HospitalInspections.org

Based on document review and interview it was determined that the Hospital failed to provide care in a safe setting and to protect and promote patient rights. As a result, the Condition of Participation, 42 CFR 482.13 Patient Rights was not in compliance.

Findings include:

1. The Hospital failed to ensure that a staff with an allegation of abuse was removed form providing patient care during an investigation. (A-145 A.)

2. The Hospital failed to ensure that patients were free from all forms of abuse and harassment by ensuring that a nurse was present during a medical examination. (A-145 B.)

An immediate jeopardy (IJ) was identified on 01/11/2023, due to the Hospital's failure to remove an accused staff from patient care immediately following allegations of abuse. The IJ was identified on 01/11/2023 at 42 CFR 482.13 Patient Rights, and was announced on 01/12/2023 at 12:35 PM, during a meeting with the President/Chief Executive Officer, Vice President of Operations, Director of Quality, Director of Behavioral Health, Vice President of Patient Safety, Regional Director of Regulatory, Interim Chief Executive Officer, National Regional Regulatory Manager, National Director of Regulatory, Vice President Behavioral Health, Senior Director Regulatory, Chief Nursing Officer, and Legal Representative. The IJ was removed by survey exit date 01/12/2023.

A. Based on document review and interview, it was determined that for 3 of 3 (Pt. #1-Pt. #) clinical records for vulnerable adolescents on the behavioral health unit reviewed for allegations of abuse, the Hospital failed to protect all patients from abuse, by not removing the accused staff from patient care immediately following allegations of abuse.

Findings include:

1. On 01/10/2023, the Hospital's policy titled, "Allegations of Patient Abuse by Amita Personnel in the Hospital" (revised 8/16/21) was reviewed and required, "A. Abuse or Abused means any physical or Mental Injury or Sexual Abuse intentionally inflicted on a patient of the hospital... B. Immediate Response... a. Address Patient Safety and Care. 1. Assure immediate protection of patient, including separating the patient from the alleged abuser..."

2. On 01/10/2023, the Hospital's policy titled, "Suspected Neglect or Patient Abuse by Hospital Staff" (revised 10/29/20) was reviewed and required, "I. The Hospital will cooperate fully with the DCFS (Department of Children and Family Services) investigation as required by law ... J. If the hospital and/or DCFS investigation finds the employee to have been negligent ... he/she may be subject to further police investigation and legal action ... will receive appropriate disciplinary action ..."

3. The clinical record for Pt. #1 was reviewed on 01/09/23. Pt.#1 was admitted to the Hospital on 12/02/22 with a diagnosis of major depressive disorder and was discharged on 12/07/22. The clinical record included the following:
-History and Physical (H&P) Exam (entered by MD #5) dated 12/03/22 at 4:20 PM, included, " ... admitted from home yesterday due to depressive thoughts, suicidal ideation. The clinical record indicated that a complete head to toe assessment was completed, including, "GU (genitourinary) Normal female. Tanner staging 3 [scale that defines physical development of children into adolescents based on physical assessment of breasts and genitalia]." The clinical record lacked documentation that a nurse was present during the examination.
-Psychiatry Progress Note (entered by MD #6) dated 12/06/22 at 10:58 AM, included, "Patient reported that she had a physical exam on Sunday by (MD #5) and she stated that he was touching her inappropriately on her breast and too low on her abdomen and inappropriately touching her buttocks. Patient reported that the nurse was there, but she was not looking towards this doctor's examination and was sitting in the corner ... Risk management was called, and investigation is going on."

4. The clinical record for Pt. #2 was reviewed on 01/09/23. Pt. #2 was admitted to the Hospital on 11/30/22 with a diagnosis of major depressive disorder and was discharged on 12/10/22. The clinical record included the following:
-History and Physical Exam (entered by MD #5) dated, 12/01/22 at 6:02 PM, included, " ... admitted form home due to aggressive behavior with yelling and screaming at her mother ... The clinical record indicated that a complete head to toe assessment was completed, including, "GU (genitourinary) Normal female. Tanner staging 3." The clinical record lacked documentation that a nurse was present during the examination.

5. The clinical record for Pt. #3 was reviewed on 01/09/23. Pt. #3 was admitted to the Hospital on 12/01/22 with a diagnosis of major depressive disorder and was discharged on 12/06/22. The clinical record included the following:
-History and Physical Exam (entered by MD #5) dated, 12/01/22 at 7:09 PM, included, " ... admitted form home for management of acute depressive episode with suicidal ideation ... The clinical record indicated that a complete head to toe assessment was completed, including, "GU (genitourinary) Normal female. Tanner staging 4." The clinical record lacked documentation that a nurse was present during the examination.

6. The Hospital provided an "Allegation Investigation Timeline" dated 12/05/22, and included,
"Patient Name: (names of Pt. #1, Pt. #2, and Pt. #3) ... Date/Time Risk Manager Notified: 12/5/22 at 8:00 PM. Brief description of allegation: RM (risk management) was notified that the mother of Pt. 1 (Pt. #1) came to the hospital at approximately 7:00 PM on 12/5 and complained that her daughter had reported to her that during the admission H&P exam by the physician, the physician touched the lower part of her hip ... on 12/6, (Pt.#1) was interviewed in the presence of her mother ... reported that there was a nurse (E #7) present during the exam but that she was looking at her clipboard the entire time. On 12/5 at approximately 9:00 PM, Pt. 2 (Pt. #2) then reported to a nurse that she too had been touched inappropriately by the same physician ... put his hand down the front of her pants and pressed down touching her vaginal area. During this interview Pt. 2 reported that Pt 1 (Pt. #1) and another (Pt. #3), had both experienced the same thing. This patient reported that there was no nurse present during the exam and the door was propped open with a chair. Pt. 3 (Pt. #3) was interviewed with the permission of the mother ... reported that during her physical exam by the same physician, he put a hand down her pants and pressed down in her pubic area ... reported that there was no nurse present during the exam and the door was closed ... "

7. On 01/11/2023 at approximately 10:55 AM, an interview with the former Risk Manager (E #8). E #8 stated that the Hospital followed their policy for allegations of abuse when they became aware on the evening of 12/05/22, of the allegations related to MD #5. E #8 stated that any staff that is accused of any form of abuse including physicians should be taken out of service during the investigation. E #8 stated that MD #5 is a Licensed Medical Provider and cannot be taken out of service completely but was taken out of service for the Behavioral Health Department.

8. On 01/11/2023 at approximately 11:45 PM, an interview was conducted with the Vice President of Patient Safety and Quality (E #11). E #11 stated that when the Hospital received these allegations of abuse on 12/6/2022, the Medical Executive Committee (MEC) called an ad hoc hearing and discussed the situation. A decision was made to remove MD #5 from patient care on the behavioral health unit. E #11 stated that MD #5 was taken off the schedule for the behavioral health unit on 12/6/2022, but there is no documentation that MD #5 was taken out of service on the behavioral health unit. However, MD #5 continued to provide services in the Hospital's Nursery. E #11 stated that MD #5 provided care for approximately 8 patients in the Nursery between 12/6/2022 and 1/10/2023 - 4 of them were telephone consults, and 4 were in person visits. E #11 stated that these allegations were reported to DCFS (Department of Children and Family Services) on 12/6/2022, but DCFS had not come to the Hospital to conduct their investigation yet. E #11 stated that, effective 1/10/2023 per Hospital's request, MD #5 was put on a leave of absence pending results of DCFS and IDPH investigations. E #11 stated that the Hospital's abuse policy applies to doctors. E #11 stated, "Retrospectively, MD #5 should've been removed from service at the Hospital, including the Nursery, during the investigation."

9. On 1/11/2023, the Hospital's Regional Director, Regulatory (E #12) presented the surveyor with a list of patients that received medical care by MD #5 between 12/6/2022 and 1/10/2023. The list included 4 patients who were seen in person by MD #5 (Pts #31 - #34).

10. On 01/11/2023, the clinical records for the 4 patients who were seen in the Family Birthing Center by MD #5 between 12/6/2022 and 1/10/2023 were reviewed and included:
-Pt #31 was born/admitted to the Hospital's Family Birthing Center on 12/5/2022. Pt #31 was seen by MD #5 on 12/6/2022 at 8:52 AM. MD #5's progress note included the completion of a head-to-toe physical examination of Pt #31.
-Pt #32 was born/admitted to the Hospital's Family Birthing Center on 12/28/2022. Pt #32 was seen by MD #5 on 12/29/2022 at 8:53 AM. MD #5's progress note included the completion of a head-to-toe physical examination of Pt #32.
-Pt #33 was born/admitted to the Hospital's Family Birthing Center on 1/3/2023. Pt #33 was seen by MD #5 on 1/4/2023 at 4:55 PM. MD #5's progress note included the completion of a head-to-toe physical examination of Pt #33.
-Pt #34 was born/admitted to the Hospital's Family Birthing Center on 1/3/2023. Pt #34 was seen by MD #5 on 1/4/2023 at 5:05 PM. MD #5's progress note included the completion of a head-to-toe physical examination of Pt #34.

11. On 1/11/2023 at approximately 12:30 PM, E #12 presented the surveyor with a letter, dated 1/10/2023 and signed by MD #5, which included a request for leave of absence from the Hospital beginning 1/10/2023 with no end date/return date. However, no documentation that the Hospital required MD #5 to be out of service or that MD #5 was suspended from services at the Hospital.

B. Based on document review and interview, it was determined that for 1 of 3 (Pt. #6) clinical records for adolescent patients in the Behavioral Health Unit that required a medical exmination by a physician, the Hosptial failed to ensure that patients were free from all forms of abuse and harassment by ensuring that a nurse was present during a medical examination.

Findings include:

1. On 01/10/2023, the Hospital provided an email, dated 12/06/22 at 6:46 PM, which included, "From Director of Behavioral Health Serices (E #5); Subject: H&P (history and physical) modifications... Moving forward all team members that work and/or float to 2W and care for our child/adolescent patients are to follow below; 1. Nurse must be present during H&P examination. 2. The nurse and/or MD will explain the H&P process to the patient prior to the examination... The nurse assigned to the patient or Charge Nurse will inform the provider of any past/current abuse prior to H&P... 5. The nurse will document that they were present with the provider for the H&P..."

2. On 01/09/2023, the clinical record of Pt. #6 was reviewed. Pt. #6 was admitted to the Hospital on 01/06/23, with a diagnosis of Suidal ideation. The clinical record included the following:
-History and Phsyical Exam (completed by pediatrician, MD #7), dated 01/07/23 at 3:45 PM, "Assessment and Plan: admitted to BH for suicidal ideations and self harm behavioral. The clinical record lacked documentation that a nurse was present during the examination.

3. On 01/10/23 at 11:37 PM, an interview was conducted with the Director of Behavioral Health Services (E #5). E #5 stated that it has always been standard practice to have staff present when the physician performs a medical examination. Since these incidents were reported (abuse allegations regarding MD #5), MD #5 has not been on the unit to conduct medical exams, and all staff were instructed to ensure that there is a witness when medical exams are being conducted and to document who was present during the exam. Staff were informed during huddles, but there was no formal in-service conducted. E #5 could not provide documentation that any monitoring/audits were conducted to ensure compliance with this process.

4. On 01/11/2023 at approximately 11:45 AM, an interview with the Director of Quality (E #12). E #12 stated that the Hospital has not been tracking to see if staff have been compliant with ensuring that staff is present during a medical examination and documentation of this in the clinical record. The Hospital does not have a policy stating that a nurse should be present during an H&P, "staff just knows that is best practice."