HospitalInspections.org

Based on document review and interview, it was determined for 1 of 1 (Pt. #1) clinical record reviewed for potential patient abuse, the Hospital failed to ensure reporting of abuse was in accordance with the IDPH (Illinois Department of Public Health) regulations.

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... 3.) 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 11/22/17 at approximately 9:00 AM, the Hospital's policy titled "Hospital Staff Responsibility for Patient, Visitor, and Employee Safety" (revised 10/16) was reviewed and required, "Hospital staff will assist in ensuring that patients, employees, and visitors are protected from unsafe acts or conditions... Allegations of Patient Abuse... Patient abuse allegations shall be managed according to... IDPH... reporting guidelines..."

3. On 11/21/17 at approximately 9:15 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 30 year old female admitted on 10/13/17 with a diagnosis of bipolar disorder. The Physician's Orders sheet dated 10/22/17 indicated that bruises of unknown origin were noted on Pt. #1. The Psychiatric Progress Notes dated 10/23/17 also indicated that Pt. #1 was sent to an outside Hospital on 10/22/17 for a medical evaluation due to an allegation of abuse by mother.

4. On 11/21/17 at approximately 11:30 AM, E #2's (Chief Compliance Officer) Notification Findings Report (identified by E #2) dated 10/27/17 was reviewed and indicated, "On October 22, 2017... noted several bruises present on the patient..." The report had a transmission verification date of 10/31/17 to IDPH (9 days after allegation of abuse by Pt. #1's mother).

5. On 11/21/17at approximately 11:30 AM, an interview was conducted with E #2. E #2 stated that she was notified of the incident on 10/22/17, verbally notified IDPH on 10/26/17, and a report was sent on 10/27/17.

6. On 11/22/17 at approximately 9:00 AM, another interview and findings were discussed with E #2. E #2 stated that the Act regarding reporting of abuse to the State says within 24 hours for a known cause. E #2 stated, "I probably missed it."