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Based on document review, and interview, it was determined that for 2 of 5 (Pt. #4 and Pt. #6) with special precautions, the Hospital failed to provide care in a safe setting by failing to conduct observation rounds every 15 minutes on the Behavioral Health Unit as required.

Findings include:

1. The clinical record for Pt. #4 was reviewed on 10/6/2020. Pt. #4 was admitted on 10/1/2020, with a diagnosis of Schizophrenia (mental disorder that affects a person's ability to think, feel, and behave clearly). A physician's order dated 10/1/2020, included, "BH (Behavioral Health) Precautions every 15 minute check." The Observation Record dated 10/4/2020, lacked documentation of the every 15 minute observation of the patient by staff from 19:00 (7:00 PM) to 19:15 (7:15 PM).

2. The clinical record for Pt. #6 was reviewed on 10/6/2020. Pt. #6 was admitted on 9/12/2020, with a diagnosis of Bipolar disorder (disorder associated with episodes of mood swings). A physician's order dated 9/12/2020, included, "BH Precautions every 15 minute check." The Observation Record dated 9/14/2020, lacked documentation of the every 15 minute observation of the patient by staff from 18:45 (6:45 PM) to 19:00 (7:00 PM).

3. The Hospital's policy titled, "Precaution Rounds" (revised 5/2017) included, "...Behavioral Health precaution rounds are used to monitor...aspects of care that might compromise a given individual's safety. Precaution rounding is conducted every 15 minutes, 24/7, for the full duration of the patient's course of hospitalization."

4. On 10/6/2020 at approximately 12:20 PM, these findings were discussed with the Charge Nurse (E #3). E #3 stated that all patients on the Behavioral Health Units must be monitored every 15 minutes at all times, and there should not be any blanks on the Observation Rounding flow sheet. E #3 stated that even if the patient of off the floor, there should be some documentation.

Based on document review and interview, it was determined that for 2 of 3 (Pt. #11 and Pt. #12) clinical records reviewed for the allegation of abuse. The Hospital failed to ensure the incidents of allegation of abuse were reported to the Illinois Department of Public Health in accordance with applicable local, State or Federal law.

Findings include:

1. Per PART 250 HOSPITAL LICENSING REQUIREMENTS TITLE 77: PUBLIC HEALTH CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER b: HOSPITALS AND AMBULATORY CARE FACILITIES PART 250 HOSPITAL LICENSING REQUIREMENTS, Any hospital administrator, agent, employee, or medical staff member who has reasonable cause to believe that any patient with whom he or she has direct contact has been subjected to abuse in the hospital shall promptly report or cause a report to be made to a designated hospital administrator responsible for providing such reports to the Department as required by this subsection (c)...(5) Upon receiving a report under subsection (c)(3), the hospital shall submit a report to the Department within 24 hours after obtaining such report.

2. On 10/8/2020, the clinical record of Pt. #11 was reviewed. Pt. #11 was admitted to the Hospital on 1/27/2020, with a diagnosis of Major Depression.

3. The Hospital provided a document titled, "Safety/Security Event #36273" for Pt. #11 dated 1/30/2020, and included, "Event Date 1/27/2020, Location: Behavioral Medicine Adult Unit. Brief Factual Description: Per patient's request, writer met with this patient (Pt. #11) on 1/30/20 at 10:50 AM. Patient reports that an AA (African American) male staff was soliciting sex...in exchange for money... I can't remember his name. He asked me to have sex with him for $50 and he showed me the money..."

4. On 10/8/2020, the clinical record of Pt. #12 was reviewed. Pt. #12 was admitted to the Hospital on 8/21/2020, with a diagnosis of Detoxification.

5. The Hospital provided a document titled, "Safety/Security Event #36212" for Pt. #12 dated 8/24/2020, and included, "Patient (Pt. #12)...witnessed NOC (night) Registered Nurse of 8/23/2020 physically strike patient in bed next to (Pt. #12)..."

6. On 10/07/2020 at approximately 9:30 AM and 10/8/2020 at approximately 8:55 AM, interviews were conducted with the the Risk Manager (E #1) and the Vice President of Patient Care Services (E #8). E #1, and E #8 stated that the Hospital follows evidence based best practice for investigations of abuse allegations. However, the Hospital does not have a policy and procedure for reporting abuse allegations. E #1 and E #8 stated that these incidents were not reported to the Illinois Department of Public Health (IDPH), due to being investigated by the Hospital and were unsubstantiated.

Based on document review and interview, it was determined that for 1 of 3 (Pt. #1) patients reviewed for restraints usage, the Hospital failed to ensure a physician's order was obtained for the use of restraint.

Findings include:

1. The clinical record of Pt. #1 was reviewed on 10/6/2020. Pt. #1 was admitted on 8/10/2020 with a diagnosis of Schizoaffective disorder (mental health disorder marked by symptoms such as hallucinations, delusions, depression or mania). The clinical record contained a document titled, "Restraint: Violent Self-Destructive Flow Sheet" dated 8/27/2020 from 11:45 (11:45 AM) to 13:00 (1:00 PM), that indicated that Pt. #1 was being continuously monitored every 15 minutes while in restraints by staff. The clinical record lacked a physician's order for the use of four (4) point restraint that was applied to Pt. #1.

2. The Hospital's policy titled, "Restraint" (revised 12/2019), was reviewed on 10/6/2020 and required, "Violent or self-destructive behavior: An order from a physician must be obtained immediately or as soon as clinically appropriate including the reason for the restraint."

3. On 10/7/2020 at approximately 9:30 AM, an interview was conducted with the Chief Operating Officer (E #7). E #7 stated that the staff should obtain a physician's order for the use of restraints immediately.

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #1) clinical records reviewed for restraint usage, the Hospital failed to ensure that the patient was seen face-to-face within 1 hour after initiation of the restraints.

Findings include:

1. The clinical record of Pt. #1 was reviewed on 10/6/2020. Pt. #1 was admitted on 8/10/2020 with a diagnosis of Schizoaffective disorder (mental health disorder marked by symptoms such as hallucinations, delusions, depression or mania). The clinical record contained a document titled, "Restraint: Violent Self-Destructive Flow Sheet" dated 8/27/2020 from 11:45 (11:45 AM) to 13:00 (1:00 PM), that indicated that Pt. #1 was being continuously monitored every 15 minutes while in restraints by staff. The clinical record lacked documentation of a 1 hour face to face evaluation within one hour of the initiation of the restraints.

2. The Hospital's policy titled, "Restraint" (revised 12/2019), was reviewed on 10/6/2020 and required, "Violent or self-destructive behavior: A physician must see and evaluate the individual in person within one hour of application to evaluate the patient's immediate situation, reaction to the intervention, medical and behavioral conditions and the need to continue or terminate the restraint..."

3. On 10/7/2020 at approximately 9:30 AM, an interview was conducted with the Chief Operating Officer (E #7). E #7 stated that any patient placed in restraints should be evaluated face to face by a physician within one hour of restraint initiation. E #7 stated that there is no documentation that a face to face was done for this restraint application.