HospitalInspections.org

Based on document review, observation and interview, it was determined that for 1 of 2 (Pt. #11) clinical records reviewed for alleged abuse, the Hospital failed to ensure a complete investigation of an allegation of abuse was conducted.

Findings include:

1. On 5/18/18 at approximately 11:30 AM, the clinical record of Pt. #11 was reviewed. On 3/20/18 at 10:02 PM, Pt. #11 was a 48 year old male who presented to the Emergency Department (ED) via wheelchair escorted by the CFD (Chicago Fire Department). Pt. #11 had a chief complaint of alcohol abuse.

The "Patient Notes" from 3/20/18 to 3/21/18 were reviewed. On 3/21/18 at 12:10 PM, the Nurse (E #31) documented "(Pt. #11) got agitated to security and one ER (Emergency Room) staff...then (Pt. #11) went towards staff, staff evaded the attack and (pt. #11) fell. No injuries noted."

2. On 5/18/18 at approximately 9:00 AM, the "Unusual Occurrence Report" dated 3/20/18 at 11:16 AM, was reviewed and indicated, "Event Type: Behavioral Incident ... Location: ED ... This incident is being reported by PSO (Public Safety Officer) (E #32). E #32 witnessed E #33 (PCT- Patient Care Technician), physically assault the patient in the above room ... PCT tech (E #33) and (Pt. #11) had a verbal altercation ... Once heated words were exchanged, the above patient (Pt. #11) rose from his wheelchair seat and began walking towards the PCT tech (E #33), leading to (E #32) getting in between the two to diffuse the situation ... the PCT (E #33) pushed the patient (Pt. #11) very hard, causing him to hit his head on the front end of the ER bed, causing a deep laceration to the head ..."

3. On 5/18/18 the policy titled, "Adult Abuse Neglect and Domestic Violence Recognition and Reporting" (1/2017), was reviewed and required, "Procedure...2...If abuse is suspected to have occurred in the hospital by hospital staff or others, the Administrative Supervisor, the Risk Manager, and Unit Director needs to be notified immediately to begin an investigation and an Unusual Occurrence Report needs to be completed..."

4. On 5/18/18 at approximately 10:37 AM, the Director of Quality (E #2) was interviewed. E #2 was the acting Director of Emergency Services at the time of the incident (3/20/18). E #2 stated that he was made aware of the incident the following day (3/21/18). However, E #2 questioned the credibility of the PSO (E #32) that wrote the incident report. E #2 also added that he read the nurse's and physician's notes, which did not indicate that the patient (Pt.#11) received a laceration. Therefore, E #2 did not proceed to conduct a complete investigation. E #2 stated that E #33 continued to work as scheduled.