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Based on document review and interview it was determined that the Hospital failed to protect and promote patients rights by failing to follow abuse policy during an investigation of alleged sexual abuse. As a result, the Condition of Participation, 42 CFR 483.13 Patient Rights was not in compliance.

Findings include

1. The Hospital failed to ensure that patients were free from all forms of abuse, by not removing staff from duty, during an ongoing investigation of alleged abuse. See deficiency at A-145.

Based on document review and interview it was determined that for 3 of 3 (Pt #1, #8, #9) clinical records reviewed for resolution of a grievance, the Hospital failed to ensure that the patient's received written notice of the initial receipt of the grievance, and the grievance closure letters, with the results of the grievance process, and the date of completion.

Findings include:

1. On 06/08/2022 at approximately 9:00 AM, the Hospital's policy titled, "Complaint and Grievance Management" dated 03/2020 was reviewed and included, " ...Grievance: A formal or informal written or verbal complaint that is made by the patient or patient representative related to ...abuse, neglect ...Grievance Process: A. The Patient Representative or designee should send written correspondence acknowledging receipt of grievance within seven business days ...upon resolution, a second letter should be sent to the patient within 30 business days recapping the issue, the steps taken to resolve issues and provide contact information to the patient ..."

2. On On 06/07/2022 at approximately 9:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was directly admitted to the Addictions Unit on 04/26/2022 at 8:59 PM, with a diagnosis of opiate detoxification. On 04/29/2022 at 2:08 PM, Pt. #1 was transferred to the Hospital's emergency room with chief complaint of hypotension, nausea, and vomiting. Pt. #1 was admitted to the Hospital's Telemetry Unit on 04/29/2022 at 4:37 PM, with a diagnosis of hypotension and acute kidney injury.

Pt. #1's clinical record included the following:

- The medical/telemetry unit nursing progress documentation by Charge Nurse (E #2) note dated 05/02/2022 at 12:11 AM, included, " ...Patient's [Pt. #1's] RN (Registered Nurse -E #3) told me that patient [Pt. #1] reported to her having been touched inappropriately during an US [ultrasound] on 04/29. House Manager (E #7) notified of incident. Patient offered physical exam by MD [hospitalist] patient refused."

3. On 06/07/2022 at approximately 11:30 AM, the Hospital's document titled, "Healthcare Safety Zone Occurrence Report #73031" dated 05/02/2022 was reviewed and included, "Occurrence: Sexual Abuse ...date of occurrence: 04/29/2022 ...while writer (Registered Nurse E #3) was in room doing nursing assessment, patient (Pt. #1) stated ...was touched inappropriately while having a US [ultrasound] done ...US male employee touched her breasts during procedure ...Charge Nurse (E #2) informed and appropriate departments...Timeline: Allegation closure date 05/09/2022 at 8:53 AM."

4. The clinical record of Pt. # 8 was reviewed on 06/08/2022. Pt. #8 was admitted on 01/04/2022, with a diagnosis of Pneumonia.
The event report for Pt. #8 dated 01/07/2022, was reviewed and included, "...(Pt. #8) stated that while her male nurse... administered her Lovenox (blood thinner) injection into her abdomen, he inappropriately touched her groin.

5. The clinical record of Pt. #9 was reviewed on 06/08/2022. Pt. #9 was admitted on 11/22/2021 with a diagnosis of hypertension (high blood presure). An event report for Pt. #9 dated 11/30/2021, was reviewed and included, "... (Pt. #9) reported to a Physical Therapist '(name of staff) in housekeeping touched me'. (Pt. #9) unable to share any information..."

6. The Hospital was not able to provide documentation that an acknowledgement and resolution letter was provided to the patients (Pt. #1, Pt. #8 and Pt. #9).

7. On 06/08/2022 at 9:00 AM, the Manager of Risk Management (E #9) was interviewed. E #9 stated that review of the allegation of sexual abuse started on 05/02/2022 when it was first notified to the nurse taking care of the patient (Pt. #1). E #9 stated that "It's our process to look into abuse allegations as incident or occurrence report and it was handled immediately, and no acknowledgement letter or closure letters were provided to the patients (Pt. #1, Pt. #8, and Pt. #9)."

8. On 06/08/2022 at 9:45 AM, the Director of Clinical Excellence (E #10) was interviewed. E #10 stated that she is not sure why the abuse case was not considered as a grievance. E #10 stated that she will need to follow-up with the staff. E #10 stated that she's not sure why the initial letter to the receipt of the events and closure letters were not provided to the grievances filed by the patients (Pt. #1, Pt. #8, and Pt. #9).

Based on document review and interview, it was determined that for 1 of 3 (Pt. #1) clinical records reviewed for allegations of abuse, the Hospital failed to ensure that patients were free from all forms of abuse, by not removing staff from duty, during an ongoing investigation of alleged abuse.

Findings include:

1. On 06/07/2022 at approximately 1:00 PM, the Hospital's policy titled, "Abuse - Patient Protection from Abuse" dated 02/05/2019 was reviewed and included, " ...Patients will be protected from abuse in the hospital. Pursuant to section 9.6 of the Hospital Licensing Act ..."

2. On 06/07/2022 at approximately 1:10 PM, the Hospital's document titled, "210 ILCS 85/9.6 Sec. 9.6. Patient Protection from Abuse" (unknown date) was reviewed and included, " ...(e) Upon receiving a report under this section ...promptly conduct an internal review to ensure the alleged victim safety ...protect the alleged victim as deemed necessary by the hospital's administrator and may include ...removing suspected violators from further patient contact during the hospital's internal review ..."

3. On 06/07/2022 at approximately 9:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital's Telemetry Unit on 04/29/2022 at 4:37 PM, with a diagnosis of hypotension and acute kidney injury. Pt. #1's clinical record included the following:

-The medical/telemetry unit nursing progress documentation by Charge Nurse (E #2) note dated 05/02/2022 at 12:11 AM, included, " ...Patient's [Pt. #1's] RN (Registered Nurse -E #3) told me that patient [Pt. #1] reported to her having been touched inappropriately during an US [ultrasound] on 04/29. House Manager (E #7) notified of incident. Patient offered physical exam by MD [hospitalist] patient refused."

4. On 06/07/2022 at approximately 11:30 AM, the Hospital's document titled, "Healthcare Safety Zone Occurrence Report #73031" dated 05/02/2022 was reviewed and included, "Occurrence: Sexual Abuse ...date of occurrence: 04/29/2022 ...while writer (Registered Nurse E #3) was in room doing nursing assessment, patient (Pt. #1) stated ...was touched inappropriately while having a US [ultrasound] done ...US male employee touched her breasts during procedure ...Charge Nurse (E #2) informed and appropriate departments ...Investigation/Follow Up: Public Safety Officer (E #4) notified and police report completed by [name of city] PD [police department] patient declined a sexual assault screening ...The performing ultrasound technologist (E #1) was interviewed and his response below: Renal ultrasound requested ...arrived from ED on cart, observed to be non-verbal, non-responsive ...per standards pre-procedure exam explained in detail, use of gel, contact with skin ...asked if any questions ...(Pt. #1) unable to assist in any way for the entire US exam ...Timeline: Allegation closure date 05/09/2022 at 8:53 AM."

5. On 06/07/2022 at approximately 12:30 PM, the Hospital's Radiology Staff Schedule dated 04/01/2022 - 05/09/2022 was reviewed and included, "[Name of Ultrasound Technician - E #1] work schedule as follows: 04/29/2022 - 8:00 AM - 8:30 AM; 05/02/2022 - 8:00 AM - 8:30 PM; 05/05/2022 - 8:00 AM - 8:30 PM + 3:00 AM (05/06/2022); 05/07/2022 - 6:30 AM - 7:00 PM; 05/08/2022 - 6:30 AM - 7:00 PM." In summary, E #1's work schedule indicated staff was working in the Hospital on 05/02/2022 and continued to work while the investigation was in progress until 05/09/2022.

6. On 06/08/2022 at 9:00 AM, the Manager of Risk Management (E #9) was interviewed. E #9 stated that review of the allegation of sexual abuse started on 05/02/2022 when it was first notified to the nurse taking care of the patient (Pt. #1). E #9 stated that the allegation was completely investigated and closed by 05/09/2022 and it was unsubstantiated. E #9 stated that during the investigation the suspected employee was not suspended.