HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 2 (Pt#1) patient records reviewed for abuse allegations, the Hospital failed to ensure that patients were free from all forms of abuse by failing to follow the Hospital's process in completting an investigation of an allegation of abuse.

Findings include:

1. On 5/18/2022, the Hospital's policy titled, "Response to Abuse and Neglect Allegations" (effective 12/2021) was reviewed and indicated, " ... Reporting: ... a. All staff are required to report immediately ... any received report of alleged abuse to their immediate supervisor. Notify Nursing Supervisor after business hours and weekends. b. Staff should complete an incident report using the Confidential Event Report c. All reported and/or allegations of abuse from staff, insurance providers, patient, family members of current and discharged patients will be initially reported to IDPH [Illinois Department of Public Health] within 24 hours through a secured website ... d. The final report will be sent to IDPH ... Investigation: After receiving an allegation of abuse or neglect occurring in the hospital premises, an internal investigation is initiated by the Chief Nursing Officer (CNO) and/or the Chief Compliance Officer or Nursing Supervisor after business hours with the collaboration with other departments deemed as necessary and completed as quickly as possible. [The Hospital] ensures, in a timely and thorough manner, objective investigation of all allegations of abuse ... Final Disposition: Upon conclusion of the investigation, the final report will be sent to outside entities or regulatory bodies in accordance with State and/or Federal law."

2. On 5/17/2022, the clinical record for Pt#1 was reviewed. Pt#1 was admitted on 7/27/2021 at 3:52 PM, after being transferred from another local Hospital, and discharged on 8/1/2021. Pt#1 was admitted with a chief complaint of manic, rapid speech, bizarre behavior, paranoid, and a primary diagnosis of bipolar. Pt#1's clinical record included:
-A Registered Nurse's (E#8) note, dated 7/31/2021 at 5:00 PM, indicated, "This writer provided [Pt#1] with grievance form following allegation of "getting beat up by staff a couple of days ago." This writer instructed [Pt#1] to provide specific details of names. Time and Date of occurrence as well as nature of injuries if any, so it can be further investigated."

-E#8's Note, dated 7/31/2021 at 9:10 PM, indicated, "[Pt#1] is restless, loud with rapid and pressured speech. [Pt#1] persistently demands to be discharged because, "my husband is downstairs now with the police to get me."... [Pt#1] agreed to this writer's suggestion and awaited there for the house supervisor to speak to her."

-E#8's Note, dated 7/31/2021 at 10:05 PM, indicated, "[Pt#1] elected to remain in quiet room following conversation with house supervisor ..."

3. On 5/17/2022, the Hospital's Incident Log for 2021 was requested, but it was not available for review. The Hospital was not able to present the abuse allegation made by Pt#1 or any investigation or follow up related to Pt#1's abuse allegation. There was no proof that the abuse allegation was reported to IDPH.

4. On 5/18/2022, at 12:35 PM, a phone interview was conducted with the Registered Nurse (E#8). E#8 stated that he did not remember Pt#1, Pt#1's complaint, or who the House Supervisor was on 7/31/2021.

5. On 5/18/2022, at 2:20 PM, an interview was conducted with the Chief Nursing Officer (E#4). E#4 stated that any time there is an abuse allegation (after the patient's safety is ensured) a report should be made, an investigation completed, and any staff allegedly involved taken off the schedule until the investigation is complete. E#4 stated that it should also be reported to Illinois Department of Public Health. E#4 stated that there is no report or investigation regarding Pt#1's allegation of abuse. E#4 stated that the House Supervisor involved in Pt#1's report of abuse is no longer employed at the Hospital.