e. Anes MD#1 was placed on a 10 day Administrative leave and was asked to immediately leave the Hospital premises.
f. Anes MD#1 was required to undergo an evaluation by a Neurologist (MD#4) to ascertain a professional evaluation of Anes MD#1 and the allegation of witnessed abuse to Pt #1.

3. A concurrent interview was conducted, during the review of internal documentation, with the Chief Operating Officer (E#16) on 8/11/15 at approximately 2:20 PM with the Director Analytics and Accreditation (E#1) and the Chief Human Resources Officer (E#17) present. When asked why IDPH was not notified of the allegation of the witnessed abuse of Pt #1, E#16 stated Hospital Administration had immediately instructed the Anesthesiologist (Anes #1) to leave the Hospital premises pending the investigation, had immediately met with those who witnessed the events and had determined the act was related to "poor judgement" and "unprofessional conduct" and was not an act for obtaining sexual gratification; therefore, "we" didn't feel it was necessary to report it to IDPH.