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A. Based on document review and interview, it was determined that for 1 of 1 abuse allegation reviewed for Pt #1, the Hospital failed to ensure patient rights to be free from all forms of abuse, by not having a physician immediately perform an exam on Pt #1 following the allegation of inappropriate touching.

Findings include:

1. On 4/21/2021, the Hospital's "Alleged Patient Abuse or Neglect Checklist: Illinois (undated) was reviewed and indicated "...Physician or other licensed provider not involved in allegation immediately performs exam of patient..."

2. On 4/21/2021, Pt #1's clinical record was reviewed. Pt #1 was admitted to the Hospital on 4/12/2021 with the diagnosis of possible CVA (cerebrovascular accident).

3. A safety event report dated 4/17/2021 noted "Pt #1 reported someone touched her inappropriately, placing their hand deep between her legs..."

4. On 4/21/2021 at 1:00 PM, an interview was conducted with MD # 1. MD #1 stated that she just became aware of the allegation on 4/20/201. MD #1 stated that she did not exam Pt #1 following the report of alleged sexual abuse.

B. Based on document review and interview, it was determined that for 1 of 1 alleged sexual abuse allegation reviewed for Pt #1, the Hospital failed to ensure reporting the sexual assault allegation to IDPH, as required.

Findings include:

1. On 4/21/2021, the Hospital's policy titled, "Allegations of Abuse or Neglect While Patients are Receiving Care: Illinois" (effective 1/29/2021) was reviewed and indicated "...Upon a designated hospital administrator receiving a report from any hospital administrator, agent, employee...Event is reported to IDPH within 24 hours after the designated hospital administrator receives such report..."

2. On 4/21/2021, Pt #1's clinical record was reviewed. Pt #1 was admitted to the Hospital on 4/12/2021 with the diagnosis of possible CVA (cerebrovascular accident).

3. A safety event report dated 4/17/2021 noted "Pt #1 reported someone touched her inappropriately, placing their hand deep between her legs..."

4. On 4/21/2021 at 11:30 AM, an interview was conducted with the Director of Quality (E #1). E #1 stated that she did not report the allegation of sexual abuse to the state because the Hospital policy stated that if you suspect the abuse occurred and then you report the incident to the state.

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

Findings include:

1. On 4/21/2021, the Hospital's policy titled, "Restraint and Seclusion Management," approved 12/20/2020, was reviewed. The policy required, "...6. Restraints or seclusion are ordered by licensed physicians... Process: 1. Obtain initial order and renewal orders for restraint or seclusion based on patient assessment, and according to the following... Non-violent / Non self destructive behavior restraint: Order renewal frequency required: once daily, every calendar day..."

2. On 4/21/2021, Pt. #3's clinical record was reviewed. Pt. #3 was admitted on 3/31/2021 with diagnoses of chronic heart failure, atrial fibrillation with rapid ventricular response (rapid heart rate) and altered mental status. Pt. #3's nursing notes included Pt. #1 was in non violent restraints continuously from 4/1/2021 at 2:00 AM through 4/21/2021 at 10:00 AM. There was no non violent restraint order written on 4/5/2021.

3. On 4/21/2021 at 10:25 AM, an interview was conducted with a Registered Nurse (E #5). E #5 stated that physician's orders for non violent restraints are written for the calendar day and Pt. #3's non violent restraint order for 4/5/2021 was not written.

Based on document review and interview it was determined that for 1 of 6 patients (Pt #6) reviewed for restraints, the Hospital failed to ensure documentation of the patient's condition or symptoms that warranted the use of restraints.

Findings include:

1. The Hospital's policy titled, "Restraint and Seclusion Management" (effective 12/21/2020) shows, " ...Non-violent/non-self destructive behavior restraint ... Order includes reason for restraint and type of restraint ..."

2. On 4/22/2021, Pt #6's clinical record, with an admission date of 4/1/2021, was reviewed. Pt #6's record shows a diagnosis of altered mental status. Pt #6's record shows that she was in restraints on 4/2/2021, 4/3/2021, and 4/4/2021 and was sedated and intubated for three days. Pt #6's chart showed no documentation of the patient's condition or symptoms that warranted the use of restraints.

3. On 4/22/2021 an interview was conducted with a Registered Nurse (E #6). E #6 stated that there was no reason documented for Pt. #6's restraints seen in Pt #6's clinical record.